What is the recommended management for a pregnant patient at 17 weeks with Respiratory Syncytial Virus (RSV) infection?

Management of RSV Infection in a Pregnant Patient at 17 Weeks

For a pregnant patient at 17 weeks with active RSV infection, provide supportive care only, as there is no specific antiviral treatment for RSV, and this gestational age is too early for RSV vaccination (which is only indicated at 32-36 weeks for infant protection, not maternal treatment). 1, 2

Acute Management of Current RSV Infection

Supportive Care Approach

• Treat symptomatically with rest, hydration, and antipyretics as needed for fever and discomfort, as RSV management is entirely supportive regardless of pregnancy status 1, 2
• Monitor for signs of severe respiratory compromise including increased work of breathing, hypoxemia, or inability to maintain oral intake 1
• Consider hospitalization if the patient develops severe respiratory distress, requires supplemental oxygen, or shows signs of respiratory failure 1

Medications Safe in Pregnancy

• Use acetaminophen as the preferred antipyretic for fever management, as it is safe throughout pregnancy 3
• Avoid NSAIDs, particularly after 20 weeks gestation due to risks of oligohydramnios and premature ductus arteriosus closure 3
• Saline nasal rinses are safe and can provide symptomatic relief for nasal congestion 3
• Avoid oral decongestants due to potential risks of fetal gastroschisis and maternal hypertension 3

Important Clinical Pitfall

• Do not routinely test for RSV in pregnant patients with mild respiratory illness, as testing should prioritize influenza and COVID-19 where specific antiviral treatments exist 2
• RSV testing is only warranted if the patient presents with severe illness requiring hospitalization 2

Future RSV Prevention Strategy (Not Applicable Now)

Timing Considerations for This Patient

• At 17 weeks gestation, this patient is too early for RSV vaccination, which is only recommended between 32 weeks 0 days and 36 weeks 6 days of gestation 3, 4, 5
• The current RSV infection does not change future vaccination recommendations 4, 6

Plan for Later in Pregnancy

• Counsel the patient that she should receive RSVpreF vaccine at 32-36 weeks gestation if she will be in that window during September through January (RSV season in most of the continental United States) 3, 4, 5
• The vaccine is given as a single 0.5 mL intramuscular dose to prevent severe RSV disease in her infant during the first 6 months of life 4, 6
• At least 14 days are required after maternal vaccination for adequate antibody development and transplacental transfer to protect the infant 3, 4

Alternative Strategy Discussion

• If the patient declines vaccination or delivers outside RSV season, her infant should receive nirsevimab (monoclonal antibody) after birth if born during or entering RSV season and aged <8 months 3, 4
• Both maternal vaccination and infant nirsevimab are not needed for most infants 3, 4

Safety Considerations for Future Vaccination

• Be aware of potential preterm birth risk: clinical trials showed 5.7% preterm births in vaccine group vs 4.7% in placebo during 24-36 weeks dosing, though not statistically significant 5
• In the approved 32-36 week interval, preterm births occurred in 4.2% vaccine group vs 3.7% placebo, with most occurring at 36 weeks (72% of vaccine group preterm births) 5
• Hypertensive disorders of pregnancy were observed more frequently in vaccine recipients, though not statistically significant 5
• The FDA determined benefits outweigh risks when administered at 32-36 weeks gestation, as RSV causes 58,000-80,000 annual hospitalizations in children under 5 years 5

Key Clinical Pearls

• Current RSV infection at 17 weeks requires only supportive care - there is no specific treatment and no role for vaccination at this gestational age 1, 2
• The patient's current infection does not contraindicate future RSV vaccination at the appropriate gestational age 4, 6
• RSV vaccine can be co-administered with Tdap, influenza, and COVID-19 vaccines at different anatomic sites when she reaches 32-36 weeks 5