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Approach to the pregnant patient with a respiratory infection

Approach to the pregnant patient with a respiratory infection
Literature review current through: Jan 2024.
This topic last updated: Jan 11, 2023.

INTRODUCTION — The clinical features, diagnosis, and management of respiratory infection are generally similar in pregnant and nonpregnant patients. However, some additional factors need to be considered in pregnancy, including changes in maternal susceptibility to infection, changes in maternal physiology, and the fetal effects of the infection and its treatment.

This topic will discuss issues specific to common respiratory infections in pregnant patients. Clinical manifestations, diagnosis, and management of respiratory infections in the general population are reviewed separately (refer to individual topic reviews on the common cold, influenza, sinusitis, pneumonia, etc).

BASIC BACKGROUND PRINCIPLES — Awareness of pregnancy-associated changes in respiratory physiology is important to the management of respiratory disease in pregnant patients (figure 1 and figure 2). Such changes enable the pregnant individual to meet the respiratory and metabolic needs of the fetus. (See "Maternal adaptations to pregnancy: Dyspnea and other physiologic respiratory changes", section on 'Physiologic pulmonary changes in pregnancy'.)

Important points to consider when evaluating pregnant patients with respiratory illness include:

Pregnancy-related physiologic changes in pulmonary function

Tidal volume and minute ventilation increase by 30 to 40 percent during normal pregnancy, resulting in a sensation of dyspnea; however, the respiratory rate remains essentially unchanged, thus tachypnea is abnormal. (See "Maternal adaptations to pregnancy: Dyspnea and other physiologic respiratory changes", section on 'Ventilation'.)

Spirometry flow rates (forced vital capacity [FVC], forced expiratory volume in 1 second [FEV1], peak expiratory flow) are unchanged or mildly affected in a normal pregnancy, thus abnormal spirometry should be a signal to assess for underlying respiratory disease.

Pregnancy is a state of mild respiratory alkalosis due to alveolar hyperventilation. Normal third-trimester arterial blood gas levels are approximately pH 7.39 to 7.45, partial pressure of carbon dioxide (PaCO2) 25 to 33 mmHg, partial pressure of oxygen (PaO2) 92 to 107 mmHg, and bicarbonate 16 to 22 mEq/L. (See "Normal reference ranges for laboratory values in pregnancy".)

An apneic pregnant patient will develop hypoxia and acidosis more quickly than a nonpregnant adult because pregnant people have less buffering capacity to an acidotic insult, a 10 to 25 percent decrease in functional residual capacity, and a 20 percent increase in oxygen consumption. (See "Maternal adaptations to pregnancy: Dyspnea and other physiologic respiratory changes", section on 'Physiologic pulmonary changes in pregnancy'.)

Pregnancy-related physiologic changes in hemodynamics – An increase in cardiac output and a reduction in systemic vascular resistance are the major hemodynamic changes induced by pregnancy. (See "Maternal adaptations to pregnancy: Cardiovascular and hemodynamic changes".)

Pregnancy-related increased risk for developing pulmonary edema – Pregnant patients are prone to acute pulmonary edema related to preexisting medical conditions, pregnancy complications (eg, preeclampsia/eclampsia, peripartum cardiomyopathy, multiple gestation, amniotic fluid embolism, pyelonephritis), medications used in managing patients with preterm labor (eg, beta-adrenergic tocolytic agents, magnesium sulfate, glucocorticoids), and iatrogenic intravenous volume overload [1]. Physiologic changes related to pregnancy are also a contributing factor. (See "Acute respiratory failure during pregnancy and the peripartum period", section on 'Pulmonary edema'.)

Pregnancy-related increased risk for aspiration pneumonia – Pregnant people are prone to aspiration pneumonia because of the physiologic reduction in lower esophageal sphincter tone due to elevated progesterone levels and increased intraabdominal pressure due to the gradual increase in uterine size (which is partially compensated for by an increase in abdominal wall compliance). The risk of aspiration is highest during labor and delivery because of the effects of sedation, analgesia/anesthesia, and recumbency. Patients with chronic gastroesophageal reflux, obesity, or preexisting esophageal disease may be at higher risk for aspiration. (See "Acute respiratory failure during pregnancy and the peripartum period", section on 'Aspiration' and "Aspiration pneumonia in adults".)

Pregnancy-related changes in the immune system – The pregnant person's immune system shows markers of both immune activation and dampening. Although there is consensus regarding the absence of generalized immunosuppression of maternal immune responses in pregnancy, selective suppression or modulation may occur and may affect host defenses against some infections. Theoretically, pregnancy-related alterations leading to reduced cell-mediated immunity (shift from Th1 cell-mediated to Th2 humoral-mediated immunity) may increase the risk and severity of infection, especially viral-mediated respiratory infection. (See "Immunology of the maternal-fetal interface".)

Respiratory infection-related maternal and perinatal mortality – Maternal mortality and stillbirth have been reported among pregnant patients with severe respiratory infections caused by coronavirus infections (Middle East respiratory syndrome [MERS], COVID-19), influenza A virus subtype H1N1, and other infections causing pneumonia [2-6]. Stillbirth is most commonly a consequence of maternal respiratory failure rather than a direct result of fetal infection, thus interventions aimed at improving maternal respiratory function and maintaining a mild respiratory alkalosis may improve perinatal outcomes. (See "COVID-19: Overview of pregnancy issues" and "Seasonal influenza and pregnancy" and "Middle East respiratory syndrome coronavirus: Clinical manifestations and diagnosis".)

GENERAL DIAGNOSTIC AND THERAPEUTIC APPROACH — The general approach to caring for pregnant patients with respiratory illness is a two-stage process:

Determine the appropriate clinical evaluation – The initial evaluation of a pregnant patient with respiratory illness is similar to that of a nonpregnant patient and includes history, physical examination, laboratory/imaging studies (as appropriate), and differential diagnosis.

Remember that tachypnea and decreased oxygen saturation are not normal physiologic changes of pregnancy; thus, the presence of these, or other abnormal lung findings such as crackles (rales) or other signs of consolidation, are indicative of an underlying disease process that requires further evaluation. (See 'Basic background principles' above.)

Determine whether implementing the diagnostic and therapeutic plan carries any additional risks for the pregnant patient or fetus – These additional risks may be related to increased maternal susceptibility to severe disease or complications (eg, influenza, COVID-19) and/or to potential fetal risks related to the disease, its evaluation, or its treatment (eg, tetracycline may stain developing teeth). If so, are there alternative diagnostic tests or treatments that reduce or eliminate these risks? What are the risks of not implementing this plan in the pregnant patient?

