Severe Pneumonia Associated With (H1N1) in a Pregnant Young Woman


 H1N1 is an acute infection that can affect any person any age as all viral infections, but it may be more aggressive in pregnant women. It may require admission to the ICU, and it carries many complications, pre-partum delivery, a severe state and even death if not treated immediately. H1N1 can correlate with a co-infection with bacterial pneumonia, and carries poor prognosis to morbidity and mortality. It needs a correlation of antibiotics and anti-swan treatment, and it needs a high intensity of clinician because, the diagnosis of H1N1 may be misleading in such cases. This case of a 14-year-old nonsmoker, a young pregnant woman, presented to the emergency department with gynecological hemorrhage 2 days prior. She was admitted to the obstetrics department and developed severe breathlessness, chest pain and nonproductive cough through hospitalization. After taking a throat swap, she was diagnosed with H1N1. She was treated with oseltamivir and antibiotics, and suspected coauthor bacterial pneumonia.


Introduction
In uenza viruses were known in novel as seasonal epidemics, usually happen in winter months, and the beginning of spring or autumn which correlated with weather changes in general [1,2]. The rst appearance of H1N1 in uenza was con rmed in 2009, from swine origin [3,4] even the rst isolated of the in uenza A virus (H3N2) was in 1968 [4,5]. Even H1N1 is an infectious case, and have a high morbidity but a new study suggests that there's no correlation between the infectious and pre-partum birth [6]. A 14-year-old non-smoker, young pregnant woman (30 weeks) has been presented to the emergency department with Gynecologic hemorrhage 2 days ago. She was admitted in obstetrics department, and developed severe breathlessness, chest pain and non-productive cough, then productive, through hospitalization. The patient is married 1 year ago and this is the rst pregnant. No previous disease and no previous surgeries. She didn't take any medication.

Case Presentation
Her Physical Examination shows a semiconscious patient. Her blood pressure was 110/70 mm hg, and her heart rate was 120/min/ regular (tachycardia). Her respiratory rate (RR): 32/ min and she has excercitional dyspnea. Oximetry on admission was 94%, and temperature (T°) 39.5 °C.
Chest sounds: wheezing, bilateral soft and coarse crackles, they are heard more clearly on the base.
Heart sounds: Tachycardia and Systolic murmur (2/6). Dyspnea is the dominant symptom. No lymphadenopathy or hemoptysis. No pitting edema on 2 legs and feet. Obstetrics team was willing to end the pregnant if there's an indication from the internal side. She was admitted in the Intensive care unit.
Posterior anterior chest x-ray shows bilateral in ltrations, interstitial changes on the lower lobes and a density on the right lobe ( gure1).
Doppler of veins in low limps was performed and no deep vein thrombosis seen. Echocardiography was performed and it was normal. A throat swap was taken and beginning with Oseltamivir 150 mg q 12 hr for 5 days. Other drugs were (Meropenim1gr three times a day, levo oxacin 500 mg/ IV Once, metronidazole 500mg/ IV three times, ranitidine 150mg/ IV twice a day with inhaler ambroxol HCL 15 mg/ 3 times) Swap was positive for H1N1. The patient state improves after 5 days, and discharged. She completed her pregnancy period, and after 2 weeks, she delivered a healthy beautiful female baby.

