Pneumonia and pregnancy

Accelerating adverse pregnancy outcomes research amidst rising medication use: parallel retrospective cohort analyses for signal prioritization

BACKGROUND

Pregnant women are significantly underrepresented in clinical trials, yet most of them take medication during pregnancy despite the limited safety data. The objective of this study was to characterize medication use during pregnancy and apply propensity score matching method at scale on patient records to accelerate and prioritize the drug effect signal detection associated with the risk of preterm birth and other adverse pregnancy outcomes.

METHODS

This was a retrospective study on continuously enrolled women who delivered live births between 2013/01/01 and 2022/12/31 (n = 365,075) at Providence St. Joseph Health. Our exposures of interest were all outpatient medications prescribed during pregnancy. We limited our analyses to medication that met the minimal sample size (n = 600). The primary outcome of interest was preterm birth. Secondary outcomes of interest were small for gestational age and low birth weight. We used propensity score matching at scale to evaluate the risk of these adverse pregnancy outcomes associated with drug exposure after adjusting for demographics, pregnancy characteristics, and comorbidities.

RESULTS

The total medication prescription rate increased from 58.5 to 75.3% (P < 0.0001) from 2013 to 2022. The prevalence rate of preterm birth was 7.7%. One hundred seventy-five out of 1329 prenatally prescribed outpatient medications met the minimum sample size. We identified 58 medications statistically significantly associated with the risk of preterm birth (P ≤ 0.1; decreased: 12, increased: 46).

CONCLUSIONS

Most pregnant women are prescribed medication during pregnancy. This highlights the need to utilize existing real-world data to enhance our knowledge of the safety of medications in pregnancy. We narrowed down from 1329 to 58 medications that showed statistically significant association with the risk of preterm birth even after addressing numerous covariates through propensity score matching. This data-driven approach demonstrated that multiple testable hypotheses in pregnancy pharmacology can be prioritized at scale and lays the foundation for application in other pregnancy outcomes.

Acute Respiratory Failure in Pregnancy

Respiratory failure may affect up to 1 in 500 pregnancies, due to pregnancy-specific conditions, conditions aggravated by the pregnant state, or other causes. Management during pregnancy is influenced by altered maternal physiology, and the presence of a fetus influencing imaging, and drug therapy choices. Few studies have addressed the approach to invasive mechanical ventilatory management in pregnancy. Hypoxemia is likely harmful to the fetus, but precise targets are unknown. Hypocapnia reduces uteroplacental circulation, and some degree of hypercapnia may be tolerated in pregnancy. Delivery of the fetus may be considered to improve maternal respiratory status but improvement does not always occur.

Changes in Clinical Care of the Newborn During COVID-19 Pandemic: From the Womb to First Newborn Visit

COVID-19 has afflicted the health of children and women across all age groups. Since the outbreak of the pandemic in December 2019, various epidemiologic, immunologic, clinical, and pharmaceutical studies have been conducted to understand its infectious characteristics, pathogenesis, and clinical profile. COVID-19 affects pregnant women more seriously than nonpregnant women, endangering the health of the newborn. Changes have been implemented to guidelines for antenatal care of pregnant women, delivery, and newborn care. We highlight the current trends of clinical care in pregnant women and newborns during the COVID-19 pandemic.

COVID-19 in pregnancy: a systematic review of chest CT findings and associated clinical features in 427 patients

Purpose

Our purpose was to conduct a comprehensive systematic review of all existing literature regarding imaging findings on chest CT and associated clinical features in pregnant patients diagnosed with COVID-19.

Materials & methods

A literature search was conducted on April 21, 2020 and updated on July 24, 2020 using PubMed, Embase, World Health Organization, and Google Scholar databases. Only studies which described chest CT findings of COVID-19 in pregnant patients were included for analysis.

Results

A total of 67 articles and 427 pregnant patients diagnosed with COVID-19 were analyzed. The most frequently encountered pulmonary findings on chest CT were ground-glass opacities (77.2%, 250/324), posterior lung involvement (72.5%, 50/69), multilobar involvement (71.8%, 239/333), bilateral lung involvement (69.4%, 231/333), peripheral distribution (68.1%, 98/144), and consolidation (40.9%, 94/230). Pregnant patients were also found to present more frequently with consolidation (40.9% vs. 21.0–31.8%) and pleural effusion (30.0% vs. 5.0%) in comparison to the general population. Associated clinical features included antepartum fever (198 cases), lymphopenia (128 cases), and neutrophilia (97 cases). Of the 251 neonates delivered, 96.8% had negative RT-PCR and/or IgG antibody testing for COVID-19. In the eight cases (3.2%) of reported neonatal infection, tests were either conducted on samples collected up to 72 h after birth or were found negative on all subsequent RT-PCR tests.

