Pregnant Women and Novel Influenza A (H1N1)
As Of the last several months – June/July 2009 – There has been an alarm raised about women who are pregnant when they contract influenza A [H1N1] strain of the virus. It appears that women who are pregnant and especially those in their final trimester, have a higher incidence of H1N1 and it appears to be more severe. Experts believe that this is a result of a diminished immune system in women at this particular time.
The Message is clear that women who appear showing influenza type symptoms or illness need to be treated as quickly as possible. There shouldn’t be any waiting for a test result to verify the illness. There has been an update of the advice for preventative prophylactic treatment with antivirals in groups prone to risk [or chemoprophylaxis]. There have also been instructions updates for infant feeding that looks further into using masks and a requirement for a careful stance on stemming viral infection in infants though there is not much information to refer to. The recommendations are fluid based upon what is currently understood about the H1N1 viral spread within America and updates are planned as data becomes available.
The first known human infection with this strain of swine flu [the name was changed by the WHO to Novel influenza A H1N1 due to concerns over pork sales among other reasons] occurred in April 2009. The illness has been severe in pregnant women though the depth and transmission of this strain is under intense examination to better understand its effect on pregnant women and infants.
Though current information is not readily available, harkening back to past epidemics and pandemics is useful and available data for seasonal influenza and the effect on pregnant women is also being used in studies. There were an above average number of influenza linked fatalities in pregnant women throughout the Spanish influenza pandemic of 1918-1919 and the pandemic of Asian flu in 1957-1958. There have been unfavorable pregnancy results reported subsequent to prior influenza pandemics including miscarriage and premature births particularly in those women who contracted pneumonia.
Case studies and epidemiology reports carried out during pandemics past and interpandemic periods concluded that a women’s risk is greater during her pregnancy for complications related to influenza and there are signs of perinatal difficulties and delivery problems.
Women who become infected with the Novel influenza H1N1 strain of the infection it is predicted would have the normal respiratory illness seen in influenza cases presenting symptoms such as sore throat, runny nose, fever and cough. Perhaps accompanied by body aches, headaches, fatigue, diarrhea and vomiting and most pregnant women will proceed with a normal infliction of influenza without complication.
However, certain pregnant women will find the illness hitting harder and faster than others and possibly have secondary infections such as bacterial pneumonia. It’s during these difficult times for the mother that prenatal fetal distress caused by the maternal illness. There are reports of maternal fatalities as well as fetal complication outcomes linked to relentless illness. The ideal scenario would have the pregnant women being tested for influenza at an early symptomatic phase but delays in treatment for testing and awaiting those results are highly inadvisable since antiviral treatment are at their most effectual in the first forty eight hours of from the beginning of symptoms.
Testing will often take several days and may not be available at all for the Novel H1N1 though research is being undertaken vigorously to discover a rapid testing kit with great progress being made.
Primary health care providers need to be aware of the influenza outbreak in local areas of their practice and bypass the testing process in favor of treatment in those women who are pregnant and presenting symptoms of H1N1 influenza A illness.
Treatment and Chemoprophylaxis
Pregnant women who present with influenza like symptoms should undergo the earliest treatment possible with antiviral medications. Health care providers mustn’t wait for test results to come in to determine if influenza exists before starting treatment. Therapy should be initiated as soon as possible once symptoms begin to show for the best chance of success with these medications. The H1N1 influenza that is currently being transmitted has shown sensitivity to the neuraminidase inhibitor antiviral drugs zanamivir [Relenza®] and oseltamivir [Generic Tamiflu] but has built a resistance to adamantane antivirals amantadine [Symmetrel®] plus rimantadine [Flumadine®] .
Generic Tamiflu is an oral medication and the drug is absorbed systemically and the zanamivir is inhaled which lowers the systemic absorption somewhat. Tamiflu and Relenza as treatments and chemoprophylaxis course of therapies are suggested for women who are pregnant and are the same as if for an adult who is inflicted with seasonal influenza. In no way should a pregnancy be measured as a contraindication to tamiflu or Relenza usage. All indicators show pregnant women are more susceptible to harsh complications resulting from a bout with Novel H1N1 influenza A infection. They would benefit from a course of treatment or preventative therapy using Generic Tamiflu or Relenza, the risks outweighed by the antiviral use at this stage of infection in a pregnant women.
There have been some unfavorable reactions in those women who have ingested the antivirals generic tamiflu and Relenza though there has been no link between these adverse effects and actually taking generic tamiflu or relenza in pregnant women. It is recommended that health care providers stay up to date on CDC releases for the further use of generic tamiflu and relenza for H1N1 influenza A infection as the virus’ data is compiled over time so patients can further benefit.
Treatment Recommendations
Pregnant women showing flu like symptoms should have their medicinal therapy initiated before a firm diagnosis is confirmed. Because of its absorption process generic tamiflu is the drug treatment of choice and the treatment course recommended should last five days. There should not be any hold up of treatment while awaiting testing results since antiviral drugs for empirical use for anyone on this regimen need to be started within forty eight hours of the onset of influenza indicators being discovered. This therapy initiative is based on information collected from research conducted during seasonal influenza outbreaks.
