What advice for pregnant women?

Recently, there has been increasing confusion among pregnant women about how to protect themselves against H1N1, as health officials and the media have been giving conflicting advice over the past few weeks. And yet, in August, the World Health Organization (WHO) reiterated that pregnant women are a high-risk group, so one would expect at least a minimum of clear and consistent information.

Avoiding crowds: yes or no?

One area of doubt concerns measures to reduce infection risk. Take, for example, the advice to avoid travels and crowed places. This has been given and dismissed, in different countries, several times. In England, the website of the Department of Health (DH), at one point, was even recommending pregnant women to leave their workplace earlier or later than usual, to avoid journeys on trains during the rush hour. This recommendation was then removed, and the DH now says, “mothers-to-be are not advised to curtail normal activities such as going to work, travelling on public transport, attending events and family gatherings.”

So, what should pregnant women do? Experts agree that there is no real need for them to avoid non-essential journeys and crowded settings at all costs. However, if you are pregnant, you should take the sensible precaution to stay away from large groups of people in communities known to have outbreaks of swine flu. This practice is called ‘social distancing.’

Hand washing is your best defense

As simple as it may seem, good hand hygiene remains the one, and most important, thing you can do to minimize your risk of infection.

Current guidelines recommend washing hands well for at least 20 seconds with soap and water or an alcohol-based handrub. Wash your hands frequently, particularly after touching things likely to be contaminated with the virus, both inside and outside the house. For example, door handles, telephones, ATM machines, and so on. If you have young children, remember to wash your hands after blowing their nose.

Other things you can do to protect yourself include the following:

• Stay at an arm-length distance from people.
• Avoid contact with those who have swine flu.
• Ask family, friends and colleagues to cover their mouth and nose when coughing or sneezing, and to stay home if they are ill.

These seemingly simple strategies may sound obvious but, since research increasingly shows that pregnant women with swine flu have a greater risk for potentially fatal complications, they may in fact help save your life and that of your baby.

Ask for prompt treatment

The elevated risk for complications is also the reason why you should be treated promptly if you become ill. Commonly observed complications of H1N1 are pneumonia and distress respiratory syndrome, occurring mostly in previously healthy young to middle-aged patients.

A study published in The Lancet by researchers of the Centers for Disease Control and Prevention (CDC) suggests that “pregnant women might be at increased risk for complications from pandemic H1N1 virus infection” and that these complications might be associated with death.

The researchers write: “From April 15 to May 18, 2009, 34 confirmed or probable cases of pandemic H1N1 in pregnant women were reported to CDC from 13 states… between April 15 and June 16, 2009 six deaths… were reported… all were in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation.”

This doesn’t mean you should panic. Just use common sense. If you feel unwell, call the doctor right away, and ask for treatment with antivirals. Remember, you don’t have to wait to be tested for H1N1 or wait for the test results to initiate treatment. Treatment should begin immediately, says the CDC, because it “is most effective when started as early as possible [i.e., within 24 to 48 hours] after the onset of symptoms.”

“The drug of choice for pregnant women is oseltamivir [Tamiflu].” You should be prescribed two 75mg capsules per day for five days.

You will also be given an antipyretic medication–usually acetaminophen–if you have high temperature, as fever during pregnancy has been associated with birth defects.

If someone in your household has swine flu, or you have been otherwise exposed to H1N1, you need to take an antiviral medication, even if you are not ill. In this case, the CDC recommends taking zanamivir (Relenza) for ten days. Relenza is the best option because is given by inhalation. Therefore, compared to Tamiflu, which is taken orally, it reaches lower concentrations in the blood, which minimizes unnecessary risks to your unborn baby. If you have respiratory problems, you will be given Tamiflu.

Be vaccinated for H1N1 and seasonal influenza

So, antivirals are important, not only to treat the illness and avoid related complications, but also to prevent infection after exposure to the virus. However, they don’t replace the vaccine. And since the vaccine for seasonal flu, which also carries risk of complications during pregnancy, does not protect against H1N1 – and vice versa – health officials advice pregnant women to receive both vaccines, as soon as they become available. Make sure you do.

What if you have a healthcare job?

Lastly, if you work in a hospital, nursing home, or a physician’s office you are, for obvious reasons, at greater risk of exposure to H1N1. The general advice by the CDC is that, in addition to the above recommendations, you adopt the same standard precautions as for your non-pregnant co-workers.

Here are some important reminders:

• Wear gloves, masks and protective eyewear.
• Wash hands with an alcohol-based handrub or, if your hands are visibly soiled, with soap and water – before and after patient contact, even if you wear gloves.
• Place soiled linen in a plastic bag in the patient’s room avoiding shaking, as this might contaminate the environment and yourself.
• Handle waste and needles safely, according to your facility’s policy.

Follow the above guidelines with all patients, regardless of whether or not they have swine flu. If you are likely to be in close contact with patients with known or suspected H1N1, the CDC recommends reassignment to tasks that involve lower risk of exposure to the virus, like administrative activities.


References

Centers for Disease Control and Prevention (CDC). http://www.cdc.gov/h1n1flu/guidance/pregnanthcw-educators.htm. [Accessed 09.01.2009]

Jamieson D.J., Honein M.A., Rasmussen S.A., Williams J.L., Swerdlow D.L., Biggerstaff M.S., Lindstrom S., Louie J.K., Christ C.M., Bohm S.R., Fonseca V.P., Ritger K.A., Kuhles D.J., Eggers P., Bruce H., Davidson H.A., Lutterloh E., Harris M.L., Burke C., Cocoros N., Finelli L., MacFarlane K.F., Shu B., Olsen S.J. “H1N1 2009 influenza virus infection during pregnancy in the USA,” The Lancet, August 8, 2009, 374(9688):451-8. doi:10.1016/S0140-6736(09)61304-0

Occupational Safety and Health Administration (OSHA), US department of Labor, Pandemic influenza preparedness and response guidance for healthcare workers and healthcare employers, 2009. http://www.osha.gov/Publications/OSHA_pandemic_health.pdf. [Accessed 09.02.2009]

Perez-Padilla R., de la Rosa-Zamboni D., Ponce de Leon S., Hernandez M., Quiñones-Falconi F., Bautista E., Ramirez-Venegas A., Rojas-Serrano J., Ormsby C.E., Corrales A., Higuera A., Mondragon E., Cordova-Villalobos J.A. “Pneumonia and respiratory failure from swine-origin influenza A9H1N1) in Mexico,” New England Journal of Medicine, August 13, 2009, 361(7):680-9.

World Health Organization (WHO). WHO guidelines for the pharmacological management of pandemic (H1N1) 2009 influenza and other influenza viruses. August 20, 2009. http://www.who.int/csr/resources/publications/swineflu/h1n1_use_antivirals_20090820/en/index.html [Accessed 09.03.2009].

By Lorena Tonarelli, MSc