Conclusion

Pregnant patients appear to present more commonly with more advanced COVID-19 CT findings compared to the general adult population. Furthermore, characteristic laboratory abnormalities found in pregnant patients tended to mirror those found in the general patient population. Lastly, results from neonatal testing suggest a low risk of vertical transmission.

Perinatal Maternal-Fetal/Neonatal Transmission of COVID-19: A Guide to Safe Maternal and Neonatal Care in the Era of COVID-19 and Physical Distancing

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19), is highly contagious and can cause serious respiratory illness and other clinical manifestations. The aim of this review is to summarize the clinical presentation, diagnosis, and outcomes of COVID-19 in pregnant women and neonates, who may be especially vulnerable to the effects of COVID-19, and to discuss what is known about potential maternal-fetal and maternal-neonatal transmission of SARS-CoV-2.

MS, pregnancy and COVID-19

Concerns regarding infection with the novel coronavirus SARS-CoV-2 leading to COVID-19 are particularly marked for pregnant women with autoimmune diseases such as multiple sclerosis (MS). There is currently a relative paucity of information to guide advice given to and the clinical management of these individuals. Much of the limited available data around COVID-19 and pregnancy derives from the obstetric literature, and as such, neurologists may not be familiar with the general principles underlying current advice. In this article, we discuss the impact of potential infection on the pregnant woman, the impact on her baby, the impact of the current pandemic on antenatal care, and the interaction between COVID-19, MS and pregnancy. This review provides a framework for neurologists to use to guide the individualised advice given to both pregnant women with MS, and those women with MS who are considering pregnancy. This includes evidence derived from previous novel coronavirus infections, and emerging evidence from the current pandemic.

The impact of maternal HIV infection on the burden of respiratory syncytial virus among pregnant women and their infants, western Kenya

Background

Respiratory syncytial virus (RSV) is an important cause of respiratory illness worldwide; however, burden data on mother–infant pairs remain sparse in sub-Saharan Africa, where human immunodeficiency virus (HIV) is prevalent. We evaluated the impact of maternal HIV infection on the burden of RSV among mothers and their infants in western Kenya.

Methods

We enrolled pregnant women (≤20 weeks’ gestation) and followed them and their newborns weekly for up to 3–6 months postpartum, to document cases of acute respiratory illness (ARI). Nasal/oropharyngeal swabs were collected and tested for RSV using polymerase chain reaction. Analyses were stratified by maternal HIV status and incidence was computed per 1000 person-months.

Results

Compared to RSV-negative ARI cases, RSV-positive cases were associated with cough, apnea, and hospitalization among infants. RSV incidence per 1000 person-months among mothers was 4.0 (95% confidence interval [CI], 3.2–4.4), and was twice that among the HIV-infected mothers (8.4 [95% CI, 5.7–12.0]) compared to the HIV-uninfected mothers (3.1 [95% CI, 2.3–4.0]). Among infants, incidence per 1000 person-months was 15.4 (95% CI, 12.5–18.8); incidence did not differ by HIV exposure or prematurity.

Conclusions

HIV infection may increase the risk of RSV illness among pregnant women. Future maternal RSV vaccines may have added benefit in areas with high HIV prevalence.

Maternal and neonatal outcomes associated with COVID-19 infection: A systematic review

Background

COVID-19 has created an extraordinary global health crisis. However, with limited understanding of the effects of COVID-19 during pregnancy, clinicians and patients are forced to make uninformed decisions.

Objectives

To systematically evaluate the literature and report the maternal and neonatal outcomes associated with COVID-19.

Search strategy

PubMed, MEDLINE, and EMBASE were searched from November 1^st, 2019 and March 28^th, 2020.

Selection criteria

Primary studies, reported in English, investigating COVID-19-positive pregnant women and reporting their pregnancy and neonatal outcomes.

Data collection and analysis

Data in relation to clinical presentation, investigation were maternal and neonatal outcomes were extracted and analysed using summary statistics. Hypothesis testing was performed to examine differences in time-to-delivery. Study quality was assessed using the ICROMS tool.

