Pregnant Women and Novel Influenza A

(H1N1) Considerations for Clinicians

NOTE On May 22, 2009, CDC issued updated Interim Recommendations for Facemask
and Respirator Use to Reduce Nove Infuen!a " #$%N%& 'irus (ransmission) (*is ne+
,uidance s*oud -e considered t*e most up.to.date and supersede previousy issued
,uidance)
Content reated to masks and respirators on t*is +e- pa,e +i -e updated to refect t*e
ne+ ,uidance in t*e near future)
May /, 2009 0123 4M 5(
On t!is Page
6ack,round
Cinica presentation
(reatment and c*emoprop*ya7is
Ot*er +ays to reduce risk for pre,nant +omen
6reastfeedin, considerations
"ac#ground
$uman infections +it* a nove infuen!a " #$%N%& virus t*at is easiy transmissi-e
amon, *umans +ere first identified in "pri 2009) (*e epidemioo,y and cinica
presentations of t*ese infections are currenty under investi,ation) (*ere are insufficient
data avaia-e at t*is point to determine +*o at *i,*er risk for compications of nove
infuen!a " #$%N%& virus infection) $o+ever, it8s reasona-e to assume t*at t*e same a,e
and risk ,roups +*o are at *i,*er risk for seasona infuen!a compications aso s*oud -e
considered at *i,*er risk for nove infuen!a " #$%N%& compications)
5vidence t*at infuen!a can -e more severe in pre,nant +omen comes from o-servations
durin, previous pandemics and from studies amon, pre,nant +omen +*o *ad seasona
infuen!a) "n e7cess of infuen!a.associated e7cess deat*s amon, pre,nant +omen +ere
reported durin, t*e pandemics of %9%9:%9%9 and %93/:%939) "dverse pre,nancy
outcomes *ave -een reported foo+in, previous infuen!a pandemics, +it* increased
rates of spontaneous a-ortion and preterm -irt* reported, especiay amon, +omen +it*
pneumonia) Case reports and severa epidemioo,ic studies conducted durin,
interpandemic periods aso indicate t*at pre,nancy increases t*e risk for infuen!a
compications for t*e mot*er and mi,*t increase t*e risk for adverse perinata outcomes
or deivery compications)
Clinical $resentation
4re,nant +omen +it* nove infuen!a " #$%N%& virus +oud -e e7pected to present +it*
typica acute respiratory iness #e),), cou,*, sore t*roat, r*inorr*ea& and fever or
feveris*ness) Many pre,nant +omen +i ,o on to *ave a typica course of uncompicated
infuen!a) $o+ever, for some pre,nant +omen, iness mi,*t pro,ress rapidy, and mi,*t
-e compicated -y secondary -acteria infections incudin, pneumonia) Feta distress
associated +it* severe materna iness can occur) 4re,nant +omen +*o *ave suspected
nove infuen!a " #$%N%& virus infection s*oud -e tested, and specimens from +omen
+*o *ave unsu-typea-e infuen!a " virus infections s*oud *ave specimens sent to t*e
state pu-ic *eat* a-oratory for additiona testin, to identify nove infuen!a " #$%N%&)
Treatment and c!emo$ro$!%la&is
(*e currenty circuatin, nove infuen!a " #$%N%& virus is sensitive to t*e
neuraminidase in*i-itor antivira medications !anamivir #Reen!a;& and osetamivir
#(amifu;&, -ut is resistant to t*e adamantane antivira medications, amantadine
#<ymmetre;& and rimantadine #Fumadine;&) 4re,nant +omen +*o meet current case.
