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作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　May 24, 2010 — 根據一項於5月24日發表於內科學誌的病例系列與觀察性分析結果，孕婦感染H1N1與產科併發症有關。
　　
　　紐約布魯克林紐約州立大學州南醫學中心與國王郡醫院中心的Andrew C. Miller醫師及其同事們寫到，新型A型流感（H1N1）大流行是個很大的威脅，且是懷孕族群發病與死亡的原因。有關於H1N1對孕婦或分娩胎兒的影響，目前並沒有太多的研究數據，而已發表的報告結果不一。然而，在過去季節性流感流行與大流行時，孕婦的住院機率是上升的，發病與死亡率也是較高的，但是先天性生產缺陷機率並未上升。
　　
　　在兩家學術醫學中心，18位罹患H1N1的婦女以鼻咽採檢進行直接抗原檢測（DAT）確認感染，再以即時反轉錄酶聚合酶鏈反應分析（rRT-PCR）或是病毒培養確認診斷。
　　
　　研究者們收集病患的流行病學、症狀、住院病程、實驗室與放射學檢驗結果、懷孕結果、以及胎盤病理學資訊，並與H1N1大流行報告及1918至1957年流感大流行報告相比。
　　
　　病患的平均年齡為27 ± 6.6歲（範圍從18-40歲）；2位婦女（11%）是健康照護工作人員，15位（83%）是黑人、2位（11%）是西班牙裔、1位（6%）是白人；沒有人有旅遊史，氣喘、鏈狀細胞疾病與糖尿病是最常見的共病，半數婦女的主訴是腸胃道或腹部症狀，13位（72%）符合敗血症條件。
　　
　　在一開始與後續DAT檢驗中，14位病患（78%）為H1N1陽性。其他4位（22%）婦女以病毒培養與rRT-PCR診斷H1N1。從住院那天開始，這18位婦女都接受oseltamivir phosphate的治療，其中3位（17%）轉到加護病房。住院天數中位數為4天。
　　
　　住院期間，7位婦女（39%）分娩，6位提早，4位是緊急剖腹。有2件（11%）胎兒死亡事件，但沒有母親因而死亡。
　　
　　試驗作者們寫到，感染H1N1住院孕婦處於產科併發症的風險，包括胎兒窘迫、早產、緊急剖腹生產以及胎兒死亡。大多數病患以腸胃道或腹部症狀表現。提早使用抗病毒藥物可能改善母親的狀況。
　　
　　這項研究的限制包括觀察性設計、缺乏控制組以及樣本數目過小。除此之外，並非所有類流感症狀病患都接受檢驗，且並未全面對檢驗陰性樣本進行確認性病毒培養或rRT-PCR。
　　
　　試驗作者們的結論是，H1N1對懷孕病患造成嚴重的健康威脅。直接抗原檢驗並沒有足夠的敏感度來診斷類流感症狀孕婦是否感染流感。如果高度懷疑，應該經驗性地投予抗病毒藥物。
　　
　　試驗作者們表示沒有相關的資金往來。


H1N1 Influenza in Pregnant Women Linked to Obstetrical Complications

By Laurie Barclay, MD
Medscape Medical News

May 24, 2010 — H1N1 influenza in pregnant women is linked to obstetrical complications, according to the results of a case series and observational analysis reported in the May 24 issue of the Archives of Internal Medicine.

"Pandemic novel influenza A(H1N1) is a substantial threat and cause of morbidity and mortality in the pregnant population," write Andrew C. Miller, MD, from the State University of New York Downstate Medical Center and Kings County Hospital Center in Brooklyn, New York, and colleagues. "Little data have been reported regarding the impact of H1N1 on pregnant patients or the gestational fetus, and published reports have been conflicting. However, during prior seasonal influenza epidemics and pandemics, pregnant women have been reported to have increased hospitalization rates, increased morbidity and mortality, but no increase in congenital birth defects."

At 2 academic medical centers, 18 pregnant women with H1N1 were identified based on direct antigen testing (DAT) of nasopharyngeal swabs, and the diagnosis was confirmed using real time reverse-transcriptase polymerase chain reaction analysis (rRT-PCR) or viral culture.

The investigators collected data on patient demographics, symptoms, hospital course, laboratory and radiographic results, pregnancy outcome, and placental pathology and compared these with published reports of the H1N1 outbreak and reports of the influenza pandemics of 1918 and 1957.

Mean age was 27 ± 6.6 years (range, 18 - 40 years); 2 women (11%) were healthcare workers, 15 (83%) were black, 2 (11%) were Hispanic, and 1 was white (6%). None reported recent travel. Asthma, sickle cell disease, and diabetes were the most common comorbid conditions. Gastrointestinal or abdominal symptoms were the presenting complaint in half of the women, and 13 women (72%) met criteria for sepsis.

On initial or repeated DAT, 14 patients (78%) tested positive for H1N1. Viral culture or rRT-PCR diagnosed H1N1 in the other 4 women (22%). Beginning on the day of admission, all 18 women received treatment with oseltamivir phosphate, and 3 (17%) were admitted to the intensive care unit. Median length of hospital stay was 4 days.

During hospitalization, 7 women (39%) delivered — 6 prematurely and 4 by emergency caesarean delivery. There were 2 fetal deaths (11%) but no recorded maternal mortality.

"Admitted pregnant patients with H1N1 are at risk for obstetrical complications including fetal distress, premature delivery, emergency cesarean delivery, and fetal death," the study authors write. "A high number of patients presented with gastrointestinal and abdominal complaints. Early antiviral treatment may improve maternal outcomes."

Limitations of this study include observational design, lack of controls, and small sample size. In addition, not all patients with influenza-like symptoms were tested, and confirmatory viral cultures or rRT-PCRs were not performed on all negative samples.

"H1N1 poses a serious health threat to pregnant patients," the study authors conclude. "Direct antigen testing is not sufficiently sensitive to diagnose influenza in pregnant patients presenting with an [influenza-like illness]. If a high index of suspicion exists, patients should be empirically treated with antiviral agents."

The study authors have disclosed no relevant financial relationships.

Arch Intern Med. 2010;170:868-873.