A Gutsy Guide to Getting Your Mojo Back

Okay, Pinkies, I’ve gotten so many emails today about swine flu and pregnancy that I thought I’d save myself some time and add an addendum to my post about swine flu.  I’ll keep adding the questions to the post as they come in, and feel free to post questions in the comment section.  I’ll help you as much as I can.  I know it’s a little off the topic of Pink inspiration, but believe me, fear of pandemics can definitely make you lose your mojo, so I thought I’d put on my white coat today and post your questions and my answers.  Here goes:

 1.If I’m pregnant and I get swine flu, will it hurt my baby?

Oh, honey, don’t worry.  While pregnant women are more susceptible to influenza viruses and can suffer more seriously, most pregnant women will recover just fine from the flu- swine flu included.  But there is some risk, so you want to be sure to protect yourself.  If pregnant women get swine flu, they will be more susceptible to dehydration, which can cause the uterus to contract and put them at risk of preterm labor. Staying hydrated is critical. If you are throwing up or have diarrhea, alert your doctor. You may need IV fluids to protect you from delivering your baby prematurely.  As long as you don’t deliver early or miscarry, the baby should be fine. The baby will be protected as long as it is safe in the uterus, and there should be no long term complications, the way there can be with some other viruses, like cytomegalovirus (CMV) or the rubella virus.

2. What can I do to avoid getting swine flu if I’m pregnant?

Wash your hands, wash your hands, wash your hands. For more tips on swine flu  prevention, check out 13 Ways to Avoid Swine Flu and Why Not to Freak Out.

3. Why are pregnant women more susceptible to influenza viruses?

Pregnant women are more susceptible to all infections, because the immune system is naturally suppressed during pregnancy, in order to prevent you from fighting your baby as something foreign.  Because the immune system is weakened, and there are two lives we need to care for, treating the flu during pregnancy can be more difficult, but with proper management, most pregnant women will recover and be healthy.  So take care, but don’t panic. 

4. Is it safe to take Echinacea during pregnancy?

Experts are mixed on this issue, but most agree that it is safe during pregnancy. A randomized study http://www.ncbi.nlm.nih.gov/pubmed/11074744 evaluated the pregnancy outcomes of women who were exposed to Echinacea during pregnancy and found no evidence of harm, but the study was small.  This is the only study performed to date, and the results appear encouraging. But larger studies are needed to know definitively if Echinacea is safe in pregnancy.

5. I got the flu vaccine during my pregnancy. Does that mean I’m protected from swine flu?

We OB/GYN’s recommend the flu vaccine during pregnancy because you’re at higher risk during pregnancy because of your suppressed immune state.  While the swine flu strain is different than the strains the vaccine immunizes you against, there may be some benefit to the flu vaccine with regard to swine flu

6. I didn’t get the flu vaccine this year, but I’m pregnant. Should I get one?

I recommend the flu vaccine to all pregnant women. And while it’s late in the year, if you have access to the flu vaccine, I would recommend it. If nothing else, it may help prevent an ordinary strain of influenza and keep you from worrying.
Have questions I haven’t answered?  Post them in the comments, and I’ll try to help.

What are the symptoms of swine flu. How will I know if I have it?

Fever, cough, fatigue, diarrhea, and nausea/vomiting are the most common symptoms.  While these symptoms are the same symptoms associated with the more common strains of the flu, regular flu season is winding down. So if you have symptoms, alert your physician.

How can you test for swine flu?

A real-time RT-PCR test or a viral culture performed on a respiratory specimen will diagnose swine flu.  

Is there a cure for swine flu?

Like most viruses, there is no easy cure for swine flu the way penicillin cures strep throat.  But there are anti-viral drugs that are effective in reducing the symptoms of swine flu.  Empiric antiviral treatment is recommended for any ill person suspected of having swine flu. Antiviral treatment with either zanamivir alone or with a combination of oseltamivir and eitheramantadine or rimantadine should be initiated as soon as possible after the onset of symptoms. The recommended duration of treatment is five days.Recommendations for use of antivirals may change as data on antiviralsusceptibilities become available. For more information on dosing, check out http://www.cdc.gov/flu/professionals/antivirals/dosagetable.htm#table

Are anti-viral drugs safe in pregnancy?

