Objective: To report five new eases of Pneumocystis carinii pneumonia (PCP) and to review and analyze the existing reports on the subject.

Method: Five new cases of PCP during pregnancy are described. The cases, ease series, and related articles on the subject in the English language were identified through a comprehensive MEDLINE search and reviewed.

Results: More than 80% of women with AIDS are of reproductive age, and PCP is the most common cause of AIDS-related death in pregnant women in the United States. Among 22 reviewed cases, the mortality rate was 50% (11 of 22 patients), which is higher than that usually reported for HIV-infected individuals with PCP. Respiratory failure developed in 13 patients (59%), and mechanical ventilation was therefore required, and the survival rate in patients requiring mechanical ventilation was 31%. Maternal and fetal outcomes were better in eases of PCP during the third trimester of the pregnancy. A variety of treatment regimens were used, including sulfamethoxazole-trimethoprim (SXT) alone or in combination with pentamidine, steroids, and eflornithine. The survival rate in patients treated with SXT alone was 71% (5 of 7 patients) and for those treated with SXT and steroids was 60% (3 of 5 patients), with an overall survival rate in both groups of 66.6% (8 of 12 patients).

Conclusion: PCP has a more aggressive course during pregnancy, with increased morbidity and mortality. Maternal and fetal outcomes remain dismal. Treatment with SXT, compared to other therapies, may result in an improved outcome. Withholding appropriate PCP prophylaxis may adversely affect maternal and fetal outcomes. (CHEST 2001; 120:666-671)

Key words: AIDS; Pneumocystis carinii pneumonia; pregnancy; sulfamethoxazole-trimethoprim

Abbreviations: LDH = lactate dehydrogenose; PCP = Pneumocystis carinii pneumonia; SXT = sulfamethoxazole-trimethoprim

The number of women with HIV disease in the United States has been steadily increasing during the past decade. The greatest increase in AIDS incidence was observed in heterosexually infected women born between 1970 and 1974.[1] As of 1995, [is greater than] 80% of women with AIDS were of reproductive age[1]; among pregnant women, Pneumocystis carinii pneumonia (PCP) was the most common cause of AIDS-related death in the United States.[2] Although there have been sporadic reports of PCP in pregnancy, there has been no comprehensive review in order to provide guidelines regarding its management in pregnancy. This article presents five cases of PCP in pregnant women as well as a review of the literature.

CASE REPORTS

Case 1

A pregnant 34-year-old African-American woman presented at 27 weeks of gestation with a 3-week history of shortness of breath, fever, and cough. On admission to the hospital, she had a temperature of 37.2 [degrees] C, a respiratory rate of 30 breaths/min, and oral thrush. CBC count showed no leukocytosis and a predominance of polymorphonuclear cells. The lactate dehydrogenase (LDH) level was 284 IU/L, and the CD4 count was 27 cells/[micro]L. An arterial blood gas analysis done with the patient breathing mom air revealed a Pa[O.sub.2] of 60 mm Hg with an alveolar-arterial gradient of 53. The chest radiograph showed bilateral interstitial infiltrates, and an abdominal sonogram showed a gravid uterus at 24 weeks and a viable fetus. She was empirically treated with sulfamethoxazole-trimethoprim (SXT), erythromycin, and oral prednisone. PCP was diagnosed using BAL. SXT was continued with a tapering dose of oral prednisone for 21 days. She was discharged and was readmitted to the hospital at 33 weeks of gestation with labor pains of a few hours in duration. She had noticed no fetal movements over the previous 2 weeks, and an abdominal sonogram confirmed fetal death. She vaginally delivered a macerated fetus (male, weighing 605 g), complicated by retained placenta and endometritis, but she recovered and was discharged home.

Case 2

A 31-year-old white woman was admitted to the hospital with respiratory distress at 29 weeks of gestation with a 10-day history of a minimally productive cough and shortness of breath. Laboratory studies revealed LDH level of 1,294 IU/L and a CD4 count of 24 cells/[micro]L. The chest radiograph showed diffuse bilateral interstitial infiltrates. She was presumptively treated for PCP with IV SXT and methylprednisone. Respiratory failure developed, and the patient required mechanical ventilation. The diagnosis was confirmed using open-lung biopsy on the fifth hospital day. Five days later, the treatment was changed to IV pentamidine due to lack of adequate response. On day 22, she delivered a live fetus vaginally. Both mother and neonate died 3 days later.

