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H1N1 in pregnancy 2010

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  • 1. 1 Pandemic swine-origin influenza A (H1N1) emerged as a threatening pathogen in April 2009. Although this specific strain of influenza is dangerous to many subsets of individ- uals, including the very young or people with chronic med- ical conditions (Table 1), it has targeted pregnant women at an alarming rate and with potential serious sequelae. For these reasons, it is imperative that providers of prenatal care become familiar with the diagnosis and treatment of preg- nant women with suspected H1N1 influenza. After reading this review, clinicians should be able to recognize patients with influenza-like illness and know how to treat such patients during both pregnancy and the postpartum period. In addition, providers should understand the importance of vaccinating all pregnant patients against influenza. Emerging Pathogen The current H1N1 influenza pandemic arose rapidly. In early April 2009, young, healthy people in several areas of Mexico began to develop a severe pneumonia-like illness. The first reported outbreak of an influenza-like illness was in a small community in the state of Veracruz on April 12, 2009. On April 17, 2009, a case of atypical pneumonia in Oaxaca State, a different region of Mexico, was reported. Laboratory testing revealed that these cases, as well as oth- ers reported on April 23, 2009, were confirmed as H1N1 virus. The Mexican Ministry of Health thereby issued an alert ordering all suspected cases of influenza-like illness be reported. As cases of this novel influenza-like illness were being reported in Mexico, others began to emerge in the United States, with five confirmed cases in the United States as of April 21, 2009. Sequence analysis revealed that patients in Mexico were infected with the same influenza strain as two children residing in California. Illness began to spread; as ofApril 27, 2009, there were 26 confirmed cases of novel H1N1 influenza in Mexico, and 1 day later, the Centers for Disease Control and Prevention (CDC) report- ed 64 confirmed cases in the United States.1 On April 27, 2009, the World Health Organization (WHO) raised the worldwide alert to pandemic level 4, indicating confirmed human-to-human transmission able to cause community-level outbreaks. Just 2 days later, WHO raised the alert to pandemic level 5, indicating that H1N1 Influenza and Pregnancy Barbra Fisher, MD, PhD, and Ronald S. Gibbs, MD Learning Objectives: After participating in this activity, the obstetrician/gynecologist should be better able to: 1. Properly diagnose and treat H1N1 influenza in pregnant patients. 2. Implement influenza vaccination during pregnancy appropriately. 3. Provide recommendations regarding postpartum influenza management. Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly. This activity expires on May 14, 2011. A BIWEEKLY PUBLICATION FOR CONTINUING MEDICAL EDUCATION IN OBSTETRICS AND GYNECOLOGY POSTGRADUATE OBSTETRICS&GYNECOLOGY POSTGRADUATE OBSTETRICS&GYNECOLOGY Dr. Fisher is Fellow/Instructor, and Dr. Gibbs is Professor and Associate Dean for ContinuingMedicalEducation,DepartmentofObstetricsandGynecology,University of Colorado Health Sciences Center, Mail Stop F763, Anschutz Inpatient Pavilion, 12605 E. 16thAvenue, Aurora, CO 60045; E-mail: barbra.fisher@ucdenver.edu. All faculty and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no finan- cial relationships with, or financial interests in, any commercial companies pertaining to this educational activity. VOLUME 30 • NUMBER 9 May 15, 2010 Table 1. Health Conditions That Increase Risk of Hospitalization from 2009 H1N1 Influenza Lung disease Asthma Chronic obstructive pulmonary disease Diabetes Heart conditions Neurologic disease Pregnancy PGO09.qxd:Layout 1 3/31/10 2:20 PM Page 1
