STORY BYYou’re probably scared. Scared because suddenly, it’s everywhere. Even the news about it is like a virus. As if one TV station coughed on another and spread it all over the place. Scared because everyone has different facts. Scared because no one seems to have facts. They just don’t know. (And, who is “They” anyway?) Even the Very Official People In The Know don’t know if we’re careening into it or coming out of it.
So, here’s the deal: During any given flu season, over 20,000 people die from complications of the flu. And that’s with a pretty swell vaccine. Then again, over 220,000 get the flu. And live to swap their “let me tell you how sick I was” stories with their fellow flu mates. So, even though you’re scared, as the warning level jumps to 5, try to remember one word: “mild.” Now go wash your hands.
Swine flu, H1N1, North American Influenza – it all spells deep concern for pregnant women and nursing mothers (and all the rest of us). UT experts in obstetrics and gynecology, infectious disease and pulmonology answer your questions.
1. I am pregnant. What should I know about swine flu? What would my symptoms be? What should I do for treatment?
Symptoms of swine flu in pregnant women are the same as those in non-pregnant women and are similar to symptoms of other forms of flu. Common symptoms include fever (temperature > 37.8°C or 100°F), chills, cough, congestion, muscle aches, headache and possibly vomiting and diarrhea. If she also has traveled to Mexico or has known exposure to a suspected or probable case of swine flu, she should report this to her health provider immediately.
If a pregnant woman suspects she has swine flu, she should contact her health provider by phone to discuss what precautions she should take and if further evaluation, treatment or hospitalization is warranted.
Symptoms of more severe respiratory illness may include shortness of breath and rapid breathing and require prompt medical attention. Persistent vomiting and diarrhea may lead to dehydration. If you are unable to keep liquids down, you may need hospitalization for intravenous hydration. Acetominophen (Tylenol) can be taken for fever, but persistent high fevers are another sign that should be reported to your care provider.
What makes flu complications so dangerous?
Richard Castriotta, MD
When the flu causes pneumonia, the symptoms and signs move from the upper airways (nose, throat, larynx, etc.) to the lower airways with certain changes in the lung sounds heard by a doctor with his stethoscope and seen on a chest x-ray. Both the flu and pneumonia cause fever and a sensation of feeling bad "all over," but when there has been a complication leading to a bacterial "super infection," there also are chills and a change in the color and quantity of phlegm or sputum that is coughed up.
When this leads to respiratory failure, there is shortness of breath (dyspnea), at first, only on exertion and later at rest. At this time, the oxygen level is low, the patient will have an increase in respiratory rate from the normal 12-20 to 30 or more breaths per minute and a simple test in the hospital (pulse oximetry or an arterial blood gas analysis) will show the low oxygen level.
In past influenza epidemics, it was usually older people with underlying heart, lung or kidney disease or diabetes that were most susceptible to getting pneumonia and respiratory failure. Also, very young children and those taking drugs that lower the ability of the immune system to do its job (e.g., people with rheumatoid arthritis on certain drugs) are prone to this.
Patients at high risk suspected of flu should be treated early with Tamiflu or Zanamvir for 5 days. Those suspected of having pneumonia and/or respiratory failure should be isolated and hospitalized. They may need supplemental oxygen, ventilator support and additional antibiotics for super infection with other bacteria. In general, if someone only has the "flu" symptoms like a very bad cold, aches all over, etc., they should see their doctor, but not go to the hospital. If they are short of breath, too weak to move, very dehydrated or have concomitant medical problems placing them at risk of complications, then they should go to the hospital. Be aware that, in general, the hospital is a dangerous place during a flu epidemic, because there is more chance of exposure and contagion there.
2. What precautions should a pregnant woman take to prevent contracting swine flu, especially if she lives in an area with confirmed cases of this disease?
Take the same precautions as anyone else who lives in an area of concern. As always, consistent practice of good hygiene is essential. Wash your hands frequently, lathering vigorously, and washing your rings, wrists and between fingers. Rinse under forceful water and dry thoroughly. Avoid touching your hands to your nose, mouth and eyes.
If you live in an area where cases have been reported, limit unnecessary trips to large public gatherings where you could be exposed to infectious people. Usually a distance of 6 feet is considered a "safe" distance. Pregnant women also should avoid unnecessary travel to locations where the virus has been confirmed.
Pregnant women should attempt to avoid exposure to people who are known to be infected. This also means that they ideally should not be the caretaker for persons with the infection if another alternative is available.
3. What are the possible complications to a pregnancy or to the fetus if the mother contracts swine flu? Are some pregnant women more at risk than others? If so, who?
Information from past influenza epidemics suggests that pregnant women are more likely to have more severe infection and increased mortality rates. Influenza can lead to a secondary bacterial infection. Generally, pneumonia of any type during pregnancy is more likely to be severe when compared to the same infection in non-pregnant women.
During an epidemic or not, influenza in general is more dangerous during pregnancy. Pregnant women are more likely to require hospitalization and to suffer respiratory complications. Why? Probably normal physiological changes that occur during pregnancy leave women more vulnerable to infection. The risk appears to be greater in the later months of pregnancy.
Since this is a new strain of virus, little information exists about H1N1 and its effects on pregnant women. Because of research gathered from previous flu epidemics, we can surmise that flu may be tougher on women during pregnancy. Risk to the fetus has more to do with the mother’s health. No specific information is available regarding direct risk to the developing fetus from flu contracted by the mother. However, an increased risk of spontaneous miscarriage and of preterm birth in women with severe respiratory infections has been suggested during prior epidemics.
