Association of Pre-Pregnancy Obesity and COVID-19 with Poor Pregnancy Outcome

BACKGROUND AND OBJECTIVES

During the COVID-19 pandemic, a possible overlap of obesity and COVID-19 infection has raised concerns among patients and healthcare professionals about protecting pregnant women from developing a severe infection and unwanted pregnancy outcomes. The aim of this study was to evaluate the associations of body mass index with clinical, laboratory, and radiology diagnostic parameters as well as pregnancy complications and maternal outcomes in pregnant patients with COVID-19.

MATERIALS AND METHODS

Clinical status, laboratory, and radiology diagnostic parameters and pregnancy outcomes were analyzed for pregnant women hospitalized between March 2020 and November 2021 in one tertiary-level university clinic in Belgrade, Serbia, due to infection with SARS-CoV-2. Pregnant women were divided into the three sub-groups according to their pre-pregnancy body mass index. For testing the differences between groups, a two-sided p-value <0.05 (the Kruskal-Wallis and ANOVA tests) was considered statistically significant.

RESULTS

Out of 192 hospitalized pregnant women, obese pregnant women had extended hospitalizations, including ICU duration, and they were more likely to develop multi-organ failure, pulmonary embolism, and drug-resistant nosocomial infection. Higher maternal mortality rates, as well as poor pregnancy outcomes, were also more likely to occur in the obese group of pregnant women. Overweight and obese pregnant women were more likely to develop gestational hypertension, and they had a higher grade of placental maturity.

CONCLUSIONS

Obese pregnant women hospitalized due to COVID-19 infection were more likely to develop severe complications.

Prevalence of Maternal Mortality and Clinical Course of Maternal Deaths in COVID-19 Pneumonia-A Cross-Sectional Study

Introduction

After initial studies suggested that pregnant women were not at a higher risk of complications due to COVID-19 infection. Recent investigations from Sweden and the US have indicated that pregnant and postpartum women are at increased risk of severe complications associated with COVID-19. This study aims to find out the prevalence of maternal mortality and the clinical course of maternal mortality cases due to COVID-19 pneumonia.

Methodology

A cross-sectional study was conducted from May 1st, 2020, to April 30th, 2021, at Postgraduate Institute and YCM Hospital Pimpri Pune (Maharashtra), a dedicated COVID hospital during COVID pandemic. During study period, all pregnant women who were diagnosed to have COVID-19 infection by RT PCR/Rapid Antigen Test were admitted and were enrolled for the study.

Aim

To audit the maternal mortality due to COVID-19 infection.

Primary

To estimate the prevalence of maternal mortality due to COVID-19 infection in obstetric patients.

Secondary

To systematically study and analyze the clinical course of infection in mothers who had mortality due to COVID-19 pneumonia. Data collected in standard format regarding Demography, clinical presentation, need for ICU/HDU, CXR findings, laboratory parameters and cases with maternal mortality were studied in detail to fulfill the study objectives.

Results

Among 871 COVID-19 cases diagnosed during pregnancy, nine patients had maternal mortality due to covid pneumonia. There was no obvious obstetric cause for mortality in these cases. The prevalence of maternal mortality was 0.01 (1.03%). Cases with maternal mortality were mostly in 3rd Trimester (5 of 9 cases) and presented with moderate to severe illness with breathlessness and myalgia in all 9 cases, cough and fever in 7 out of 9 cases, Tachypneoa was noted in all patients. Saturation below 90 in 6 cases and below 94 in 3 cases. Chest X-ray showed bilateral lung affection in all 9 cases. Leukocytosis with raised N:L ratio was predominantly seen, thrombocytopenia noted in 5 cases and elevated levels of acute phase reactants and inflammatory markers such as CRP, S. ferritin, ESR, LDH, D-dimer and S. fibrinogen was observed. None of the study participants received vaccine for COVID-19.

Conclusions

COVID-19 pneumonia is an additional toll for maternal mortality. Obstetric patients in 2nd and 3rd trimester having COVID-19 infection with late presentation to hospital, moderate to severe disease (RR > 30 min), with raised inflammatory markers (N:L ratio, CRP, Ferritin, d-Dimer, etc.) at presentation, having bilateral lung affection are at risk of poor maternal outcome.