This data also showed that there are benefits to those patients who are in hospital receiving the medication even after the forty eight hour time period so the antivirals are to be initiated for all high risk individuals who are symptomatic and in need of care whether or not the forty eight hour onset rule is exceeded, including pregnant women, persons with chronic illness and lowered immunity levels and those who require hospitalization.
Chemoprophylaxis Recommendations
Subsequent contact viral prophylactic use of medications like generic tamiflu and zanamivir should be judged useful for pregnant women who are confirmed or suspected of being infected with the Novel influenza A H1N1 virus. The medication most recommended for disease prevention or as a transmission inhibitor is likely zanamivir because of its partial systemic absorption properties. There could be certain problems associated with zanamivir usage because it is administered as an inhalant which may result in respiratory complications in women at risk of these ailments. Tamiflu then becomes the drug of choice for these patients.
The duration for this preventative treatment course is ten days after exposure to H1N1 virus was finally noticed. Pregnant women in multiple exposure situations to the virus in familial circumstances as an example, need to be monitored closely to determine the actual time period for preventative treatment depending on their medical situation and how it develops.
Hyperthermia [Fever] Treatment
One severe unpleasant symptom that affects influenza sufferers is the related hyperthermia or fever condition in a patient. Research has revealed that hyperthermia in pregnant women specifically in the first three months of pregnancy doubles the odds of having developmental problems with the fetal central nervous system or neural tube defects and could also be responsible for other birth defects and unfavorable birth results. Some research shows that hyperthermia related birth complications may be lessened by medications such as antipyretics or multivitamins such as folic acid which is highly recommended even for naturally progressing pregnancies.
Pregnancy related fever during labor constitutes further risks like developmental complications and neonatal problems such as seizures, cerebral palsy, encephalopathy and even neonatal fatality. Trying to determine the cause of a fevers effects from the fever itself is troubling so treatment of the hyperthermia is the first priority and Acetaminophen seems to be the choice option for fever control during a pregnancy.
The suggested dosages for antiviral drug treatment for novel influenza A H1N1 strain virus infections are as follows:
Tamiflu [Oseltamivir]
Adults should take 75 mg capsule twice daily for five days – 75 mg capsule once daily.
Zanamivir
Adults should inhale two 5 mg doses [10 mg total] twice daily for 5 days – Two 5 mg inhalations [10 mg total] once daily.
Other Ways To Reduce Risk For Pregnant Women
Currently there is not a vaccine available for the prevention of influenza A H1N1 infection though medical researchers are working feverishly to develop a potent anti virus vaccine. Therefore, the risk of getting infected by the influenza virus could be dramatically reduced if certain precautions are taken to decrease the chance of accidental exposure. Individuals should practice the following steps:
- Washing hands frequently for twenty seconds
- Minimize one’s contact with infected individuals
- Making certain those infected with the flu remain house bound [leaving only for medical aid]
- Coughing or sneezing into the elbow crook
- Practice social distancing by keeping at least six feet away from groups or crowded environments and staying away from areas of H1N1 infectious outbreak exposure.
- When required use a mask or respirator in the proper fashion.
Infant Feeding Considerations
Babies who are not being breast fed are at more risk of respiratory infection and are further susceptible to illness and a hospital stay than babies who are being nursed. Those women who remain influenza free should be positively reinforced to start or continue their breast feeding regimen and do so often. Under the proper conditions infants should be receiving their primary nourishment and nutritional enrichment from breast milk and so any bottle supplements should cease so babies can take in as many of their mothers antibodies as possible.
When considering H1N1 influenza and children it is thought that infants are at the most risk of all from H1N1 infection and precious little is known or understood about the infection in tiny infants. Recommendations such as only healthy adults should care for babies including feedings. Again little is known about the transmission of influenza A H1N1 virus through breast milk though reports of virus in the bloodstream for seasonal influenza is uncommon, the passing of infection into mother’s milk is likely just as infrequent an occurrence. If the possibility exists to pump milk from a virus infected mother for bottle supplementation feeding by a healthy family member, this process should be reinforced positively. It should once again be noted that generic tamiflu or relenza are not contraindicated for breast feeding.
Proper hygienic etiquette is crucial to women who are alone caring for infants while infected with influenza H1N1 virus. Ideally when ill there will be someone else available to assist with infant children. Women who are infected should also wear a facemask when feeding babies and caring for them in general to reduce the transmission of the virus.
Parents and caretakers need to be instructed on the proper methods for reducing the spread of infections like influenza A H1N1 virus which can result in respiratory complications and illness.
- Always wash hands and practice cough etiquette
- Use social distancing with children and keep them away from crowds.
- Be careful to control sharing of toys or other personal things which may have been in a child’s mouth and clean with soap and water if these items have been touched orally.
- Keep a supply of disinfectant wipes available for quick cleansing of hands or objects.