Remember that most acute respiratory tract infections, which include the common cold, acute uncomplicated bronchitis, rhinosinusitis, and influenza, are caused by viruses and do not warrant antibiotic therapy. The use of unwarranted antibiotic therapy in such cases is an important contributor to antibiotic resistance, medication-related adverse events, and unnecessary cost [7]. Antibiotic stewardship plays an important role in controlling rates of Clostridioides difficile infection, which is associated with significant maternal morbidity and mortality [8].

The preponderance of viral infection was illustrated in a prospective study conducted in 2015-2016 in which 51 of 52 pregnant patients with an acute respiratory infection and a positive molecular diagnostic assay had a viral etiology: human rhinovirus (22), a human coronavirus (14), respiratory syncytial virus (8), influenza virus (4), human metapneumovirus (2), and parainfluenza virus (1; the remaining positive patient had Bordetella pertussis) [9]. Approximately one-third of the patients had symptoms consistent with acute lower respiratory tract illness (difficulty breathing or shortness of breath, wheezing) in addition to rhinorrhea, sore throat, or cough. (See "Clostridioides difficile infection in adults: Clinical manifestations and diagnosis" and "Clostridioides difficile infection in adults: Treatment and prevention" and "Clostridioides difficile infection in adults: Epidemiology, microbiology, and pathophysiology".)

CLINICAL FINDINGS AND TREATMENT OF SELECTED DISORDERS

The common cold

Clinical findings and diagnosis — Nasal congestion is the most common symptom; other common symptoms include sore throat, cough, and malaise. Fever is uncommon; conjunctivitis occurs variably. The diagnosis of the common cold is clinical, based upon these reported symptoms and/or observed signs. (See "The common cold in adults: Diagnosis and clinical features" and "The common cold in adults: Treatment and prevention".)

Treatment — As in nonpregnant patients, symptoms are usually mild and self-limited and generally neither require nor respond well to intervention. However, many pregnant people with the common cold will seek advice and symptomatic therapy from their clinician.

Patients with the common cold can be reassured that their symptoms will generally resolve within 10 days, although the cough may linger longer. Drug therapy may relieve some symptoms; however, treatment does not shorten the duration of symptoms, and the risks of drug therapy for the common cold in pregnancy have not been studied in randomized trials. If the patient still seeks symptomatic relief after being informed of the self-limited nature of the illness, the limited efficacy of all available treatments, and the absence of high-quality evidence of safety, they should be steered toward those agents with the most evidence of lack of fetal harm.

Data about the safety and efficacy of several drugs used to treat the common cold are provided in the tables (table 1A-D). The safety of acetaminophen is reviewed in more detail separately. (See "Prenatal care: Patient education, health promotion, and safety of commonly used drugs", section on 'Acetaminophen'.)

Nasal congestion – Use of heated humidified air is a safe and effective therapy for nasal congestion. Saline nasal sprays may help nasal symptoms of the common cold.

If inadequate and the patient requests pharmacotherapy, ipratropium bromide nasal spray is an option; animal studies have not observed teratogenic effects, but there are no human data. The 0.06 percent ipratropium bromide nasal spray is typically administered as two 42 mcg sprays to each nostril three to four times a day.

Intranasal cromolyn sodium is another option. Inhaled cromolyn preparations may cause transient bronchospasm, throat irritation, and cough; caution is warranted in asthmatics. (See "The common cold in adults: Treatment and prevention".)

Sore throat Pain relief approaches for acute pharyngitis in adults include systemic oral analgesics, topical therapies, and environmental measures (avoidance of irritants). Acetaminophen offers the best balance of safety and efficacy. Over the counter topical therapies have not been studied in pregnancy. (See "Symptomatic treatment of acute pharyngitis in adults".)

Headache Acetaminophen offers the best balance of safety and efficacy. (See "Headache during pregnancy and postpartum".)

Fever – If fever is present, it is reasonable to suggest use of acetaminophen to relieve associated discomfort, and fever reduction may have additional benefits. A large epidemiologic study (National Birth Defects Prevention Study, 1997 to 2011) described an association between maternal report of cold or flu with fever in early pregnancy and congenital anomalies, but no association in similar individuals without fever [10]. Although fever may be a marker for more severe cold/flu or other differences between the groups, the possibility of a causal association between fever and congenital anomalies cannot be excluded. In another report, among pregnant patients reporting a first-trimester infection and fever, use of acetaminophen was associated with a reduction of some congenital anomalies that have been related to maternal hyperthermia [11].

Cough – Treatment with honey or honey-containing preparations may reduce cough frequency and severity. Cough may be suppressed with guaifenesin; dextromethorphan may be less effective. (See "The common cold in adults: Treatment and prevention".)

Antibiotics are not indicated for treatment of the common cold, except in the small subset of patients (less than 2 percent) with evidence of secondary bacterial sinus infection [12] (see 'Acute sinusitis' below). The pregnant state does not change the usual standards for administering or withholding antibiotics. (See "The common cold in adults: Treatment and prevention", section on 'Antibiotic therapy'.)

Acute bronchitis

Clinical findings and diagnosis — Acute bronchitis should be suspected in patients with acute onset of a persistent cough (often lasting one to three weeks) who do not have clinical findings suggestive of pneumonia (eg, fever, tachypnea, rales, signs of parenchymal consolidation). The cough is usually accompanied by sputum production. Acute bronchitis cannot be distinguished from the common cold in the first few days of illness, but should be considered when cough persists for one to three weeks. Febrile patients are more likely to have influenza or pneumonia than bronchitis or the common cold.

Bronchitis is caused by a virus in approximately 90 percent of cases. Etiologic agents include influenza A and B, parainfluenza virus 3, coronavirus, adenovirus, metapneumovirus, rhinovirus, and respiratory syncytial virus. Purulent sputum is reported in 50 percent of patients with acute bronchitis [13]. This usually represents sloughing of cells from the tracheobronchial epithelium, along with inflammatory cells. Purulence and sputum discoloration do not signify bacterial infection.

Occasional patients have acute bronchitis caused by Mycoplasma pneumoniae, Chlamydia pneumoniae or, increasingly, Bordetella pertussis. In general, testing for Mycoplasma pneumoniae or Chlamydia pneumoniae is not recommended unless there is evidence of a local outbreak [14]. The clinical case definition of pertussis is a cough illness lasting at least two weeks without an apparent cause with at least one of the following symptoms: paroxysms of coughing, inspiratory whoop, or post-tussive emesis. In the setting of a pertussis outbreak or known close contact with a confirmed case, the presence of a cough lasting ≥2 weeks is sufficient for clinical diagnosis (even in the absence of other symptoms). (See "Mycoplasma pneumoniae infection in adults" and "Pneumonia caused by Chlamydia pneumoniae in adults" and "Pertussis infection in adolescents and adults: Clinical manifestations and diagnosis".)