Severe acute respiratory syndrome coronavirus 2(SARS-CoV-2) infection during late pregnancy: a report of 18 patients from Wuhan, China

Background

Compared with Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), Corona Virus Disease 2019(COVID-19) spread more rapidly and widely. The population was generally susceptible. However, reports on pregnant women infected with SARS-CoV-2 were very limited. By sharing the clinical characteristics, treatments and outcomes of 18 patients with COVID-19 during late pregnancy, we hope to provide some references for obstetric treatment and management.

Methods

A total of 18 patients with COVID-19 treated at Renmin Hospital of Wuhan University were collected. The epidemiological characteristics, clinical manifestations, laboratory tests, chest CT and pregnancy outcomes were performed for analysis.

Results

1. 18 cases of late pregnancy infected with SARS-CoV-2 pneumonia were delivered at 35 ^+ 5 weeks to 41 weeks. According to the clinical classification of COVID-19, 1 case was mild type, 16 cases were ordinary type, and 1 case was severe type. 2. According to imaging examinations: 15 (83%) cases showed unilateral or bilateral pneumonia, 2 (11%) cases had pulmonary infection with pleural effusion, and 1 (6%) case had no abnormal imaging changes. 8 (44%) cases were positive and 10 (56%) cases were negative for nasopharyngeal-swab tests of SARS-CoV-2. 3. Among the 18 newborns, there were 3 (17%) premature infants, 1 (6%) case of mild asphyxia, 5 (28%) cases of bacterial pneumonia, 1 (6%) case of gastrointestinal bleeding, 1 (6%) case of necrotizing enteritis, 2 (11%) cases of hyperbilirubinemia and 1 (6%) case of diarrhea. All the newborns were negative for the first throat swab test of SARS-CoV-2 after birth. 4. Follow-up to Mar 7, 2020, no maternal and neonatal deaths occurred.

Conclusions

The majority of patients in late term pregnancy with COVID-19 were of ordinary type, and they were less likely to develop into critical pneumonia after early isolation and antiviral treatment. Vertical transmission of SARS-CoV-2 was not detected, but the proportion of neonatal bacterial pneumonia was higher than other neonatal diseases in newborns.

Special Populations: Disaster Care Considerations in Chronically Ill, Pregnant, and Morbidly Obese Patients

Special populations, which include the morbidly obese and patients with chronic, complex medical conditions that require long-term health care services and infrastructure, are at increased risk for morbidity and mortality when these services are disrupted during a disaster. Past experiences have identified significant challenges in restoring necessary care services to these patients following major environmental events. This article describes the impact of disasters on special populations, provides a framework for future disaster preparation and planning, and identifies areas in need of further research. Gravid patients, who are often overlooked in disaster planning and preparation, are also discussed.

Emerging Infectious Diseases in Pregnancy

It has been recognized for centuries that pregnant women have unique susceptibilities to many infectious diseases that predispose them to untoward outcomes compared with the general adult population. It is thought a combination of adaptive alterations in immunity to allow for the fetal allograft combined with changes in anatomy and physiology accompanying pregnancy underlie these susceptibilities. Emerging infectious diseases are defined as those whose incidence in humans has increased in the past two decades or threaten to increase in the near future. The past decade alone has witnessed many such outbreaks, each with its own unique implications for pregnant women and their unborn fetuses as well as lessons for the health care community regarding response and mitigation. Examples of such outbreaks include, but are not limited to, severe acute respiratory syndrome, the 2009 H1N1 pandemic influenza, Ebola virus, and, most recently, the Zika virus. Although each emerging pathogen has unique features requiring specific considerations, there are many underlying principles that are shared in the recognition, communication, and mitigation of such infectious outbreaks. Some of these key principles include disease-specific delineation of transmission dynamics, understanding of pathogen-specific effects on both mothers and fetuses, and advance planning and contemporaneous management that prioritize communication among public health experts, clinicians, and patients. The productive and effective working collaboration among the Centers for Disease Control and Prevention, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine has been a key partnership in the successful communication and management of such outbreaks for women's health care providers and patients alike. Going forward, the knowledge gained over the past decade will undoubtedly continue to inform future responses and will serve to optimize the education and care given to pregnant women in the face of current and future emerging infectious disease outbreaks.

