Epidural Use and Clinical Chorioamnionitis among Women Who Delivered Vaginally
17 April 2013
02 January 2014
04 April 2014 (online)
Objective Chorioamnionitis, an important cause of maternal and neonatal morbidity, is influenced by epidural use and the occurrence of epidural fever. We evaluated the association between chorioamnionitis, histologic placental findings, and intrapartum factors focusing on epidural use.
Materials and Methods We conducted a secondary analysis of a randomized controlled trial of different doses of oxytocin to prevent postpartum hemorrhage among women who delivered vaginally. The primary outcome was clinical diagnosis of chorioamnionitis leading to antibiotic therapy. Intrapartum factors examined included epidural use, parity, labor induction, gestational age, maternal age, ethnicity, body mass index, cervical dilatation at admission, preeclampsia/eclampsia, preterm labor, and duration of labor.
Results Of the 1,798 women randomized, we excluded 13 multifetal births leaving 1,785 for analysis: 1,491 had an epidural and 294 did not. Of those with epidural, 8.0% had clinically diagnosed chorioamnionitis compared with only 1.0% without epidural: unadjusted odds ratio (OR) = 8.3 (95% confidence interval [CI]: 2.63–26.40); p < 0.0001. After multivariable logistic regression, epidural use (adjusted OR: 5.80; 95% CI: 1.77–19.11), increasing parity (0.42; 0.32–0.55), and preeclampsia (0.31; 0.14–0.66) were significantly associated with chorioamnionitis.
Conclusion Epidural use is statistically associated with an increase in clinical diagnosis of chorioamnionitis. A cause and effect relationship cannot be confirmed from this study. Independently of labor duration and increasing parity, preeclampsia appeared protective.
This article was presented in part as a poster at the Society for Maternal-Fetal Medicine 32nd Annual Meeting, February 9, 2012, Dallas, TX.
- 1 Gibbs RS, Duff P. Progress in pathogenesis and management of clinical intraamniotic infection. Am J Obstet Gynecol 1991; 164 (5, Pt 1) 1317-1326
- 2 Yancey MK, Duff P, Kubilis P, Clark P, Frentzen BH. Risk factors for neonatal sepsis. Obstet Gynecol 1996; 87 (2) 188-194
- 3 Duff P. Maternal and perinatal infection. In: Gabbe S, Niebyl J, Simpson JL, , eds. Obstetrics: Normal and Problem Pregnancies. 5th ed. New York: Churchill Livingstone; 2007
- 4 Fusi L, Steer PJ, Maresh MJA, Beard RW. Maternal pyrexia associated with the use of epidural analgesia in labour. Lancet 1989; 1 (8649) 1250-1252
- 5 Camann WR, Hortvet LA, Hughes N, Bader AM, Datta S. Maternal temperature regulation during extradural analgesia for labour. Br J Anaesth 1991; 67 (5) 565-568
- 6 Ramin SM, Gambling DR, Lucas MJ, Sharma SK, Sidawi JE, Leveno KJ. Randomized trial of epidural versus intravenous analgesia during labor. Obstet Gynecol 1995; 86 (5) 783-789
- 7 Gambling DR, Sharma SK, Ramin SM , et al. A randomized study of combined spinal-epidural analgesia versus intravenous meperidine during labor: impact on cesarean delivery rate. Anesthesiology 1998; 89 (6) 1336-1344
- 8 Lieberman E, Lang JM, Frigoletto Jr F, Richardson DK, Ringer SA, Cohen A. Epidural analgesia, intrapartum fever, and neonatal sepsis evaluation. Pediatrics 1997; 99 (3) 415-419
- 9 Goodlin RC, Chapin JW. Determinants of maternal temperature during labor. Am J Obstet Gynecol 1982; 143 (1) 97-103
- 10 Thierrin L, Mercier FJ. Epidural analgesia and fever during labor [in French]. J Gynecol Obstet Biol Reprod (Paris) 2005; 34 (5) 423-426