definitions for confirmed, pro-a-e or suspected nove infuen!a " #$%N%& infection
s*oud receive empiric antivira treatment) 4re,nant +omen +*o are cose contacts +it*
persons +it* suspected, pro-a-e or confirmed cases of nove infuen!a " #$%N%& s*oud
receive c*emoprop*ya7is)
"s is recommended for ot*er persons +*o are treated, antivira treatment +it* !anamivir
or osetamivir s*oud -e initiated as soon as possi-e after t*e onset of infuen!a
symptoms, +it* -enefits e7pected to -e ,reatest if started +it*in 09 *ours of onset, -ased
on data from studies of seasona infuen!a) $o+ever, some data from studies on seasona
infuen!a indicate -enefit for *ospitai!ed patients even if treatment is started more t*an
09 *ours after onset) Recommended duration of treatment is five days, and for
c*emoprop*ya7is is %0 days) Osetamivir and !anamivir treatment and
c*emoprop*ya7is re,imens recommended for pre,nant +omen are t*e same as t*ose
recommended for aduts +*o *ave seasona infuen!a) Recommendations for use of
antiviras for pre,nant +omen mi,*t c*an,e as data on antivira suscepti-iities -ecome
avaia-e)
One of t*e more +e.studied adverse effects of infuen!a is its associated *ypert*ermia)
<tudies *ave s*o+n t*at materna *ypert*ermia durin, t*e first trimester dou-es t*e risk
of neura tu-e defects and may -e associated +it* ot*er -irt* defects and adverse
outcomes) =imited data su,,est t*at t*e risk for -irt* defects associated +it* fever mi,*t
-e miti,ated -y antipyretic medications or mutivitamins t*at contain foic acid) Materna
fever durin, a-or *as -een s*o+n to -e a risk factor for adverse neonata and
deveopmenta outcomes, incudin, neonata sei!ures, encep*aopat*y, cere-ra pasy,
and neonata deat*) 5ven t*ou,* distin,uis*in, t*e effects of t*e cause of fever from t*e
*ypert*ermia itsef is difficut, fever in pre,nant +omen s*oud -e treated -ecause of t*e
risk t*at *ypert*ermia appears to pose to t*e fetus) "cetaminop*en appears to -e t*e -est
option for treatment of fever durin, pre,nancy, at*ou,* data on even t*is common
e7posure are aso imited)
4re,nancy s*oud not -e considered a contraindication to osetamivir or !anamivir use)
4re,nant +omen mi,*t -e at *i,*er risk for severe compications from nove infuen!a "
#$%N%&, and t*e -enefits of treatment or c*emoprop*ya7is +it* !anamivir or osetamivir
ikey out+ei,* t*e t*eoretica risks of antivira use) Osetamivir and !anamivir are
>4re,nancy Cate,ory C? medications, indicatin, t*at no cinica studies *ave -een
conducted to assess t*e safety of t*ese medications for pre,nant +omen) 6ecause of t*e
unkno+n effects of infuen!a antivira dru,s on pre,nant +omen and t*eir fetuses,
osetamivir or !anamivir s*oud -e used durin, pre,nancy ony if t*e potentia -enefit
@ustifies t*e potentia risk to t*e em-ryo or fetus) "t*ou,* a fe+ adverse effects *ave
-een reported in pre,nant +omen +*o took t*ese medications, no reation -et+een t*e
use of t*ese medications and t*ose adverse events *as -een esta-is*ed) 6ecause of its
systemic activity, osetamivir is preferred for treatment of pre,nant +omen) (*e dru, of
c*oice for prop*ya7is is ess cear) Aanamivir may -e prefera-e -ecause of its imited
systemic a-sorptionB *o+ever, respiratory compications t*at may -e associated +it*
!anamivir -ecause of its in*aed route of administration need to -e considered, especiay
in +omen at risk for respiratory pro-ems)
Ot!er 'a%s to reduce ris# for $regnant 'omen
(*ere is no vaccine avaia-e yet to prevent nove infuen!a " #$%N%&B *o+ever, t*e risk
for nove infuen!a " #$%N%& mi,*t -e reduced -y takin, steps to reduce t*e c*ance of
-ein, e7posed to respiratory infections) (*ese actions incude freCuent *and+as*in,,
coverin, cou,*s, and *avin, i persons stay *ome e7cept to seek medica care, and
minimi!e contact +it* ot*ers in t*e *ouse*od) "dditiona measures t*at can imit
transmission of a ne+ infuen!a strain incude vountary *ome Cuarantine of mem-ers of
*ouse*ods +it* confirmed or pro-a-e nove infuen!a " #$%N%& cases, reduction of
unnecessary socia contacts, and avoidance +*enever possi-e of cro+ded settin,s) If
used correcty, facemasks and respirators may *ep reduce t*e risk of ,ettin, infuen!a,
-ut t*ey s*oud -e used aon, +it* ot*er preventive measures, suc* as avoidin, cose
contact and maintainin, ,ood *and *y,iene) " respirator t*at fits snu,y on t*e face can
fiter out sma partices t*at can -e in*aed around t*e ed,es of a facemask, -ut