A chest radiograph can be done safely in pregnancy and should be performed when there are findings suggestive of pneumonia (such as tachypnea, tachycardia, hypoxia, fever, crackles) or evidence of consolidation on examination. The absence of abnormalities on chest radiography distinguishes acute bronchitis from pneumonia. (See "Acute bronchitis in adults", section on 'Clinical features' and "Acute bronchitis in adults", section on 'Diagnosis' and "Diagnostic imaging in pregnant and lactating patients".)

Treatment

Viral etiology – Symptomatic treatment is the same as for the common cold (see 'The common cold' above). Antibiotic therapy of viral bronchitis is not beneficial [15] and rarely indicated. (See "Acute bronchitis in adults", section on 'Antimicrobial therapy'.)

Nonviral etiology – Antibiotic therapy is indicated for pregnant patients, particularly those who are near term, with a clinical or microbiologic diagnosis of pertussis within six weeks after cough onset to prevent transmission to neonates [16]. This is based on the observation that shedding of Bordetella pertussis has been described up to six weeks after onset of illness. (See "Pertussis infection in adolescents and adults: Treatment and prevention".)

Bronchitis related to Mycoplasma pneumoniae or Chlamydia pneumoniae does not require treatment in the absence of pneumonia. (See "Mycoplasma pneumoniae infection in adults" and "Pneumonia caused by Chlamydia pneumoniae in adults".)

Acute sinusitis

Clinical findings and diagnosis — The classic findings of acute rhinosinusitis include nasal congestion, purulent nasal discharge, maxillary tooth discomfort, hyposmia, and facial pain or pressure that is worse when bending forward; however, many pregnant patients with documented disease do not have these classic findings [17]. Pregnant patients with the common cold are at increased risk of developing rhinosinusitis and Eustachian tube dysfunction, which has been attributed to congestion from hormonal effects on the nasal mucosa [18]. Almost all acute rhinosinusitis is due to viruses; only a small fraction of cases develop a secondary bacterial infection. Uncomplicated acute viral rhinosinusitis typically resolves in 7 to 10 days.

Despite the increased frequency of atypical presentations in pregnant patients, there are no specific recommendations for distinguishing viral from acute bacterial rhinosinusitis in pregnancy. Therefore, we use the following criteria to diagnose acute bacterial rhinosinusitis in pregnant patients, which are supported by several guidelines [7,19-21] (see "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis", section on 'Symptoms'):

Persistent symptoms or signs of acute rhinosinusitis lasting ≥10 days without evidence of clinical improvement.

Presence of severe symptoms (such as high fever (>39°C or 102°F), purulent nasal discharge, or facial pain) for at least three to four consecutive days at the beginning of the upper respiratory infection.

Substantial worsening of symptoms or signs (such as doubling in severity or the new onset of fever, headache, nasal discharge) following a typical viral upper respiratory infection that lasted five to six days and was initially improving.

Radiographic imaging is not required for patients with uncomplicated sinusitis, but may be indicated for the evaluation of refractory sinusitis symptoms. As an example, imaging studies are indicated in patients with clinical signs or symptoms of complicated acute bacterial rhinosinusitis, including diminished visual acuity, diplopia, periorbital edema, severe headache, or altered mental status. If imaging is necessary, sinus radiographs are usually obtained initially to avoid the higher doses of radiation associated with computed tomography (CT). In complicated cases, magnetic resonance imaging (MRI) can provide necessary information without radiation exposure, but head and neck CT can be performed in pregnancy without exceeding radiation safety guidelines. When either sinus radiographs or CT is performed, appropriate pelvic shielding should be provided. Ultrasonography is not a good substitute for sinus radiographs, CT, or MRI because of variable performance [22]. (See "Diagnostic imaging in pregnant and lactating patients" and "Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis" and "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis".)

Treatment

Initial management – We suggest observation (watchful waiting) with symptomatic management for seven days for immunocompetent pregnant patients with suspected acute bacterial rhinosinusitis who have good follow-up (assurance that antibiotic therapy can be started if the patient does not improve or worsens). This approach is similar to that from a multidisciplinary expert panel [19] and differs from the 2012 Infectious Diseases Society of America guidelines, which prefer prompt initiation of antibiotics when the clinical diagnosis of acute bacterial sinusitis has been established based on one of the criteria listed above [20]. However, we are more likely to initiate antibiotic therapy for pregnant patients with fever >102°F (38.9°C) associated with severe symptoms.

Choice of antibiotic therapy – The choice of antibiotic is generally the same as in nonpregnant females (eg, either amoxicillin 500 mg orally three times daily or 875 mg orally twice daily or amoxicillin-clavulanate 500 mg/125 mg orally three times daily or 875 mg/125 mg orally twice daily or an oral third-generation cephalosporin with or without clindamycin for penicillin-allergic patients who can tolerate cephalosporins); however, fluoroquinolones and doxycycline are typically avoided.

In the pregnant patient who requires antibiotics for the treatment of acute bacterial rhinosinusitis but cannot take any of the preferred agents, the use of doxycycline or levofloxacin can be justified. Doxycycline and fluoroquinolones are recommended for other serious infections in pregnancy, such as Rocky Mountain spotted fever (doxycycline) and anthrax (fluroquinolones) (see "Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment"). Fluoroquinolones and tetracyclines are generally avoided in pregnancy because of potential effects on fetal cartilage, bones, and teeth. Although doxycycline appears to be safer than older tetracyclines, data are low quality and insufficient to conclude that there is no risk. If there is a safer, effective drug that can be used as an alternative, it should be used, but if there is no good alternative, doxycycline should be used rather than tetracycline. (See "Prenatal care: Patient education, health promotion, and safety of commonly used drugs", section on 'Antibiotics'.)

Adjunctive treatments – Acceptable adjunct treatments in pregnancy include saline nasal spray or buffered saline nasal irrigation, acetaminophen, and steroid nasal sprays (eg, beclomethasone or budesonide) for patients who cannot tolerate ongoing nasal congestion and pain while awaiting resolution of the infection with antibiotic therapy. Nasal steroids provide only small symptomatic benefits in patients with sinusitis and are likely to be most beneficial for those with underlying allergic rhinitis.

