- The indications for chest radiograph are the same in pregnant as in nonpregnant patients.
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- Provide supplemental O2 to maintain oxygen saturation ≥95% or to maintain maternal pO2 >70 mmHg. Maintain frequent or continuous evaluations of oxygen saturation.
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- Obtain blood gas, especially if there is concern for CO2 retention, and remember that the normal pCO2 in pregnancy is 25 to 33 mmHg. Thus, a pCO2 of 35 mmHg already represents CO2 retention and possible impending respiratory failure.
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- Treat fever with acetaminophen.
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- Consult the obstetrics service for fetal well-being assessment (such as fetal heart rate monitoring, obstetric ultrasound). This may require the presence of obstetric nurses who are comfortable with fetal heart rate monitoring.
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- Monitor fluid status carefully as these patients are prone to the development of pulmonary edema.
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- Obtain blood cultures and sputum for Gram stain and culture.
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- The choice of antibiotics for treatment is similar to those used in nonpregnant patients but because of an increase in renal clearance, higher and more frequent doses may be indicated. However, the use of tetracyclines, clarithromycin, and the fluoroquinolones should be avoided.
- For pregnant patients with community-acquired pneumonia (CAP) who have mild disease for which outpatient therapy is indicated, we use a combination of amoxicillin or amoxicillin/clavulanate plus azithromycin. For patients with mild non-IgE-mediated reactions (eg, maculopapular rash), we use a third-generation cephalosporin (eg, cefpodoxime, cefditoren) plus azithromycin. For patients with IgE-mediated reactions (hives, angioedema, anaphylaxis) or severe delayed reactions, we use clindamycin plus azithromycin.
- For pregnant patients hospitalized for CAP who do not have severe disease or risk factors for drug-resistant pathogens, we use a combination of an antipneumococcal beta-lactam (ceftriaxone, cefotaxime, ampicillin-sulbactam) plus azithromycin. Patients with mild, non-immunoglobulin(Ig) E-mediated reactions to penicillins can generally receive a third-generation cephalosporin safely. The antibiotic choice in patients with IgE-mediated reactions varies based on the need to treat MRSA or Pseudomonas.
- We add empiric therapy of MRSA for hospitalized patients who have septic shock, respiratory failure requiring mechanical ventilation, or strong risk factors for MRSA (eg, known MRSA colonization or prior infection, gram-positive cocci in clusters on a good-quality Gram stain). For patients with other risk factors for MRSA colonization, the decision to add vancomycin is based on local MRSA prevalence and the severity of illness. If vancomycin is administered empirically, we obtain a nasal swab for MRSA polymerase chain reaction (PCR); if negative, vancomycin can be discontinued.
- We add empiric therapy of Pseudomonas for hospitalized patients with risk factors this infection (eg, known Pseudomonas colonization, gram negative rods in sputum on a good-quality Gram stain, prior Pseudomonas infection, hospitalization with receipt of IV antibiotics in the prior 3 months).
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- If clinically indicated, obtain urine for Streptococcus pneumonia and Legionella antigen, and Legionella culture of respiratory specimen. Multiplex molecular panels can be used to quickly detect M. pneumoniae, C. pneumoniae, Legionella, B. pertussis, and noninfluenza respiratory viruses. Results are available within 60 minutes; sensitivity and specificity are >95%. However, these panels are not universally available.
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- Try to anticipate intubation well in advance so appropriate equipment and experienced personnel are readily available.
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- Try to position the patient so that the gravid uterus does not obstruct venous return (ie, on left side or with right hip elevated, if necessary).
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- Bronchoscopy can be performed safely in pregnant patients and should not be withheld if the information obtained will be important for the management of the patient.
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- Ill pregnant patients confined to bed are likely to benefit from prophylaxis for venous thromboembolic disease.
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