Pneumonia in pregnancy

Pneumonia in 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 intraalveolar exudation.

Pneumonia in pregnant and parturient women - pathology, often found in obstetric practice - poses a serious danger to the mother and child. Even in recent years, this disease is one of the causes of maternal mortality in Ukraine. Carried over during pregnancy, pneumonia leads to an increase in the frequency of premature birth, fetal distress, the birth of children with low body weight.

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

[1], [2], [3], [4], [5], [6], [7]

Causes of pneumonia in pregnancy

Among the chronic concomitant diseases, chronic obstructive pulmonary disease, bronchiectatic disease, kyphoscoliosis, diabetes mellitus, severe heart defects, congestive heart failure, immunodeficiency diseases / conditions, including iatrogenic (long-term therapy with glucocorticosteroids, immunosuppressants and etc.).

Factors that increase the virulence of microorganisms (which leads to antibiotic resistance), increasing the risk of aspiration, pathological colonization of the upper respiratory tract, negatively affecting the body's defenses, that is, modifying factors, include: bed rest, especially in the supine position, abortion or labor, surgery on the pelvic organs, abdominal cavity, chest, long stay in the intensive care unit (ICU), artificial ventilation, trauma eostomiya, impaired consciousness, therapy with beta-lactam or other broad-spectrum antibiotics, conducted during the last three months, smoking, alcohol, psycho-emotional stress.

[8], [9], [10]

Symptoms of pneumonia in pregnancy

Clinical symptoms of pneumonia in pregnancy include general manifestations (weakness, adynamia, decreased appetite, fever), local respiratory symptoms (cough, sputum, dyspnea, chest pain), physical findings (dullness or dull percussion sound, weak or hard breathing, focus small bubbling rales and / or crepitation). The severity of these symptoms depends on the condition of the woman at the onset of the disease, the severity of the course of pneumonia, the volume and localization of the lesion of the lung tissue. In almost 20% of patients, pneumonia symptoms may differ from typical or completely absent.

For pneumonia, leukocytosis (> 10 * 10 ⁹ / L) and / or stab shift (more than 10%) is also characteristic . When radiographing chest organs, focal infiltration of the lung tissue is determined.

Pneumonia in pregnant women has no fundamental differences either in the nature of the pathogen, or in clinical manifestations. It can develop in any period of pregnancy and the postpartum period. Delivery on the background of pneumonia does not reduce the risk to the health of women. In the case of unresolved pneumonia after childbirth, the disease often acquires an extremely unfavorable course and can lead to the death of the parturient woman.

Classification of pneumonia in pregnancy

• non-hospital (out-of-hospital, out-patient, home);
• nosocomial (hospital, nosocomial);
• aspiration,
• pneumonia in persons with severe impairment of immunity (congenital
• immunodeficiency, HIV infection, iatrogenic immunosuppression).

In addition to the above forms of pneumonia, the clinical course is characterized by a severe and non-severe disease.

Criteria for severe pneumonia: impaired consciousness; respiratory rate more than 30 per 1 min; hypothermia (up to 35 "C) or hyperthermia (above 40 ° C); tachycardia (more than 125 in 1 min); pronounced leukocytosis (more than 20 * 10 ⁹ / l) or leukopenia (up to 4 * 10 ⁹ / l); bilateral or polysegmentary lung injury, cavity decay, pleural effusion (according to X-ray study data); hypoxemia (8aO, <90% or PaO ₂ <60 mm Hg....); acute renal failure.

[11], [12], [13], [14], [15], [16], [17]

Diagnosis of pneumonia in pregnancy

Diagnosis of pneumonia in pregnant women assumes a detailed history, including epidemiological, physical examination, laboratory examination (blood test common with the leukocyte formula, determination of the blood in the blood of creatinine, urea, electrolytes, liver enzymes), coagulogram, lung X-ray, bacterioscopic and bacteriological study phlegm. With symptoms of respiratory failure, it is necessary to carry out a pulse of oximetry or to determine the indices of oxygen saturation with oxygen in another way.

[18], [19], [20]

Treatment of pneumonia during pregnancy

Preventive care for pregnant women with pneumonia is usually provided by district therapists. To diagnose the disease in difficult, complex cases, it is necessary to attract the most qualified specialists, including pulmonologists.

Pregnant without chronic diseases and with a mild course of pneumonia, provided that proper care is provided and daily medical supervision can be treated at home. In all other cases, after diagnosis of pneumonia, pregnant women need to be monitored and treated in a hospital setting. In the first half of pregnancy it is advisable to hospitalize a patient in a hospital of a therapeutic profile, after the 22nd week - only in an obstetric hospital. Women with severe pneumonia need admission to the ICU. Regardless of the place of stay, the patient should be monitored by a therapist (pulmonologist) and an obstetrician-gynecologist. In addition to a therapeutic examination aimed at diagnosing pneumonia and assessing the condition of a woman, control of pregnancy and fetal status is necessary, for which any modern diagnostic methods are used.

Unfinished pneumonia is not an indication for the termination of pregnancy in either early or late term. On the contrary, interruption of pregnancy is contraindicated, since it can aggravate the condition of a pregnant woman. Severe pneumonia does not require early delivery. Moreover, the severe condition of a woman due to pneumonia is a contraindication to delivery due to the danger of aggravation of the course of pneumonia and generalization of infection.

Births in patients with incomplete pneumonia should, if possible, be conducted through the natural birth canal. In severe disease, the presence of respiratory failure, shortening of attempts is shown by the operation of superimposing obstetric forceps. Caesarean section on the background of pneumonia is potentially dangerous.