Antihistamines have no role in the symptomatic relief of acute bacterial sinusitis in nonatopic patients [19]. There is no convincing evidence of benefit from use of decongestants or guaifenesin. (See "Recognition and management of allergic disease during pregnancy", section on 'Corticosteroid nasal sprays'.)

Monitoring and follow-up of patients with uncomplicated bacterial rhinosinusitis are reviewed in detail separately. (See "Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment".)

Influenza

Clinical findings and diagnosis — Influenza should be suspected in patients with abrupt onset of fever, cough, and myalgia when influenza virus activity is present in the community. Other symptoms, such as malaise, sore throat, nausea, nasal congestion, and headache, are common as well. A positive test for influenza virus confirms the diagnosis; however, a negative test cannot rule out infection, especially if the test does not have adequate sensitivity or the specimen was collected >4 days after illness onset.

The influenza pandemics of 1918, 1957, and 2009 were associated with increased morbidity and mortality in pregnant patients. The highest risk for maternal mortality appears to be in the third trimester, but influenza can be serious in any trimester due to pregnancy-related attenuation of Th1 immunity. Additionally, influenza A virus can cross the placenta [23]. Because of the potential seriousness of influenza infection in pregnancy, and the safety of immunization, universal vaccination of pregnant people across gestation is recommended by the American College of Obstetricians and Gynecologists (ACOG) and the United States Centers for Disease Control and Prevention (CDC). (See "Immunizations during pregnancy", section on 'Inactivated influenza vaccine'.)

Treatment

Antiviral therapy – For pregnant patients and those up to two weeks postpartum with suspected acute influenza, prompt empiric treatment with appropriate influenza antiviral medications (eg, oseltamivir 75 mg orally twice daily for five days) is recommended regardless of vaccination status. Pregnant and recently pregnant patients are more likely to be hospitalized and admitted to an intensive care unit (ICU) and have a higher mortality compared with the general population. While the benefits of antiviral therapy are greatest when initiated within the first 48 hours following symptom onset, antiviral treatment is still warranted for patients who present >48 hours after symptom onset, particularly if their clinical condition has not started to improve. The diagnosis, clinical course, acute treatment, and prevention of influenza in pregnancy are reviewed in detail separately. (See "Seasonal influenza and pregnancy".)

Community-acquired pneumonia

Clinical findings and diagnosis — The classic symptoms of community-acquired pneumonia (CAP) are sudden onset of rigors followed by fever, pleuritic chest pain, shortness of breath, and cough productive of purulent sputum; however, most patients do not present with classic symptoms. The clinical manifestations of CAP and the diagnostic evaluation of patients with suspected CAP are similar to those in nonpregnant individuals. (See "Overview of community-acquired pneumonia in adults", section on 'Clinical presentation' and "Overview of community-acquired pneumonia in adults", section on 'Diagnosis'.)

A chest radiograph is required to diagnose CAP and should not be withheld from a pregnant patient in whom this diagnosis is suspected. The indications for obtaining a chest radiograph (posteroanterior and lateral views) in pregnancy are the same as in nonpregnant patients and include shortness of breath and/or cough in association with fever, tachycardia, tachypnea, decreased oxygen saturation, or rales, or signs of consolidation on lung examination. The estimated fetal absorption for the chest radiographs is <0.01 mGy (<0.001 rad); this dose is well below doses that have been associated with any short- or long-term adverse effects [24]. The abdomen should be shielded. (See "Diagnostic imaging in pregnant and lactating patients".)

Although the chest radiograph remains the gold standard for diagnosis of CAP in pregnancy [25-28], lung ultrasound is emerging as a valuable diagnostic tool, particularly in the emergency department and ICU. Currently, there are no recommendations for use of ultrasound instead of a diagnostic chest radiograph in nonpregnant patients; therefore, while it may be an additional tool to consider in specific circumstances where there is local expertise, more research is needed about its diagnostic performance in pregnancy.

Epidemiology — The incidence of CAP in pregnancy appears to be similar to that in nonpregnant patients, with reported rates varying from 0.2 to 8.5 per 1000 deliveries [15]. The wide range is likely related to differences in the patient populations studied, as well as the availability and state of medical care at the time of the study. CAP accounted for 30 percent of concurrent infections diagnosed in pregnant patients with severe sepsis in the United States (1998 to 2008 [29]). Risk factors for CAP in pregnancy include anemia (hematocrit ≤30 percent [30]), asthma, smoking, illicit drug use, and immunosuppressive illness (eg, HIV/AIDS) or immunosuppressive therapy [31].

Consequences — CAP is associated with significant maternal and fetal morbidities, but death of pregnant patients is rare [32-36]. Pregnant patients with CAP are prone to preterm labor and birth [37], as well as pulmonary edema [30]. While there does not appear to be an increase in perinatal mortality, the frequency of low birth weight newborns among mothers with CAP is higher than among controls without CAP [38].

Pregnant people may be predisposed to a severe CAP course (including respiratory failure) because of physiologic changes of pregnancy, including elevation of the diaphragm by up to 4 cm, decrease in functional residual capacity, increase in oxygen consumption, and increase in lung water. These changes make the pregnant patient less able to tolerate even brief periods of hypoxia. In addition, tachypnea can cause respiratory alkalosis, which reduces uterine blood flow. (See 'Basic background principles' above.)

Indications for hospitalization — Severity of illness is the primary factor for determining the site of treatment. Pregnant patients with CAP who have very mild disease (eg, stable normal heart and respiratory rates, oxygen saturation (SaO2) ≥95 percent during ambulation, absence of serious comorbidities) and who can maintain oral intake and adhere to medical therapy can be treated as outpatients. However, the authors of this topic have a low threshold for admitting pregnant patients with CAP to the hospital, where they can receive intravenous hydration, supplemental oxygen, and close maternal-fetal monitoring until there is clinical improvement.

Most hospitalized patients can be managed initially on either a general medical ward or labor and delivery unit; ICU admission is needed for those requiring mechanical ventilation or with severe sepsis/septic shock. The severe spectrum of illness is suggested by respiratory rate >30 breaths/minute, partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio <250, multilobar infiltrates, confusion/disorientation, uremia (blood urea nitrogen level >20 mg/dL), leukopenia (white blood cell count <4000 cells/mm3), thrombocytopenia (platelet count <100,000 cells/mm3), hypothermia (core temperature <36°C), hypotension requiring aggressive fluid resuscitation, hypoglycemia (in nondiabetic patients), hyponatremia, or unexplained metabolic acidosis or elevated lactate level. (See "Community-acquired pneumonia in adults: Assessing severity and determining the appropriate site of care".)