Main results

Of 73 identified articles, nine were eligible for inclusion (n = 92). 67.4% (62/92) of women were symptomatic at presentation. RT-PCR was inferior to CT-based diagnosis in 31.7% (26/79) of cases. Maternal mortality rate was 0% and only one patient required intensive care and ventilation. 63.8% (30/47) had preterm births, 61.1% (11/18) fetal distress and 80% (40/50) a Caesarean section. 76.92% (11/13) of neonates required NICU admission and 42.8% (40/50) had a low birth weight. There was one indeterminate case of potential vertical transmission. Mean time-to-delivery was 4.3±3.08 days (n = 12) with no difference in outcomes (p>0.05).

Conclusions

COVID-19-positive pregnant women present with fewer symptoms than the general population and may be RT-PCR negative despite having signs of viral pneumonia. The incidence of preterm births, low birth weight, C-section, NICU admission appear higher than the general population.

Maternal health care management during the outbreak of coronavirus disease 2019

Coronavirus disease 2019 (COVID-19) is a novel type of highly contagious pneumonia caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Despite the strong efforts taken to control the epidemic, hundreds of thousands of people were infected worldwide by 11 March, and the situation was characterized as a pandemic by the World Health Organization. Pregnant women are more susceptible to viral infection due to immune and anatomic alteration, though hospital visits may increase the chance of infection, the lack of medical care during pregnancy may do more harm. Hence, a well-managed system that allows pregnant women to access maternal health care with minimum exposure risk is desired during the outbreak. Here, we present the managing processes of three pregnant women who had fever during hospitalization in the gynecology or obstetrics department, and then, we further summarize and demonstrate our maternal health care management strategies including antenatal care planning, patient triage based on the risk level, admission control, and measures counteracting emergencies and newly discovered high-risk cases at in-patient department. In the meantime, we will explain the alterations we have done throughout different stages of the epidemic and also review relative articles in both Chinese and English to compare our strategies with those of other areas. Although tens of COVID-19 cases were confirmed in our hospital, no nosocomial infection has occurred and none of the pregnant women registered in our hospital was reported to be infected.

Fact versus Fiction: a Review of the Evidence behind Alcohol and Antibiotic Interactions

Many antibiotics carry caution stickers that warn against alcohol consumption. Data regarding concurrent use are sparse. An awareness of data that address this common clinical scenario is important so health care professionals can make informed clinical decisions and address questions in an evidence-based manner. The purpose of this systematic review was to determine the evidence behind alcohol warnings issued for many common antimicrobials. The search was conducted from inception of each database to 2018 using PubMed, Medline via Ovid, and Embase. It included studies that involved interactions, effects on efficacy, and toxicity/adverse drug reactions (ADR) due to concomitant alcohol consumption and antimicrobials. All interactions were considered in terms of three components: (i) alteration in pharmacokinetics/pharmacodynamics (PK/PD) of antimicrobials and/or alcohol, (ii) change in antimicrobial efficacy, and (iii) development of toxicity/ADR. Available data support that oral penicillins, cefdinir, cefpodoxime, fluoroquinolones, azithromycin, tetracycline, nitrofurantoin, secnidazole, tinidazole, and fluconazole can be safely used with concomitant alcohol consumption. Data are equivocal for trimethoprim-sulfamethoxazole. Erythromycin may have reduced efficacy with alcohol consumption, and doxycycline may have reduced efficacy in chronic alcoholism. Alcohol low in tyramine may be consumed with oxazolidinones. The disulfiram-like reaction, though classically associated with metronidazole, occurs with uncertain frequency and with varied severity. Cephalosporins with a methylthiotetrazole (MTT) side chain or a methylthiodioxotriazine (MTDT) ring, ketoconazole, and griseofulvin have an increased risk of a disulfiram-like reaction. Alcohol and antimicrobial interactions are often lacking evidence. This review questions common beliefs due to poor, often conflicting data and identifies important knowledge gaps.

Respiratory Diseases of Pregnancy

Pregnant patients can suffer from the same respiratory diseases as the general population in addition to unique syndromes of pregnancy (such as pre-eclampsia and tocolytic induced pulmonary edema, and pregnancy induced cardiomyopathy). Pregnancy by itself may add certain challenges such as difficult intubation. The critically ill pregnant patient requires a multidisciplinary approach and early inclusion of obstetrical expertise is paramount in managing these patients especially in the third trimester.

Postpartum cryptococcal pulmonary lesion incidentally discovered during a pulmonary-embolism evaluation of a 28-year-old caucasian woman

We report a case of localized pulmonary cryptococcal infection in a 28-year-old Caucasian woman who was 1 month postpartum at the time of her arrival at the hospital. The patient reported right-side chest pain; on further work up, she was found to have an incidental pulmonary lesion of the left lower lung lobe. Surgical pathology examination and microbiology studies revealed localized cryptococcal infection. Cases of cryptococcal pneumonia in pregnant women and in the postpartum period have been described in the literature. However, cryptococcal infections are usually associated with various immunocompromised states, including human immunodeficiency virus (HIV) infection. Because pregnancy is associated with physiological immunosuppression, cryptococcal pneumonia should be considered in pregnant women, or women in the postpartum period, who have respiratory symptoms.