  • 2. Postgraduate Obstetrics & Gynecology May 15, 2010 2 The continuing education activity in Postgraduate Obstetrics & Gynecology is intended for obstetricians, gynecologists, and other health care professionals with an interest in the diagnosis and treatment of obstetric and gynecological conditions. Postgraduate Obstetrics & Gynecology (ISSN 0194-3898) is published biweekly by Lippincott Williams & Wilkins, Inc., 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116.Customer Service Manager,Audrey Dyson:Phone (800) 787-8981 or (410) 528-8572, 24-Hour Fax (410) 528-4105,or E-mail audrey.dyson@wolterskluwer.com.Visit our website at LWW.com.Publisher, Matthew Jozwiak. Copyright 2010 Lippincott Williams & Wilkins. Priority Postage paid at Hagerstown, MD, and at additional mailing offices. POSTMASTER: Send address changes to Postgraduate Obstetrics & Gynecology, Subscription Dept., Lippincott Williams & Wilkins, P.O. Box 1600, 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116. PAID SUBSCRIBERS: Current issue and archives from 2004 on are now available FREE online at www.lwwnewsletters.com. Subscription rates: Personal: $368.98 US, $523.98 Foreign.Institutional: $729.98 US, $871.98 Foreign.In-training: $113.98 resident non- scored US, $113.98 Foreign. GST Registration Number: 895524239.Send bulk pricing requests to Publisher. Single copies: $37. COPY- ING: Contents of Postgraduate Obstetrics & Gynecology are protected by copyright. Reproduction, photocopying, and storage or trans- mission by magnetic or electronic means are strictly prohibited.Violation of copyright will result in legal action, including civil and/or crim- inal penalties. Permission to reproduce in any way must be secured in writing; e-mail journalpermissions@lww.com. For reprints, e-mail matt.westcoat@wolterskluwer.com. Opinions expressed do not necessarily reflect the views of the Publisher, Editor, or Editorial Board. A mention of products or services does not constitute endorsement. All comments are for general guidance only; professional counsel should be sought for specific situations. a worldwide pandemic was probably immi- nent. A short time later, on June 11, 2009, WHO declared a level 6 pandemic, the high- est possible level, and the first such level in more than 40 years. A level 6 pandemic indi- cates that there are community-level out- breaks in at least two different WHO regions. When Margaret Chan, WHO Director- General, made this declaration, she also noted that “No previous pandemic has been detect- ed so early or watched so closely, in real- time, right at the very beginning.” The early course of spread of H1N1 influenza was rapid and widespread.2,3 Through July 23, 2009, a total of 43,677 laboratory-confirmed infections had been reported in the United States by the 50 states and the District of Columbia, including 5009 hospitalizations and 302 deaths.4 The most recent CDC estimates5 reveal that from April through December 12, 2009, between 39 and 80 million cases occurred in the United States, with between 173,000 and 362,000 H1N1-related hospitalizations dur- ing this period. These estimates are based on mathematical models, as not all patients are seen by health care providers, and not all cases are confirmed with laboratory tests. Susceptible Populations Surveillance of H1N1 influenza illness has revealed that patients affected most seriously by this illness, similar to seasonal influenza outbreaks, often have underlying chronic medical conditions. Such conditions account for more than 70% of cases. These underly- ing medical conditions include asthma (28%), chronic obstructive pulmonary dis- ease (8%), diabetes (15%), immunosuppres- sion (15%), and chronic cardiovascular dis- ease (15%).6 In contrast to seasonal influenza, severe illness has also been reported among young, healthy persons without any under- lying medical conditions. The age distribu- tion of patients affected with novel H1N1 influenza is much younger than that typi- cally seen in seasonal influenza outbreaks. Almost half of the hospitalizations result- ing from this illness have involved persons under the age of 18 years, with more than one-third of the patients being between the ages of 18 and 49 years. Pregnancy has also been identified as a condition portend- ing a potential serious course of illness after infection with H1N1 influenza virus. H1N1 Influenza Virus and Pregnancy Pregnant women infected with H1N1 influenza virus have been more likely to suf- fer severe complications than other popula- tion groups infected with this virus. The increased minute ventilation, reduced tidal volumes, and decreased functional residual capacity of normal pregnancy physiology leave less reserve capacity for significant stress on pulmonary function.7 Immune sys- tem differences in pregnancy may account for increased severity of disease.8 Finally, there is also speculation that the higher mor- bidity and mortality among pregnant patients is related to the overall greater metabolic demands of pregnancy.9 One of the first publications to address 2009 H1N1 