Drugs Urged for Swine Flu in Pregnancy
By DONALD G. McNEIL Jr.
Published: May 12, 2009
Pregnant women who get swine flu are at such high risk of complications like pneumonia, dehydration and premature labor that they should be treated at once with the antiviral drug Tamiflu ― even though it is not normally recommended in pregnancy, the Centers for Disease Control and Prevention said Tuesday.
Because a positive test for the new H1N1 flu can take days, the agency said, Tamiflu should be given to any pregnant patient with flu symptoms and a history of likely contact with someone else with swine flu.
“If I’m thinking influenza ― the classic symptoms, febrile, aching all over, came on all of a sudden ― and this flu is in the community, and I’d otherwise give the patient Tamiflu if she wasn’t pregnant, we’re saying, ‘Don’t delay because she’s pregnant,’ ” said Dr. Denise Jamieson, a C.D.C. medical officer. “At that point, the benefit of giving Tamiflu outweighs the risk.”
Tamiflu is not normally recommended for use by pregnant women because the effects on the unborn child are unknown, according to its maker, Roche.
Dr. Jamieson, an obstetrician, said most medicines had insufficient safety data for pregnancy “because you don’t do clinical trials in pregnant women.” But she added, “Tamiflu and Relenza are fairly safe in pregnancy.”
Tamiflu and Relenza are in the same class of drugs. But Tamiflu is a pill and liquid, while Relenza is a powder that must be inhaled, so it is prescribed much less often.
The C.D.C. and the World Health Organization said case histories in Mexico and the United States suggested that pregnancy was emerging as a risk factor rivaling asthma, diabetes, immunosuppression and cardiovascular disease.
One of the three deaths in the United States involved a pregnant Texas woman who was on no medication other than prenatal vitamins, the disease centers said. The agency knows of 20 confirmed or probable swine flu infections in pregnant Americans, and “a few have had severe complications,” said Dr. Anne Schuchat, the interim deputy director for public health.
American doctors are often reluctant to prescribe flu drugs for pregnant women unless they develop severe symptoms like pneumonia. Pregnant women are often reluctant to take medication. A pregnant woman is at higher risk from flu because hormonal changes depress the immune system to protect the fetus.
Details about the death of the pregnant woman in Texas emerged Friday in the disease centers’ weekly morbidity and mortality report. Dr. Jamieson said the woman had mild asthma and psoriasis, but was relatively healthy. The woman has been widely identified as Judy Trunnell, 33.
Mrs. Trunnell was eight months pregnant when she entered the hospital with pneumonia on April 19, five days after flu symptoms began and she had been found flu-positive in a doctor’s office test. Her baby was delivered by Caesarean section and is healthy. She developed acute respiratory distress on April 21 and needed mechanical ventilation. She did not get Tamiflu until April 28. She died May 4.
It is becoming clear that the epidemic in the United States will mirror the epidemic in Mexico, and similar rates of severe illness should be expected. The outbreak across Europe is still spreading slowly because the Europeans aggressively treat every suspected mild case with Tamiflu, health officials said.
The United States now has more than 3,000 confirmed cases ― two-thirds in people younger than 18 ― but only 116 hospitalizations. But officials note that hospitalizations take slightly longer to appear in statistics and deaths take much longer.
What Pregnant Women Should Know About H1N1 (formerly called swine flu) Virus
May 3, 2009 3:00 PM ET
* What if I get this new virus and I am pregnant?
* What can I do to protect myself, my baby and my family?
* What are the symptoms of H1N1?
* What should I do if I get sick?
* How is H1N1 flu treated?
* When should I get emergency medical care?
* How should I feed my baby?
* Is it ok to breastfeed my baby if I am sick?
* Is it OK to take medicine to treat or prevent H1N1 flu while breastfeeding?
How is H1N1 flu treated?
* Treat any fever right away. Tylenol(acetaminophen) is the best treatment of fever in pregnancy.
* Drink plenty of fluids to replace those you lose when you are sick.
* Your doctor will decide if you need antiviral drugs such as Tamiflu(oseltamivir) or Relenza(zanamivir). Antiviral drugs are prescription pills, liquids or inhalers that fight against the flu by keeping the germs from growing in your body. These medicines can make you feel better faster and make your symptoms milder.
* These medicines work best when started soon after symptoms begin (within two  days), but they may also be given to very sick or high risk people (like pregnant women) even after 48 hours. Antiviral treatment is taken for 5 days.
* Tamiflu and Relenza are also used to prevent H1N1 flu and are taken for 10 days.
* There is little information about the effect of antiviral drugs in pregnant women or their babies, but no serious side effects have been reported. If you do think you have had a side effect to antiviral drugs, call your doctor right away.