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.

Combining corticosteroids and acyclovir in the management of varicella pneumonia: a prospective study

BACKGROUND

Studies found in the literature which describe the treatment of varicella pneumonia with a combination of acyclovir and corticosteroids tend to be retrospective in nature and limited with regard to the data supplied.

METHODS

This prospective study was performed at King Abdul Aziz Specialist Hospital in Taif, Saudi Arabia. The study covered adult patients admitted with a diagnosis of varicella pneumonia over a period of 10 years (January 2003 to December 2012). All patients were treated uniformly according to the predefined protocol with acyclovir and corticosteroids. The clinical characteristics, laboratory investigations, hospital course, any complications and the treatment outcomes were studied.

RESULTS

A total of 32 patients (25 males, mean age 43.5 ±14.5 years) were enrolled into this study; 3 patients (2 patients aged <12 years, 1 patient with advanced cardiac failure) were excluded. Of these 32 patients, 18 (58%) were current smokers, 16 patients (50%) were admitted to the intensive care unit and of these, 14 (87.5%) required mechanical ventilation. The mean duration of intensive care unit stay was 5.59 ±5.37 days. All patients were treated with intravenous acyclovir, corticosteroids and antibiotics were added when indicated. 31 patients improved and were discharged home. There was one death (a 32 year-old female with underlying systemic lupus erythematosus).

CONCLUSIONS

Patients with varicella pneumonia are at high risk of respiratory failure. Early implementation of supportive therapy seems to positively influence the recovery rate and outcome. Our study supports treatment using a combination of acyclovir and corticosteroids.

Pulmonary imaging during pregnancy

The diagnosis of pulmonary disorders associated with pregnancy is complicated by concerns about maternal/fetal radiation exposure, administration of contrast media, and medicolegal issues. This article reviews diagnostic imaging modalities, radiation exposure policy statements and provides a brief review of radiographic findings in selected pulmonary disorders associated with pregnancy. Clinicians should familiarize themselves with the benefit/risk of imaging modalities. Institution-specific imaging algorithms that minimize maternal/fetal radiation exposure are recommended. Institutional system-wide protocols would minimize confusion among healthcare providers.

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).

Azithromycin-chloroquine and the intermittent preventive treatment of malaria in pregnancy

In the high malaria-transmission settings of sub-Saharan Africa, malaria in pregnancy is an important cause of maternal, perinatal and neonatal morbidity. Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) reduces the incidence of low birth-weight, pre-term delivery, intrauterine growth-retardation and maternal anaemia. However, the public health benefits of IPTp are declining due to SP resistance. The combination of azithromycin and chloroquine is a potential alternative to SP for IPTp. This review summarizes key in vitro and in vivo evidence of azithromycin and chloroquine activity against Plasmodium falciparum and Plasmodium vivax, as well as the anticipated secondary benefits that may result from their combined use in IPTp, including the cure and prevention of many sexually transmitted diseases. Drug costs and the necessity for external financing are discussed along with a range of issues related to drug resistance and surveillance. Several scientific and programmatic questions of interest to policymakers and programme managers are also presented that would need to be addressed before azithromycin-chloroquine could be adopted for use in IPTp.

Infections related to pregnancy

Infections in pregnancy and in the postpartum period represent an important knowledge base that emergency physicians should have. Being able to understand the risk that pregnancy-related infections have on maternal and fetal health in addition to the initiation of appropriate treatment for these infections is crucial. In the postpartum period, most infections (94%) are likely to manifest after hospital discharge; therefore, patients frequently present to the emergency department.

A step-by-step diagnosis of exclusion in a twin pregnancy with acute respiratory failure due to non-fatal amniotic fluid embolism: a case report

INTRODUCTION

Respiratory failure may develop during the later stages of pregnancy and is usually associated with tocolysis or other co-existing conditions such as pneumonia, sepsis, pre-eclampsia or amniotic fluid embolism syndrome.

