Posted on the Pediatric SuperSite on March 26, 2010
H1N1 caused severe disease, complications in pregnant women
Pregnant women and one postpartum woman with
pandemic influenza A (H1N1) in New York City had
severe illness and various complications such as hospitalization, acute
respiratory distress syndrome and emergency cesarean delivery, according
to Morbidity and Mortality Weekly Report.
“For pregnant and postpartum women and for those women considering
becoming pregnant, clinicians and health departments should emphasize the
importance of vaccination against seasonal influenza and 2009 H1N1 to prevent
life-threatening complications,” the researchers wrote.
Researchers at the New York City Department of Health and Mental Hygiene
(DOHMH) began active surveillance on April 25, 2009, to monitor cases of H1N1
in pregnant and postpartum women during three separate periods: April to June,
July to September and October to December.
The researchers defined cases of severe illness as pregnant or
postpartum women with lab-confirmed or probable H1N1 infection that led to ICU
admission or death.
The DOHMH reported 16 pregnant patients and one postpartum patient who
met inclusion criteria. Nine were admitted to ICUs from April to June, and
eight were admitted from October to December. The researchers also noted the
following:
- Median length of hospital stay was 12 days.
- Median patient age was 23 years.
- Median gestational age at hospital admission was 34 weeks.
- 11 women were in their third trimester.
Investigation revealed that five women had risk factors for influenza
complications including cardiovascular disease, sickle cell disease, asthma,
seizure disorder and diabetes.
The researchers said all women were
treated with oseltamivir (Tamiflu, Roche), but only
one patient initiated treatment within two days after symptom onset. Four women
did not start treatment until five days or more after the appearance of
symptoms. Only one woman was vaccinated; she was administered the seasonal
influenza vaccine more than eight weeks and the H1N1 vaccine more than four
weeks before symptom onset.
Nine women gave birth during hospitalization for H1N1, according to the
researchers, four of whom had emergency cesarean deliveries. Eight infants were
live-born, although one died soon after birth, and one infant was stillborn.
The researchers also outlined the disease progression of a 27-year-old
woman who was at 32 weeks gestation and visited her primary care physician
after one day of fever and cough. She exhibited no improvement after a
three-day course of antibiotic treatment and was admitted to the ED five days
after symptom onset.
The woman reported persistent fevers, chills, cough, wheezing and an
episode of near-syncope but was afebrile at ED admission. A chest radiograph
showed bilateral lobar pneumonia, and she was administered treatment for
community-associated pneumonia. On her second hospital day, the woman developed
a fever of 102.9·F and tachycardia and was diagnosed with acute
respiratory distress syndrome. Rapid influenza diagnostic tests from hospital
days one and three were negative.
On hospital day four, an emergency cesarean was performed due to
worsening oxygen saturations. The woman was hypotensive and needed multiple
blood transfusions throughout the procedure. Bronchoalveolar lavage cultures
from the previous day grew Acinetobacter baumanii, and on hospital day
11, a nasopharyngeal swab sent to the DOHMH Public Health Laboratory confirmed
H1N1 infection.
The woman was transferred to another ICU on hospital day 16 for
extracorporeal membrane oxygenation after exhibiting
refractory hypoxemia and severe ARDS. Oseltamivir was increased to 150 mg twice
daily. Other complications included volume overload, septic shock and
ventilator-associated pneumonia.
The woman died on hospital day 38. Her infant weighed 1,500 g at birth
and had Apgar scores of 1 at one minute and 1 at five minutes after birth.
However, the infant stopped breathing, and neonatal resuscitation efforts were
unsuccessful.
The researchers also described a second case involving a woman aged 21
years who was at 34 weeks gestation. She presented to the hospital with
respiratory distress; six days of fever, cough and myalgia; and two days of
blood-tinged sputum. The woman was prescribed antibiotics and oseltamivir a few
days before admission but reported only taking the antibiotics. Her chest
radiograph also indicated bilateral pulmonary infiltrates consistent with ARDS.
The woman was transferred to the ICU after two hospital days for
mechanical ventilation. She developed septic shock requiring vasopressors and
was administered broad-spectrum antibiotic treatment with 150 mg of oseltamivir
twice daily. Her respiratory status deteriorated, however, and she underwent
emergency cesarean delivery.
On hospital day three, the woman was transferred to another hospital ICU
for ECMO treatment for severe ARDS and septic shock. She experienced cardiac
arrest with ventricular fibrillation, but defibrillation was successful in less
than two minutes with no pulse. Her treatment course was switched from
oseltamivir to empiric IV peramivir and broad-spectrum antibiotics.
The DOHMH Public Health Laboratory confirmed a diagnosis of H1N1 on
hospital day four after testing a nasopharyngeal swab specimen from hospital
day two. Her hospital course involved spontaneous pneumothoraces; hypotension
requiring vasopressors; disseminated intravascular coagulation; and
tracheostomy placement.
The woman’s respiratory status improved, and she was discharged
with physical therapy on hospital day 32. Her infant weighed 2,080 g at birth
and had Apgar scores of 3 at one minute and 6 at five minutes after birth. The
infant required mechanical ventilation and was assigned to antibiotic treatment
for suspected sepsis, although the infant improved and was discharged on day
three of life, according to the researchers.
Fine A. MMWR. 2010; 59:321-326.
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