Title: Pandemic 2009 H1N1 Influenza (Swine Flu) With Pregnancy Dr
1Pandemic 2009 H1N1 Influenza(Swine Flu) With
Pregnancy
Dr. Mohamed El SherbinyMD Ob. Gyn. Senior
Consultant Damietta, Egypt
2Topics
- Epidemiology
- Clinical picture
- Diagnosis
- Complications
- Treatment
- Prevention
3Part 4 Treatment
4General Measures
- Antipyretics
- Antibacterial thereby
- Oral fluids
- Nutrition
- Bed rest
5Hazard of Hyperthermia
- First trimester has been associated with neural
tube defects and other birth defects - During labor Neonatal seizures, encephalopathy,
cerebral palsy, and neonatal death - Acetaminophen is the drug of choice
CDC November 3, 2009
Throner UpToDateJanuary 14, 2010
6Antibacterial Therapy
- Recommended for secondary bacterial pneumonia
- It is suspected when
- Secondary fever after a period of defervescence
- Sputum gram stain and/or culture showing a
predominant organism (e.g. Streptococcus
pneumoniae, Staphylococcus aureus, ) - Lobar consolidation on chest imaging rather than
the diffuse pattern - Leucocytosis
- Onset of respiratory compromise occurring 4 -7
days after initial symptoms rather than 1-2 days
Chan-Tack et al . N Engl J Med 2009 3611713.
Throner UpToDateJanuary 14, 2010
7Antibacterial Thereby
- For secondary bacterial pneumonia .
- Azithromycin
- Azithromycin Ceftriaxon (severe cases)
- Penicillins beta-lactams
- Clindamycin aminoglycosides.
Throner UpToDateJanuary 14, 2010
8Clinical Triage Algorithms For ILI In
Resource-poor Settings
Uncomplicated ILI
Any deterioration or failure to improve within 72
hours
No risk factors
At-risk groups
- Symptomatic care at home
- Instruction on
- infection prevention
- to return for care
- Antiviral
- Close observation
- Instruction to return for care.
- Antiviral
- Hospitalization
November 2009
9CDC Guidance Peripartum Care
- Management of Pregnant women who enter the
hospital setting with suspected or confirmed 2009
H1N1 influenza Virus - Antepartum Care
- Intrapartum Care
- Postpartum Care
- Newborn Care
CDC November 2009
10Antepartum Care
- Pregnant women who enter the hospital setting
with suspected or confirmed 2009 H1N1 influenza
should - Placed in a private room (Single room when
possible) - Cared for using current infection control
guidance throughout hospitalization - Use facemask when outside of the room
- Underwent diagnostic testing immediately
- Receive empiric antiviral therapy (oseltamivir or
zanamivir),
CDC November 2009
11Intrapartum Care
- In order to protect the infant from exposure, the
following guidance is provided - The mother should use a face mask throughout
labor, as tolerated. - Adhere to current infection control guidance.
- During delivery, all persons should wear a
surgical mask with face shield, gloves and gown. - Upon delivery of the newborn, immediately
separate the newborn to an open warmer by a
distance of gt 6 feet - If stable, the newborn may remain in the delivery
room prior to transition to newborn/postpartum
care. - Bathe the infant as soon as the temperature is
stable.
CDC November 2009
12Postpartum Care
- Step 1 Consider temporarily separating the
infected mother from the newborn until met ALL of
the following criteria - The mother has received antiviral medications for
at least 48 hours - The mother is without fever for 24 hours without
antipyretics and - The mother can control cough and respiratory
secretions. - (Criteria for close contact)
CDC November 2009
13Newborn Care
- The mother should be fully
- supported for breastfeed as it is the best way
to protect the Infant - Immediately following delivery, the mother should
be assisted and supported to express her
milk/colostrum.
CDC November 2009
14Newborn Care
- The mothers milk should be fed to the newborn by
a healthy caregiver until criteria are met for
close contact - Milk from an infected mother is
- not considered infectious.
- Anti-viral medication use by the mother is not a
contraindication to breastfeeding.
CDC November 2009
15Newborn Care
- Step 2 Once the criteria for close contact,
the following guidance is offered prior to
feeding handling the infant - The mother should wash her hands with soap and
water - The mother should put on a face mask
- The mother should observe all respiratory hygiene
CDC November 2009
16Prevention
- 1- Immunize persons before exposure
- 2-Antiviral prophylaxis after exposure
- 3-Infection control in healthcare settings
- 4-Community social distancing measures
17Vaccination of Pregnant Women
Centers for Disease Control and Prevention
(CDC)2007
18Case 2
- A schoolteacher at 26 weeks gestation has been
informed that one of her first row pupils has
admitted to the hospital and diagnosed as
pandemic H1N1 -
19Case 2
- She is extremely worried
- How can I prevent The disease? . She asked
- I has heard a conflicting debates in the mass
media - Can Tamiflu protect me ? Is it safe ?
- What is the safety of the vaccine to my fetus ?
- Does it contain toxic mercuric compound ?
- Has it a future risk of autism to my baby?
- 4. Does vaccine lead to Paralysis ?
20When Is Antiviral Prophylaxis indicated?
- Close contact with a confirmed or suspected case
meet one of the following criteria - At high risk for complications of influenza
- Pregnant women and women who are up to two weeks
postpartum - Children who are lt2 years of age or who are at
high risk of complications of influenza - Health care workers and emergency medical
personnel.
November 2009
21What About Safety For Pregnant Women?
- In view of the elevated risk for severe illness
for pregnant women, pregnant women are a group
that should be vaccinated against infection, as
supplies allow. - The benefits of vaccination far outweigh the
risks.