Acute Respiratory Failure in Pregnancy

Acute respiratory failure in pregnancy has multiple etiologies, including thromboembolism, amniotic fluid embolism, venous air embolism, aspiration of gastric contents, respiratory infections, asthma, beta-adrenergic tocolytic therapy, and pneumomediastinum and pneu mothorax. Proper management of acute respiratory fail ure in pregnancy requires an understanding of the specific diseases and the normal gestational changes that occur in maternal respiration (decreased functional re sidual capacity, increased minute ventilation, mild respi ratory alkalosis) and hemodynamics (increased cardiac output, increased blood and plasma volume, unchanged central pressures). Knowledge of the determinants of oxygen delivery to fetal tissue (uterine blood flow, pla cental transfer, fetal circulation) and how they are af fected by changes in maternal hemodynamics, position, acid-base status, and medications can help sustain nor mal fetal development, whenever possible, without compromising maternal care. Diagnostic testing such as radiography, hemodynamic monitoring, and fetal moni toring are considered in terms of attendant risk to the mother or the fetus, alterations in normal values related to gestation, and indications for usage. Similarly, the risks and benefits of supportive and specific therapies for the various etiologies of acute respiratory therapy are reviewed.

Acute respiratory failure in pregnancy

Respiratory failure affects up to 0.2% of pregnancies, more commonly in the postpartum period. Altered maternal respiratory physiology affects the assessment and management of these patients. Respiratory failure may result from pregnancy-specific conditions such as preeclampsia, amniotic fluid embolism or peripartum cardiomyopathy. Pregnancy may increase the risk or severity of other conditions, including thromboembolism, asthma, viral pneumonitis, and gastric acid aspiration. Management during pregnancy is similar to the nonpregnant patient. Endotracheal intubation in pregnancy carries an increased risk, due to airway edema and rapid oxygen desaturation following apnea. Few data are available to direct prolonged mechanical ventilation in pregnancy. Chest wall compliance is reduced, perhaps permitting slightly higher airway pressures. Optimizing oxygenation is important, but data on the use of permissive hypercapnia are limited. Delivery of the fetus does not always improve maternal respiratory function, but should be considered if benefit to the fetus is anticipated.

Number needed to vaccinate to prevent hospitalizations of pregnant women due to inter-pandemic influenza in Sweden, 2003-2009

BACKGROUND

The evidence of increased risk of severe disease for healthy pregnant women due to inter-pandemic influenza consists mainly of observational studies of health service utilization in USA and Canada. However, these results can be context dependent and estimates in a European setting are sparse. For policy purposes we therefore decided to elucidate the potential value of vaccination in Sweden.

MATERIALS AND METHODS

We conducted a retrospective, register-based study of hospitalizations due to inter-pandemic influenza or respiratory infection attributable to influenza in pregnant women in Sweden. With aggregated data from 2003 to 2009 we assessed the number needed to vaccinate (NNV) to prevent one such hospitalization.

RESULTS

We included on average 96,000 pregnant women/year and identified 9-48 hospitalizations/season fulfilling the case definition. Assuming 80% vaccine effectiveness the NNV was >1,900 pregnant women. The estimate is higher than those found in the USA, Canada, and UK. The difference may be explained by differing methods to estimate NNV, but also differences in propensity to hospitalize and the basic health status of the pregnant women.

CONCLUSIONS

Because of the increased risk associated with influenza A(H1N1)pdm09, vaccination is presently offered to all pregnant women in Sweden, but vaccination against other inter-pandemic influenza types seems disputable. The study illustrates the context dependence of preventive health measures and points to the need for national NNV estimates and international harmonization of study methods for comparisons between countries.