Novel Influenza A (H1N1) Virus Infections in Three Pregnant Women ― United States, April–May 2009
CDC first identified cases of respiratory infection with a novel influenza A (H1N1) virus in the United States on April 15 and 17, 2009 (1). During seasonal influenza epidemics and previous pandemics, pregnant women have been at increased risk for complications related to influenza infection (2–5). In addition, maternal influenza virus infection and accompanying hyperthermia place fetuses at risk for complications such as birth defects and preterm birth (6). As part of surveillance for infection with the novel influenza A (H1N1) virus, CDC initiated surveillance for pregnant women who were infected with the novel virus. As of May 10, a total of 20 cases of novel influenza A (H1N1) virus infection had been reported among pregnant women in the United States, including 15 confirmed cases and five probable cases.* Among the 13 women from seven states for whom data are available, the median age was 26 years (range: 15–39 years); three women were hospitalized, one of whom died. This report provides preliminary details of three cases of novel influenza A (H1N1) virus infection in pregnant women. Pregnant women with confirmed, probable,
or suspected novel influenza A (H1N1) virus infection should receive antiviral treatment for 5 days. Oseltamivir is the preferred treatment for pregnant women, and the drug regimen should be initiated within 48 hours of symptom onset, if possible. Pregnant women who are in close contact with a person with confirmed, probable, or suspected novel influenza A (H1N1) infection should receive a 10-day course of chemoprophylaxis with zanamivir or oseltamivir.
Patient A. On April 15, a woman aged 33 years at 35 weeks’ gestation with a 1-day history of myalgias, dry cough, and low-grade fever was examined by her obstetrician-gynecologist. She had been in relatively good health and had been taking no medications other than prenatal vitamins, although she had a history of psoriasis and mild asthma. The patient had not recently traveled to Mexico. Rapid influenza diagnostic testing performed in the physician’s office was positive.
On April 19, she was examined in a local emergency department,
with worsening shortness of breath, fever, and productive
cough. She experienced severe respiratory distress, with an oxygen saturation of approximately 80% on room air and a respiratory rate of approximately 30 breaths per minute. A chest radiograph revealed bilateral nodular infiltrates. The patient required intubation and was placed on mechanical ventilation. On April 19, an emergency cesarean delivery was performed, resulting in a female infant with Apgar scores of 4 at 1 minute after birth and of 6 at 5 minutes after birth; the infant is healthy and has been discharged home. On April 21, the patient developed acute respiratory distress syndrome (ARDS). The patient began receiving oseltamivir on April 28. She also received broad-spectrum antibiotics and remained on mechanical ventilation. The patient died on May 4.
On April 25, a nasopharyngeal swab specimen collected from patient A indicated an unsubtypable influenza A strain by real-time reverse transcription–polymerase chain reaction (rRT-PCR) at the San Antonio Metro Health Laboratory. The specimen was forwarded to the Virus Surveillance and Diagnostic Branch Laboratory, Influenza Division, CDC, where testing was inconclusive for novel influenza A (H1N1) virus. On April 30, a repeat nasopharyngeal specimen was collected, which was positive by rRT-PCR for novel influenza A (H1N1) virus at CDC.
Patient B. A previously healthy woman aged 35 years at 32 weeks’ gestation was seen at a local emergency department on April 20 with a 1-day history of shortness of breath, fever, cough, diarrhea, headache, myalgias, sore throat, and inspiratory chest pain. She was febrile (101.6°F [38.7°C]), with a heart rate of 128 beats per minute, respiratory rate of 22 breaths per minute, and oxygen saturation of >97% on room air. A chest radiograph was normal. Rapid influenza diagnostic testing was negative. The patient received a parenteral nonsteroidal anti-inflammatory medication, acetaminophen, and inhaled albuterol and was discharged home. She was evaluated the following day in her obstetrician-gynecologist’s office, where a nasopharyngeal swab sample was collected and sent for rRT-PCR testing. The patient received antibiotics, antinausea medication, acetaminophen, and an inhaled corticosteroid. The patient recovered fully, and her pregnancy is proceeding normally.
Patient B had been in Mexico during the 3 days preceding
her arrival at the emergency department. Several family members in Mexico and the United States had recently been ill with influenza-like illness, and her sister had been hospitalized
for pneumonia during the preceding week. Testing of the nasopharyngeal swab specimen from patient B collected on April 21 was identified as an unsubtypable influenza A strain by rRT-PCR testing at the Naval Health Research Laboratory in San Diego. Additional testing at CDC confirmed infection with novel influenza A (H1N1) virus.
Patient C. On April 29, a woman aged 29 years at 23 weeks’ gestation was experiencing cough, sore throat, chills, subjective fever, and weakness of 1 day’s duration and was seen at the family practice clinic where she had been receiving prenatal care. The patient had a history of asthma but was not taking any asthma medications. Her son, aged 10 years, reportedly had similar symptoms the week before the onset of her symptoms.
Another son, aged 7 years, had become ill on the same day as his mother and accompanied her to the clinic. At the clinic, the younger son was coughing vigorously and was asked to put on a mask by office staff members. Rapid influenza diagnostic testing in the family practice clinic of a nasopharyngeal sample from patient C was positive. The woman was prescribed oseltamivir, which she began taking later the same day. Her symptoms are resolving without complications, and her pregnancy is proceeding normally.
Patient C had not traveled to Mexico recently. Her son aged 7 years also was prescribed oseltamivir on April 29 but was not tested for influenza. The physician who evaluated patient C was also pregnant (13 weeks’ gestation). The physician began chemoprophylaxis with oseltamivir and has remained asymptomatic.
A nasopharyngeal swab collected from patient C on April 29 was identified as an unsubtypable influenza A strain by the Washington State Public Health Laboratory. Additional testing at CDC confirmed infection with novel influenza A (H1N1) virus.
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