influenza virus infection dur- ing pregnancy in the United States sum- marized cases identified during the first month of this outbreak.10 In this report, the estimated rate of hospital admission for pandemic H1N1 influenza virus in pregnant women was more than four-fold EDITORS William Schlaff, MD Professor and Vice Chairman, Chief of Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado Lorraine Dugoff, MD Associate Professor, Section of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado FOUNDING EDITORS Edward E. Wallach, MD Roger D. Kempers, MD ASSOCIATE EDITORS J. Christopher Carey, MD Denver Health Medical Center Denver, Colorado Susan A. Davidson, MD University of Colorado Aurora, Colorado Marc A. Fritz, MD University of North Carolina Chapel Hill, North Carolina Alice R. Goepfert, MD University of Alabama, Birmingham, Alabama Veronica Gomez-Lobo, MD Washington Hospital Center Washington, District of Columbia Hope K. Haefner, MD University of Michigan Ann Arbor, Michigan Nancy Hueppchen, MD Johns Hopkins University Baltimore, Maryland Bradley S. Hurst, MD Carolinas Medical Center Charlotte, North Carolina Christine Isaacs, MD VCU Medical Center Richmond, VA Julia V. Johnson, MD University of Vermont Burlington, Vermont Peter G. McGovern, MD University of Medicine and Dentistry of New Jersey Newark, New Jersey William D. Petok, PhD Clinical Psychologist Baltimore, Maryland Lynn L. Simpson, MD Columbia University Medical Center New York, NY Robert K. Zurawin, MD Baylor College of Medicine Houston, TX PGO09.qxd:Layout 1 3/31/10 2:20 PM Page 2
  • 3. higher than it was in the general population (0.32 per 100,000 pregnant women compared with 0.076 per 100,000 population at risk). In addition, a high proportion of the early deaths attributed to H1N1 influenza virus was in pregnant women; this special population accounted for more than 10% of deaths. Early in the course of the 2009 H1N1 influenza out- break, the California Department of Public Health initiat- ed a statewide surveillance for patients hospitalized with or who died from this virus. The California experience was reported recently in a number of publications11,12 and revealed findings for H1N1 influenza infection during pregnancy that were similarly concerning to early reports by the CDC. In 10% of patients with the most serious complications of this virus, requiring hospitalization or resulting in death, were pregnant. Of these severe cases, 95% of the pregnant patients were infected in the second or third trimester, and almost one-fifth required intensive care. The severity of illness seen in pregnancy has not been limited to the United States experience. In Australia and New Zealand, pregnant women represent 1% of the population yet accounted for 9.1% of the total patients admitted to the intensive care unit with H1N1 infection from June 1 through August 31, 2009.13 The rapid clinical deterioration observed in some preg- nant patients infected with H1N1 influenza virus appears to be different than that associated with seasonal influen- za.12 In the reported California series, one quarter of women requiring mechanical ventilation were severely ill at the time of presentation and required intubation on the day of admission. There were six emergency deliver- ies in the intensive care unit, implying that the condition of these patients was too unstable to transfer to an appro- priate labor and delivery unit or operating room. In addition to death, serious complications of H1N1 influenza virus include viral pneumonitis, acute respirato- ry distress syndrome, secondary bacterial pneumonia, and exacerbation of airflow limitation. Complications specific to pregnancy include adverse maternal and neonatal out- comes such as preterm labor, preterm birth, and pregnancy loss. Nonreassuring fetal status (tachycardia most com- monly) and febrile morbidity have also been described.3,14 Diagnosis and Treatment Symptoms Patients with novel H1N1 influenza present with an influenza-like illness, most commonly with fever of 37.8°C (100.0°F) and cough or sore throat. Other report- ed symptoms include chills, body aches/muscle pain, headache, fatigue, runny nose, and occasionally diarrhea and vomiting. Some patients with this illness do not have a fever, making it important that providers of prenatal care have a low threshold for diagnosis and treatment based on clinical suspicion of disease. Diagnosis Definitive diagnosis of H1N1 influenza virus relies on a nasopharyngeal