swine flu- h1n1 in pregnancy by dr shashwat jani

H1N1 Challenges In Pregnancy

Dr. Shashwat K. Jani.M. S. ( Obs – Gyn )

Diploma in Advance Laparoscopy.

Consultant Assistant Professor,

Smt. N.H.L. Municipal Medical College.

Sheth V. S. General Hospital , Ahmedabad.

Mobile : 99099 44160.E-mail : [email protected]

Apr 17, 2023 Dr Shashwat Jani 99099 44160. 2

Greetings From Ahmedabad…


Indian Scenario

Dangerous Swine Flu in India…


6 years back… Influenza like

illness caused by Influenza A [H1N1], was reported from Mexico on 18th March, 2009 and rapidly spread to all the continents.

India reported its first case on 13th May, 2009.

H1N1Swine Flu: India 2015

Image Courtesy: http://oregonprogressive.com/wp-content/uploads/2014/01/h1n1.jpg

0102

0304

2015 Indian Swine Flu outbreak refers

to that of 2009 widespread of H1N1 virus in India, which

is existent as of February 2015.

State of Rajasthan is

the most effected.

India reported 937 cases & 218 deaths

from swine flu in 2014.

By mid-February 2015, reported

cases & deaths in 2015 have

surpassed past figures.


What is H1N1…???

It is an Orthomyxovirus that contains the glycoproteins : Haemagglutinin and Neuraminidase.

For this reason, they are described as H1N1, H1N2 etc. depending on the type of H or N antigens they express.

Haemagglutinin causes red blood cells to clump together and binds the virus to the infected cell.

Neuraminidase are a type of glycoside hydrolase enzyme which help to move the virus particles through the infected cell and assist in budding from the host cells.


EPIDEMIOLOGY

Incubation period: 1-7 days. Transmission : by droplet infection and fomites. Communicability : From 1 day before to 7 days

after onset of symptoms.


Risk of severe illness is highest in:

Pregnant women especially during third trimester,

Children less than 2 years of age. People with chronic lung disease

including asthma.

H1N1Symptoms of Swine Flu

Image Courtesy: http://upload.wikimedia.org/wikipedia/commons/f/f0/Symptoms_of_swine_flu.png


Investigations… CBC, LFTs, RFTs, Coagulation profile, X-ray Chest, CT scan ( when required. ) Real-time Reverse Transcriptase (RT-PCR) is done

for confirmation of diagnosis. Clinical specimens such as nasopharyngeal swab,

throat swab, nasal swab and tracheal aspirate (for intubated patients) are to be obtained preferably before administration of the anti-viral drug.


Preferred Respiratory Specimens…

Nasopharyngeal swab, nasal aspirate OR a combined nasopharyngeal swab with oropharyngeal swab.

If these specimens cannot be collected, a nasal swab or oropharyngeal swab is acceptable.


For patients who are intubated, an endotracheal aspirate should also be collected. Bronchoalveolar lavage (BAL) and sputum specimens are also acceptable.

Should be placed into sterile viral transport media (VTM) and immediately placed on ice or cold packs or at 4°C (refrigerator) for transport to the laboratory


Pregnancy at Risk…

Pregnancy does not predispose women to an increased risk of acquiring influenza infection.

However, pregnant women are at increased risk of morbidity and mortality as compared to women who are not pregnant.

This is due to the changes in their immune systems to accommodate the developing fetus and adaptations in body as a result of the hormonal and physical changes.


Other factors such as : Family commitments, Lack of awareness, and Gender discrimination have been

identified to cause delay in seeking health care…


Categories… Category A : • Mild Symptoms: fever, cough, sore throat with or without body ache,

headache, diarrhea and vomiting. • Not a high risk for severe disease. Non- pregnant patients. • No testing recommended. • The patients should be monitored for their progress

and reassessed at 24 to 48 hours by the doctor. Confine at home. Patient should avoid mixing up with public and high risk members in the family.

• Anti Viral therapy not indicated.


Category B :• All category A symptoms in high risk group:• Pregnancy, Age <5 & >65yrs, Co morbid

conditions: lung diseases, heart disease, liver disease, kidney disease, blood disorders, diabetes, neurological disorders, cancer and HIV/AIDS; Immunosuppressed: on long term corticosteroid therapy.

