The case of a pregnant woman who succumbed to influenza

The death of a pregnant woman is something dreaded in medicine. Well…loosing any patient is tough, but loosing a pregnant woman is particularly heart breaking, because among other things, you think – this woman never got to see her precious baby, and the baby never got to know it’s mother.

The only time I can remember loosing a pregnant woman was in 2009, to influenza. It was in the heart of the ‘swine flu’ outbreak in May 2009. I was doing my last ICU rotation 1 month before completing residency in New York. On one of my last calls, one of the patients I was told to keep an eye on was a pregnant woman who was admitted earlier in the day with fever and shortness of breath. I went to check on her soon after our sign-out rounds (when the doctors who worked in the day tell the doctors covering for the night about the patients, particularly which sick ones to keep a close eye on) and met a woman about 8 months pregnant, sitting at the side of the bed, leaning over trying to catch her breath. Her chest X-ray earlier showed some patches in the lungs consistent with pneumonia. We knew there was a flu outbreak but her influenza rapid screen test came back negative and so she was put on antibiotics for possible bacterial pneumonia.

When I saw her she looked quite sick and the scary thing was that the oxygen concentration in her blood had dropped to less than 80% (it should be 100%). Because of her degree of distress, her chest X-ray was repeated and lo and behold it showed almost complete “white-out” of both lungs. The pneumonia had worsened dramatically in just a matter of hours.

It was clear that for the survival of the mother and baby, she needed to be put on the ventilator (breathing machine) immediately and the baby needed to be delivered. A healthy baby was delivered by C-section later that night but the mother remained on the breathing machine fighting for her life. Five days after she was admitted to the hospital, the influenza test result came back from the health department as positive for H1N1 (swine flu). She was started on Tamiflu but it was too late. She ended up dying from severe influenza pneumonia, complicated by failure of all her other organs a few weeks later.

A lot was learned from the 2009 influenza pandemic. Among other things it reiterated the fact that pregnant women are significantly more likely to have severe cases of the flu, especially during the 3rd trimester. We also realized after that outbreak, that when you suspect influenza infection, you should start treatment with antiviral medications immediately, rather than wait for the test result. Because at the time we were dealing with a new strain of influenza, the tests were not sensitive enough to pick it up and we had to wait days for the health department to do more detailed testing. Unfortunately, treatment is not very helpful if it is stated more than 48 hours after onset of illness.

So why is influenza a more severe illness in pregnant women? A big reason is the fact that pregnant women have a relatively weaker immune system. Because half of the baby’s makeup is material from the father (which is foreign to the mother), in order to avoid rejection of the baby by the mother, her immune system is reduced. Additionally, circulatory and hormonal changes in pregnancy also increase risk to certain infections.

Fortunately, the part of the immune system which causes a positive response to vaccination remains intact during pregnancy. Sadly, the influenza vaccine remains a severely underused resource in pregnant women. It’s sad because in addition to the mother denying herself protection from influenza by vaccination, the baby is also being denied protection. Babies of vaccinated mothers are protected against the flu for up to 6 months of life due to passage of protective antibodies from the mother to the baby while it is in the womb.

Stuck in my mind forever is the image of the pregnant woman with influenza sitting at the edge of her bed trying to catch her breath. I know this is a morbid thought but I keep wondering to myself – did she know she was going to die? Her baby must be a healthy 6 year old by now.