Pandemic 2009 H1N1 Influenza (Swine Flu) With Pregnancy Dr

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Pandemic 2009 H1N1 Influenza(Swine Flu) With
Pregnancy
Dr. Mohamed El SherbinyMD Ob. Gyn. Senior
Consultant Damietta, Egypt
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Topics

• Epidemiology
• Clinical picture
• Diagnosis
• Complications
• Treatment
• Prevention

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Part 4 Treatment

• General Measures

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General Measures

• Antipyretics
• Antibacterial thereby
• Oral fluids
• Nutrition
• Bed rest

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Hazard 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
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Antibacterial 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
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Antibacterial Thereby

• For secondary bacterial pneumonia .
• Azithromycin  
• Azithromycin Ceftriaxon (severe cases)
• Penicillins beta-lactams
• Clindamycin aminoglycosides.

Throner UpToDateJanuary 14, 2010
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Clinical 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
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CDC 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
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Antepartum 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
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Intrapartum 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
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Postpartum 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
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Newborn 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
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Newborn 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
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Newborn 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
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Prevention

• 1- Immunize persons before exposure
• 2-Antiviral prophylaxis after exposure
• 3-Infection control in healthcare settings 
• 4-Community social distancing measures

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Vaccination of Pregnant Women
Centers for Disease Control and Prevention
(CDC)2007
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Case 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

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Case 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 ?

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When 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
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What 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
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Are 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
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What 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
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• 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
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Why 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
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• 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
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• 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
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• 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
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ACOG Message November -2009
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Priority 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.
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What 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
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Is 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
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Has 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
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Has 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
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Is 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
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Vaccine 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)

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Does 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
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Thank You