compared +it* a facemask it is *arder to -reat*e t*rou,* a respirator for on, periods of
time)
"reastfeeding considerations
Infants +*o are not -reastfeedin, are particuary vunera-e to infection and
*ospitai!ation for severe respiratory iness) Domen +*o deiver s*oud -e encoura,ed
to initiate -reastfeedin, eary and feed freCuenty) Ideay, -a-ies s*oud receive most of
t*eir nutrition from -reast mik) 5iminate unnecessary formua suppementation, so t*e
infant can receive as muc* materna anti-odies as possi-e)
If a +oman is i, s*e s*oud continue -reastfeedin, and increase feedin, freCuency) If
materna iness prevents safe feedin, at t*e -reast, -ut s*e can sti pump, encoura,e *er
to do so) (*e risk for nove infuen!a " #$%N%& transmission t*rou,* -reast mik is
unkno+n) $o+ever, reports of viremia +it* seasona infuen!a infection are rare)
57pressed mik s*oud -e used for infants too i to feed at t*e -reast) In certain
situations, infants may -e a-e to use donor *uman mik from a $M6"N".certified mik
-ank)
"ntivira medication treatment or prop*ya7is is not a contraindication for -reastfeedin,)
Instruct parent and caretakers on *o+ to protect t*eir infant from t*e spread of ,erms t*at
cause respiratory inesses ike nove infuen!a " #$%N%&1
Das* aduts8 and infants8 *ands freCuenty +it* soap and +ater, especiay after
infants pace t*eir *ands in t*eir mout*s)
Eeep infants and mot*ers as cose to,et*er as possi-e and encoura,e eary and
freCuent skin.to.skin contact -et+een mot*ers and t*eir infants)
=imit s*arin, of toys and ot*er items t*at *ave -een in infantsF mout*s) Das*
t*orou,*y +it* soap and +ater any items t*at *ave -een in infantsF mout*s)
Eeep pacifiers #incudin, t*e pacifier rin,G*ande& and ot*er items out of adutsF
or ot*er infantsF mout*s prior to ,ivin, to t*e infant)
4ractice cou,* and snee!e etiCuette)
=inks to non.federa or,ani!ations are provided soey as a service to our users)
(*ese inks do not constitute an endorsement of t*ese or,ani!ations or t*eir
pro,rams -y CDC or t*e federa ,overnment, and none s*oud -e inferred) CDC
is not responsi-e for t*e content of t*e individua or,ani!ation De- pa,es found
at t*ese inks)
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$o+ do you vie+ different fie formats#4DF, DOC, 44(, M45H& on t*is siteK
4a,e ast revie+ed May /, 2009 0123 4M 5(
4a,e ast updated May /, 2009 0123 4M 5(
W!at Pregnant Women -!ould 1no'
A2out H1N1 (formerl% called s'ine flu)
(irus
May 2, 2009 2100 4M 5(
On t!is Page
D*at if I ,et t*is ne+ virus and I am pre,nantK
D*at can I do to protect mysef, my -a-y and my famiyK
D*at are t*e symptoms of $%N%K
D*at s*oud I do if I ,et sickK
$o+ is $%N% fu treatedK
D*en s*oud I ,et emer,ency medica careK
$o+ s*oud I feed my -a-yK
Is it ok to -reastfeed my -a-y if I am sickK
Is it OE to take medicine to treat or prevent $%N% fu +*ie -reastfeedin,K
W!at if I get t!is ne' virus and I am $regnant.
De don8t kno+ if t*is virus +i cause pre,nant +omen
to *ave a ,reater c*ance of ,ettin, sick or *ave serious
pro-ems) De aso do not kno+ *o+ t*is virus +i
affect t*e -a-y)
De do kno+ t*at pre,nant +omen are more ikey to ,et
sick t*an ot*ers and *ave more serious pro-ems +it*
seasona fu) (*ese pro-ems may incude eary a-or or
severe pneumonia) De don8t kno+ if t*is virus +i do
t*e same, -ut it s*oud -e taken very seriousy)
W!at can I do to $rotect m%self3 m% 2a2% and m%
famil%.
(ake t*ese everyday steps to *ep prevent t*e spread of ,erms and protect your *eat*1
Cover your nose and mout* +it* a tissue +*en you cou,* or snee!e, or snee!e
into your seeve) (*ro+ t*e tissue in t*e tras* after you use it)
Das* your *ands often +it* soap and +arm +ater, especiay after you cou,* or
snee!e) "co*o.-ased ,e *and ceaners are aso ,ood to use)
"void touc*in, your eyes, nose or mout*) Herms spread t*is +ay)
(ry to avoid cose contact +it* sick peope) #If you are pre,nant and you ive or
*ave cose contact +it* someone +*o *as $%N% fu, tak to your doctor a-out
medicines to prevent fu)&
$ave a pan to care for sick famiy mem-ers)
<tock up on *ouse*od, *eat*, and emer,ency suppies, suc* as +ater, (yeno;,
non.peris*a-e foods)
Was!ing %our !ands often 'ill !el$ $rotect %ou
from germs
Was!ing 'it! soa$ and 'ater
Use +arm +ater)
Das* for %3 to 20 seconds)
*sing alco!ol/2ased gel !and cleaner
Don8t add +ater)
Ru- t*e ,e on your *ands unti dry)
W!at are t!e s%m$toms of H1N1.