Effect of pregnancy on anti-HEV antibody titres, plasma cytokines and the corresponding gene expression levels in the PBMCs of patients presenting with self-recovering clinical and subclinical hepatitis E

High mortality in pregnant women (PR) is a characteristic of hepatitis E in developing countries. To understand the pathogenesis of HEV infection in self-limiting disease during pregnancy, we compared clinical (PR-patients) and subclinical-HEV-infections in pregnant women in the first (SC-PR-1) and later (2nd and 3rd, SC-PR-2+3) trimesters with the respective healthy controls and acute non-PR patients. The SC-PR-2+3 exhibited lower ALT, bilirubin levels, anti-HEV-IgM/IgG titres than the acute-PR/non-PR-patients (p<0.05-0.0001). IFNγ/IL4ratios indicated Th2/Th1 bias in non-PR and PR-patients respectively. Raised levels of 10/20 plasma cytokines in the non-PR-patients reflect predominant inflammatory response, unaltered- IFNγ/reduced-IFNα responses and a robust chemokine secretion. On contrary, the acute-PR-patients exhibited drastic reduction in majority of the cytokines relative to in the non-PR-patients. Importantly, diminished or unaltered response was noted in the acute-PR-group when compared to the corresponding controls. The only exception was sIL2RA, increasing in both patient categories. Of the 14 genes evaluated, the expression of IFNγ/IL10/IL1A/IL7/CCL2/CCL3/CXCL8/CXCL10 was higher in the non-PR patients. Of these, the expression of IFNγ/IL10/IL1A/CCL2/CCL3/CXCL8 and, additionally, IL2/IL6/TNF genes was higher in the clinical-PRs. Almost identical pattern was noted in the control-PR-2+3 category indicating no influence of HEV infection. Comparison of patient-categories identified significant elevation of IFNγ(P<0.001), CCL2(p<0.01), CXCL8(P<0.05), IL1B(p<0.05) and IL10(P<0.0001) and decrease in CXCL10(<0.05) in the PR-patients. The results suggest antibody-dependent disease severity and impaired immune response in the PR patients. Higher expression of cytokine-genes in the PBMCs did not correlate with the plasma-cytokine levels in the PR-patients.

Fatal outcome of pandemic H1N1 2009 influenza virus infection is associated with immunopathology and impaired lung repair, not enhanced viral burden, in pregnant mice

Pandemic A (H1N1) 2009 influenza virus (pH1N1) infection in pregnant women can be severe. The mechanisms that affect infection outcome in this population are not well understood. To address this, pregnant and nonpregnant BALB/c mice were inoculated with the wild-type pH1N1 strain A/California/04/09. To determine whether innate immune responses are associated with severe infection, we measured the innate cells trafficking into the lungs of pregnant versus nonpregnant animals. Increased infiltration of pulmonary neutrophils and macrophages strongly correlated with an elevated mortality in pregnant mice. In agreement with this, the product of nitric oxide (nitrite) and several cytokines associated with recruitment and/or function of these cells were increased in the lungs of pregnant animals. Surprisingly, increased mortality in pregnant mice was not associated with higher virus load because equivalent virus titers and immunohistochemical staining were observed in the nasal cavities or lungs of all mice. To determine whether exacerbated inflammatory responses and elevated cellularity resulted in lung injury, epithelial regeneration was measured. The lungs of pregnant mice exhibited reduced epithelial regeneration, suggesting impaired lung repair. Despite these immunologic alterations, pregnant animals demonstrated equivalent percentages of pulmonary influenza virus-specific CD8(+) T lymphocytes, although they displayed elevated levels of T-regulator lymphocytes (Tregs) in the lung. Also, pregnant mice mounted equal antibody titers in response to virus or immunization with a monovalent inactivated pH1N1 A/California/07/09 vaccine. Therefore, immunopathology likely caused by elevated cellular recruitment is an implicated mechanism of severe pH1N1 infection in pregnant mice.

Pneumonia complicating pregnancy

Community-acquired pneumonia (CAP) can affect pregnancy, posing risks to mother and fetus. CAP is the most common fatal nonobstetric infectious complication and a common cause of hospital readmission. Risk factors of pneumonia in pregnancy relate to anatomic and physiologic respiratory changes and immune changes. Aspiration can occur during labor, can cause life-threatening disease, and is more common in cesarean deliveries. Influenza pneumonia can cause severe disease, increasing the risk of preterm delivery, abortion, cesarean section, maternal respiratory failure, and death. CAP treatment requires considering antimicrobial appropriateness and safety, choosing therapy in line with guidelines, but considering maternal and fetal risk.

