Delivery of fetus death with misoprostol in a pregnant woman with H7N9 avian influenza A virus pneumonia and ARDS

Pregnant women are susceptible to severe pneumonia and acute respiratory distress syndrome (ARDS) from influenza, which has been associated with increased fetal loss [1]. There is very little experience for the management of pregnant women with severe pneumonia and ARDS from avian influenza A (H7N9) virus, especially when complicated by intrauterine fetal death (IUFD). A 28-year-old pregnant woman was admitted to the hospital due to dyspnea, dry cough, and fever. The patient was at 26 weeks gestation. Infection with influenza A (H7N9) virus was confirmed from a tracheal aspirate sample using polymerase chain reaction assays. The fetus was monitored daily to check the heart rate and on admission the fetal heart rate was 140 beats/minute. The patient’s initial blood pressure was 70/45 mmHg, which was unresponsive to volume resuscitation. Norepinephrine was administrated to rescue septic shock and was required until day 11. On day 2, the beating of the fetal heart stopped as a result of severe, refractory hypoxemia (arterial oxygen pressure <50 mmHg, 24 hours). Echocardiography showed severe right ventricular dysfunction and severe left ventricular systolic dysfunction with decreased ejection fraction (26%). The renal function was slightly reduced with an elevated serum creatinine level (225 μmol/l). Despite the administration of oseltamivir, the patient’s condition progressed quickly. Thoracic imaging showing diffuse bilateral infiltrates along with evidence of impaired gas exchange led to the diagnosis of ARDS. Difficulties in oxygenation and a deteriorating medical