Clinical:H1N1 in Pregnancy: Practical Considerations

November 27th, 2009

Of great concern is the recent finding that H1N1in pregnancy may result in a higher risk of hospital admission, serious morbidity, and even death when compared to H1N1 in the general population. (1) While pregnant women represent only about 1% of H1N1 cases, they have been reported to account for up to 5% of H1N1 deaths, and early reports suggest pregnant women with H1N1 are about four times more likely to require hospital admission. This document provides a summary of current recommendations and active links to more information. It also provides practical, logistical information in dealing with patients who have, or are suspected to have, H1N1 in pregnancy. At the time of this writing, there are no evidence-based recommendations that address the triage of suspected H1N1 in pregnancy, care of a mother and newborn if a mother is delivered at the time of acute H1N1 infection, and concerns about breastfeeding. This document offers a preliminary opinion on these topics, pending more complete evidence.

The CDC provides specific guidance on pregnant women at http://www.cdc.gov/h1n1flu/clinician_pregnant.htm

Clinical Considerations

Realizing that information continues to accrue, and that the suggestions in this document may become quickly dated, the following is offered for consideration by clinicians caring for pregnant women:

• Assuring that pregnant patients are educated about the symptoms of H1N1 and the benefits of handwashing. It may be wise to print out and hand to each patient the CDC information found on the CDC website^[1]. It is very clear and concise information designed to be read by patients.

• ACOG recommends inactivated seasonal flu vaccine for all pregnant women in every trimester Please consider immunizing your patients in your office. As ACOG implores “If you have not already done so, please immediately order your seasonal flu vaccine from an IVATS distributors. IVATS was developed to enable healthcare providers to find influenza vaccine to purchase, especially during the critical vaccination period. ^[2]

• Contact your local health department to obtain a free supply of H1N1 vaccine when available.

• Remember-CDC advises that you do not need to confirm influenza to initiate treatment. Assume that pregnant women with bona fide flu symptoms such as fever, muscle aches, GI upset and sore throat are infected.

• Treat those with flu-like symptoms with a therapeutic course of oseltamivir (75 mg twice daily for 5 days. You need not wait for a confirmatory test to treat. Early treatment (within 48 hours of symptoms) is recommended.

• Treat flu exposure with a prophylactic course of oseltamivir (75 mg once daily for 10 days).

• Consider working with your hospital’s emergency department to create an alternative space to evaluate women with suspected H1N1. In our practice at Yale, we are discouraging our providers from evaluating suspected cases in their offices or the Labor and Delivery suite. Patients are referred to the ED unless they have a more significant OB-related complaint (like active labor). In the ED, they are evaluated, and if they require admission, they are masked before being transported to the floor to help prevent transmission. We think it is unwise for women with suspected H1N1 to share waiting room or other close quarters with healthy pregnant women.

• If it is impractical to divert suspected H1 N1 cases to your local ED and you must evaluate such patients in your office, consider having such patients being greeted outside your office, having a face mask placed, and being escorted directly to an exam room (thereby bypassing the waiting area). The exam room which should have all surfaces appropriately cleaned after the evaluation.

• Consider a low threshold for hospital admission for suspected cases in pregnancy.

• For those patients not admitted to the hospital, consider daily phone contacted with you or a staff member to help identify rapid disease and morbidity progression.

• ACOG has an excellent triage/treatment algorithm found here:

http://www.acog.org/departments/resourceCenter/2009H1N1TriageTreatment.pdf

Treatment in Pregnancy

Cases of H1N1 influenza have been reported in pregnancy in the United States ^[3].

Pregnancy is a state of alterations in the immunological, cardiovascular, and respiratory systems that place patients at increased risk during some illnesses. With seasonal influenza, pregnant women are at increased risk of morbidity and mortality, with complications such as respiratory failure. It is not yet known whether pregnant women with Influenza A H1N1 will be similarly affected. Pregnant women who become ill with flu-like symptoms should contact their health care worker early in the course of illness to confirm the diagnosis of influenza and to determine if antiviral medications are indicated. The CDC is preferentially recommending oseltamivir at this time, because its systemic absorption may provide better protection against mother-to-child transmission.^[4] Treatment should be initiated within 48 hours of symptom onset and a 5 day course is recommended. Pregnant women with exposure to confirmed, probable, or suspected H1N1 influenza should consider taking a preventative course of oseltamivir or zanamivir for 10 days.^[5] Illness with influenza is NOT a contraindication to nursing. Furthermore, pregnancy or nursing are NOT contraindications to taking antiviral zanamivir or oseltamivir.^[6]

Following delivery of a mother suspected of being H1N1 infected, you may also consider:

• Refraining from placing the infant on the mother’s chest and in close contact. If the mother desires close contact then she must wear a mask (N95 or other) and contact should be limited to a few minutes.