or oropharyngeal swab, nasal aspirate, or combined nasopharyngeal and oropharyngeal swab for sampling. A rapid influenza antigen test has been used commonly for patients suspected of having H1N1 influenza. The rapid test evaluates for influenza A, for which H1N1 influenza virus is a subtype, and positive tests are helpful so long as seasonal influenza A is not yet circulating in the community. An advantage of the rapid test is that results are available in 30 minutes. However, these rapid tests have the ability to detect only 10% to 70% of H1N1 influenza; a negative rapid test is unreli- able due to this high false-negative rate. Real-time reverse transcriptase polymerase chain reaction (RT-PCR) or cul- ture is recommended for confirmation of H1N1 influenza. For tracking purposes, the CDC defines a confirmed case of novel H1N1 influenza as an influenza-like illness and laboratory-confirmed H1N1 influenza A either by RT- PCR or culture. A probable case is defined as influenza- like illness in a person who has tested positive for influen- za A by RT-PCR, but in whom a strain has not yet been determined.15 Several days may be required to obtain definitive diag- nosis of H1N1 influenza with RT-PCR assay or culture: 48 to 96 hours with nucleic acid amplification testing such as RT-PCR, and 2 to 10 days for viral isolation in tissue cell culture. Although assays to diagnose H1N1 influenza infection definitively are available, with rapidly rising numbers of cases and because providers should not wait for the results of testing to initiate therapy, some authorities rec- ommend that providers treat patients without comorbidi- ty or severe symptoms presumptively and without collec- tion of specimens for laboratory testing. The American College of Obstetricians and Gynecologists (ACOG) has provided a triage algorithm with recommendations for over-the-phone antiviral therapy in appropriate candi- dates.16 At some institutions such as the University of Colorado Denver, however, face-to-face patient evalua- tion with H1N1 influenza testing is recommended prior to use of antiviral medication. Treatment Because rapid clinical deterioration has been observed among pregnant patients, the CDC has recommended that a high priority is to “treat pregnant women with influenza-like illness as soon as possible; treatment should not be withheld pending results of testing for influenza, if testing is done.” On October 15, 2009, ACOG revealed a recommended triage algorithm for managing pregnant patients with suspected illness.15 This algorithm helps providers determine which patients need to be evaluated immediately based on signs, symptoms, and other medical history, and it recommends initiation of antiviral medications for all such patients. The rapid test has a high false-negative rate and definitive testing is time-prohibitive when making clinical decisions. The treatment of choice for H1N1 influenza virus16 is oseltamivir (75 mg orally twice daily for 5 days) or zanamivir (two 5-mg inhalations twice daily for 5 days) May 15, 2010 Postgraduate Obstetrics & Gynecology 3 PGO09.qxd:Layout 1 3/31/10 2:20 PM Page 3
  • 4. Postgraduate Obstetrics & Gynecology May 15, 2010 4 (Table 2).17 Both of these medications are pregnancy cate- gory C, and no adverse outcomes related to these medica- tions have yet to be reported in humans. In vitro studies using human placentas reveal incomplete transfer of oseltamivir carboxylate, the active metabolite of oseltamivir, resulting in minimal accumulation in the fetus. Both oseltamivir and zanamivir are FDA-approved for use in pregnancy, and both are safe to take in all three trimesters of pregnancy.18 Zanamivir, because it is an inhalational medication, should be avoided in women with underlying respiratory conditions such as asthma. In addition to antiviral medications, support- ive care is also recommended. Acetaminophen is the recom- mended antipyretic for use in pregnancy. For pregnant women with close contact to someone with H1N1 influenza—defined by the CDC as having cared for or lived with a person who has confirmed, prob- able, or suspected influenza, or having been in a setting where there was a high likelihood of contact with respi- ratory droplets and/or body fluids of such a person— postexposure antiviral chemoprophylaxis is recommend- ed. Medications prescribed for prophylaxis are the same as treatment medications, but the recommended dosages differ. Oseltamivir is prescribed as 75-mg capsules