<ymptoms are ike seasona fu and incude t*e foo+in,1
Fever
Cou,*
<ore t*roat
6ody ac*es
$eadac*es
C*is and fati,ue
<ometimes, diarr*ea and vomitin,
W!at s!ould I do if I get sic#.
If t*ere is $%N% fu in your community pay e7tra attention to your -ody and *o+
you are feein,)
If you ,et sick +it* fu.ike symptoms, stay *ome, imit contact +it* ot*ers, and
ca your doctor) Iour doctor +i decide if testin, or treatment is needed) (ests
may incude a nasa s+a- +*ic* is -est to do +it*in t*e first 0.3 days of ,ettin,
sick) =ike re,uar fu, $%N% fu may make ot*er medica pro-ems +orse)
If you are aone at any time, *ave someone c*eck in +it* you often if you are
feein, i) (*is is a+ays a ,ood idea)
If you *ave cose contact +it* someone +*o *as $%N% fu or is -ein, treated for
e7posure to $%N% fu, contact your doctor to discuss +*et*er you need treatment
to reduce your c*ances of ,ettin, t*e fu)
Ho' is H1N1 flu treated.
(reat any fever ri,*t a+ay) (yeno; #acetaminop*en& is t*e -est treatment of
fever in pre,nancy)
Drink penty of fuids to repace t*ose you ose +*en you are sick)
Iour doctor +i decide if you need antivira dru,s suc* as (amifu;
#osetamivir& or Reen!a; #!anamivir&) "ntivira dru,s are prescription pis,
iCuids or in*aers t*at fi,*t a,ainst t*e fu -y keepin, t*e ,erms from ,ro+in, in
your -ody) (*ese medicines can make you fee -etter faster and make your
symptoms mider)
(*ese medicines +ork -est +*en started soon after symptoms -e,in #+it*in t+o
N2O days&, -ut t*ey may aso -e ,iven to very sick or *i,* risk peope #ike
pre,nant +omen& even after 09 *ours) "ntivira treatment is taken for 3 days)
(amifu; and Reen!a; are aso used to prevent $%N% fu and are taken for %0
days)
(*ere is itte information a-out t*e effect of antivira dru,s in pre,nant +omen or
t*eir -a-ies, -ut no serious side effects *ave -een reported) If you do t*ink you
*ave *ad a side effect to antivira dru,s, ca your doctor ri,*t a+ay)
W!en s!ould I get emergenc% medical care.
If you *ave any of t*ese si,ns, seek emer,ency medica
care ri,*t a+ay1
Difficuty -reat*in, or s*ortness of -reat*
4ain or pressure in t*e c*est or a-domen
<udden di!!iness
Confusion
<evere or persistent vomitin,
Decreased or no movement of your -a-y
" *i,* fever t*at is not respondin, to (yeno;
Ho' s!ould I feed m% 2a2%.
Fu can -e very serious in youn, -a-ies) 6a-ies +*o are -reastfed do not ,et as sick and
are sick ess often from t*e fu, t*an do -a-ies +*o are not -reastfed)
6reastfeedin, protects -a-ies) 6reast mik passes on anti-odies from t*e mot*er to a
-a-y) "nti-odies *ep fi,*t off infection)
Is it o# to 2reastfeed m% 2a2% if I am sic#.
" mot*er8s mik is made to fi,*t diseases in *er -a-y) (*is is reay important in
youn, -a-ies +*en t*eir immune system is sti ,ro+in,)
Do not stop -reastfeedin, if you are i) 6reastfeed eary and often) =imit formua
feeds if you can) (*is +i *ep protect your -a-y from infection)
6e carefu not to cou,* or snee!e in t*e -a-y8s face, +as* your *ands often +it*
soap and +ater)
Iour doctor mi,*t ask you to +ear a mask to keep from spreadin, t*is ne+ virus
to your -a-y)
If you are too sick to -reastfeed, pump and *ave someone ,ive t*e e7pressed mik
to your -a-y)
Is it O1 to ta#e medicine to treat or $revent H1N1
flu '!ile 2reastfeeding.
Ies) Mot*ers +*o are -reastfeedin, can continue to nurse t*eir -a-ies +*ie -ein,
treated for t*e fu)