Case Study: Respiratory Syncytial Virus May Cause Complications in Pregnant Patients

Human respiratory syncytial virus (RSV) may cause complications in those who are pregnant and should be on the differential for respiratory illness in pregnancy, though it remains to be determined whether the current RSV surge is more dangerous to pregnant patients than past seasons, according to an analysis of 2 case studies published in IDCases.

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There have been some associations of increased morbidity of RSV infections in immunocompromised populations, yet increased morbidity has not been reported in pregnancy. However, pregnant patients have been shown to have increased mortality and morbidity to other respiratory viruses, including SARS-CoV-2 and influenza.

The investigators presented 2 cases of RSV-associated hospitalizations in pregnancy to evaluate the effects and outcomes of these patients.

The first patient was a 40-year-old who transferred to the investigator’s facility at 39 weeks gestation with significant respiratory distress. Her medical history was significant for obesity with a body mass index (BMI) of 47 and limited prenatal care.

The patient was emergently intubated and immediately transferred to the operating room for cesarean delivery due to maternal compromise. The delivery was uncomplicated, and a healthy male infant was born.

Following delivery, a laboratory assessment of the patient was notable for leukocytosis to 23.7 x 10(9)/L, anion gap of 16, and arterial gases of pH 7.19. A chest X-ray showed consolidation and volume loss in both lower lungs, and broad antibiotic coverage was initiated.

Infectious work-up returned positive for RSV on respiratory panel polymerase chain reaction (PCR) as well as streptococcus pneumoniae on bacterial culture of bronchoalveolar lavage. The patient was extubated on post-operate day 1, and she eventually recovered with an antibiotic course and supportive care.

The second patient was a 32-year-old admitted to the researchers’ facility at 35 weeks gestation with complaints of wheezing, dyspnea, and oxygen saturations of 93% on home pulse oximetry. Her medical history indicated obesity with body mass index of 31 and a prior hospital admission at 26 weeks due to reactive airway disease, thought to be a result of mild COVID-19 illness weeks prior.

Her laboratory analysis was unrevealing and chest X-ray and EKG were unremarkable, but her respiratory panel was positive for RSV by PCR. She was started on treatment, yet on hospital day 2, her dyspnea worsened, and oxygen requirements increased.

The day following her discharge, the patient was readmitted to the hospital due to increasing shortness of breath. Another chest X-ray showed no significant changes, and there was no evidence of pulmonary embolism. It was concluded that her airway disease flared in the setting of her prednisone taper, and her prednisone dose was increased to 40 mg/day with clinical improvement.

Due to the complication of fetal growth restriction and intermittent hypoxemia, it was decided to deliver the pregnancy at 37 weeks gestation. Induction of labor resulted in an uncomplicated vaginal delivery of a small but otherwise healthy female infant, and both mother and baby were discharged on postpartum day 2.

Case 1 did not have any traditional risk factors of severe RSV, including age exceeding 50 years, immunocompromising conditions, and underlying lung and cardiac disease. The investigators discussed the possibility that the combination of pregnancy and obesity placed the patient at heightened risk.

Moving to case 2, the patient reported no history of reactive airway disease prior to her infection with SARS-CoV-2 at 23 weeks gestation. Whether SARS-CoV-2 infection can cause obstructive pulmonary disease is subject to debate, but the researchers noted it carries interesting implications for the possibility of increased susceptibility to and morbidity from future respiratory infections.

In conclusion, the investigators write that these cases highlight the importance of maintaining RSV on the differential for cough and shortness of breath in pregnancy, and that clinicians should continue to counsel pregnant patients on general infectious precautions.

Reference

Santos J, Theiler RN, Szymanski LM. Hospitalization in pregnancy due to human respiratory syncytial virus associated disease. IDCases. 2023;(33):e01849. doi:10.1016/j.idcr.2023.e01849