4. If diagnosed with swine flu, what would be the treatment for pregnant women?
If you are pregnant and think you have H1N1 you should contact your health care provider by phone to arrange a visit to test for the virus and be examined. You would be taken directly to a private area, bypassing the waiting room to limit your exposure to others.
Antiviral medications which have been recommended for treatment of this swine flu infection for non-pregnant patients include either Oseltamivir or Zanamivir. Oseltamivir is typically given orally or by an intravenous infusion. Zanamivir is given as an inhaled medication. If necessary, these medications can be used in pregnancy, but unfortunately limited information regarding the safety of use of their use is available. Talk with your doctor about the appropriateness of treatment with one of these medications. Further information specific to pregnant women is available through the Web site for the Centers for Disease Control ( http://www.cdc.gov/swineflu/clinician_pregnant.htm ).
Other treatment measures include keeping yourself well hydrated by drinking fluids, taking acetaminophen(Tylenol) to reduce fever and using an over-the-counter decongestant such as pseudoephedrine if needed. Specific situations should be discussed with your pregnancy health care provider.
If you’re pregnant and you know you’ve been exposed to H1N1, your doctor may believe that anti-viral medications are warranted to prevent infection. This is called prophylaxis.
5. How soon would I have to decide if I should start on medication if I knew I had been exposed to someone with H1N1?
These drugs are most effective if taken within the first 48 hours of initial onset of symptoms. These drugs serve to lessen the severity of illness and shorten the length of illness. They are not flu cures.
The decision to take anti-viral medications with a suspected case of H1N1 requires a detailed discussion between the pregnant patient and her health care provider. The potential benefits for the pregnant mother and the potential risks for the developing fetus should be weighed on a case-by-case basis. The period of greatest sensitivity to medication exposure for developing fetus is typically in the first trimester. The period of greatest risk to the mother from influenza is typically the last trimester or late term.In between these two considerations is the relative health of the mother. And, if the mother is sick enough to be hospitalized, antiviral medications may be worth prescribing even past the 48-hour window.
6. Doesn’t last fall’s flu shot afford me any protection during my pregnancy?
You were wise to get it for the 2008-09 seasonal flu, since you are pregnant. Unfortunately, this flu shot was not designed to give protection against this flu strain. There is no current vaccine for H1N1, but the Centers for Disease Control and Prevention (CDC) is working to add it to next season’s vaccine.
7.I’m carrying the very first grandchild, and my family lives near Mexico City. They’re all healthy and want to be here for the birth. Since travel is still allowed, can they come?
I would advise your family to wait a few weeks until this uncertain period is over. Though travel has not been restricted (H1N1 has already made it to the US) it does not mean that there is no threat of exposure, especially if your family lives near an infected area.
8. Can I breastfeed my infant if I’m taking an antiviral?
Not much information about the use of these medications during breastfeeding is available. What is available suggests that Oseltamivir levels in breast milk are low, with one study suggesting the infant would be exposed to approximately 0.5 percent of the mother’s weight-adjusted dose.
Zanamivir, administered through an inhaler device, appears to result in low plasma levels, which suggests that it is unlikely to result in high levels in breast milk or the breastfed infant. But again, there’s not much information to find. You would need to discuss the pros and cons with your doctor.
Oseltamivir may be prescribed directly for use in infants as young as 1 year. Questions regarding nursing mothers should address the age and overall health of the infant and the amount of the diet that breast milk comprises. Breastfeeding is generally beneficial in limiting the severity of respiratory infections in infants but solid information specific to this new strain of influenza isn’t available—it’s just too soon.
9. What can I take to relieve the aches and congestion of flu while breastfeeding?
10. How can I protect my infant during this outbreak?
Often during influenza in general, the infant has been exposed to the virus prior to the mother realizing that she has an infection. Since influenza is spread through respiratory droplets, good hygiene and regular hand washing are vital while you’re around your baby.
Politely ask others not to touch or kiss the baby and limit unnecessary excursions to areas with large crowds if this virus has been reported in your area. Ask your friends and family not to hold or play with the baby’s hands. Hands of infants go straight to their mouths.
For updated information on H1N1, TamiFlu while breastfeeding, go to the CDC's Web site.
Last Updated: 4-30-2009Editorial Board | Legal Disclaimer | Privacy & Security | Contact Us
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Dr. Pamela Berens is an associate professor in the Department of Obstetrics and Gynecology at the UT Medical School.
See Dr. Berens also at:
Dr. Luis Ostrosky-Zeichner is an associate professor in the Division of Infectious Diseases at the UT Medical School.
See Dr. Ostrosky also at:
Dr. Richard Castriotta is director of the Division of Pulmonary, Critical Care and Sleep Medicine at UT Medical School.
See Dr. Castriotta also at:
Packing Bag Lunches Safely
If you pack lunches for your child to take to school, be careful that you do not accidentally expose them to foodborne illness.
Bagged lunches, especially those containing perishable foods, need to be packed and handled properly in order to keep the food safe. In general, perishable foods should not be left at room temperature for more than two hours. If left out too long, the temperature of the food can enter the danger zone where bacteria grow most rapidly, which is between 40 and 140 degrees Fahrenheit.
Below are some tips to help families pack bagged lunches safely:
Before eating lunch or snacks at school, make sure your child washes his or her hands with soap and warm water for at least 20 seconds. If your child's school does not have a handwashing program in place, encourage them to adopt a such a program, as handwashing is one of the best ways kids and parents can protect health and stop the spread of germs.