once daily for 10 days, and zanamivir is prescribed as two 5- mg inhalations once daily for 10 days. It is recommend- ed that the duration of postexposure chemoprophylaxis is 10 days after the last known exposure. Postpartum Management Studies have revealed that postpartum patients appear to have a response to the H1N1 influenza virus similar to that of pregnant women.12 The CDC includes women up to 2 weeks postpartum, including following pregnancy loss, as a high- risk group for H1N1 influenza-associated complications. In the immediate postpartum period, patients are in transition to normal immune, cardiac, and respiratory function and hence are at increased risk of influenza-related complications. In the series of patients reported to be most ill in California, there were several hospitalized patients that had an onset of symp- toms within 2 weeks after delivery. Of eight reported cases, half required intensive care, and two patients died. Treatment and chemoprophylaxis of postpartum patients are similar to those for the pregnant population. The CDC recommends the use of either oseltamivir or zanamivir in postpartum patients, at dosing suggested above. Interestingly, the manufacturer of oseltamivir does not rec- ommend its use during lactation.18 Risks and benefits need to be considered on an individual basis, with an under- standing that the immediate postpartum period is a high- risk time for H1N1 influenza-related complications. For patients with active infection during recovery and the immediate postpartum period, it is recommended that the infant be separated from the mother until she has received antiviral medications for at least 48 hours, is without fever for 24 hours without antipyretics, and can control cough and respiratory secretions. It is recommend- ed that lactation be initiated with the use of a breast pump; the infant should be fed with the mother’s milk by a healthy caregiver. Antiviral medication is not a contraindi- cation to breastfeeding. Once the above criteria are met and the mother and infant are able to initiate direct contact, it is recommended that the mother protect the newborn from droplet exposure by washing her hands with soap and water, wearing a face mask, and observing all respiratory hygiene and cough etiquette guidelines. These precautions should be observed for 7 days after symptom onset or 24 hours after resolution of symptoms, whichever is longer. The infant should be monitored closely for symptoms of influenza illness, and if such symptoms develop, notify the pediatric team immediately. Although antiviral medica- tions are not recommended for infants under the age of 1 year, the FDA has issued an Emergency Use Authorization for infants less than 1 year old.19 Transmission 2009 H1N1 influenza virus appears to be transmitted from person to person through close contact in ways sim- ilar to seasonal influenza viruses. The primary mode of spread is thought to be large droplet transmission and transmission by direct contact with mucous membranes or small-particle droplet nuclei.20 Prevention It is recommended that healthcare workers use respirato- ry protection, such as an N95 filtering face-piece respira- tor, when entering the rooms of patients with suspected or confirmed H1N1 influenza. Persons with suspected or confirmed illness should be reminded to use appropriate respiratory and hand hygiene precautions, such as frequent hand-washing with soap and water; not touching eyes, nose, or mouth; avoiding close contact with others; and staying at home during the most infectious period. The CDC recommends that infected persons stay home for at least 24 hours after fever is gone without the use of antipyretic medications. Interestingly, these guidelines do not apply to health care settings, in which the exclusion period should be continued for 7 days from symptom onset or until the resolution of symptoms, whichever is longer.20 Vaccination ACOG is committed to the concept of immunizing preg- nant women against influenza. Even prior to the current H1N1 influenza pandemic,ACOG’s Committee on Obstetric Practice supported the CDC’s expanded recommendation that women who will be pregnant during the influenza sea- son (October through May) should be vaccinated.According Table 2. Antiviral Therapy and Chemoprophylaxis for H1N1 Influenza Virus Agent Treatment Chemoprophylaxis Oseltamivir 75-mg capsule twice 75-mg capsule once daily (Tamiflu) daily for 5 days for 10 days Zanamivir Two 5-mg inhalations Two 5-mg inhalations (Relenza) (10 mg total) twice (10 mg total) once daily for 5 days daily for 10 days PGO09.qxd:Layout 1 3/31/10 2:20 PM Page 4