- 11 Glosten B, Savage M, Rooke GA, Brengelmann GL. Epidural anesthesia and the thermoregulatory responses to hyperthermia—preliminary observations in volunteer subjects. Acta Anaesthesiol Scand 1998; 42 (4) 442-446
- 12 Philip J, Alexander JM, Sharma SK, Leveno KJ, McIntire DD, Wiley J. Epidural analgesia during labor and maternal fever. Anesthesiology 1999; 90 (5) 1271-1275
- 13 Dashe JS, Rogers BB, McIntire DD, Leveno KJ. Epidural analgesia and intrapartum fever: placental findings. Obstet Gynecol 1999; 93 (3) 341-344
- 14 Roberts DJ, Celi AC, Riley LE , et al. Acute histologic chorioamnionitis at term: nearly always noninfectious. PLoS ONE 2012; 7 (3) e31819
- 15 Riley LE, Celi AC, Onderdonk AB , et al. Association of epidural-related fever and noninfectious inflammation in term labor. Obstet Gynecol 2011; 117 (3) 588-595
- 16 Lieberman E, O'donoghue C. Unintended effects of epidural analgesia during labor: a systematic review. Am J Obstet Gynecol 2002; 186 (5, Suppl Nature): S31-S68
- 17 Marmor TR, Krol DM. Labor pain management in the United States: understanding patterns and the issue of choice. Am J Obstet Gynecol 2002; 186 (5, Suppl Nature): S173-S180
- 18 Tita AT, Szychowski JM, Rouse DJ , et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. Obstet Gynecol 2012; 119 (2, Pt 1): 293-300
- 19 Langston C, Kaplan C, Macpherson T , et al. Practice guideline for examination of the placenta: developed by the Placental Pathology Practice Guideline Development Task Force of the College of American Pathologists. Arch Pathol Lab Med 1997; 121 (5) 449-476
- 20 Redline RW, Faye-Petersen O, Heller D, Qureshi F, Savell V, Vogler C ; Society for Pediatric Pathology, Perinatal Section, Amniotic Fluid Infection Nosology Committee. Amniotic infection syndrome: nosology and reproducibility of placental reaction patterns. Pediatr Dev Pathol 2003; 6 (5) 435-448
- 21 Alexander JM, Sharma SK, McIntire DD, Leveno KJ. Epidural analgesia lengthens the Friedman active phase of labor. Obstet Gynecol 2002; 100 (1) 46-50
- 22 Anim-Somuah M, Smyth RM, Jones L. Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev 2011; (12) CD000331
- 23 Herbst A, Wølner-Hanssen P, Ingemarsson I. Risk factors for fever in labor. Obstet Gynecol 1995; 86 (5) 790-794
- 24 Vinson DC, Thomas R, Kiser T. Association between epidural analgesia during labor and fever. J Fam Pract 1993; 36 (6) 617-622
- 25 Herbst A, Wølner-Hanssen P, Ingemarsson I. Risk factors for fever in labor. Obstet Gynecol 1995; 86 (5) 790-794
- 26 Macaulay JH, Bond K, Steer PJ. Epidural analgesia in labor and fetal hyperthermia. Obstet Gynecol 1992; 80 (4) 665-669
- 27 Tita AT, Andrews WW. Diagnosis and management of clinical chorioamnionitis. Clin Perinatol 2010; 37 (2) 339-354
- 28 Dowling O, Chatterjee PK, Gupta M , et al. Magnesium sulfate reduces bacterial LPS-induced inflammation at the maternal-fetal interface. Placenta 2012; 33 (5) 392-398
- 29 Heller DS, Rimpel LH, Skurnick JH. Does histologic chorioamnionitis correspond to clinical chorioamnionitis?. J Reprod Med 2008; 53 (1) 25-28
- 30 Goetzl L, Evans T, Rivers J, Suresh MS, Lieberman E. Elevated maternal and fetal serum interleukin-6 levels are associated with epidural fever. Am J Obstet Gynecol 2002; 187 (4) 834-838
- 31 Sharma SK, Rogers BB, Alexander JM, McIntire DD, Leveno KJ. A randomized trial of the effects of antibiotic prophylaxis on epidural-related fever in labor. Anesth Analg 2013;
- 32 Segal S. Labor epidural analgesia and maternal fever. Anesth Analg 2010; 111 (6) 1467-1475