Influenza and Pregnancy

Flu season is in full swing in my city, and based on NPR's constant coverage of national incidence rates, I thought a quick review for myself and for y'all would be helpful.Need quick information for women? Watch this video. The March of Dimes also has an outline of this information for pregnant women readers. Other information is also available from Flu.gov.Here's some important information for healthcare providers:All pregnant women should be offered the inactivated, thimerosal-free, injectable flu vaccine regardless of trimester of pregnancy. The recently-published largest study regarding pregnant women and flu vaccine recently aligned with other studies demonstrating the flu vaccine to be safe for the fetus in pregnancy.***Symptoms of the flu include fever, cough, rhinorrhea, and sore throat. High fever and dry cough are more typical of flu than a "cold" (Varney's Midwifery, p. 143). Symptoms may also include myalgia, severe nausea and vomiting, confusion, and shortness of breath - depending on severity of symptoms, women should report to the hospital for evaluation.If a woman reports minimal symptoms or is without fever, home management is similar to that for an upper respiratory infection (URI) : "rest, increased humidity (hot showers, humidifiers), increased fluids, over-the-counter drugs - including antipyretics, analgesics, and cough suppressants or decongestants as needed" (Varney's Midwifery, p. 143).To test for the flu, a nasal swab is collected, but may take 24-48 hours to return with a diagnosis.For pregnant women highly symptomatic for flu or with confirmed flu diagnosis, strategies for prophylaxis or treatment are as follows:

• Bedrest
• Administer oral or IV fluids
• Antipyretics, namely acetaminophen/Tylenol
• Antiviral medication for early infection, neuraminidase inhibitors: Oseltamavir (aka, Tamiflu) (75mg PO BID) or Zanamivir (10mg [2 inhalations] inhaled BID, not for asthmatics) - both Category C drugs. These may decrease duration of infection and possibly decrease the risk of pneumonitis (Williams, p. 1003). Treatment of the flu within 48 hours of onset of symptoms may shorten the duration by 1-2 days (Varney's Midwifery, p. 144).

Advanced influenza in pregnant women, as with the general population, can lead to pneumonia, which is life-threatening. Progression to pneumonitis may be more likely in pregnant women due to immunosuppression in pregnancy and decreased pulmonary capacity (UptoDate.com, "Influenza and Pregnancy")."Data on the safety of antiviral medications during lactation are limited..." (UptoDate.com, "Influenza and Pregnancy").***Important considerations:Given ongoing investigations into concerns about vaccinations, preservatives, guessing games with the vaccine, and long-term outcomes, research into this area continues. Women should be informed about the increased risk of both maternal and fetal death with confirmed influenza diagnosis in pregnancy, as with increased risk of death with confirmed influenza in the general population. As with any healthcare intervention, women have the right to delay, research, accept or decline the flu vaccine. (I realize this is obvious and I am likely preaching to the choir on this, but I think it is still important to say).This article from December 2011 is a fantastic review posted by Melinda @lovebirthllc on Twitter. A few quotes:

"In the literature made available to doctors and other healthcare professionals, the CDC admits that there are several challenges to creating an effective influenza vaccine, and that vaccine effectiveness is greatly lowered when the strains of influenza in the vaccine are not “well matched” to the strains of influenza in circulation in the population—which is what occurred in the 2003–2004 flu season.³⁵

The information the CDC provides to doctors about the inefficacy and imperfect nature of the flu vaccine is surprisingly candid. Their website states: “[I]n some years when vaccine and circulating strains were not well-matched, no vaccine effectiveness may be able to be demonstrated.” (My italics.) “It is not possible in advance of the influenza season to predict how well the vaccine and circulating strains will be matched, and how that may affect vaccine effectiveness.”...

In an interview on National Public Radio, Ruth Faden, MD, disagreed. She argued that pregnant women shouldget the flu shot, but acknowledged that, because of the reluctance to do testing on pregnant women, “medicine is flying blind” in administering drugs, including the vaccine, to pregnant women. “It’s a terribly unsatisfying and arguably utterly unethical situation that we’re in,” Faden admitted..."Also, an interesting study reported on ABC News with Diane Sawyer:As someone coming from a public health background, I struggle with research, arguments, anecdotal reports,  published evidence, and national guidelines around vaccines of all kinds, including influenza. I have been recommending the thimerosal-free vaccine to all of my pregnant patients, and am honest about the minimal research about the vaccine in pregnancy, its newness yearly, and possible worsening of infection in pregnant women. Additionally, I discuss that treatment for flu rests on Pregnancy Category C drugs, that with any ailment in pregnancy, typically rest and fluids is the go-to before anything else. That to be vaccinated against flu in pregnancy is her decision. (This being said, most women respond, "Well, what do you think?")How are you all counseling pregnant women on the flu, the vaccine, symptom management, and testing/treatment?