H1 N1 virus infection and pregnancy

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 H1 N1 virus infection and pregnancy

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H1N1 virus infection and Pregnancy Aboubakr Elnashr Contents Introduction Clinical picture Diagnosis Complications Treatment Prevention Conclusion Aboubakr Elnashar Introduction April 2009: First identified Epidemiology: not fully understood May 2009: CDC: severe complications in pregnant women Aboubakr Elnashar Clinical presentation Acute respiratory influenza-like illness cough, sore throat, rhinorrhea fever. Other symptoms: body aches headache Fatigue vomiting diarrhea. Pregnant women shortness of breath (Dynamed,2009) Aboubakr Elnashar Social History (SH): Ask about contact with patients : febrile respiratory illness in areas with pandemic (H1N1) 2009 cases Symptoms develop within 1 w of exposure patients are contagious for 8 d thereafter. Aboubakr Elnashar Diagnosis Ideally: pregnant suspected (H1N1) virus. Rapid influenza antigen test Confirmed by reverse transcription polymerase chain reaction (RT-PCR) Treatment should not be delayed pending results withheld in the absence of testing {1. TT is most effective when started within the first 2 d 2. Testing is not available in many clinics 3. Results take several days}. Aboubakr Elnashar Complications High risk group 1.children < 2 y old 2.adults 65 y old 3.pregnant women 4.chronic medical conditions 5.disorders that compromise res function 6.persons with immunosuppression, 7.persons < 19 y on long-term aspirin 8.Morbid obesity& possibly obesity Aboubakr Elnashar Complications exacerbation of underlying ch conditions res tract disease cardiac complications musculoskeletal complications neurologic complications toxic shock syndrome Aboubakr Elnashar Effect of pregnancy on influenza 1. Many: uncomplicated course. 2. Some Rapidly, complicated Secondary bacterial infections, pneumonia. Mortality is higher especially in 3rd trimester. 5-fold increased rate of serious illness& hospitalization. Aboubakr Elnashar Effect of (H1N1) virus infection on pregnancy Severe illness: 1. Maternal deaths 2. Adverse pregnancy outcomes Spontaneous abortion PTL Fetal distress Fetal death 34 cases of (H1N1) in pregnant women (CDC from April 15, 2009 to May 18, 2009) 32% admitted to hospital 6 (17%) maternal deaths {pneumonia& ARDS} 1 in 1st trim, 1 in 2nd trim & 4 in 3rd trim Aboubakr Elnashar Hyperthermia on the foetus I. During 1st trimester: Doubles the risk of NTD other birth defects. Birth defects might be mitigated by antipyretics folic acid II. During labor: adverse neonatal& developmental outcomes: neonatal seizures encephalopathy cerebral palsy neonatal death. Aboubakr Elnashar Treatment I. Antiviral II. General III. Infection control IV. Breast feeding Aboubakr Elnashar I. Antiviral Early TT is recommended for pregnant women with suspected influenza illness. Do not wait for test results Benefit even if TT is started >48 h after onset. Empiric TT based on telephone consultation when hospitalization is not indicated (Dynamed, 2009) Influenza A (H1N1) virus is sensitive to the neuraminidase inhibitor antiviral medications Aboubakr Elnashar 1. Oseltamivir (Tamiflu) Drug of choice for TT of pregnant {systemic absorption &activity} Available: Caps: 30-mg, 45-mg, 75-mg Powder: for suspension contains 12 mg/mL after reconstitution. Duration of TT: 5 d > 5d: hospitalized patients with severe infections (CDC,2009) Dose: 75 mg orally twice daily for 5 d for adults and children 13 y 75 mg orally once daily for 5 d if creatinine clearance 10-30 mL/min Aboubakr Elnashar 2. Zanamivir (Relenza) Results in lower systemic absorption. Dose: Two 5-mg inhalations (10 mg total) twice/d for 5 d Aboubakr Elnashar Use in pregnancy: 1. Oseltamivir& zanamivir: Category C 2. Reassuring Few adverse effects in pregnant women No relation between the use of medications& adverse events. Oseltamivir is extensively metabolized by the placenta: minimal accumulation on the fetal side. 3. Benefits outweigh the theoretical risks Aboubakr Elnashar II. General Antipyretics (avoid aspirin in children).Acetaminophen is the best Oral fluids Nutrition Bed