  • 5. to the November 2004 ACOG Committee Opinion entitled “Influenza Vaccination and Treatment During Pregnancy,” reaffirmed in 2006, “Influenza vaccination is an essential ele- ment of prenatal care.”21 Vaccination is important due to con- cerns regarding influenza illness in pregnancy, as well as benefits to the neonate. Because infants age 6 months or younger do not respond to the influenza vaccine, immuniz- ing pregnant women confers protection to their fetuses. The timing of the novel 2009 H1N1 strain of influenza was such that the seasonal influenza vaccination devel- oped for distribution in fall 2009 did not confer protection against this strain. Development of an H1N1 influenza vaccine began in May 2009, soon after emergence of the pathogen, and it was first available several months later. In many areas, distribution began in October 2009. Initially, there were concerns regarding a shortage of vaccine. Pregnant women were among the high-risk groups target- ed to receive the vaccination when first available. Concerns regarding potential shortages have been largely unfounded. In the 2010 influenza season, it has been rec- ommended that pregnant women receive vaccinations for both seasonal influenza and the H1N1 strain. These injec- tions may be administered on the same day; however, it is recommended that they be administered at different sites on the body, such as one upper extremity followed by the contralateral extremity for the second injection. Both seasonal and H1N1 influenza vaccines are avail- able in either inactivated form, for intramuscular injec- tion, or live form administered via nasal spray. Only the inactivated, intramuscular form is considered safe for use during pregnancy. It can be administered safely and effectively in all three trimesters. Many studies have demonstrated the safety of influenza vaccination during pregnancy. A recent review highlights these data.22 In addition to published studies, which include prospective and retrospective cohorts, the Vaccine Adverse Event Reporting System (VAERS), cosponsored by the CDC and the FDA, contains a database of reports regarding influenza vaccination during pregnancy.23 This postmarket- ing surveillance system entails voluntary reporting of adverse events by patients, family members, and health care providers. Some adverse events are considered nonserious, such as discomfort at the injection site, whereas others are considered serious, such as death thought to be related to vac- cine administration. As of December 31, 2009, 99.3 million H1N1 vaccines had been shipped to vaccination providers in the United States, although the precise number of vaccines administered is unknown. After H1N1 vaccination (to both pregnant and nonpregnant populations), VAERS had received 7326 adverse event reports (approximately 70 events per 1 million vaccinations administered), with the vast majority (94%) of reported adverse events classified as nonserious. Only 6% of reports (440) were classified as serious. The proportion of serious events reported for the H1N1 vaccination was not different than that calculated for the 2009 seasonal influenza vaccine. In addition, no new or unusual events or patterns of adverse events have emerged since administration of this new vaccine began. Summary Since the first case of H1N1 influenza illness was diag- nosed in early April 2009, its rapid spread led to a world- wide pandemic. Pregnant women infected with H1N1 virus have been more likely to suffer severe complica- tions compared with other population groups. In addition to increased mortality, other serious complications of H1N1 virus include viral pneumonitis, ARDS, secondary bacterial pneumonia, and exacerbation of airflow limita- tion. Complications specific to pregnancy include adverse maternal and neonatal outcomes such as preterm labor, preterm birth, and pregnancy loss. For these rea- sons, recognition of symptoms and prompt treatment, without awaiting the results of diagnostic testing, is essential. The most recent query of the CDC reveals that cases are now declining. After reading this continuing medical education review about H1N1 influenza in pregnancy, readers should be better able to diagnose and treat such infections properly during both pregnancy and the postpartum period. In addition, such cases should continue to decline as more and more patients are properly vaccinated, with recom- mendations for implementing an immunization program as outlined in this review. REFERENCES 1. Update: Novel influenza A (H1N1) virus infections: worldwide, May 6, 2009. MMWR 2009;58:453-458. 