The decision to admit a pregnant patient with features of severe illness to the ICU is complex, as most hospitals do not have an obstetric ICU. Discussions regarding the best location in the hospital to manage the sick pregnant patient with CAP need to include the input of the obstetrician and intensivist. Early anticipation of possible intubation allows for better preparation and execution, should it be needed. Management of respiratory failure is discussed separately. (See "Airway management for the pregnant patient" and "Acute respiratory failure during pregnancy and the peripartum period".)

Treatment — The table summarizes the major points in treatment of CAP (table 2).

SaO₂ — Maternal oxygen saturation (SaO2) ideally should be maintained at ≥95 percent for maintaining adequate fetal oxygenation. If SaO2 falls below 95 percent, an arterial blood gas is obtained to measure PaO2. Maternal PaO2 ≥70 mmHg is desirable to maintain a favorable oxygen diffusion gradient from the maternal to the fetal side of the placenta.

As severe anemia (hemoglobin <7 g/dL) is an independent risk factor for mortality in patients with CAP, transfusion can be considered to improve oxygen carrying capacity [39].

Antibiotic therapy

General principles

The spectrum of pathogens that cause CAP in pregnant patients is similar to that in nonpregnant patients [40]. For all patients, empiric regimens are designed to treat:

Streptococcus pneumoniae (most common bacterial CAP pathogen)

Atypical pathogens (eg, Legionella spp, Mycoplasma pneumoniae, Chlamydia pneumoniae)

For patients who require hospitalization due to severe illness, comorbidities, or other factors, empiric regimens are expanded to treat methicillin-susceptible Staphylococcus aureus, beta-lactamase-producing Haemphilus influenzae, Moraxella catarrhalis, and certain Gram-negative bacilli (eg, Escherichia coli, Klebsiella pneumoniae). For hospitalized patients with risk factors for methicillin-resistant Staphylococcus aureus (MRSA) or Pseudomonas spp, empiric treatment regimens are further expanded to cover these pathogens.

In all cases, the backbone of the antibiotic regimen is the beta-lactam, which treats S. pneumoniae and other typical bacterial pathogens. Azithromycin is added to the beta-lactam to treat atypical pathogens. Azithromycin monotherapy is typically not used or recommended because rates of macrolide-resistant S. pneumoniae exceed 25 percent in most regions of the United States and in many regions of the world.

Influenza, SARS-CoV-2, and other viruses should be considered when those viruses are active in the community or during respiratory virus season.

Choice of outpatient antibiotic therapy — Antibiotic therapy is described below and in the following algorithm (algorithm 1).

Most patients – For pregnant patients with CAP who have mild disease for which outpatient therapy is indicated, we suggest a combination of amoxicillin or amoxicillin-clavulanate plus azithromycin.

Amoxicillin-clavulanate covers a broader spectrum of pathogens than amoxicillin (eg, beta-lactamase-producing Haemophlius influenzae); these pathogens tend to occur in older patients and those with comorbidities or with recent antibiotic use and are less common in younger, otherwise healthy pregnant patients with CAP. In the absence of comorbidities or other predisposing factors, we select between them based on patient preference (eg, for thrice or twice daily dosing, narrower versus broader antibiotic).

Patients with hypersensitivity reactions to penicillin – For patients with hypersensitivity reactions to penicillin, antibiotic selection varies based on the type of reaction (table 3).

Patients with mild non-immunoglobulin (Ig) E-mediated reactions (eg, maculopapular rash) to penicillin can generally use later-generation cephalosporins safely. We typically treat these patients with a third-generation cephalosporin (eg, cefpodoxime, cefditoren) plus azithromycin.

Patients with IgE-mediated reactions (hives, angioedema, anaphylaxis) or severe delayed reactions should generally avoid empiric treatment with beta-lactams. We typically treat these patients with clindamycin plus azithromycin.

Diagnosis of penicillin and cephalosporin hypersensitivity is discussed in detail elsewhere. (See "Penicillin allergy: Immediate reactions" and "Penicillin allergy: Delayed hypersensitivity reactions" and "Cephalosporin hypersensitivity: Clinical manifestations and diagnosis".)

Choice of inpatient antibiotic therapy

Most patients – For pregnant patients hospitalized for CAP who do not have severe disease or risk factors for drug-resistant pathogens (table 4), we suggest combination therapy with:

An antipneumococcal beta-lactam (ceftriaxone [(1 to 2 g IV daily], cefotaxime [1 to 2 g IV every eight hours], ampicillin-sulbactam [3 g IV every six hours]) plus

Azithromycin (500 mg IV or orally daily)

Indications for adding empiric MRSA therapy – We add vancomycin (table 5) to this regimen to treat MRSA for the following patients:

Patients with septic shock or respiratory failure requiring mechanical ventilation

Hospitalized patients with strong risk factors for MRSA (eg, known MRSA colonization or prior infection, Gram-positive cocci in clusters on a good-quality Gram stain)

Other factors that should raise suspicion for MRSA infection, such as recent antibiotic use, recent influenza, acute necrotizing or cavitary pneumonia, end-stage kidney disease, injection drug use, or risk factors for MRSA colonization (table 4). For patient with these risk factors, the decision to add vancomycin should be based on local MRSA prevalence and the severity of illness. If vancomycin is administered empirically, we recommend obtaining nasal swab for MRSA polymerase chain reaction (PCR); if negative, vancomycin can be discontinued.

Indications for adding empiric Pseudomonas treatment – Although Pseudomonas is an uncommon pathogen in pregnant patients with CAP, for those with risk factors (table 4), we select an antipneumococcal beta-lactam or carbapenem that also has antipseudomonal activity (eg, cefepime [2 g IV every eight hours], ceftazidime [2 g IV every eight hours], piperacillin-tazobactam [4.5 g IV every six hours], imipenem [500 mg IV every six hours], meropenem [1 g IV every six hours]). Selection among these medications should take into account the susceptibility pattern of any prior pseudomonal isolates and the hospital antibiogram, if available.

Patients with hypersensitivity reactions to penicillin

For patients with mild, non-IgE-mediated reactions to penicillins (eg, maculopapular rash), a third-generation cephalosporin is generally safe.

For patients who cannot use cephalosporins (eg, due to IgE-mediated reaction or severe delayed reactions to beta-lactams) (table 3), antibiotic selection varies based on the need to treat MRSA or Pseudomonas.

-For those who do not need treatment for MRSA or Pseudomonas, we treat with clindamycin (600 mg IV every eight hours) plus aztreonam (2 g IV every eight hours) plus azithromycin (500 mg IV or orally daily).