Oseltamivir, zanamivir, amantadine, and rimantadine are all “Pregnancy Category C” medications, meaning that we have no evidence that it’s harmful, but no clear evidence that it’s safe. According to the CDC, only two cases of amantadine use for severe influenza illness during the thirdtrimester have been reported. However, both amantadine and rimantadine (which appear not to work for this particular strain of flu) have been demonstrated to cause birth defects in animal studies when given at  very high doses. Oseltamivir and zanamivir are effective with swine flu, but less data exists about them.  Because we can’t know for sure that they’re safe, these drugs should be used during pregnancy only if the potential benefit justifies the potential risk.  However, no adverse effects to pregnant women or their fetuses/infants have been reported among womenwho received oseltamivir or zanamivir during pregnancy.  

A friend of mine who is pregnant just called me and told me she was worried because she has the sniffles. She doesn’t know what to do. She normally has allergies this time of year but she’s afraid it might be the swine flu. She’s not sure if she should go to an ER or whether she can wait until morning to call her doctor.

Symptoms of swine flu should be very different than the seasonal allergies that are so pervasive this time of year.  Swine flu usually presents with fever, body aches, fatigue, cough, occasional runny nose, and sometimes nausea, vomiting, and diarrhea.  Allergies usually result in a drippy, runny, sneeze nose, watery, itchy, bloodshot eyes, hives on the skin, and, for those with a tendency towards asthma, wheezing and/or cough.  A fever is the best way to differentiate, although a low grade fever and the sniffles could be a simple common cold.  If your friend has a fever as well as other symptoms of swine flu, I would recommend she call her doctor.  If not, she might try taking an allergy medicine. like Benadryl or Claritin, which are available over the counter and are safe in pregnancy.  If the symptoms improve, it’s probably not swine flu.

I am 26 weeks pregnant, with twins  and planning a trip to Spain. I was so worried and your advice has helped me relax, thanks very much for that! There is just one thing still on my mind… If a pregnant woman gets a virus, swine flu included, does this pass to the baby? I mean, can they get ill,or can they suffer as a cause of it (Does it pass the placenta)? And, if not (would be a great relief), could the antiviral medicaction do that? (could the medication be more harmfull than the illness?) Sorry if I made your head spin…

No, no head spinning, sweetie. That’s a very good question, and the reason I didn’t address it specifically is because we just don’t know yet. When new flu strains emerge, they have mutated from other flu strains, so their capacity to do things like cross the placenta can change. We know that some viruses- like the herpes virus and CMV- can cross the placenta during pregnancy and affect the fetus. There is evidence that other strains of flu, such as the avian flu, have crossed the placenta as well. Perhaps swine flu can also. But this is not necessarily cause for alarm. Unlike herpes and CMV, which can cause severe birth defects, the flu virus does not usually affect how the organs develop in a fetus. And because you and your placenta are nurturing your twins while you gestate, your baby doesn’t have to worry about things like coughing, breathing problems, or even vomiting and diarrhea. So yes, if you get a fever, your baby will get a fever. If you get dehydrated, your baby gets dehydrated, but for the most part, your baby is protected, even if you get swine flu. You are your babies incubator. You’re the ICU. So you don’t need to worry about your babies, just you. If you were to get swine flu, you would likely be hospitalized because of the twins, because getting the flu in pregnancy can increase your risk of preterm birth, which you are already at risk of because of your twins. So do be careful and make every effort to avoid being infected. But don’t be alarmed. If you were to get it, the decision of whether or not to treat you with anti-virals would depend on the severity of your illness. Since we anti-virals are Category C, meaning we don’t have good data, you would likely only be treated if you were quite ill. As for Tamiflu and Relenza, the anti-virals, we do not know if they cross the placenta. Until we know more, we are cautious about how we use any medication in pregnancy. Stay tuned, and feel free to ask more questions if they arise. I’m sure your questions mirror what many women are thinking.

I am 27 weeks pregnant and is supposed to be traveling to London in two days..I am really panicking about being on an airplane or in an airport at this time with the swine flu. If I catch it can I be treated with out harming the baby? Do you reccomend that with what is happening, I should cancel the trip or not? 

I imagine this is a frightening time for anyone to travel, much less someone who is 27 weeks pregnant. So far, travel recommendations from CDC and WHO do not call for us to change our travel plans (except the CDC, which recommends against non-essential travel to Mexico). But I can understand why being in crowded places would be scary at the time of an international pandemic.

