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V) Guidelines for pandemic influenza case management in Pregnant women-
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Pregnant women are at increased risk of infection from H1N1 virus.
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H1N1 virus and pregnancy forms a high risk combination. Every ILI in pregnancy irrespective of trimester needs to be seen by a doctor. Morbidity is higher in pregnancy than in non-pregnant population.
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Fever, cough, sore throat, rhinorhea, headache, shortness of breath, muscle weakness with vomiting and diarrhea in pregnancy irrespective of its trimester must be considered as indicators towards possible H1N1 infection.
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Pregnant women are likely to be admitted for Cardiopulmonary event and therefore that must be kept in mind while assessing the pregnant women.
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Obesity, hypertension, asthmatic tendency and diabetes melitus are comorbid conditions which do exacerbate risk during pregnancy in H1N1 infection. It is recommended for pregnant patients that throat swab be taken as soon as they are seen and sent to diagnostic lab and report is asked at the earliest.
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An individualized consent explaining the risk Vs benefit ratio to mother – fetus from the expecting mother is advisable. It is recommended for pregnant patients that the anti-viral drugs be started as soon as possible after the onset of infection symptoms. The benefit is expected to be greatest if Oseltamivir (Tamiflu) is started within 36-48 hrs of onset of symptoms.
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In view of the expected effect of Pandemic H1N1 infective virus on the pregnant woman, the benefit of treatment with these drugs are likely to outweigh potential risk to the fetus.
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The pregnant woman with a positive swab or with more than one severe symptoms when the swab report is awaited, to be advised indoor admission.
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Admitted indoor patients should also undergo assessment for cardiac status in the form of ECG, Eco-cardiography, CPK-MB enzymes. These tests be reported to monitor early occurrence of mayocarditis.
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In the case of pregnant woman, the symptoms may worsen very rapidly and viral pneumonia or secondary bacterial pneumonia may set in.
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Monitoring of fetal distress is very important.
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Even after Tamiflu is started, and symptoms appear to have been relieved, patients should not be discharged for 48 hrs. They should be monitored till the last dose of Tamiflu.
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The patient must complete the course of Tamiflu for 5 days even if he/she feels symptomatically better after first or second day of anti-viral treatment.