Australian and New Zealand Journal of Obstetrics and Gynaecology 2010; 50: 294296 DOI: 10.1111/j.1479-828X.2010.01151.

Short Communication

Respiratory failure in pregnant women infected by Swine-Origin

influenza A (H1N1)
Luan Thiam ANG,1 Kalpesh GANDHI2 and Yu-Hong Victoria QIN1
Departments of 1Obstetrics and Gynaecology and 2Intensive Care Medicine, Blacktown Hospital, Blacktown, New South Wales,
Australia

Two pregnant women developed acute respiratory distress syndrome from Swine-Origin influenza A (H1H1) virus. They
were put on mechanical ventilation. We discussed the issues that face obstetricians and intensive care physicians in such
situations.
Key words: extracorporeal membrane oxygenation, oseltamivir, pregnancy, respiratory failure, Swine-Origin influenza A
(H1N1).

Introduction gravid woman because of the uterine compression on the

Swine-Origin Influenza A (H1N1) virus (S-OIV) infection
is a novel disease that the World Health Organisation has
raised to the highest level of pandemic alert. As of 4
September 2009, there were 35 143 confirmed cases of
H1N1 influenza in Australia. Of the 4548 hospitalised cases,
134 (4.4%) were pregnant women. Four of the 161 deaths
from H1N1 were pregnant.1 Pregnancy, particularly in the
second and third trimester, is a risk factor.1,2
Case A
A 35-year-old G8P7 with an uncomplicated 28 weeks
pregnancy was admitted for influenza-like symptoms of
fever, cough, breathlessness, myalgia and vomiting for four
days. She had hypoxia requiring supplemental oxygen. She
deteriorated rapidly and was transferred to the intensive care
unit (ICU) 12 h after admission. She required mechanical
ventilation for acute respiratory distress syndrome (ARDS)
from suspected S-OIV. The infection was later confirmed by
polymerase chain reaction (PCR) testing of the
nasopharyngeal swabs. Oseltamivir was commenced 17 h
after her initial hospital admission. Steroids to improve fetal
lung maturation were given.
The patient remained unstable and was at risk of dying.
The NSW Statewide extracorporeal membrane oxygenation
(ECMO) referral service was consulted about ECMO
therapy for the mother. The femoral vessels are cannulated
for the procedure. This is technically difficult in a very
Correspondence: Dr Luan Thiam Ang, Department of Obstet-
rics and Gynaecology, Blacktown Hospital, Blacktown Road,
Blacktown, NSW 2148, Australia. Email: alt@bigpond.net.au
Received 17 August 2009; accepted 18 February 2010.
femoral blood vessels. To facilitate ECMO, the obstetrician
and intensivist jointly decided on a Caesarean section to take
the uterine load off the femoral vessels. It was performed
when the NETS retrieval team for the baby arrived. A live
female baby weighing 1000 g was delivered and was
transferred to a tertiary neonatal ICU. The patients
oxygenation improved to such an extent that ECMO was
not required. She had nine days of mechanical ventilation
support and stayed for ten days in the ICU. She was
discharged home 14 days after her hospital admission.
The baby suffered Grade 4 intraventricular haemorrhages
and associated obstructive hydrocephalus from Grade 3
hypoxia ischaemic encephalopathy.
Case B
A 28-year-old primigravida was admitted at 38 weeks
gestation for management of suspected respiratory tract
infection. She had influenza-like symptoms of fever, non-
productive cough and breathlessness. She was an asthmatic.
On the third day, her respiratory condition deteriorated
severely to require mechanical ventilation. The ICU team
felt that ventilation of the heavily pregnant mother would be
very difficult and consulted the obstetric team about
delivering the baby. A caesarean section was performed
under general anaesthesia. A healthy baby was delivered.
The mother was then transferred to ICU. She was
mechanically ventilated for ARDS, more than 72 h after her
hospital admission. The mother was commenced on
oseltamavir just before the caesarean section, approximately
68 h after her hospital admission. The PCR testing of the
endotracheal aspirate confirmed S-OIV. The mother was on
mechanical ventilation for 32 days and discharged home
40 days after her hospital admission.