And yes, pregnancy is a time to be more concerned about the flu. While most people who get swine flu will be watching chick flicks at home and merely feeling crappy, pregnant women must also worry about preterm labor, and at 27 weeks, you don’t want to go there.

But the likelihood is that if you fly to London, you and your baby will be just fine. What does your intuition tell you? I know when I have tough decisions to make, taking a moment to listen to my inner guide helps. (I know- sounds floofy, but you’d be surprised). If your intuition fails to help you, ask your doctor. Most likely, your doctor will turn the decision back around to you.

I hate to ever say this- because I’m not, and will never be, you. But if it were me and it was non-essential travel, I might reconsider at 27 weeks pregnant. If I was not pregnant and planning a trip to London (even if I was pregnant but not at the critical 24-32 week time of pregnancy), I would probably go. But that’s just me- I chose not to travel in my third trimester at all, so talk my advice with a grain of salt.

Here are some Travel Guidelines:

Only you can decide. Talk to your family and your doctor, seek your inner answers, go with your gut, and let it go after that.

As for whether you can be treated if you do get swine flu, the answer is that it all depends.  Because the medications we use for swine flu are Category C, meaning we don’t have data about whether they are safe or not during pregnancy, anti-viral treatment would be reserved for pregnant women who are very ill, when the benefits are determined to outweigh any potential risk.  But other supportive treatments, such as IV fluids, Tylenol, and most cough medicine, are safe in pregnancy.  Remember that the likelihood that you will get it is exceedingly low. More people were in car crashes today than caught swine flu. It’s important to keep things in perspective.  Let you Pink wisdom be your guide, sweetie, and best of luck.

Here’s the Center for Disease Control (CDC) Interim Guidelines for Pregnancy and Swine Flu:

Background

Human infections with a swine influenza A (H1N1) virus that is easily transmissible among humans were first identified in April 2009 with cases in the United States and Mexico. The epidemiology and clinical presentations of these infections are currently under investigation. There are insufficient data available at this point to determine who is at higher risk for complications of swine influenza A (H1N1) virus infection. However, in 1988 a previously healthy 32-year-old pregnant woman was hospitalized for pneumonia and died 8 days later after infection with another variant of swine influenza virus. Pregnant women are also known to be higher risk for seasonal influenza complications and during prior pandemics, and it is reasonable to assume that pregnant women are also at higher risk for swine influenza complications.

Evidence that influenza can be more severe in pregnant women comes from observations during previous pandemics and from studies among pregnant women who had seasonal influenza. An excess of influenza-associated deaths among pregnant women were reported during the pandemics of 1918–1919 and 1957–1958. Adverse pregnancy outcomes have been reported following previous influenza pandemics, with increased rates of spontaneous abortion and preterm birth reported, especially among women with pneumonia. Case reports and several epidemiologic studies conducted during interpandemic periods also indicate that pregnancy increases the risk for influenza complications for the mother and might increase the risk for adverse perinatal outcomes or delivery complications.

Clinical Presentation

Pregnant women with swine influenza would be expected to present with typical acute respiratory illness (e.g., cough, sore throat, rhinorrhea) and fever or feverishness. Many pregnant women will go on to have a typical course of uncomplicated influenza. However, for some pregnant women, illness might progress rapidly, and might be complicated by secondary bacterial infections including pneumonia. Fetal distress associated with severe maternal illness can occur. Pregnant women who have suspected swine influenza A (H1N1) virus infection should be tested (http://www.cdc.gov/swineflu/specimencollection.htm), and specimens from women who have unsubtypeable influenza A virus infections should have specimens sent to the state public health laboratory for additional testing to identify swine influenza A (H1N1).

Treatment and chemoprophylaxis

The currently circulating swine influenza A (H1N1) virus is sensitive to the neuraminidase inhibitor antiviral medications zanamivir and oseltamivir, but is resistant to the adamantane antiviral medications, amantadine and rimantadine. Pregnant women who meet current case-definitions for confirmed, probable or suspected swine influenza A (H1N1) infection (http://www.cdc.gov/swineflu/casedef_swineflu.htm) should receive empiric antiviral treatment. Pregnant women who are close contacts with persons with suspected, probable or confirmed cases of swine influenza A (H1N1) should receive antiviral chemoprophylaxis. These recommendations for treatment and chemoprophylaxis are the same ones used for others who are at higher risk of complications from influenza.