• No testing required; should start anti viral therapy.• The patients should confine themselves at home

and avoid mixing with public and high risk members in the family


Category C :

Category A & B with any of the following: - Chest pain, - breathlessness, - drowsiness, - cyanosis, - blood stained sputum, - hypotension.Testing is mandatory; admission to ICU; start anti viral

therapy


Complications…

Influenza in pregnancy is associated with increased risk of adverse pregnancy outcomes such as spontaneous abortion, preterm birth, and fetal distress.

The risk of complications in newborn infants increases, if their nutritional status is poor and fluid intake is low because of prolonged vomiting, diarrhoea, or inability to feed.


Respiratory failure &

Refractory shock are the most common

causes of death…


Management

Prevention is always better than cure.

H1N1Precautions of Swine Flu

Cover your mouth and nose while coughing

and sneezing.

Dispose of used tissues immediately

after using.

Washing hands frequently with soap and hot running water or utilize an alcohol-

based hand gel.

If you have flu-like symptoms, get medical

advise immediately.

Stay home if infected, to refrain from

affecting others.

Maintain 1m distance if infected or have flu like

symptoms to refrain from affecting others.

Do not shake hands, hug, or kiss when greeting anyone.

Do not touch eyes, nose or mouth without

washing hands.

Image Courtesy: https://lh6.googleusercontent.com/-UjlFHUzhRng/VOgJzW0ALdI/AAAAAAABlUI/1OnkkL2sbqo/w827-h1169/Swine-Flu.jpg


Protection against infection

Avoid contact with people who exhibit symptoms. Avoid touching nose & mouth Wash hands thoroughly with soap and water or clean

them with an alcohol based hand sanitizer on a regular basis.

Reduce the time spent in crowded settings during epidemics.

Improve airflow in living spaces by opening windows.


It is advisable to practice…

Additional good health habits, including…

getting adequate sleep, eating nutritious food, and staying physically active.


Special considerations :for pregnant women and new mothers and their babies

Avoid crowded public places whenever possible.

Avoid providing care for those with confirmed, probable, or suspected influenza infection, except for their own newborns.

Anyone with respiratory symptoms should not provide care for a pregnant woman or a mother and newborn baby.


Antenatal care Hospitalize in a private room. Current Infection Control guidance throughout the

hospital. A single-patient room whenever possible. Use of face mask by patients when outside the room. Standard precautions for all patient care. Diagnostic testing and empirical antiviral therapy

immediately. Do not delay antiviral treatment pending diagnostic

results. Healthy attendants may be allowed inside the room.


Intra partum care

• Protect the infant from exposure to respiratory secretions during or immediately after delivery.

• Mother should use face mask throughout labor, as tolerated.

• Adhere to current infection control guidance.• During delivery all persons should face mask,

gloves and gown.• Immediately separate newborn to an open

warmer by a distance of > 6 ft.• Bath infant as soon as the temperature is stable.


Post Natal Care

Temporary separation of the infected mother from the newborn within her room OR in a separate room…

Until, the risk of infection transmission is reduced, which is when ALL of

the following criteria are met: The mother has received Antiviral Medications for at least

48hrs. The mother is without fever for 24hrs without antipyretics. The mother can control cough and respiratory secretions. Once these criteria are met, the mother and the newborn

can initiate close contact throughout the postpartum period with droplet precautions and mother can start breast feeds.


Breast feeding

Mothers should be encouraged to begin breastfeeding within one hour of giving birth and to breastfeed frequently and exclusively including a period of pandemic (H1N1) 2009 circulation.

Infants who are not breastfed are more vulnerable to infectious diseases, including severe respiratory tract infection.


Care of the Newborn• Washing hands frequently with soap and water and

cleaning soiled surfaces to keep the environment free from virus contamination, especially since infants have a tendency to place their hands in their mouths.

• Adhering to respiratory etiquette—that is, covering their mouth and nose, when coughing or sneezing. If a tissue is used, it should be discarded in a bin with a lid and then hands should be washed.

• Keeping newborn infants close to their mothers. In general, this closeness promotes infant survival from various threats.


Treatment


Implementation of infection control measures.