Case 3

A 31-year-old African-American woman was admitted to the hospital at 26 weeks of gestation with cough, severe shortness of breath, fever, and a 20-lb weight loss. A chest radiograph revealed diffuse bilateral infiltrates. The Pa[O.sub.2] was 48 mm Hg on a nonrebreathing mask. She was placed on mechanical ventilation and empirically treated with cefuroxime and erythromycin. An abdominal sonogram showed a gravid uterus at 25 weeks of gestation, and fetal heart sounds were detected. Further investigation revealed a CD4 count of 33 cells/[micro]L, and the therapy was changed to SXT and oral prednisone. The HIV-antibody test result was positive, and PCP was confirmed using BAL. On day 10, because of poor response to SXT, the therapy was again changed to IV pentamidine. She responded well and was successfully extubated on day 17. Her hospital course was complicated by Escherichia coli sepsis, but she recovered and was discharged home. She was readmitted to the hospital at 37 weeks with sonographic findings of oligohydramnios. She had a normal vaginal delivery of a live female infant.

Case 4

A 30-year-old white woman at 17 weeks of gestation was admitted to the hospital with dry cough, progressive shortness of breath, and occasional fever with night sweats of a 2-week duration. The chest radiograph revealed bilateral interstitial infiltrates, and Pa[O.sub.2] was 56 mm Hg on room air with an alveolar-arterial gradient of 45. She was treated with erythromycin, SXT, and oral prednisone. The CD4 count was 33 cells/[micro]L. On day 3, she was prophylactically intubated for bronchoscopy but she desaturated after intubation, became hypotensive, and the chest radiograph findings worsened. Bronchoscopy was deferred. On day 4, she had a cardiac arrest and died. A limited autopsy was done that confirmed the diagnosis of PCP in the mother; the fetus was not examined.

Case 5

A 23-year-old Hispanic woman at 20 weeks of gestation was admitted to the hospital with a 2-month history of progressive dyspnea, nonproductive cough, fever, and weight loss. She had a temperature of 38.9 [degrees] C, a respiratory rate of 40 breaths/min, oral thrush, and scattered rhonchi in both lung fields. The LDH level was 562 IU/L, and Pa[O.sub.2] was 92 mm Hg on room air. The chest radiograph revealed bilateral diffuse infiltrates. She was treated with erythromycin but subsequently deteriorated. On day 6 of her hospitalization, a fiberoptic bronchoscopy was performed and her therapy was changed to SXT. The diagnosis of PCP was confirmed using BAL, and she completed a 21-day course of IV SXT with clearing of her chest radiograph. The patient was discharged home, but she was lost to follow-up.

Data Collection and Analysis

The MEDLINE (National Library of Medicine, Bethseda, MD) search of the literature was performed using the following key words: "human immunodeficiency virus," "HIV," "acquired immunodeficiency virus," "AIDS," "Pneumocystis carinii pneumonia," and "PCP," which were cross-referenced with the word "pregnancy." All English-language articles were reviewed. Data were manually extracted from all cases, case series, and studies, and emphasis was placed on to arrange and formulate all information and observations reported so far into a format that provides a brief but comprehensive overview of the subject. Seventeen cases of PCP during pregnancy reported previously were identified. All 22 cases (including the 5 cases presented in this article) were analyzed for clinical characteristics, maternal and fetal outcomes, and management.

RESULTS

All cases of PCP during pregnancy in HIV-infected patients are summarized in Tables 1, 2. In this series of 22 pregnant women with PCP, 11 patients (50%) died of pneumonia. The incidence of respiratory failure among pregnant women with PCP is also quite high. Thirteen of 22 patients (59%) required mechanical ventilation, 4 of 22 patients (18%) did not require mechanical ventilation, and in five case reports (22%) the issue was not addressed. Of those requiring mechanical ventilation, the survival rate was 31%.