Pneumonia in pregnancy

Pneumonia during pregnancy is an acute infectious disease of predominantly bacterial etiology, characterized by focal lesions of the respiratory parts of the lungs with the presence of intra-alveolar exudation.

Pneumonia in pregnant women and women in labor is a pathology that is often encountered in obstetric practice and poses a serious danger to the mother and child. Even in recent years, this disease has been one of the causes of maternal mortality in Ukraine. Pneumonia suffered during pregnancy leads to an increase in the frequency of premature births, fetal distress, and the birth of children with low body weight.

The occurrence, course, and outcome of pneumonia are largely determined by two factors - the pathogen and the state of the macroorganism. However, the possibilities of etiological verification of pneumonia, especially in the early stages of the disease, are significantly limited. At the same time, as a result of large epidemiological studies, it was established that when pneumonia occurs under certain conditions, an absolutely specific and fairly limited number of pathogens are detected. This made it possible to develop a classification of pneumonias taking into account the conditions of infection. Its use allows empirically, before receiving the results of bacteriological studies, to conduct rational initial antibacterial therapy.

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Causes of pneumonia during pregnancy

Among chronic concomitant diseases, the most adverse effects on the course of pneumonia during pregnancy are provided by chronic obstructive pulmonary diseases, bronchiectasis, kyphoscoliosis, diabetes mellitus, severe heart defects, congestive heart failure, immunodeficiency diseases/conditions, including iatrogenic ones (long-term therapy with glucocorticosteroids, immunosuppressants, etc.).

Factors that increase the virulence of microorganisms (which leads to antibiotic resistance), increase the risk of aspiration, pathological colonization of the upper respiratory tract, negatively affect the body's defenses, i.e. modifying factors, include: bed rest, especially in the supine position, termination of pregnancy or childbirth, surgery on the pelvic organs, abdominal cavity, chest, long-term stay in the intensive care unit (ICU), artificial ventilation of the lungs, tracheostomy, impaired consciousness, therapy with beta-lactam or other broad-spectrum antibiotics carried out during the last three months, smoking, alcoholism, psychoemotional stress.

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Pneumonia Symptoms During Pregnancy

Clinical symptoms of pneumonia during pregnancy include general manifestations (weakness, weakness, decreased appetite, fever), local respiratory signs (cough, sputum production, dyspnea, chest pain), physical data (dullness or dullness of percussion sound, weakened or harsh breathing, focus of fine bubbling rales and/or crepitus). The severity of these symptoms depends on the woman's condition at the onset of the disease, the severity of pneumonia, the volume and localization of lung tissue damage. In almost 20% of patients, pneumonia symptoms may differ from typical or be absent altogether.

Pneumonia is also characterized by leukocytosis (over 10*10 ⁹ /l) and/or band shift (over 10%). Chest X-ray reveals focal infiltration of the lung tissue.

Pneumonia in pregnant women has no fundamental differences either in the nature of the pathogen or in clinical manifestations. It can develop at any stage of pregnancy and in the postpartum period. Childbirth against the background of pneumonia does not reduce the risk to the woman's health. In the case of unfinished pneumonia after childbirth, the disease often takes an extremely unfavorable course and can lead to the death of the mother.

Classification of pneumonia in pregnancy

• non-hospital (outpatient, ambulatory, home);
• nosocomial (hospital, intra-hospital);
• aspiration,
• pneumonia in individuals with severe immune deficiencies (congenital
• immunodeficiency, HIV infection, iatrogenic immunosuppression).

In addition to the above forms of pneumonia, according to the clinical course, severe and non-severe diseases are distinguished.

Criteria for severe pneumonia: impaired consciousness; respiratory rate over 30 per 1 min; hypothermia (up to 35 °C) or hyperthermia (over 40 °C); tachycardia (over 125 per 1 min); severe leukocytosis (over 20*10 ⁹ /l) or leukopenia (up to 4*10 ⁹ /l); bilateral or polysegmental lung damage, cavities, pleural effusion (according to X-ray examination); hypoxemia (SAO, < 90% or PaO2 _< 60 mm Hg); acute renal failure.

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Diagnosis of pneumonia during pregnancy

Diagnosis of pneumonia in pregnant women involves a detailed anamnesis, including epidemiological, physical examination, laboratory testing (general blood test with leukocyte formula, determination of creatinine, urea, electrolytes, liver enzymes in the blood), coagulogram, X-ray examination of the lungs, bacterioscopic and bacteriological examination of sputum. In case of symptoms of respiratory failure, pulse oximetry or determination of blood oxygen saturation indicators in another way is necessary.