H1N1 novel influenza A in pregnant and immunocompromised patients

OBJECTIVE

To describe the increased risk of severe disease and the appropriate management of patients at high risk such as pregnant women and immunosuppressed patients who acquire novel influenza A (H1N1).

DESIGN

Review of the literature regarding influenza A in these patient groups, and review of published and unpublished data with regard to novel influenza A (H1N1).

MAIN RESULTS

Pregnant women are at increased risk for severe pneumonitis and respiratory failure from influenza infection, particularly during pandemics, including the current pandemic. Fetal morbidity is significant, usually resulting from maternal fever and severe hypoxemia. Early antiviral therapy using oseltamivir may be beneficial, and intensive care unit support should target adequate oxygenation at all times. Immunosuppressed patients are at increased risk for influenza, as well as at risk for more severe or prolonged infection. Patients after hematopoietic stem cell transplantation, after lung transplantation, and those receiving chemotherapy for leukemia are at highest risk, whereas the risk for human immunodeficiency virus-infected individuals appears relatively low. Treatment with antiviral therapy may be beneficial, even after the usual cut-off of 48 hrs after symptom onset.

CONCLUSIONS

Optimal management of these patients is preventive by influenza vaccination, but the neuraminidase inhibitor antiviral agents provide effective treatment.

Safety of influenza vaccination during pregnancy

The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices recommends routine influenza vaccination for all women who are or will be pregnant during the influenza season. During seasonal influenza epidemics, during previous pandemics, and with the current influenza A (H1N1) pandemic, pregnancy places otherwise healthy women at increased risk for serious complications from influenza, including death. Inactivated influenza vaccine can be safely and effectively administered during any trimester of pregnancy. No study to date has demonstrated an increased risk of either maternal complications or adverse fetal outcomes associated with inactivated influenza vaccination. Moreover, no scientific evidence exists that thimerosal-containing vaccines are a cause of adverse events among children born to women who received influenza vaccine during pregnancy. In this article, we review the evidentiary basis for the recommendation of vaccination of all women who will be pregnant during the influenza season and safety data of influenza vaccination during pregnancy.

Pneumonia in the Pregnant Patient

Community acquired pneumonia is a common illness, and pneumonia and influenza serve as the seventh leading cause of death in the United States. In the pregnant patient, pneumonia is the most common cause of fatal non-obstetric infection (1–3). Pneumonia can have adverse consequences for both the mother and her fetus, with certain infections (particularly viral and fungal) assuming greater virulence and mortality than in non-pregnant women of similar age (2, 3). Pneumonia is a relatively common cause of respiratory failure in pregnant patients, but in contrast to older studies, newer data suggest that not all pneumonias are more common or more serious in pregnant women than in other populations. However, because pneumonia can impact both the mother and fetus, it may lead to an increased likelihood of complicated preterm delivery, compared to pregnancies in which infection is absent.

The pathogens responsible for community-acquired pneumonia (CAP) are similar in pregnant and non-pregnant patients, with Streptococcus pneumoniae, Hemophilus influenzae, Mycoplasma pneumoniae, Legionella spp., Chlamydophila pneumoniae, and influenza A accounting for the majority of cases (2–4). However, reduction in cell-mediated immunity associated with pregnancy (especially during the third trimester) places women at an increased risk of more severe forms of pneumonia and disseminated diseases from pathogens normally contained by this type of immune response, including herpes virus, influenza, varicella, and coccidioidomycosis (3, 5–7).

