Introduction Pregnant women with 2009 pandemic influenza A (H1N1) are shown to be at risk of respiratory complications and adverse outcomes. The authors present an atypical case of a pregnant lady with swine flu and discuss the dilemmas surrounding her management.

History A 20-year-old Caucasian, admitted at 26+5 weeks gestation with atypical symptoms of fever, dysuria and loin pain was treated initially as pyelonephritis before developing non-productive cough and chest tightness the following day. Her respiratory compromise worsened over the next 72 h resulting in type-I respiratory failure and requiring transfer to intensive care unit (ICU) and later intubation. While in ICU swabs for H1N1 were sent and found positive. She was given antenatal steroids. Aggressive ICU management stabilised but did not improve her condition. In our case the dilemma was whether delivery of a preterm baby in order to improve the outcome for ventilation of a very ill mother was justified, as there is no robust evidence to suggest or refute the above. At 28+4 days she ruptured her membranes and delivered by emergency caesarean section. She was transferred to the ward after 24 days in ICU and is doing well.

Discussion Dilemmas regarding atypical presentations, delivery and management of a critically ill mother with swine flu will be presented.

Conclusion Our case highlights the challenges from atypical clinical presentations, especially in pandemics. However, the dilemma of whether delivery improves outcome for ventilation of critically ill mothers remains unsolved.