294 2010 The Authors

Journal compilation 2010 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
The Australian and
New Zealand Journal
of Obstetrics and
Gynaecology

Discussion
The warning by Jamieson et al.3 in 2006 about novel
infections and pregnancy is proving true in the current
H1N1 influenza pandemic. Pregnant women had an
estimated four fold increase than the general population for
H1N1 influenza admission.4 Despite pregnant women
representing 1% of the population, they formed 9.1% of the
Australian and New Zealand patients admitted to the ICU
for H1N1 influenza from 1 June to 31 August 2009.5 The
shift from cell-mediated immunity is believed to be
responsible for the increased susceptibility. Influenza and
Varicella infections may lead to increased mortality rates.3
The initial presentation in most pregnant women with
H1N1 influenza is typical influenza-like symptoms (eg
cough, sore throat, rhinorrhoea) and fever.4 Most will
recover but some, like our two patients, will deteriorate
rapidly to ARDS.6 There are few documented cases of
managing severely affected patients with ARDS from H1N1
infection. Most clinical experience is derived from those
suffering from amniotic fluid embolism, status asthmaticus,
or thromboembolism.7 Obstetric patients, although younger
than general intensive care patients, have a greater risk of
dying and a higher infant mortality rate.8 The initial WHO
guideline is to manage them according to evidence-based
guideline for sepsis-associated ARDS. Lung protective
mechanical ventilation should be used.9 As far we are aware,
our report is the first of pregnant women in Australia
suffering from H1N1 influenza-affected ARDS and
requiring mechanical ventilation. These patients should
ideally be referred early to the ICU. At the height the H1N1
pandemic in July 2009, 40% of Australian patients
hospitalised for H1N1 influenza were admitted to the ICU.10
The availability of ICU beds, the exposure to multi-resistant
organisms in the ICU and the novel nature of the infection
mean that such referrals, as reflected in the admission times
of the two patients to the ICU, should be on a case-by-case
basis.
Pregnancy increases heart rate, stroke volume and oxygen
consumption and decreases lung capacity. The oxygen cost
of breathing is increased by 50%.11 Delivery of the baby
would obviate these changes. Nevertheless, there is some
controversy about emptying the uterus in the ARDS-
affected pregnant mother. Mabie et al.12 advised against the
routine delivery of the baby. Despite a 28% reduction in
oxygen requirement within 24 h after delivery, Tomlinson
et al.13 cautioned against emptying the uterus. Daily et al.14
reported a case of RDS that improved dramatically 24 h
after delivery to be extubated. Catanzarite and Willms15 in
their review of 83 cases believed that timing delivery was
crucial in patients with ARDS. For reasons of increasing
maternal oxygen consumption and cardiac performance,
consideration should be given to delivering the baby from
32 weeks gestation and more. Even in the stable ventilated
pregnant woman, abrupt fetal deterioration was common.
Unless the underlying cause of the ARDS was pyelonephritis
or varicella, significant prolongation of the pregnancy was
unlikely. In the deteriorating pregnant woman, they
2010 The Authors
Journal compilation 2010 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 50: 294296
Respiratory failure in H1N1 infected pregnant women
advocated delivery of the baby for three reasons. First, the
baby is unlikely to do well in the worsening maternal
condition. Second, delivery per se has a positive impact on
maternal status. Third, delivery may increase the therapeutic
option for the mother.
Patient As risk of dying was the rationale for delivering
the baby. It improved the maternal condition and added the
therapeutic option of ECMO to keep her alive. Prolonging
the pregnancy to 32 weeks was not an option. We were
cognisant that the babys prematurity would result in the
poor outcome. Sacrificing the baby for the sake of the
mother is a moral dilemma that obstetricians sometimes
face. Fortuitously, patient A recovered sufficiently enough
after the Caesarean section to negate the need for ECMO.
The decision to deliver the baby was less complicated in
patient B. The baby was mature enough to have a good
outcome.
Oseltamivir was commenced in patient A 17 h after her
hospital admission. Despite the respiratory physicians
considering H1N1 as a possible diagnosis in patient B at her
admission and 24 h later, oseltamivir was commenced 68 h
after admission. Both patients were admitted in the first few
days of July 2009 when H1N1 influenza was novel to the
majority of clinicians in the Southern hemisphere and is the
probable reason for the delay in commencing oseltamivir.
The NSW Health Department on 29 July 2009 issued
guidelines for managing pregnant women with suspected
influenza. One of the recommendations is to offer anti
influenza medicine while awaiting test results.16 For the
greatest benefit, the medicine should commence within 48 h
of symptoms onset.4
There is scarce literature on performing ECMO in
pregnant women afflicted by H1N1 ARDS and who are not
responding to mechanical ventilation. Based on four identified
cases, maternal and fetal outcomes were better if ECMO was
initiated in <7 days of mechanical ventilation.17 The authors
suggest that guidelines be developed on this issue.
It is important that the obstetrician, the intensive care and
respiratory physicians cooperate and coordinate the
management of the pregnant woman infected with H1N1
influenza. The key aspects are the commencement of anti-
viral medicines in patients presenting with influenza-like
symptoms, early consideration of ICU referral and in
refractory hypoxia, referral for ECMO.
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2010 The Authors