Preferably isolation room should be there, if it is not available then patients can be kept in well-ventilated isolation ward with beds kept one meter apart.

Standard Operating Procedures All those entering the room must use

high efficiency masks, gowns, goggles, gloves, cap and shoe cover.


Restrict number of visitors.

Provide antiviral prophylaxis to health care personnel managing the case and ask them to monitor their own health twice a day.

Dispose waste properly by placing it in sealed impermeable bags labeled as biohazard.


Drug Treatment( Neuraminidase Inhibitor )

Oseltamivir ( TAMIFLU ) is the recommended and safe drug both for prophylaxis and treatment.

FDA Category – C Drug.


Dose is 75 mg BD for 5 days for adults.

This is safe in pregnancy in all trimesters.

A negative laboratory test should not stop treatment in a patient with clinical suspicion of influenza.


• Zanamivir is inhaled as Powder … 10 mg BD for 5 days. Contraindicated in Asthmatic patients. Less systemic absorption.


Supportive therapy is given as- Symptomatic treatment, IV Fluids, parenteral

nutrition, Oxygen therapy/ ventilatory support. Paracetamol is prescribed for fever, myalgia

and headache. Salicylate / aspirin is strictly contra-indicated

in any influenza patient due to its potential to cause Reye’s syndrome.

Antibiotics should be administered, if required


Fever ( > 38° C) in early pregnancy is associated with increased risk of fetal anomalies and, in late pregnancy, with adverse perinatal outcomes.

Treat fever associated with pandemic (H1N1) 2009 virus infection in pregnant women or women in labour or breastfeeding with paracetamol (acetaminophen).

Explain the importance of adequate nutrition and fluid intake to the woman and her family.


Chemo prophylaxis

• It is recommended for contacts of suspected, probable and confirmed cases.

• Contacts include household /social contacts, family members, workplace or school contacts, fellow travelers, and health care personnel.

• It should be provided till 10 days after last exposure.

• Oseltamivir ( TAMIFLU ) is the drug of choice with dose of 75 mg OD for 10 days for adults.


H1N1 Vaccination

FDA has approved the H1N1 monovalent vaccine as intramuscular injection (inactivated) and an intranasal spray (Live).

Inactivated vaccine is administered to individuals above 6 months.

It is safe and recommended for pregnant women.


Inactivated vaccine should not be administered to those having history of anaphylaxis to any constituents of vaccine, moderate to severe illness with fever and children below 6 months,.

Live intranasal vaccine should not be administered to pregnant women, individuals below 2 years and above 50 years, those having chronic illness with fever.

To date studies do not show harmful effects from pandemic influenza vaccine with respect to pregnancy, fertility or developing the embryo or fetus.


How many vaccine doses will a pregnant woman need to get?

FDA has approved 1 dose of Monovalent Vaccine during pregnancy.


If delivered before vaccination , should she still receive vaccine ?

YES, To protect herself from infectionTo protect newborn,( Because , vaccine is contraindicated before 6

months of age )


Can pregnant woman receive Nasal spray vaccine ?

NO,She can receive only after delivery even if she is

breastfeeding


What are the possible side effects ? Soreness, redness, tenderness, or swelling where

the shot was given. Some people might experience headache, muscle

aches, fever, fatigue, and nausea. If these problems occur, they usually begin soon

after the shot is given and may last as long as 1-2 days.

Rarely GBS can occur…


Safety Precautions for Health care Professionals…


Before Clinical Assessment…

Ensure pt. is still wearing a surgical mask. Perform hand hygiene ( Alcohol based hand

rub OR Soap & Water ) before & after assessment.

Put on gloves A gown is needed only when there is a risk of

clothing or skin contamination. Consider appropriate respiratory protection


Respiratory Protection… Wear respiratory protection when within 3

meters of a suspect H1N1 case. A N95 respirator with eye protection is for

all clinical contact.


After clinical assessment… Eye or face protection should be removed

only after leaving the room and to be disposed.

The Surgical Mask or N95 Mask should be removed by straps, being careful not to touch the mask or respirator.

Hand hygiene after removing protection.

Thank you

swine flu- h1n1 in pregnancy by dr shashwat jani

Health & Medicine