During labor, patients need thorough anesthesia, oxygen therapy, continuation of antibacterial treatment, symptomatic therapy.

Babies who are sick with pneumonia need careful observation of the therapist (pulmonologist) and obstetrician-gynecologist, treatment in a hospital,

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. However, suppress lactation should not be. After the normalization of the puerperal condition against the background of the treatment of pneumonia, breastfeeding is possible. The risk of switching to milk and the negative effect on the child of most antibacterial and other drugs used to treat pneumonia is significantly lower than the benefit of natural feeding.

The basis for the treatment of pneumonia in pregnancy is antibiotics.

Empirical antibacterial therapy of hospital pneumonia in pregnant women

Features of pneumonia	The drug of choice	Alternative drugs
Early or late with a mild course, early with severe course in the absence of concomitant chronic pathology and modifying factors	Ceftriaxone or cefotaxime Protected aminopenicillin	Another cephalosporin III-IV generation + gentamicin, Azrethra + 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 Vancominin + clindamycin Cephalosporin III generation + macrolide ± rifampicin
Early with severe course and concomitant chronic pathology or presence of modifying factors or late with severe course	Cefoperazone / sulbactam or cefepime + gentamycin	Carbapenem Azrethra + amikacin

Etiotropic therapy is carried out according to the following principles:

1. the antibiotic is administered empirically immediately after the establishment of the clinical diagnosis, without waiting for the identification of the pathogen;
2. the nature and extent of antibiotic therapy is determined based on the characteristics of infection, the severity of the disease, 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 administered in therapeutic doses, with observance of the necessary time intervals;
5. 48 hours after initiation of antibiotic therapy, an assessment of its clinical efficacy is performed: in the case of a positive result from the starting therapy, it is continued without changing the antibiotic, in the absence of the effect, the antibiotic is changed, and in case of a severe condition, a combination of antibiotics is prescribed;
6. in the case of severe pneumonia, the antibiotic begins to be injected intravenously, after reaching a stable result, after 3-4 days, they switch to oral administration (stepwise therapy).

The most objective and universally recognized reference points in the world that determine the possibility of using medicines, including antibiotics, in pregnancy are the recommendations developed by the FDA for the control of the quality of medicines and food products in the United States.

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

The basis for assigning drugs to a certain group is the results of experimental and clinical observations that establish the safety or harm of the drug in relation to the embryo and / or fetus both in the I trimester and later in pregnancy.

• To category A, that is safe medications that can be used without restriction at any time of pregnancy, and also to category X - harmful drugs, categorically contraindicated during pregnancy, does not belong to any antibiotic.
• To category B (conditionally safe drugs, can be used according to the relevant indications) include all penicillins (natural and semisynthetic), cephalosporins I-IV generation, monobactams, macrolides (except clarithromycin), carbapenems, phosphomycin trometamol, nifuroxazide.
• The rifampicins, imipenem, gentamicin, clarithromycin, vancomycin, nitrofurans, sulfanilamide preparations, trimethroperm, nitroxoline, metronidazole, isoniazid, pyrazinamide, ethambutol belong to the category C (potentially dangerous, are limitedly used when it is impossible to find an adequate substitute).
• To category D (dangerous, used during pregnancy only for vital reasons, can not be used in the first trimester) include aminoglycosides (except gentamycin), tetracyclines, fluoroquinolones, chloramphenicol.

In the period of breastfeeding the most safe is the use of penicillins, cephalosporins, macrolides. If necessary, without refusal of lactation, vancomycin, aminoglycosides, rifampicins and other antimycobacterial agents are prescribed. Although imipenem and meropenem fall into breast milk in a small amount, there is no sufficient evidence of their safety at the present time. Contraindicated during breastfeeding tetracyclines, fluoroquinolones, chloramphenicol, lincosamides, metronidazole, long-acting sulfanilamide preparations, spectinomycins, polymyxins. In case of their use, lactation should be discarded.

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

In severe non-hospital pneumonia, the causative agents of the disease can be both extracellular Gram-positive and Gram-negative organisms, as well as intracellular pathogens, especially Legionella spp. Drugs of choice are intravenous amoxicillin / clavulanate and macrolide or cephalosporins of generation II and macrolide. Alternative therapy - intravenous cephalosporin IV generation + macrolide or carbapenem + macrolide.

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

Given that the emergence of small pneumonia is often played by the role of intracellular microflora, especially important in the treatment of pregnant women with this pathology belongs to macrolides. 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. Of the macrolides, spiramycin is the drug most safe for pregnant women, which confirms the 50-year experience of its use.

The most frequent pathogens of hospital pneumonia in pregnancy are gram-negative microorganisms.

There is also pneumonia early, which developed up to 5 days in hospital, and pneumonia late, which appeared after 5 days in hospital.

Patients with early and late pneumonia with a mild course, with early pneumonia with severe course and lack 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 presence of modifying factors, along with the above pathogens, the probability of infection with anaerobes, Staphylococcus aureus (MR), Legionella spp., Pseudomonas aeruginosa, which is characterized by a high frequency of strains with multiple resistance to antibacterial drugs.

Given the severe course of early pneumonia and the presence of modifying factors or severe course of late pneumonia, along with the main previously listed microorganisms, probable etiopathogens may be highly resistant and virulent Pseudomonas aeruginosa and Acinetobacter spp.

It should be noted that pneumonia is diagnosed in the case of the appearance of clinical and radiological signs after 48 hours of hospital stay and further.

Timely diagnosis of the disease, the 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 the mother and child.

[21], [22], [23], [24], [25], [26], [27], [28]