FW: QOD 1 19 10

According to a recent study published in the NEJM, what was the approximate mortality rate among pregnant women hospitalized with 2009 H1N1 influenza?
		A.	8%.
		B.	14%.
		C.	22%.
		D.	30%. In this large series of pregnant and postpartum patients who were hospitalized with or died from 2009 H1N1 influenza, 95% of the pregnant patients were infected in the second or third trimester, and almost one fifth required intensive care. One third of the pregnant patients had medical conditions besides pregnancy that are recognized risk factors for complications from influenza. Eight patients who were hospitalized had an onset of symptoms within 2 weeks post partum; half required intensive care and two died, highlighting the continued high risk immediately after pregnancy. The pregnant women were less likely to have underlying medical conditions than the nonpregnant women hospitalized with 2009 H1N1 influenza. Although pregnant women frequently presented with mild or moderate symptoms, many had a rapid clinical progression and deterioration. Over the 4-month study period, the cause-specific maternal mortality ratio for 2009 H1N1 influenza was estimated at 4.3 in California. The maternal mortality ratio for death from any cause was 19.3 in California in 2005 and 13.3 in the United States in 2006. More than two thirds of maternal deaths in the United States each year are directly related to obstetrical factors, and maternal deaths due to influenza have been rare. The high 2009 H1N1 influenza–specific maternal mortality suggests that this pandemic has the potential to notably increase overall maternal mortality in the United States in 2009. The severity of influenza seen in this case series is consistent with the increased risk of severe disease among pregnant women that has been documented for seasonal influenza and previous pandemics. Consistent with the excess number of influenza-associated deaths among pregnant women observed during previous pandemics is the disproportionate number of pregnant women, as compared with their prevalence in the overall population, among all patients who have died and all critically ill patients, as was recently reported in the United States and other countries during the current pandemic. Although an association between severe illness and pregnancy is well documented for seasonal influenza, the rapid clinical deterioration observed in some of our patients appears to be qualitatively different from the course of seasonal influenza observed previously. One quarter of the women requiring mechanical ventilation in the study were severely ill at the time of presentation and required intubation on the day of admission. Six deliveries occurred in an ICU, including four emergency cesarean deliveries, which is a relatively rare obstetrical occurrence and suggests that the condition of the patients was too unstable at the time of delivery for them to be transferred to an appropriate labor and delivery unit. Furthermore, although the data are limited, deaths among pregnant women due to seasonal influenza appear to be uncommon. In a study of more than 4000 women enrolled in the Tennessee Medicaid program between 1974 and 1993 who had a cardiopulmonary event during the influenza season, none of the 104 maternal deaths that occurred were likely to have been due to influenza. The Centers for Disease Control and Prevention (CDC) recommends prompt antiviral treatment of pregnant women with suspected or confirmed 2009 H1N1 influenza, ideally within 48 hours after symptom onset. In this study, pregnant women who received treatment after 48 hours had a risk of admission to the ICU or death (8%) that was about 4 times the risk among those who received earlier treatment. Delay in treatment was often multifactorial in cause; in some cases, pregnant women did not promptly seek medical care after symptom onset, whereas in other cases, there were delays by health care providers in initiating antiviral treatment. The recognition and diagnosis of influenza-like illness may be complicated during pregnancy, when women and their health care providers may attribute certain signs and symptoms (e.g., myalgia or shortness of breath) to pregnancy rather than influenza. Furthermore, pregnant women or their health care providers may want to avoid antiviral treatment during pregnancy because of concerns about the fetus. Although rapid influenza tests are widely available and can be completed within 15 minutes, reliance on rapid test results might have contributed to treatment delays. In this study, 38% of patients who underwent testing had false negative results; less than 30% of the pregnant women with false negative results received antiviral treatment within 48 hours after symptom onset, and five of the patients who died had false negative results. Recently, the CDC issued a health advisory alerting clinicians about the poor sensitivity of rapid test results and stating that clinical decisions about the treatment of influenza should not be guided or delayed by negative results on rapid testing. The fact that eight of the cases of influenza in this study involved a postpartum onset of symptoms, with severe disease and death in some of these cases, highlights the continued high risk immediately after pregnancy. A variety of cardiac, respiratory, hormonal, and immunologic changes that occur during pregnancy may contribute to the increased risk of influenza-related morbidity and mortality among pregnant women. Although it is unknown how long after delivery these changes persist, some of them (i.e., immunologic alterations) might persist longer than others (e.g., decreased lung capacity due to uterine compression). Although some studies of seasonal influenza have not shown an increased period of risk during the postpartum period, the immediate postpartum period probably represents a transitional period during which the risk of severe disease is returning to, but has not yet reached, the baseline level. In light of these emerging data, the CDC recently issued revised guidelines, recommending prompt initiation of antiviral treatment in patients with suspected or confirmed influenza up to 2 weeks after delivery. Answer: A