H1N1 virus infection and

Pregnancy

Aboubakr Elnashr

Contents •Introduction •Clinical picture •Diagnosis •Complications •Treatment •Prevention •Conclusion

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Introduction •April 2009: First identified

Epidemiology: not fully understood

•May 2009: CDC: severe complications in pregnant women

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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)

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•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.

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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}.

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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

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Complications exacerbation of underlying ch conditions

res tract disease

cardiac complications

musculoskeletal complications

neurologic complications

toxic shock syndrome

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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.

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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

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•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.

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Treatment I. Antiviral

II. General

III. Infection control

IV. Breast feeding

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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

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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

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2. Zanamivir (Relenza®) •Results in lower systemic absorption.

•Dose:

Two 5-mg inhalations (10 mg total) twice/d

for 5 d

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•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

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II. General •Antipyretics (avoid aspirin in children). Acetaminophen is the best •Oral fluids •Nutrition •Bed rest

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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.

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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.

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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 }

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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.

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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.

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Prevention of H1N1 influenza in

pregnancy 1. General precautions

2. Antiviral chemoprophylaxis for close contacts at high-risk

for complications

3. Vaccination

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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

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•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

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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

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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

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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

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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

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•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

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Conclusions • All obstetricians should be familiar with the

symptoms, TT& prevention of H1N1 infection

in pregnant women.

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• For pregnant females 1. General precautions for prevention are important 2. Chemoprophylaxis if close contacts with

suspected or confirmed cases within 7d 3. Vaccination with inactivated& not live attenuated

vaccine 4. Treat as soon as possible; do not wait results of

testing for influenza 5. Breast feeding is encouraged

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Thank you Prof. Aboubakr Elnashar

Benha University Hospital, Egypt elnashar53@hotmail.com

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