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Treatment of pneumonia during pregnancy

First aid to pregnant women with pneumonia is usually provided by local therapists. In severe, complicated cases, the most qualified specialists, including pulmonologists, must be involved in diagnosing the disease.

Pregnant women without chronic diseases and with mild pneumonia, provided that they receive proper care and are under daily medical supervision, can be treated at home. In all other cases, after pneumonia has been diagnosed, pregnant women need to be monitored and treated in a hospital. In the first half of pregnancy, it is advisable to hospitalize the patient in a therapeutic hospital, and after the 22nd week - only in an obstetric hospital. Women with severe pneumonia need to be hospitalized in an intensive care unit. Regardless of the place of stay, the patient should be monitored jointly by a therapist (pulmonologist) and an obstetrician-gynecologist. In addition to a therapeutic examination aimed at diagnosing pneumonia and assessing the woman's condition, it is necessary to monitor the course of pregnancy and the condition of the fetus, for which any modern diagnostic methods are used.

Unfinished pneumonia is not an indication for termination of pregnancy either early or late. On the contrary, termination of pregnancy is contraindicated, as it may worsen the condition of the pregnant woman. Severe pneumonia does not require early delivery. Moreover, the woman's severe condition caused by pneumonia is a contraindication to delivery due to the risk of worsening the course of pneumonia and generalization of the infection.

Childbirth in patients with incomplete pneumonia should be performed through the natural birth canal if possible. In severe cases of the disease, the presence of respiratory failure, it is indicated to shorten the pushing by applying obstetric forceps. Caesarean section against the background of pneumonia is potentially dangerous.

During childbirth, patients require careful pain relief, oxygen therapy, continued antibacterial treatment, and symptomatic therapy.

Women in labor who are sick with pneumonia need careful observation by a therapist (pulmonologist) and obstetrician-gynecologist, and treatment in a hospital setting.

Breastfeeding is contraindicated at the peak of the disease, which is due to the severity of the mother's condition and the possibility of infection of the child. At the same time, lactation should not be suppressed. After the mother's condition has normalized against the background of pneumonia treatment, breastfeeding is possible. The risk of most antibacterial and other drugs used to treat pneumonia passing into milk and having a negative effect on the child is significantly lower than the benefit of natural feeding.

The mainstay of treatment for pneumonia during pregnancy is antibiotics.

Empirical Antibacterial Therapy for Hospital Acquired Pneumonia in Pregnant Women

Features of pneumonia	Drug of choice	Alternative drugs
Early or late with a mild course, early with a severe course in the absence of concomitant chronic pathology and modifying factors	Ceftriaxone or cefotaxime Protected aminopenicillin	Other cephalosporin III-IV generation + gentamicin, Aztreonam + clindamycin
Early or late with a mild course and the presence of concomitant chronic pathology and/or modifying factors	Ceftazidime or cefoperazone or cefepime or cefoperazone/sulbactam	Protected aminopenicillin + vancomycin Vancomycin + clindamycin Third generation cephalosporin + macrolide ± rifampicin
Early with a severe course and concomitant chronic pathology or the presence of modifying factors, or late with a severe course	Cefoperazone / sulbactam or cefepime + gentamicin	Carbapenem Aztreonam + amikacin

Etiotropic therapy is carried out according to the following principles:

1. the antibiotic is prescribed empirically immediately after establishing a clinical diagnosis, without waiting for the pathogen to be identified;
2. the nature and volume of antibiotic therapy is determined based on the characteristics of the infection, the severity of the disease, and the presence of concomitant extragenital pathology;
3. the antibiotic is selected taking into account its effect on the embryo, fetus and newborn;
4. the antibiotic is prescribed in therapeutic doses, observing the necessary time intervals;
5. 48 hours after the start of antibiotic therapy, its clinical effectiveness is assessed: if the initial therapy is positive, it is continued without changing the antibiotic; if there is no effect, the antibiotic is changed, and if the patient’s condition is severe, a combination of antibiotics is prescribed;
6. In case of severe pneumonia, the antibiotic is administered intravenously, and after achieving a stable result after 3-4 days, it is switched to oral administration (step therapy).

The most objective and generally accepted guidelines in the world that determine the possibility of using medications, including antibiotics, during pregnancy are the recommendations developed by the Food and Drug Administration in the United States (FDA).

According to the FDA classification, all drugs are divided into 5 categories - A, B, C, D, X.

The basis for classifying medicinal products into a certain group is the results of experimental and clinical observations establishing the safety or harm of the medicinal product in relation to the embryo and/or fetus both in the first trimester and in later stages of pregnancy.