-For those who need MRSA treatment, we typically treat with vancomycin (for coverage of MRSA and S. pneumoniae) (table 5), plus aztreonam (2 g IV every eight hours) plus azithromycin (500 mg IV or orally daily).

-For the rare patient who requires treatment for Pseudomonas and cannot tolerate any beta-lactam or any carbapenem, we individualize treatment. Vancomycin (table 5) plus aztreonam (2 g IV every eight hours) plus azithromycin (500 mg IV or orally daily) is a potential option, though the severity of illness, prior pseudomonal susceptibility patterns, and hospital antibiogram should be taken into account. In some cases, where baseline resistance to aztreonam is high, we add gentamicin empirically. We prefer weight-based dosing (5 mg/kg/day IV as a single dose or 1.5 mg/kg/day IV every eight hours) but will adjust the weight (ie, use the dosing weight) if the dose seems too high. (See "Dosing and administration of parenteral aminoglycosides", section on 'Dosing weight'.) . In addition, because intolerance to all beta-lactams and all carbapenems is rare, we review the hypersensitivity carefully and/or consult the allergy service to help determine whether administration of a cephalosporin or meropenem can be given safely after a test dose.

In all cases, it should be noted that aztreonam should be avoided in patients with ceftazidime due to cross-reactivity. (See "Immediate cephalosporin hypersensitivity: Allergy evaluation, skin testing, and cross-reactivity with other beta-lactam antibiotics".)

Antibiotics to avoid – Some antibiotics to be avoided in pregnancy include tetracyclines, clarithromycin, and the fluoroquinolones (table 6). Although azithromycin has a good safety profile, clarithromycin has produced adverse pregnancy outcomes in animal studies at low-order multiples of human doses; human experience is very limited and has not suggested an increase in congenital anomalies in exposed pregnancies [41,42], but an increased risk of miscarriage has been reported, possibly related to the underlying disease [42,43]. The fluoroquinolones are avoided during pregnancy because of concerns about fetal arthropathy and malformations based on animal studies. However, safe use in pregnancy has been reported, suggesting that they may be used if alternatives are less safe or effective [44]. As discussed above, although doxycycline appears to be safer than older tetracyclines, data are low quality and insufficient to say that there is no risk. If there is a safer, effective drug that can be used as an alternative, it should be used. But if there is no good alternative (eg, in cases of Rocky Mountain spotted fever), doxycycline should be used rather than tetracycline.

Three antimicrobials for treatment of CAP became available since 2017: lefamulin (a pleuromutilin drug), omadacycline (a tetracycline derivative), and delafloxacin (a fluoroquinolone). All should be avoided in pregnancy due to some nonreassuring animal data, lack of human safety data, and the potential for adverse pregnancy outcomes. (See "Treatment of community-acquired pneumonia in adults in the outpatient setting" and "Treatment of community-acquired pneumonia in adults who require hospitalization".)

Antibiotic dosing and duration of treatment — Antibiotic dosing and duration are the same as in nonpregnant adults and discussed in detail separately. The usual duration of therapy is five days, but ultimately depends on reaching clinical stability within three days. 

(See "Treatment of community-acquired pneumonia in adults in the outpatient setting".)

(See "Treatment of community-acquired pneumonia in adults who require hospitalization".)

Other respiratory infections

Varicella-zoster pneumonia — Varicella-zoster pneumonia is especially severe in pregnant patients. Fulminate pneumonia develops in approximately 10 to 20 percent of pregnant people with chickenpox and maternal mortality is as high as 40 percent [45]. Treatment with acyclovir or valacyclovir is warranted in infected pregnant patients to reduce the risk of respiratory failure and maternal death. The clinical features and treatment of varicella pneumonia in pregnancy are reviewed in detail elsewhere. (See "Varicella-zoster virus infection in pregnancy".)

The maternal complications along with the potentially serious fetal/neonatal consequences of varicella underline the importance of establishing the immune status of females with respect to varicella and vaccinating those who are not immune prior to a planned pregnancy.

Hospital-acquired and aspiration pneumonia — The causes of hospital-acquired pneumonia in pregnancy include the same causes as in the nonpregnant patient, but certain caveats exist. Pregnant people are prone to aspiration during labor and birth, and this must always be a major consideration. Infection with Gram-negative rods, including Pseudomonas, also becomes more likely in this setting. Prevention and treatment are discussed separately. (See "Risk factors and prevention of hospital-acquired and ventilator-associated pneumonia in adults" and "Aspiration pneumonia in adults".)

Virus-induced wheezing and asthma — Viral respiratory infections, particularly with respiratory syncytial virus and human rhinovirus, are the most common causes of wheezing in infants and young children and are common triggers of asthma exacerbations in up to 50 percent of adult patients and up to 85 percent of pediatric patients with preexisting asthma (see "Role of viruses in wheezing and asthma: An overview"). The evaluation and differential diagnosis of wheezing in adults are reviewed separately. (See "Evaluation of wheezing illnesses other than asthma in adults".)

Inhaled beta agonists, such as albuterol, can be used safely in pregnancy to treat wheezing, as in nonpregnant patients. Treatment is reviewed in more detail separately. (See "Management of asthma during pregnancy", section on 'Acute exacerbations' and "An overview of asthma management".)

COVID-19 — Multiple issues related to COVID-19 in pregnancy are reviewed separately:

(See "COVID-19: Overview of pregnancy issues".)

(See "COVID-19: Antepartum care of pregnant patients with symptomatic infection".)

(See "COVID-19: Intrapartum and postpartum issues".)

INTRAPARTUM ANALGESIA AND ANESTHESIA — Patients have many options for intrapartum analgesia and anesthesia (see "Pharmacologic management of pain during labor and delivery" and "Nonpharmacologic approaches to management of labor pain"). General anesthesia issues for patients with upper respiratory infections are reviewed separately. Early epidural analgesia may reduce the need for general anesthesia and airway management should emergency cesarean delivery become necessary. (See "Anesthesia for adults with upper respiratory infection".)

POSTPARTUM ISSUES

Infection control — Patients who give birth while being treated for most respiratory infections do not need to be separated from their newborns, but practicing good hand hygiene and wearing a face mask is advised to minimize the risk of transmission.

Active tuberculosis is a noteworthy exception and requires at least temporary separation between mother and newborn. (See "Tuberculosis disease (active tuberculosis) in pregnancy", section on 'Controlling transmission'.)

Recommendations about infection control of influenza-infected patients in the peripartum and postpartum settings can be found on the United States Centers for Disease Control and Prevention (CDC) website and in a separate topic review. (See "Infection control measures for prevention of seasonal influenza".)

