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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
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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.
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
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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.
Aboubakr Elnashar
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
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
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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
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.
Aboubakr Elnashar
• 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
Aboubakr Elnashar
Thank you Prof. Aboubakr Elnashar
Benha University Hospital, Egypt [email protected]
Aboubakr Elnashar