WHO 30 October 2009
22Are Pandemic Vaccines Safe?
- Outcomes of studies completed to date suggest
that pandemic vaccines are as safe as seasonal
influenza vaccines. - Side effects seen so far are similar to those
observed with seasonal influenza vaccines.
November 2009
23What About Safety For Pregnant Women?
- To date No harmful effects from the pandemic
influenza vaccine with respect to - Pregnancy
- Fertility
- Developing embryo or fetus
- Birthing or post-natal development.
-
WHO 30 October 2009 November 2009
24- Dear Colleague
- The American Academy of Family Physicians
- (AAFP), the American College of Obstetricians
- And Gynecologists (ACOG), the American
- Medical Association (AMA), and the Centers
- for Disease Control and Prevention (CDC) are
- asking for your Help in urging your pregnant
- patients to get vaccinated Gainst 2009 H1N1
- and seasonal influenza.
ACOG Message November -2009
25Why pregnant women should receive 2009 H1N1
monovalent and seasonal influenza vaccines
- Vaccination during pregnancy reduced febrile
respiratory illness both in the mothers and
infants and reduced lab-confirmed influenza in
the infants. - Caregivers of newborns are potential sources of
transmission of H1N1 influenza. - Women who were not vaccinated during pregnancy
should receive the vaccine postpartum to prevent
the mothers to infants transmission.
ACOG Message November -2009
26- Vaccinating everyone who lives with or cares for
infants aged lt6 months (too young to
vaccination) is the best way to prevent these
children from getting influenza. - 2009 H1N1 monovalent and seasonal influenza
vaccines can be given to pregnant women in any
trimester and can be given at the same time but
in different injection sites. - Pregnant women should receive inactivated
vaccine but should NOT receive the live
attenuated vaccine (nasal spray).
ACOG Message November -2009
27- Postpartum women, even if they are
- breastfeeding, can receive either inactivated
- vaccine or live attenuated vaccine (nasal spray).
- As healthcare providers, physicians and their
healthcare staff are also a target group
designated by the ACIP to receive 2009 H1N1
monovalent and seasonal influenza vaccines to
protect themselves as well as their pregnant
patients.
ACOG Message November -2009
28- Please help to protect your pregnant
- patients against influenza by encouraging
- them to get the 2009 H1N1 monovalent and
- seasonal influenza vaccines and addressing their
concerns. - You are playing a crucial role in helping to
- prevent influenza in your patients, which can
save their lives.
ACOG Message November -2009
29ACOG Message November -2009
30Priority of Vaccination( If vaccine supply is
limited)
- Pregnant women
- Household contacts and caregivers of children lt 6
months of age - Healthcare and emergency medical services
personnel who have direct contact with patients
or infectious material - Children aged 6 months to 4 years
- Those aged 5 to 18 years who have medical
conditions that put them at increased risk of
complications
National Center for Immunization and Respiratory
Diseases, CDC. (ACIP), 2009. MMWR 2009 581.
31What Is The Efficacy of The 2009 H1N1 Vaccine?
- No vaccines, including pandemic influenza
vaccines, provide 100 protection against disease
(approximately 95 with pregnancy). - Also, influenza vaccines only become effective
about 14 days after vaccination. - Those infected shortly before (1 to 3 days) or
shortly after immunization can still get the
disease. -
WHO 30 October 2009
32Is Getting The Flu Vaccine Safer Than Getting The
Flu ?
- Severe illness and possible death can be
associated with influenza for the following
priority groups - Healthy young people from birth through age 24
- Pregnant women
- Adults 25 to 64 who have certain underlying
medical conditions - Vaccination is the best way to prevent influenza
infection and its complications.
CDC January 14, 2010
33Has The Preservative Thiomersal A Risk To
Health?
- Thiomersal is a used as vaccine preservative to
prevent contamination in multi-dose vials. - Thiomersal does not contain methyl mercury, which
is toxic. - Thiomersal contains ethyl mercury Nontoxic
- No evidence of toxicity in infants, children or
adults, including pregnant women, exposed to
thiomersal in vaccines.
WHO 30 October 2009
34Has Thiomerosal A Future Risk of Autism To The
Fetus?
- Research shows no link between thimerosal and the
neurodevelopmental disorder Autism - In fact, sadly, autism rates have actually gone
up since thimerosal was taken out of childhood
vaccines in 2001, providing further evidence that
thimerosal-containing vaccines are not related to
autism.
WHO 30 October 2009
35Is There A Possibility Of Guillain-Barré Syndrome
(GBS) Cases Following The 2009 H1N1 Vaccine?
- GBS in which the body damages its own nerve
cells, causing muscle weakness and sometimes
paralysis is very rare - GBS occurs at a rate of 10-20 cases per 1 million
adults, per year, regardless of vaccination. - One additional person out of 1 million
vaccinated people may be at risk for GBS
associated with the 1976 influenza vaccine -
CDC January 14, 2009
36Vaccine Types
- A-Live attenuated vaccine Nasal spray (not
licensed for use in pregnant women) - B- Inactivated vaccine Intramuscular
- Multidose inactivated vaccine
- Prefilled single dose inactivated vaccine
(preservative-free) - 1- Monovalent Used with pregnancy
- 2-with adjuvants (such as squalene)
37Does the 2009 H1N1 monovalent flue vaccine have
an adjuvant or squalene in it?
- Adjuvants are agents that are sometimes added to
a vaccine to increase its effectiveness. - There are no adjuvants (such as squalene) in
either the 2009 H1N1 monovalent or seasonal flu
vaccines.
CDC January 14, 2010
38Thank You