CASE PRESENTATION

We present the case of a 34-year-old healthy woman with a twin pregnancy at 31 weeks and 6 days who experienced acute respiratory failure, a few hours after administration of tocolysis (ritodrine), due to preterm premature rupture of the membranes. Her chest discomfort was significantly ameliorated after the ritodrine infusion was stopped and a Cesarean section was performed 48 hours later under spinal anesthesia; however, 2 hours after surgery she developed severe hypoxemia, hypotension, fever and mild coagulopathy. The patient was intubated and transferred to the intensive care unit where she made a quick and uneventful recovery within 3 days. As there was no evidence for drug- or infection-related thromboembolic or myocardial causes of respiratory failure, we conclude that our patient experienced a rare type of non-fatal amniotic fluid embolism.

CONCLUSION

In spite of the lack of solid scientific support for our diagnosis, we conclude that our patient suffered an uncommon type of amniotic fluid embolism syndrome and we believe that this report highlights the need for extreme vigilance and a high index of suspicion for such a diagnosis in any pregnant individual.

Pulmonary tuberculosis in a young pregnant female: challenges in diagnosis and management

Background. With the world becoming a global village, tuberculosis is no longer limited to endemic areas. Our case emphasizes the impact of immigration on infectious disease epidemiology and challenges associated with diagnosis and treatment in pregnancy. Case. A 21-year-old Hispanic female presented in preterm labor and was found to be hypoxic. Chest X-ray revealed a paratracheal mass which a CT scan confirmed. PPD test was positive. Bronchoalveolar lavage did not reveal acid-fast bacilli and biopsy revealed caseating granulomas. Diagnosis and treatment were challenging due to constraints in radiological investigations, lack of initial evidence of acid-fast bacilli, and toxic profile of medications. Due to her high risk, she was started on antituberculosis regimen. The diagnosis was confirmed on Day 26 when Mycobacterium tuberculosis was isolated by DNA probe. Conclusion. A high index of suspicion is required to recognize the changing face and disease spectrum of tuberculosis and initiate treatment for better outcomes.

Pneumonia during pregnancy

BACKGROUND

We determined the incidence, clinical course, risk factors, and outcomes of community-acquired pneumonia complicating pregnancy.

METHODS

A prospective study was performed of pregnant and nonpregnant patients in the same age range who presented to any of 6 hospitals in Edmonton, Alberta, with signs and symptoms of pneumonia together with an acute infiltrate evident on chest radiography compatible with pneumonia.

RESULTS

There were 28 patients with pneumonia during pregnancy, for an incidence of 1.1 per 1000 deliveries, whereas there were 333 nonpregnant females in the 20- to 40-year age group with pneumonia, for an incidence of 1.3 per 1000. No significant differences in signs and symptoms were present between the two groups. Asthma requiring treatment was present in 46.4% of the pregnant patients, compared with 17.1% of the nonpregnant patients. No maternal or fetal deaths were noted except an abortion at 10 weeks of gestation. No anomaly was detected among newborns. Two patients had preterm deliveries.

CONCLUSIONS

Pneumonia is well tolerated during pregnancy. Asthma may be a predisposing factor for pneumonia in this group of patients.

The effect of number of births on women's mortality: systematic review of the evidence for women who have completed their childbearing

Mortality in women who have completed their childbearing may increase with the number of births experienced because of maternal depletion or a trade-off between reproduction and mortality. We report a systematic review of the evidence on this association. We searched Medline, Embase, Popline, and the Science Citation Index for published and unpublished studies up to September 2003, and the book catalogues of relevant London libraries. Where necessary we also contacted authors for additional information. Mortality declined with increasing numbers of births in twelve historical cohorts, but in eight contemporary cohorts the highest mortality was seen in the nulliparous and in women with more than four births. All effects seen were small and there were few statistically significant results. Studies examining the relationship in other ways (such as by linear trends or by mean number of births by age at death) found inconsistent associations. We discuss methodological, social, and biological factors that may have affected these associations.

The use of radiographic modalities to diagnose infection in pregnancy

The usefulness of sonography, plain film, CT, and MRI in diagnosing infections in pregnancy is discussed. Imaging modality choices for specific clinical indications in pregnancy are reviewed. The overall safety of most techniques in pregnancy is emphasized.

Pulmonary complications of pregnancy

Pregnancy induces significant physiologic stresses on the pulmonary and cardiovascular systems that may precipitate respiratory compromise. In addition, certain disease states that are unique to the pregnant woman, such as amniotic fluid emboli syndrome, may be associated with respiratory failure. The physiologic changes that affect the pregnant woman are reviewed. Pregnancy-related conditions are discussed as well as how common diseases, such as the acute respiratory distress syndrome, asthma, pneumonia, and AIDS,have to be approached when balancing the needs of the fetus with maternal well-being.

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.