Update care of pregnant women in light of H1N1
As the United States gears up to combat the H1N1 flu (also known as swine flu), be sure your practice includes the latest Centers for Disease Control and Prevention (CDC) recommendations for care of pregnant women.
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, according to a CDC analysis of the outbreak.1 Eleven (32%) women were admitted to hospitals. The estimated rate of admission for pandemic H1N1 influenza virus infection in pregnant women during the first month of the outbreak was higher than it was in the general population [0.32 per 100,000 pregnant women, 95% CI (confidence interval) 0.13-0.52 vs. 0.076 per 100,000 population at risk, 95% CI 0.07-0.09]. Between April 15 and June 16, 2009, six deaths in pregnant women were reported to the CDC. All were in women who had developed pneumonia and subsequent acute respiratory distress syndrome requiring mechanical ventilation. These data have led the CDC to recommend clinicians to promptly treat pregnant women with H1N1 influenza virus infection with anti-influenza drugs.
Pregnant women are at higher risk for severe complications and death from influenza, including 2009 H1N1 influenza and seasonal influenza, says the CDC. Treatment with oseltamivir (Tamiflu) or zanamivir (Relenza) is recommended for pregnant women with suspected or confirmed influenza and can be taken during any trimester of pregnancy. The duration of antiviral treatment is five days. For oseltamivir, the treatment dosage for adults is one 75 mg capsule twice per day for five days; for chemoprophylaxis, the adult dosage is one 75 mg capsule once per day for 10 days. For zanamivir, the treatment dosage for adults is two 5 mg inhalations (10 mg total) twice per day for five days; for chemoprophylaxis, the adult dosage is two 5 mg inhalations (10 mg total) once per day for 10 days.2
Zanamivir might be the preferable antiviral for chemoprophylaxis of pregnant women because of its limited systemic absorption, the CDC states. However, respiratory complications that might be associated with zanamivir because of its inhaled route of administration need to be considered, especially in women at risk for respiratory problems. For these women, oseltamivir is a reasonable alternative, says the CDC.2
Oseltamivir and zanamivir have been classed as "Pregnancy Category C" medications, indicating that no clinical studies have been conducted to assess their safety for pregnant women. However, the available risk-benefit data indicate pregnant women with suspected or confirmed influenza should receive prompt antiviral therapy, advises the CDC. Pregnancy should not be considered a contraindication to oseltamivir or zanamivir use.
Be sure to initiate treatment as early as possible because studies show that treatment initiated early (i.e., within 48 hours of illness onset) is more likely to provide benefit. Do not delay treatment for laboratory confirmation of influenza, the CDC recommends. Laboratory testing can delay treatment, and a negative rapid test for influenza does not rule out influenza. The sensitivity of rapid tests can range from 10% to 70%, the CDC states.2
Talk with pregnant women about signs and symptoms of influenza, and the need for early treatment. In a recent series of pregnant women with 2009 H1N1 influenza, manifestations included fever (97%), cough (94%) rhinorrhea (59%), sore throat (50%), headache (47%), shortness of breath (41%), myalgia (35%), vomiting (18%), diarrhea (12%), and conjunctivitis (9%), similar to those in the general population.1
Since rapid access to antiviral medications is essential, health care providers who care for pregnant women should develop methods to ensure that treatment can be started quickly after symptom onset, according to the CDC. They should ensure rapid access to telephone consultation and clinical evaluation for pregnant women; also consider empiric treatment of pregnant women based on telephone contact if hospitalization is not indicated, states the CDC.2
ACOG issues guidance
The American College of Obstetricians and Gynecologists (ACOG) has joined a national coalition of health care and information providers for pregnant women and children to get out H1N1 information to patients and providers. The coalition has issued a joint statement to pregnant women, which includes five important messages, which should be shared with your pregnant patients:
- Pregnant women are at increased risk for serious disease and even death from pandemic H1N1 influenza infection.
- Pregnant women who have flu-like symptoms such as fever, cough, and sore throat should contact their pregnancy care provider immediately so that flu medications can be started and further instructions can be given. Women also may begin treating their fever with acetaminophen.
- Pregnant women also should speak to their pregnancy care provider if they have come in close contact with someone who has flu-like symptoms.
- All pregnant women should receive immunization for seasonal flu immediately and H1N1 flu as soon as the vaccine becomes available. The immunizations pregnant women receive are safe and provide flu protection for themselves and their newborns.
- Pregnant women can protect themselves from the flu by washing their hands frequently, by encouraging their family to do the same, and by avoiding contact with sick people.3
Your facility might be administering flu vaccinations. While the government is providing the H1N1 vaccine and administration supplies for free, providers cannot charge for the vaccine, but providers can charge for administering the injection. Use the following CPT codes issued by the American Medical Association that are specific to the H1N1 vaccine product: 90470 — H1N1 immunization administration (intramuscular, intranasal), including counseling when performed, and 90663 — Influenza virus vaccine, pandemic formulation, H1N1.3
References
- Jamieson DJ, Honein MA, Rasmussen SA, et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet 2009; 374:451-488.
- Centers for Disease Control and Prevention. Updated interim recommendations for obstetric health care providers related to use of antiviral medications in the treatment and prevention of influenza for the 2009-2010 season. Sept. 17, 2009. Accessed at www.cdc.gov/H1N1flu/pregnancy/antiviral_messages.htm.
- Joint Statement for Pregnant Women about Influenza. Sept. 14, 2009. Accessed at www.acog.org/departments.
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