Mother-newborn issues related to COVID-19 are also addressed separately. (See "COVID-19: Intrapartum and postpartum issues".)

Breastfeeding — Breastfeeding is the preferred method of infant feeding and will likely confer some passive immunity to the newborn. Therefore, it generally should not be discouraged because of a maternal respiratory infection.

Both the UpToDate drug database and the Drugs and Lactation Database of the United States National Library of Medicine (LactMed) provide information on drug levels in milk and possible drug effects on breastfed infants and on lactation. Most medications used to treat respiratory infection in pregnancy are also acceptable for use in breastfeeding mothers. Medications that should be avoided during breastfeeding include the quinolones and tetracyclines [40,46].

Issues related to breastfeeding in mothers with COVID-19 or tuberculosis are addressed separately. (See "COVID-19: Intrapartum and postpartum issues", section on 'Breastfeeding and formula feeding' and "Tuberculosis disease (active tuberculosis) in pregnancy", section on 'Breastfeeding'.)

LONG-TERM OUTCOME OF OFFSPRING — Offspring of mothers with a respiratory infection during pregnancy appear to have no increased risk of long-term adverse neurodevelopmental outcome, but information is limited and no high-quality data are available [47].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Respiratory disease in pregnancy".)

SUMMARY AND RECOMMENDATIONS

General principles

Pregnancy-related changes in respiratory function – Awareness of pregnancy-associated changes in respiratory physiology is important to the management of respiratory disease in pregnancy. (See 'Basic background principles' above.)

Clinical diagnosis and treatment – The two major considerations when medically treating pregnant patients for respiratory infection are to first determine the appropriate clinical evaluation and treatment of a nonpregnant patient with the same presentation and then to determine whether implementing this diagnostic and therapeutic plan carries any additional risks for the pregnant patient or fetus. These additional risks may be related to increased maternal susceptibility to severe disease or complications in pregnancy (eg, influenza) and/or to potential fetal risks related to the disease (eg, congenital infection), its evaluation (eg, radiation from diagnostic imaging), or its treatment (eg, tetracycline may stain developing teeth). (See 'General diagnostic and therapeutic approach' above.)

Avoiding unnecessary use of antibiotics – Most acute respiratory tract infections, which include acute uncomplicated bronchitis, pharyngitis, rhinosinusitis, and the common cold, are caused by viruses and do not warrant antibiotic therapy. The use of unwarranted antibiotic therapy in such cases is an important contributor to antibiotic resistance, medication-related adverse events, and unnecessary cost. (See 'Acute sinusitis' above.)

The common cold – Heated humidified air can help relieve congestion and acetaminophen can help relieve sore throat, headache, and/or fever. If the patient requests pharmacotherapy for symptomatic relief of rhinorrhea, we use ipratropium bromide and cromolyn nasal spray. (See 'The common cold' above.)

Sinusitis

The approach to treatment is the same as in nonpregnant adults, except doxycycline and levofloxacin are avoided. (See "Uncomplicated acute sinusitis and rhinosinusitis in adults: Treatment".)

Fluoroquinolones and tetracyclines are generally avoided in pregnancy because of potential effects on fetal cartilage, bones, and teeth. Although doxycycline appears to be safer than older tetracyclines, data are low quality and insufficient to say that there is no risk. If there is a safer, effective drug that can be used as an alternative, it should be used. (See 'Acute sinusitis' above.)

Acceptable adjunct treatments in pregnancy include saline nasal spray or buffered saline nasal irrigation, acetaminophen, and steroid nasal sprays for patients who cannot tolerate ongoing nasal congestion and pain while awaiting resolution of the infection. Nasal steroids provide only small symptomatic benefits in patients with sinusitis and are likely to be most beneficial for those with underlying allergic rhinitis. (See 'Acute sinusitis' above.)

Bronchitis – Treatment of bronchitis is similar to that of the common cold. We suggest that patients use a steam humidifier. Antibiotic therapy of viral bronchitis is rarely indicated. (See 'Acute bronchitis' above.)

Community-acquired pneumonia (CAP)

The treatment approach is summarized in the table (table 2). Empiric selection of antibiotic therapy in outpatients is shown in the algorithm (algorithm 1). Pregnant patients with CAP are prone to develop preterm labor and pulmonary edema. The authors have a low threshold for admitting pregnant patients with CAP to the hospital, where they can receive intravenous hydration, supplemental oxygen if needed, and close maternal-fetal monitoring until there is clinical improvement. (See 'Community-acquired pneumonia' above.)

Hypoxia and acidosis are poorly tolerated by the fetus and should be aggressively avoided. Maternal PaO2 is kept at ≥70 mmHg (or at an oxygen saturation [SaO2] ≥95 percent) to maintain adequate fetal oxygenation. Severe anemia may be corrected to improve total oxygen carrying capacity. (See 'Community-acquired pneumonia' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Raymond Powrie, MD, who contributed to an earlier version of this topic review.