Life history theory and the immune system: steps toward a human ecological immunology

Within anthropology and human biology, there is growing interest in immune function and its importance to the ecology of human health and development. Biomedical research currently dominates our understanding of immunology, and this paper seeks to highlight the potential contribution of a population-based, ecological approach to the study of human immune function. Concepts from life-history theory are applied to highlight the major challenges and demands that are likely to shape immune function in a range of ecological contexts. Immune function is a major component of maintenance effort, and since resources are limited, trade-offs are expected between investment in maintenance and other critical life-history functions involving growth and reproduction. An adaptationist, life-history perspective helps make sense of the unusual developmental trajectory of immune tissues, and emphasizes that this complex system is designed to incorporate information from the surrounding ecology to guide its development. As a result, there is substantial population variation in immune development and function that is not considered by current biomedical approaches. In an attempt to construct a framework for understanding this variation, immune development is considered in relation to the competing life-history demands that define gestation, infancy, childhood, adolescence, and adulthood. Each life stage poses a unique set of adaptive challenges, and a series of hypotheses is proposed regarding their implications for immune development and function. Research in human ecological immunology is in its earliest stages, but this is a promising area of exploration, and one in which anthropology is well-positioned to make important contributions.

Community influenza activity and risk of acute influenza-like illness episodes among healthy unvaccinated pregnant and postpartum women

This study investigated the relation between weekly levels of influenza activity and the risk of acute influenza-like illness episodes among 8,323 healthy pregnant and postpartum women enrolled in a Puget Sound region, Washington, health maintenance organization, Group Health Cooperative, between June 1991 and December 1997. The authors classified weeks between October and May for isolate activity level based on surveillance data for influenza, respiratory syncytial virus, parainfluenza, and adenovirus infection. Influenza-like illness episodes were identified from medical encounters assigned a diagnostic code consistent with a symptomatic influenza infection. The authors compared the occurrence of influenza-like illness episodes within each pregnancy stage for periods with varying levels of influenza isolate detection in the community. Repeated-measures logistic regression methods accounted for time-dependent factors. The adjusted strength of association between influenza exposure and influenza-like illness episodes increased as the pregnancy stage progressed (first trimester odds ratio = 1.12, 95% confidence interval: 0.79, 1.59; second trimester odds ratio = 1.30, 95% confidence interval: 0.97, 1.73; third trimester odds ratio = 1.84, 95% confidence interval: 1.31, 2.59; postpartum period odds ratio = 2.28, 95% confidence interval: 1.42, 3.68). Pregnancy stage modified the association between influenza activity and influenza-like illness episodes. Findings estimate that 20-43 pregnant/postpartum women would need to be vaccinated with an 80% effective vaccine to prevent one influenza-like illness episode.

A case-controlled study comparing clinical course and outcomes of pregnant and non-pregnant women with severe acute respiratory syndrome

Objective  To compare the clinical courses and outcomes of pregnant severe acute respiratory syndrome (SARS) patients and non‐pregnant SARS patients.

Design  A case–control study.

Setting  Tertiary Hospital for Infectious Disease.

Sample  Ten pregnant and 40 non‐pregnant female patients infected with SARS.

Methods  Clinical course and outcomes of pregnant SARS patients were compared with a group of non‐pregnant SARS patient. Cases and controls were matched with respect to sex, age, timing of contracting SARS, health care workers status and underlying illness.

Main outcome measures  The incidence of intensive care unit admission, intubation, medical complications and death rate.

Results  Pregnancy had no discernible impact on clinical symptoms and presentation delay. Four out of the 10 pregnant patients, nevertheless, required endotracheal intubation and six were admitted to the intensive care unit (ICU), as compared with 12.5% intubation rate (P= 0.065) and 17.5% ICU admission rate (P= 0.012) in the non‐pregnant group. More pregnant SARS patients developed renal failure (P= 0.006) and disseminated intravascular coagulopathy (P= 0.006), as compared with non‐pregnant SARS group. There were three deaths in the pregnant group, whereas there was no death in the non‐pregnant control group (P= 0.006).

Conclusion  Pregnant women with SARS experience a worse clinical course and poorer outcomes compared with non‐pregnant women.

Treatment of community-acquired lower respiratory tract infections during pregnancy

The incidence of lower respiratory tract infection (LRTI) in women of child-bearing age is approximately 64 per 1000 population. The spectrum of illness ranges from acute bronchitis, which is very common, through influenza virus infection and exacerbations of underlying lung disease, to pneumonia, which, fortunately is uncommon (<1.5% LRTI), but can be severe.