Discussion
H1N1 is a risk factor of hospitalization through pregnancy [7]. Bacterial pneumonia can happen as a pulmonary complication of H1N1 which developed a severe state, and can cause acute respiratory distress syndrome (ARDS), as a result [8].
High temperature is a result of infectious state, and soft crackles refers to pulmonary edema or overload according to pregnancy. Systolic murmurs are common during pregnancy. Most often these are ejection murmurs caused by increased ow through the right and left ventricular out ow tracts. The murmurs tend to be grade 1/6 or 2/6 mid-systolic murmurs that do not radiate. [9]. CRP was too high, but WBC is normal. That refers to viral infection more than bacterial, even though bacterial infection can be a reason and a result of viral infection.
HgB on low limitation, anemia by Fe de ciency is common in pregnancy anyway. Glucose isn't fast, and the later tests excluded the diabetes. Other tests were normal. Posterior anterior shows bilateral In ltrations and interstitial changes on the lower lobes. Patients and her husband refused to get CT scan.
According to the American College of Radiology, no single diagnostic x-ray has a radiation dose signi cant enough to cause adverse effects in a developing embryo or fetus. In general, CAT scans are not recommended during pregnancy unless the bene ts of the CAT scan clearly outweigh the potential risk [10].
Respiratory rate is 32/min: more than 30 so it will be emergent to de ne the acid-base disorder, and if there's any need of mechanical ventilation.
ECG shows sinus tachycardia with depression of ST segment which is a common nding in H1N1 [11].
Pulmonary embolism is a common complication in pregnancy. Wells score for PE in this patient was: 1.5 points for tachycardia (pulse >100): low probability for PE [12], but it still suspected.
Acute pulmonary edema is one of the most dramatic complications of pregnancy because of changes in blood volume, especially in obese women, anyway our patient wasn't.
Acute respiratory infection has high probability diagnosis suspected in this patient.
There's no risk factor to per-partum cardiomyopathy in this patient, she is young, no history of initial cardiac morbidity.
Profound changes occur in the cardiovascular system early in pregnancy. By the early second trimester, circulating blood volume increases 40-50%. This is due to an increase in both the circulation red cell mass and an even larger increase in the plasma volume. The larger increase in plasma volume leads to a delusional anemia and a decrease in the serum colloid oncotic pressure. These changes increase the susceptibility of pregnant patients to the development of pulmonary edema.
In patients with underlying cardiac disease this further worsens the tendency toward pulmonary edema. Gas exchange is also affected by pregnancy. Minute ventilation is increased during pregnancy.
FRC decreases substantially during pregnancy due to increased pressure from the gravid abdomen. This results in an increased susceptibility to atelectasis especially in the supine position. This may lead to mild arterial hypoxemia if blood gases are measured supine [13]. Acute myocarditis is a complication of in uenza A H1N1 infection and signs of cardiac dysfunction in a patient diagnosed or suspected to have the infection should alert the clinician to myocarditis [14], and its complication.
There's no risk factor to peripartum cardiomyopathy in this patient. Risk factors for peripartum cardiomyopathy include include advanced age, race, multiparity, socioeconomic disparity, and medical comorbidities primiparity like hypertension and multifetal pregnancies [15]. Echocardiography was performed to exclude both of dilated cardiomyopathy and acute myocarditis, and it was no signs for the both.
Patient was admitted to the ICU, a swap taken from throat. Initial treatment with Oseltamivir 150 mg twice a day plus levo oxacin 500 mg once a day and meropenim 1gr twice a day. The treatment with antibiotics was suspected because the co-bacterial infection is suspected too. The rst choice was meropenim because it has the pregnant category B. The patient was immunized by H1N1 vaccine as it is recommended from many studies with safe effects for mom and natal after birth [16,17].
Ending pregnancy in this level will be harmful to the fetus; premature babies require long NICU stays and mom not in emergent state at this time. It needs a special and accurate follow, delivery will be suspected in anytime anyway.
Testing a throat or nose swap will be suitable in this time, In uenza is suspected according to clinical story and laboratory tests.
Beginning with Oseltamivir 75 mg q 12 hr for 5 days will be good for the patient even I prefer to begin with 150mg twice because the risk of developing acute myocarditis is still suspected 5 days later, the patient discharged, and 2 weeks after discharge, she delivered a female baby 2.45 kg weight, no need of hospitalization later.

Conclusion
It is important to suspect H1N1 in uenza in pregnant women who developed an acute onset of breathlessness, cough, wheezing and high temperature. Initial therapy with Oseltamivir by the time of suspecting the diagnosis and even before the result of nose or throat swap, will improve prognosis.
Co-bacterial infection must be suspected in cases admitted to ICU and treatment with antibiotics with Oseltamivir as prophylactic treatment from myocarditis and ARDS.

Declarations
Financial support and sponsorship: No nancial or non nancial competing interests to report.

Con icts of interest:
Author has nothing to declare in relation to this article.

Data Availability:
Data availability is not applicable.

Consent:
Consent was obtained from the parents of patient, as she was under 18years old, and also from the patient, herself, for publication of this manuscript, and they gave their consent for images and other clinical information to be reported in the journal.  Figure 1 Posterior Anterior Chest X-RAY for the patient on admission after breathlessness.