2. World Health Organization. Influenza A (H1N1): Pandemic alert phase 6 declared, of moderate severity. Available at: www.euro.who.int/influenza/ AH1N1/20090611_11. 3. Carlson A, Thung SF, Norwitz ER. H1N1 influenza in pregnancy: what all obstetric care providers ought to know. Rev Obstet Gynecol 2009;2:139-145. 4. Reed C, Angula FJ, Swerdlow DL, et al. Estimates of the prevalence of pandemic (H1N1) 2009, United States, April-July 2009. Emerg Infect Dis [serial on the Internet]. 2009 Dec [Epub ahead of print]. 5. Centers for Disease Control and Prevention. CDC estimates of 2009 H1N1 influenza cases, hospitalizations and deaths in the united states, April–December 12, 2009. Available at: www.cdc.gov/h1n1flu/estimates/ April_December_12.htm 6. Jain S, Kamimoto L, Bramley AM, et al. Hospitalized patients with 2009 H1N1 influenza in the united states. N Engl J Med 2009;361:1935-1944. 7. Saleeby E, Chapman J, Morse J et al. H1N1 influenza in pregnancy: cause for concern. Obstet Gynecol 2009;114:885-891. 8. Gonzalez JM, Ofori E, Burd I, et al. Maternal mortality from systemic ill- ness: unraveling the contribution of the immune system. Am J Obstet Gynecol 2009;200:430.e1-8. 9. Phillippe M. Ob gyns on the front line in the H1N1 flu pandemic. Ob Gyn News 2009;Oct:24-25. 10. Jamieson DJ, Honein MA, Rasmussen SA, et al. Lancet 2009;374:451-458. 11. Louie JK, Acosta M, Winter K. et al. Factors associated with death or hos- pitalization due to pandemic 2009 influenza A (H1N1) infection in California. JAMA 2009;302:1896-1902. 12. Louie JK,Acosta M, Jamieson DJ, et al. Severe 2009 H1N1 influenza in preg- nant and postpartum women in California. N Engl J Med 2010;362:27-35. 13. ANZIC Influenza Investigators. Critical care services and 2009 H1N1 influen- za in Australia and New Zealand. N Engl J Med 2009;361(20):1925-1952. 14. Centers for Disease Control and Prevention. Interim guidance: considera- tions regarding 2009 H1N1 influenza in intrapartum and postpartum hospi- tal settings. Available at: www.cdc/gov/h1n1flu/guidance/obstetric.htm. 15. Centers for Disease Control and Prevention. H1N1 flu: diagnosis and lab testing. Available at: www.cdc.gov/h1n1flu/diagnosis. 16. American College of Obstetricians and Gynecologists. 2009 H1N1 (‘Swine flu’) updates. Available at: www.acog.org/departments/dept_ notice.cfm?recno=20&bulletin=4973. 17. American College of Obstetricians and Gynecologists. 2009-2010 influenza season assessment and treatment for pregnant women with May 15, 2010 Postgraduate Obstetrics & Gynecology 5 PGO09.qxd:Layout 1 3/31/10 2:20 PM Page 5
  • 6. influenza-like illness. Available at: www.acog.org/departments/resource Center/2009H1N1TriageTreatment.pdf. 18. Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2005. 19. Centers for Disease Control and Prevention. 2009 H1N1 flu (swine flu) and feeding your baby: what parents should know. Available at: www.cdc/gov/h1n1flu/infantfeeding.htm. 20. Centers for Disease Control and Prevention. H1N1 flu: infection control. Available at: www.cdc/gov/h1n1flu/infectioncontrol/. 21. ACOG Committee on Obstetric Practice. ACOG committee opinion num- ber 305, November 2004. Influenza vaccination and treatment during pregnancy. Obstet Gynecol 2004;104:1125-1126. 22. Tamma PD, Ault KA, del Rio C, et al. Safety of influenza vaccination dur- ing pregnancy. Am J Obstet Gynecol 2009;201:547-552. 23. Centers for Disease Control and Prevention. Summary of 2009 monova- lent H1N1 influenza vaccine data: vaccine adverse event reporting sys- tem. Data through January 15, 2010. Available at: http://vaers.hhs.gov/ resources/2010H1N1Summary_Jan08.pdf. Postgraduate Obstetrics & Gynecology May 15, 2010 6 1. Influenza vaccination is safe for use in pregnancy during A. the first trimester B. the second trimester C. the third trimester D. all trimesters 2. A pregnant patient calls the office at 4 p.m. on Friday after- noon reporting a sore throat and temperature of 100.5°F. You should A. ask her to take acetaminophen and call back if symp- toms worsen B. call in an antiviral medication prescription to the local pharmacy and ask her to call your office if she feels worse C. advise her to go to the nearest emergency department