As is recommended for other persons who are treated, antiviral treatment with zanamivir or oseltamivir should be initiated as soon as possible after the onset of influenza symptoms, with benefits expected to be greatest if started within 48 hours of onset based on date from studies of seasonal influenza. However, some data from studies on seasonal influenza indicate benefit for hospitalized patients even if treatment is started more than 48 hours after onset. Recommended duration of treatment is five days, and for chemoprophylaxis is 10 days. Oseltamivir and zanamivir treatment and chemoprophylaxis regimens recommended for pregnant women are the same as those recommended for adults who have seasonal influenza. Recommendations for use of antivirals for pregnant women might change as additional data on the benefits and risks of antiviral  therapy in pregnant women become available (http://www.cdc.gov/swineflu/recommendations.htm).

Oseltamivir and zanamivir are “Pregnancy Category C” medications, indicating that no clinical studies have been conducted to assess the safety of these medications for pregnant women. Because of the unknown effects of influenza antiviral drugs on pregnant women and their fetuses, oseltamivir or zanamivir should be used during pregnancy only if the potential benefit justifies the potential risk to the embryo or fetus. However, no adverse effects have been reported among women who received oseltamivir or zanamivir during pregnancy or among infants born to women who have received oseltamivir or zanamivir. Pregnancy should not be considered a contraindication to oseltamivir or zanamivir use. Pregnant women might be at higher risk for severe complications from swine influenza, and the benefits of treatment or chemoprophylaxis with zanamivir or oseltamivir likely outweigh the theoretical risks of antiviral use.  Because of its systemic activity, oseltamivir is preferred for treatment of pregnant women.  The drug of choice for prophylaxis is less clear.  Zanamivir may be preferable because of its limited systemic absorption; however, respiratory complications and medication delivery system challenges that may be associated with zanamivir because of its inhaled route of administration need to be considered, especially in women at risk for respiratory problems.

Several studies have shown that fever during pregnancy is associated with an increased risk of birth defects and other adverse outcomes.  For this reason, fever in pregnant women should be treated. Acetaminophen appears to be the best option for treatment of fever during pregnancy.

Other ways to reduce risk for pregnant women

The risk for swine influenza A (H1N1) might be reduced by taking steps to reduce the chance of being exposed to respiratory infections. There is no vaccine available yet to prevent swine influenza A (H1N1). These actions include frequent handwashing, covering coughs, and having ill persons stay home, except to seek medical care, and minimize contact with others in the household who may be ill with swine flu. Additional measures that can limit transmission of a new influenza strain include voluntary home quarantine of members of households with confirmed or probable swine influenza cases, reduction of unnecessary social contacts, and avoidance whenever possible of crowded settings. If used correctly, facemasks and respirators may help reduce the risk of getting influenza, but they should be used along with other preventive measures, such as avoiding close contact and maintaining good hand hygiene. A respirator that fits snugly on the face can filter out small particles that can be inhaled around the edges of a facemask, but compared with a facemask it is harder to breathe through a respirator for long periods of time.

Breastfeeding considerations

Women who are breastfeeding can continue while receiving antivirals. However, women who are ill with swine influenza A (H1N1) should take steps to reduce the risk to their infants, such as frequent hand washing and possibly wearing a mask (see below). The risk for swine influenza transmission through breast milk is unknown.  However, reports of viremia with seasonal influenza infection are rare.

Efforts to identify the risk for pregnant women from swine influenza A (H1N1) during 2009 are underway.  Enhanced surveillance for hospitalized patients with swine influenza A (H1N1) has been initiated. Additional information about swine influenza is available.

Hang in there, Pinkies. The world’s not ending, I swear.  We just need to get past this scary little blip in time, and then we can get back to fun, healing mojo exercises!

With lots of piggie love,
Lissa Rankin, MD

PS. Yes, that photo is me, pregnant with Siena…

Tags: swine flu, Swine Flu, swine flu and pregnancy

This entry was posted on Monday, April 27th, 2009 at 3:04 pm and is filed under Owning Health, Personal Empowerment. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.