During seasonal influenza epidemics, pregnant women constitute a high-risk group for disease-related morbidity and mortality [
The first lethal case of respiratory infection with H1N1 in an adult in the United States was diagnosed in a pregnant woman on April 30 [
On May 26, 2009, a 27-year old middle-eastern P0000 at 32 weeks of gestation with no significant past medical history presented complaining of cough with blood-tinged sputum and fevers for four days. The patient did not recall any contacts with ill individuals and denied recent travel. She had been evaluated in the emergency room two days prior to admission and had been diagnosed with viral syndrome which had not improved. Her vital signs were pulse 110, respiratory rate 22, blood pressure 119/74, and temperature 100.1 F, while her oxygen saturation ranged from 93% to 96%. On physical examination, she had bilateral ronchi in her lungs. Her white blood count (WBC) was 6.6 K/Ul. Her chest X-ray revealed bilateral middle and lower lobe infiltrates consistent with pneumonia. When the patient was admitted, she started on ceftriaxone and azithromycin. Her nasal swab was negative for influenzas both A and B, and when repeated three days later, it was again negative.
The next day the patient developed acute respiratory distress syndrome, had difficulty breathing, had a respiratory rate of 22–28, and a temperature of 102.0 her pulse oxygen saturation declined to 86. Due to the deterioration of her respiratory functions, she was intubated and transferred to the ICU. She started on piperacillin-tazobactam and vancomycin, and on hospital day four, she started on oseltamivir. On hospital day five her condition continued to deteriorate, with her arterial oxygen saturation decreasing to 88% on 100%
The patient was a 29-year old white P1011 at 37 weeks of gestation who presented in early labor with fever, dry cough, headache, nausea, and vomiting. Her prenatal course was uneventful. She had a temperature of 102.3, a respiratory rate of 22, a heart rate of 105, and a pulse oxygen saturation of 100% in room air. She reported that her daughter had some respiratory symptoms and fever a few days earlier. Her lab results were unremarkable, with a white blood count of 4.9, with 8% lymphocytes.
The patient was having irregular contractions, and her cervix was 1-2 cm open and 70% effaced. The fetal heart rate was 170 with moderate variability. Chorioamnionitis was suspected and she was admitted for labor augmentation. Because of the ongoing epidemic of H1N1 in the community, she was isolated with droplet precautions, placed in negative pressure room, and started on oseltamivir and ampicillin-clavulanic acid. The patient was augmented with oxytocin and had an uncomplicated vaginal delivery in 8 hours of a female infant weighing 3220 g, Apgar 9/9. She had an uneventful postpartum period and was discharged on postpartum day 2. Nasopharyngeal swab cultures that were sent on admission were reported as positive for influenzas A on the next day, and novel influenza H1N1 was confirmed by the DOH. The newborn tested negative for influenza A and B by real-time reverse transcription PCR. On her six-week postpartum visit she was asymptomatic, and the baby was doing well.
This series of two patients with novel influenza A (H1N1) virus demonstrates the variation in course that the disease may take in pregnancy. The first case was a pregnant woman with late initiation of antiviral therapy. The patient rapidly progressed to ARDS despite the fact that all the supportive measures expired. This is illustrative of the importance of early initiation of antiviral therapy since delayed initiation has not been shown to have a salutary effect on individuals with H1N1. A second case—apparently a more frequent scenario with mild viral symptoms—was appropriately managed and had no major sequel. Though mild cases are undoubtedly underrepresented in our report (as they are in other ones), it is reasonable to suggest that, as with seasonal influenza, pregnant women constitute a population at risk for morbidity and mortality.
Patients with H1N1 viral infection present with acute respiratory symptoms—dry cough, sore throat, nasal congestion, and fever. Almost one third of them report contact with an ill individual on admission [
Current CDC recommendation suggests that pregnant women who had contact with someone suspected of infection with novel H1N1 influenza virus should receive prophylactic treatment with either oseltamivir (75 mg daily) or zanamivir (two 5 mg inhalations daily) for 10 days. The CDC states that zanamivir is preferable due to its low systemic absorption, but because of its inhaled route of administration, respiratory complications must be considered [
Currently all subtyped influenza A viruses reported to CDC (99% of all specimens sent to CDC) are H1N1 [
Since this article was initially submitted, two additional patients with H1N1, including one who ended up on ECMO and the other in the ICU, have been cared for at our facility.