  1. Dennis AT, Solnordal CB. Acute pulmonary oedema in pregnant women. Anaesthesia 2012; 67:646.
  2. Maxwell C, McGeer A, Young Tai KF, et al. Management guidelines for obstetric patients and neonates born to mothers with suspected or probable severe acute respiratory syndrome (SARS). J Obstet Gynaecol Can 2009; 31:358.
  3. Jamieson DJ, Honein MA, Rasmussen SA, et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet 2009; 374:451.
  4. Figueiró-Filho EA, Oliveira ML, Pompilio MA, et al. Obstetric, clinical, and perinatal implications of H1N1 viral infection during pregnancy. Int J Gynaecol Obstet 2012; 116:214.
  5. Ramsey PS, Ramin KD. Pneumonia in pregnancy. Obstet Gynecol Clin North Am 2001; 28:553.
  6. Payne DC, Iblan I, Alqasrawi S, et al. Stillbirth during infection with Middle East respiratory syndrome coronavirus. J Infect Dis 2014; 209:1870.
  7. Harris AM, Hicks LA, Qaseem A, High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med 2016; 164:425.
  8. Ruiter-Ligeti J, Vincent S, Czuzoj-Shulman N, Abenhaim HA. Risk Factors, Incidence, and Morbidity Associated With Obstetric Clostridium difficile Infection. Obstet Gynecol 2018; 131:387.
  9. Hause AM, Avadhanula V, Maccato ML, et al. A Cross-sectional Surveillance Study of the Frequency and Etiology of Acute Respiratory Illness Among Pregnant Women. J Infect Dis 2018; 218:528.
  10. Waller DK, Hashmi SS, Hoyt AT, et al. Maternal report of fever from cold or flu during early pregnancy and the risk for noncardiac birth defects, National Birth Defects Prevention Study, 1997-2011. Birth Defects Res 2018; 110:342.
  11. Feldkamp ML, Meyer RE, Krikov S, Botto LD. Acetaminophen use in pregnancy and risk of birth defects: findings from the National Birth Defects Prevention Study. Obstet Gynecol 2010; 115:109.
  12. Fokkens W, Lund V, Mullol J, European Position Paper on Rhinosinusitis and Nasal Polyps Group. EP3OS 2007: European position paper on rhinosinusitis and nasal polyps 2007. A summary for otorhinolaryngologists. Rhinology 2007; 45:97.
  13. Wenzel RP, Fowler AA 3rd. Clinical practice. Acute bronchitis. N Engl J Med 2006; 355:2125.
  14. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of uncomplicated acute bronchitis: background. Ann Intern Med 2001; 134:521.
  15. Lim WS, Macfarlane JT, Colthorpe CL. Treatment of community-acquired lower respiratory tract infections during pregnancy. Am J Respir Med 2003; 2:221.
  16. CDC. Pertussis (Whooping Cough). Treatment. https://www.cdc.gov/pertussis/clinical/treatment.html (Accessed on November 04, 2022).
  17. Sorri M, Hartikainen-Sorri AL, Kärjä J. Rhinitis during pregnancy. Rhinology 1980; 18:83.
  18. Incaudo GA. Diagnosis and treatment of allergic rhinitis and sinusitis during pregnancy and lactation. Clin Rev Allergy Immunol 2004; 27:159.
  19. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015; 152:S1.
  20. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012; 54:e72.
  21. American Academy of Family Physicians: Twenty Things Physicians and Patients Should Question. Choosing Wisely. Available at: https://www.choosingwisely.org/societies/american-academy-of-family-physicians/ (Accessed on March 09, 2021).
  22. Engels EA, Terrin N, Barza M, Lau J. Meta-analysis of diagnostic tests for acute sinusitis. J Clin Epidemiol 2000; 53:852.
  23. Larsen JW Jr. Influenza and pregnancy. Clin Obstet Gynecol 1982; 25:599.
  24. Groen RS, Bae JY, Lim KJ. Fear of the unknown: ionizing radiation exposure during pregnancy. Am J Obstet Gynecol 2012; 206:456.
  25. Gillman LM, Kirkpatrick AW. Portable bedside ultrasound: the visual stethoscope of the 21st century. Scand J Trauma Resusc Emerg Med 2012; 20:18.
  26. Testa A, Soldati G, Copetti R, et al. Early recognition of the 2009 pandemic influenza A (H1N1) pneumonia by chest ultrasound. Crit Care 2012; 16:R30.
  27. Tsung JW, Kessler DO, Shah VP. Prospective application of clinician-performed lung ultrasonography during the 2009 H1N1 influenza A pandemic: distinguishing viral from bacterial pneumonia. Crit Ultrasound J 2012; 4:16.
  28. Volpicelli G, Elbarbary M, Blaivas M, et al. International evidence-based recommendations for point-of-care lung ultrasound. Intensive Care Med 2012; 38:577.
  29. Bauer ME, Bateman BT, Bauer ST, et al. Maternal sepsis mortality and morbidity during hospitalization for delivery: temporal trends and independent associations for severe sepsis. Anesth Analg 2013; 117:944.
  30. Munn MB, Groome LJ, Atterbury JL, et al. Pneumonia as a complication of pregnancy. J Matern Fetal Med 1999; 8:151.
  31. Khan S, Niederman MS. Pneumonia in the pregnant patient. In: Pulmonary Problems in Pregnancy, Rosene-Montela K, Bourjeily G (Eds), Humana Press, New York 2009. p.177e96.
  32. Lim WS, Macfarlane JT, Colthorpe CL. Pneumonia and pregnancy. Thorax 2001; 56:398.
  33. Kaunitz AM, Hughes JM, Grimes DA, et al. Causes of maternal mortality in the United States. Obstet Gynecol 1985; 65:605.
  34. Visscher HC, Visscher RD. Indirect obstetric deaths in the state of Michigan 1960-1968. Am J Obstet Gynecol 1971; 109:1187.
  35. Menéndez C, Romagosa C, Ismail MR, et al. An autopsy study of maternal mortality in Mozambique: the contribution of infectious diseases. PLoS Med 2008; 5:e44.
  36. Chen YH, Keller J, Wang IT, et al. Pneumonia and pregnancy outcomes: a nationwide population-based study. Am J Obstet Gynecol 2012; 207:288.e1.
  37. Bánhidy F, Acs N, Puhó EH, Czeizel AE. Maternal acute respiratory infectious diseases during pregnancy and birth outcomes. Eur J Epidemiol 2008; 23:29.
  38. Yost NP, Bloom SL, Richey SD, et al. An appraisal of treatment guidelines for antepartum community-acquired pneumonia. Am J Obstet Gynecol 2000; 183:131.
  39. Rahimi-Levene N, Koren-Michowitz M, Zeidenstein R, et al. Lower hemoglobin transfusion trigger is associated with higher mortality in patients hospitalized with pneumonia. Medicine (Baltimore) 2018; 97:e0192.
  40. Sheffield JS, Cunningham FG. Community-acquired pneumonia in pregnancy. Obstet Gynecol 2009; 114:915.
  41. Doxycycline. www.reprotox.org (Accessed on March 04, 2021).
  42. Einarson A, Phillips E, Mawji F, et al. A prospective controlled multicentre study of clarithromycin in pregnancy. Am J Perinatol 1998; 15:523.
  43. Andersen JT, Petersen M, Jimenez-Solem E, et al. Clarithromycin in early pregnancy and the risk of miscarriage and malformation: a register based nationwide cohort study. PLoS One 2013; 8:e53327.
  44. Bar-Oz B, Moretti ME, Boskovic R, et al. The safety of quinolones--a meta-analysis of pregnancy outcomes. Eur J Obstet Gynecol Reprod Biol 2009; 143:75.
  45. Duong CM, Munns RE. Varicella pneumonia during pregnancy. J Fam Pract 1979; 8:277.
  46. Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactaton, 9th ed, Lippincott Williams & Wilkins, Philadelphia 2011.
  47. San Martín-González N, Castro-Quintas Á, Marques-Feixa L, et al. Maternal respiratory viral infections during pregnancy and offspring's neurodevelopmental outcomes: A systematic review. Neurosci Biobehav Rev 2023; 149:105178.
Topic 4793 Version 66.0

References

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