Acute bronchitis is generally mild, self-limiting and usually does not require antibacterial therapy. Influenza virus infection in pregnant women has been recently related to increased hospitalization for acute cardiorespiratory conditions. At present, the safety of the newer neuraminidase inhibitors for the treatment of influenza virus infection has not been established in pregnancy and they are not routinely recommended. In influenza virus infection complicated by pneumonia, antibacterial agents active against Staphylococcus aureus and Streptococcus pneumoniae superinfection should be used.

There are few data on infective complications of asthma or COPD in pregnancy. The latter is rare, as patients with COPD are usually male and aged over 45 years. Management is the same as for nonpregnant patients.

The incidence and mortality of pneumonia in pregnancy is similar to that in nonpregnant patients. Infants born to pregnant patients with pneumonia have been found to be born earlier and weigh less than controls. Risk factors for the development of pneumonia include anemia, asthma and use of antepartum corticosteroids and tocolytic agents. Based on the few available studies, the main pathogens causing pneumonia are S. pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae and viruses. β-Lactam and macrolide antibiotics therefore remain the antibiotics of choice in terms of both pathogen coverage and safety in pregnancy. In HIV-infected pregnant patients, recurrent bacterial pneumonia, but not Pneumocystis carinii pneumonia (PCP), is more common than in nonpregnant patients. Trimethoprim/sulfamethoxazole (cotrimoxazole) has not definitely been associated with adverse clinical outcomes despite theoretical risks. Currently it is still the treatment of choice in PCP, where mortality remains high.

In conclusion, there are few data specifically related to pregnant women with different types of LRTI. Where data are available, no significant differences compared with nonpregnant patients have been identified. In considering the use of any therapeutic agent or investigation in pregnant patients with LRTI, safety aspects must be carefully weighed against potential benefit. Otherwise, management strategies should not differ from those for nonpregnant patients. Further research in this area is warranted.

Immunologic adaptations during pregnancy

Many complementary changes occur in a pregnant woman's immune system to protect the fetus from attack while maintaining maternal defenses against disease. Enhancements occur in immune elements that fight bacterial infections. Conversely, suppression of T-cell activity causes increased susceptibility to viral infections, such as hepatitis, rubella, herpes, and human papilloma virus, and leads to an irreversible reduction in helper T cells in women infected with the human immunodeficiency virus. Local secretion of corticosteroids and changes in cytokine concentration in the reproductive tract protect the fetus from rejection. Understanding these changes assists the perinatal nurse in assessing and counseling women of childbearing age.

Severe pneumonia in pregnancy three months after resolution of cutaneous zoster

A 22 weeks pregnant women was affected by a life-threatening pneumonia and a paresis of the proximal muscles with cerebrospinal fluid pleocytosis. Her past medical history had been unremarkable except for recurrent episodes of paraumbilical herpes zoster. The clinical findings suggested a dissemination of varicella-zoster virus without skin lesions. Acyclovir was added to the therapy, and the clinical picture began to improve. Varicella-zoster virus DNA was detected in placental tissue by DNA-hybridisation analysis.

Tuberculin testing, BCG in pregnancy

The issue of tuberculin skin testing in pregnant health care workers of third-world ethnicity who may have previously received bacille Calmette-Guerin (BCG) immunization is complex and multifaceted. The relevant issues are:

• Is tuberculin skin testing safe in the pregnant female?

• Is tuberculin skin testing indicated in the pregnant female?

• Is tuberculin skin testing accurate and reliable in the pregnant female?

• Does previous BCG vaccination alter the diagnostic utility of tuberculin skin testing?

• Finally, is tuberculin skin testing safe in the BCG-immunized pregnant female?

Is tuberculin skin testing safe in the pregnant female?

When purified protein derivative (PPD) tuberculin is injected locally into the skin, most of it is removed within hours by lymphocytes. The remainder is engulfed by macrophages, and a mild brief local inflammatory reaction develops in both nonsensitive and hypersensitive patients. The reaction goes no further in the nonsen-sitized patient. In the sensitized patient-who has had Mycobacterium tuberculosis infection in the past-the area becomes heavily infiltrated by mononuclear cells, and an inflammatory reaction continues to increase for several days.