immediately 3. A patient with active H1N1 influenza infection should be advised to discard breast milk while taking oseltamivir. A. True B. False 4. Which of the following medications should be prescribed for H1N1 influenza infection in a patient who is 23 weeks preg- nant and manages asthma with chronic corticosteroids? A. Oseltamivir B. Zanamivir C. Both of the above D. Neither of the above 5. A pregnant health care worker on day 3 of oseltamivir use has been afebrile for 48 hours. She may return to work A. at this time B. after completion of the 5-day course of antiviral medication C. 72 hours after being afebrile and without symptoms D. 7 days after resolution of symptoms 6. At the first prenatal visit, a patient reports that she has not yet received either an H1N1 influenza vaccine or the sea- sonal influenza vaccine. You should A. administer the H1N1 vaccine and have her return in 1 week for her seasonal influenza vaccine B. administer the seasonal influenza vaccine and have her return in 1 week for her H1N1 vaccine C. administer both vaccinations at this visit but on con- tralateral extremities D. explain that as it is February and past the peak time for influenza infection this year, she does not need either vaccination 7. You are seeing an otherwise healthy pregnant patient in the clinic who you suspect has H1N1 influenza. Which one of the following regimens should you prescribe? A. Oseltamivir 75 mg twice daily for 5 days B. Oseltamivir 75 mg once daily for 10 days C. Tylenol 650 mg PO every 6 hours as needed for fever D. A and C 8. A patient calls the office 1 week postpartum to report fever and cough. You tell her A. she needs to be treated for H1N1 influenza, as the immediate postpartum period is associated with high risk of complications B. she is no longer pregnant and thus no longer needs antiviral medication, but she should call the office if her symptoms worsen C. she should see her internist or family physician, as you only evaluate pregnant patients 9. Fever is invariably present at some point in the course of disease in a patient with H1N1 influenza illness. A. True B. False 10. A pregnant hospital employee escorts a patient infected with H1N1 from the emergency department to an inpatient unit. She then reads in the newspaper of the potential dan- gers of H1N1 influenza during pregnancy and calls you to advise her. You tell her A. she needs to initiate antiviral therapy immediately B. the CDC has defined close contact with an infected patient, and this encounter does not constitute such an encounter C. she should stay home from work tomorrow to see whether symptoms of influenza arise, and if they do, to call your office To earn CME credit, you must read the CME article and complete the quiz and evaluation on the enclosed answer form, answering at least seven of the 10 quiz questions correctly.Select the best answer and use a blue or black pen to completely fill in the corresponding box on the enclosed answer form. Please indicate any name and address changes directly on the answer form.If your name and address do not appear on the answer form, please print that information in the blank space at the top left of the page. Make a photocopy of the completed answer form for your own files and mail the original answer form in the enclosed postage-paid business reply envelope.Your answer form must be received by Lippincott CME Institute by May 14, 2011. Only two entries will be considered for credit. At the end of each quarter, all CME participants will receive individual issue certificates for their CME participation in that quarter.Participants will receive CME certificates quarterly in April, July, October, and the fourth quarter in January of the following year. For more information, call (800) 787-8981. Online quiz instructions: To take the quiz online, go to http://cme.LWWnewsletters.com, and enter your username and password. Your username will be the letters LWW (case sensitive) followed by the 12-digit account number on your mailing label.You may also find your account number on the paper answer form mailed with your issue.Your password will be 1234; this password may not be changed. Follow the instructions on the site.You may print your official certificate immediately. Please note: Lippincott CME Institute will not mail certificates to online participants. Online quizzes expire at 11:59 pm Pacific Standard Time on the due date. CME QUIZ: Volume 30, Number 9 PGO09.qxd:Layout 1 3/31/10 2:20 PM Page 6