rest Aboubakr Elnashar III. Infection control: 1. Avoid crowded antenatal clinics (to avoid transmission to others) 2. Isolation from other patients 3. Discharge home as early as possible. Aboubakr Elnashar 4. If a pregnant delivers while infected with H1N1 Isolate from her infant immediately after delivery until antiviral medications for at least 48 h No fever can control her coughing& secretions. After that, continue Good hand hygiene cough etiquette facemask for the next 7 d. Aboubakr Elnashar IV. Breast feeding Antiviral medication is not a contraindication Encouraged {1. Tamiflu is unlikely to have any adverse effect on the infant. 2. Risk for transmission through breast milk is unknown. 3. Viremia with seasonal influenza infection is rare: risk of virus crossing into breast milk is rare 4. infants who are not breastfeeding are at increased risk for infection& hospitalization for severe respiratory illness } Aboubakr Elnashar 1. Hand hygiene 2. Cough etiquette 3. Facemasks If maternal illness prevents safe feeding at breast: Express their milk for bottle feedings by a healthy family member. Aboubakr Elnashar Protect infant: Hand hygiene Cough etiquette Keep the infant away from persons who are ill& out of crowded areas. Limit sharing of toys& other items that have been in infants' mouths. Wash thoroughly with soap& water any items that have been in infants' mouths. Aboubakr Elnashar Prevention of H1N1 influenza in pregnancy 1. General precautions 2. Antiviral chemoprophylaxis for close contacts at high-risk for complications 3. Vaccination Aboubakr Elnashar I. General precautions: CDC , 2009 The most important strategies in the prevention of H1N1 influenza in pregnancy. frequent hand washing with soap& water or alcohol- based hand cleaner covering coughs& sneezes & hygienic disposal of tissues avoid touching eyes, nose& mouth Aboubakr Elnashar ill (confirmed or probable) persons to: stay home (except to seek medical care) minimize contact with others in household for at least 24 h after fever is gone (fever should be gone without use of fever-reducing medicine, fever defined as tem > 37.8 C) does not apply to health care settings where exclusion period should be continued for 7 d from symptom onset or until the resolution of symptoms reduction of unnecessary social contacts avoidance of crowded settings when possible Aboubakr Elnashar II. Chemoprophylaxis: CDC Recommendation, 2009 Indication: Pregnant women who are close contacts of persons with suspected or confirmed cases Initiated within 7 d of exposure. Dose: 75 mg orally daily for 10 d Duration: At least 10 d May be >: where multiple exposures are likely to occur e.g. within families Aboubakr Elnashar III. Vaccination CDC recommendations , 2009 5 key target populations to be vaccinated on first- come, first-served basis 1.pregnant women 2.people who live with or care for children < 6 ms old 3.health care& emergency services personnel 4.persons aged 6 ms through 24 ys 5.people aged 25-64 ys at higher risk for pandemic (H1N1) due to ch health disorders or compromised immune systems Aboubakr Elnashar FDA approved vaccines 3 monovalent inactivated injectable vaccines (CSL): approved for adults > 18 y (Novartis ): approved for persons > 4 y (Sanofi Pasteur): approved for persons > 6 ms Dosing single 0.5 mL dose for adults and children 10 ys two 0.5 mL doses about 1 month apart for children ages 36 ms to 9 ys two 0.25 mL doses about 1 month apart for children ages 6-36 months Aboubakr Elnashar 1 live attenuated intranasal Monovalent vaccine (MedImmune LLC): approved for persons aged 2-49 y Dose: single 0.2 mL dose for adults and children 10 years old two 0.2 mL doses about 1 month apart for children ages 2-9 years each 0.2 mL dose given as 0.1 mL per nostril Aboubakr Elnashar Side effects: similar to seasonal influenza vaccines {manufactured using similar processes} live attenuated intranasal vaccines; not recommended for children < 2 y pregnant women people with ch underlying conditions Aboubakr Elnashar Conclusions All obstetricians should be familiar with the symptoms, TT& prevention of H1N1 infection in pregnant women. 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