• Not a single antibiotic belongs to category A, that is, safe drugs that can be used without restrictions at any stage of pregnancy, or to category X - harmful drugs that are categorically contraindicated during pregnancy.
• Category B (conditionally safe drugs, can be used according to appropriate indications) includes all penicillins (natural and semi-synthetic), cephalosporins of the first to fourth generations, monobactams, macrolides (except clarithromycin), carbapenems, fosfomycin trometamol, and nifuroxazide.
• Category C (potentially dangerous, limited use if it is impossible to find an adequate replacement) includes rifampicin, imipenem, gentamicin, clarithromycin, vancomycin, nitrofurans, sulfonamides, trimethoprim, nitroxoline, metronidazole, isoniazid, pyrazinamide, ethambutol.
• Category D (hazardous, used during pregnancy only for vital indications, cannot be used in the first trimester) includes aminoglycosides (except gentamicin), tetracyclines, fluoroquinolones, and chloramphenicol.

During breastfeeding, the safest drugs are penicillins, cephalosporins, and macrolides. If necessary, vancomycin, aminoglycosides, rifampicins, and other antimycobacterial agents are prescribed without stopping lactation. Although imipenem and meropenem enter breast milk in small quantities, there is currently no sufficient evidence of their safety. Tetracyclines, fluoroquinolones, chloramphenicol, lincosamides, metronidazole, prolonged-release sulfonamides, spectinomycins, and polymyxins are contraindicated during breastfeeding. In case of their use, it is advisable to stop lactation.

In mild cases of the disease without concomitant pathology and the presence of modifying factors, the main pathogens of pneumonia are Streptococcus pneumoniae, Haemophilus influenzae, as well as intracellular pathogens - Mycoplasma pneumoniae and Chlamydia pneumoniae (the proportion of the latter exceeds 50%). The drug of choice is a macrolide (spiramycin) or amoxicillin used orally; an alternative drug is another macrolide or amoxicillin / clavulanate. Along with the specified microflora, gram-negative enterobacteria, Staphylococcus aureus, as well as such an intracellular pathogen as Legionella spp. acquire a certain significance in the genesis of the disease. The drugs of choice are amoxicillin / clavulanate and / or a macrolide (spiramycin), used per os or parenterally. Alternative drugs are macrolides and cephalosporins of the I-III generation, administered orally or parenterally.

In severe community-acquired pneumonia, the causative agents may be extracellular gram-positive and gram-negative organisms, as well as intracellular pathogens, especially Legionella spp. The drugs of choice are intravenous amoxicillin/clavulanate and a macrolide or second-generation cephalosporins and a macrolide. Alternative therapy is intravenous fourth-generation cephalosporin + macrolide or carbapenem + macrolide.

If Pseudomonas aeruginosa infection is suspected, therapy is initiated with ceftazidime and gentamicin; an alternative is meropenem and amikacin.

Considering that intracellular microflora often plays a role in the development of community-acquired pneumonia, macrolides play a particularly important role in the treatment of pregnant women with this pathology. This is the only group of antibiotics that is safe for pregnant women (category B), which has an antimicrobial effect on both extracellular and intracellular pathogens. Among macrolides, spiramycin is the safest drug for pregnant women, which is confirmed by 50 years of experience in its use.

The most common pathogens of hospital pneumonia during pregnancy are gram-negative microorganisms.

A distinction is also made between early pneumonia, which develops before 5 days of hospital stay, and late pneumonia, which appears after 5 days of hospital stay.

Patients with early and late pneumonia with a mild course, with early pneumonia with a severe course and the absence of concomitant chronic pathology and modifying factors are most likely infected with gram-negative bacteria of the Enterobacteriaceae series, as well as Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae (MS).

In patients with early and late pneumonia with a mild course and the presence of modifying factors, along with the above-mentioned pathogens, the likelihood of infection with anaerobes, Staphylococcus aureus (MR), Legionella spp., Pseudomonas aeruginosa, which are characterized by a high frequency of strains with multiple resistance to antibacterial drugs, significantly increases.

In the case of severe early pneumonia and the presence of modifying factors or severe late pneumonia, along with the main microorganisms listed earlier, highly resistant and virulent Pseudomonas aeruginosa and Acinetobacter spp. may act as probable etiopathogens.

It should be noted that pneumonia is diagnosed if clinical and radiological signs appear after 48 hours of the patient’s stay in the hospital and beyond.

Timely diagnosis of the disease, rational differentiated use of modern antibacterial agents, the correct choice of tactics for managing pregnancy, childbirth, and the postpartum period can significantly limit the negative consequences of pneumonia for mother and child.

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