• That the infant be admitted to the well newborn nursery and not have contact with mother while she continues to have symptoms.

• No family members with suspected H1N1 should visit the newborn

• If a mother refuses to allow the infant to remain in the nursery then the infant should “room in” and not be transferred back and forth from the nursery.

As of November 10, 2009, the CDC recommends:

• The healthy term newborn of a mother with ILI should be considered exposed, rather than infected if they are born in the hospital setting following infection control guidelines and be observed for signs of infection. These newborns should be cared for with standard precautions whether they are cared for in the mother’s room or in the Well Baby Nursery.

It is recommended that the infant be temporarily separated from the infected mother until the risk of infectious transmission is reduced, defined as having met ALL of the following:

1.The mother has received antiviral medication for at least 48 hours and

2. The mother is without fever for 24 hours without antipyretics and

3. The mother can control cough and respiratory secretions

Once these criteria are met, the mother and infant can initiate close contact with droplet precautions observed.

Breastfeeding Recommendations with suspected maternal H1N1:

• All patients should be aware that while giving the baby breastmilk may help protect the baby from infections, including H1N1, it is not known if the virus is found in breastmilk or if latching on to the breast may increase the chance of infection. We do not recommend that a healthy baby latch on to the breast of a symptomatic mother.

• Sick women who are able to express their milk for bottle feedings by a healthy family member should be encouraged to do so. Antiviral medication treatment or prophylaxis is not a contraindication for breastfeeding.

• We recommend that if mother chooses to breastfeed then a lactation consultation should be initiated.

• We recommend mother should begin pumping as soon as possible. Initial colostrum should not be discarded but saved for the infant. The patient may request “no formula” and that request should be honored unless medically contraindicated.

• When pumping, the mother should don a mask, complete meticulous hand hygiene and then apply gloves. She should cleanse the area around the areola with soap and water and allow todry prior to pumping. Bottles should be wiped with an appropriate solvent prior to leaving the mother’s room.

• If a mother becomes symptomatic with H1NI following delivery, and following extensive contact with the baby, that baby should be roomed in and fed at the breast if possible.

External Links

• The Centers for Disease Control and Prevention( CDC) have established an excellent web resource for information: 2009 H1N1 Flu . Likewise, the CDC provides specific guidance on pregnant women at Pregnant Women and Novel Influenza A (H1N1) Virus: Considerations for Clinicians.

• The American College of Obstetricians and Gynecologists (ACOG) web pages should also be checked regularly for updates.

References:

1. ↑ CDC H1N1 Flu. What Should Pregnant Women Know About 2009 H1N1 Flu (Swine Flu)? http://www.cdc.gov/h1n1flu/guidance/pregnant.htm
2. ↑ Influenza Vaccine Availability Tracking System http://www.preventinfluenza.org/ivats/
3. ↑ CDC Morbidity and Mortality Weekly Report. Novel Influenza A (H1N1) Virus Infections in Three Pregnant Women --- United States, April--May 2009 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0512a1.htm?s_cid=mm58d0512a1_e
4. ↑ CIDRAP. CDC urges vigilance for pregnant women with flu symptoms. http://www.cidrap.umn.edu/cidrap/content/influenza/swineflu/news/may1209pregnancy-br.html
5. ↑ Novel Influenza A (H1N1) Virus Infections in Three Pregnant Women --- United States, April--May 2009 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm58d0512a1.htm?s_cid=mm58d0512a1_e
6. ↑ CDC. What Pregnant Women Should Know About H1N1 (formerly called swine flu) Virus. http://www.cdc.gov/h1n1flu/guidance/pregnant.htm, acc 5/16/09

7. Jamieson DJ, Honein MA, Rasmussen SA, Williams JL, Swerdlow DL, Biggerstaff MS, Lindstrom S, Louie JK, Christ CM, Bohm SR, Fonseca VP, Ritger KA, Kuhles DJ, Eggers P, Bruce H, Davidson HA, Lutterloh E, Harris ML, Burke C, Cocoros N, Finelli L, MacFarlane KF, Shu B, Olsen SJ; Novel Influenza A (H1N1) Pregnancy Working Group. H1N1 2009 influenza virus infection during pregnancy in the USA. 1: Lancet. 2009 Aug 8;374(9688):451-8. Epub 2009 Jul 28.