This document discusses influenza (H1N1), Zika virus, and Ebola virus infections during pregnancy. It covers the causative agents, signs and symptoms, complications, management including treatment and vaccination, and delivery considerations for pregnant women infected with these viruses. Precautions are needed during delivery and postpartum to prevent transmission from mother to baby or healthcare workers. Termination of pregnancy may be considered in some Ebola cases. Vaccines exist for H1N1 and Ebola but not yet for Zika.

1. DR ALKA MUKHERJEE
NAGPUR M.S. INDIA
INFLUENZA-H1N1, ZIKA & EBOLA
IN PREGNANCY

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Life member, IMA, NOGS, NARCHI, AMWN & Menopause Society,
India, Indian medico-legal & ethics association(IMLEA), ISOPRB,
HUMAN RIGHTS
 Founder Member of South Rapid Action Group, Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS Nagpur,
NKPSIMS, ESIS and Treasury, Nagpur for “ WOMEN SEXUAL
HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 APPRECIATION Award IMA - MS
 Past Position
 Organizing joint secretary ENDO-GYN 2019
 Vice President IMA Nagpur (2017-2018)
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Organizing secretary AMWICON – 2019

3. H1N1 (INFLUENZA) DURING PREGNAMCY
• Introduction
• Influenza is caused by influenza viruses such as influenza A HINI, H3N2,
influenza B. Influenza viruses belong to orthomyxoviridae family of
viruses.
• Pregnant women especially those with comorbidity are at increased risk
for complications from all forms of influenza virus infections seasonal,
zoonotic, and pandemic.
• Pregnant women appear to be approximately 4 – 5 times more likely to
develop severe disease when compared to non- pregnant individual in
general population and risk is highest in third trimester, infants , and
young children <2 years with underiying chronic medical illness.
• Transmission is airborne from person to person through large droplet
infection, indirect contact by touching surface, or through direct close
contact

4. Signs and symptoms
o Spectrum of disease is caused by H1N1 broadly ranges from non –
febrile to mild upper respiratory tract infection (UTRI) and severe/fatal
pneumonia .
o Symptoms commonly develop within 1 week of exposure and patients
are contagious for approximately 8 days thereafter.
o Main route of transmission of influenza is via droplets that are expelled
by speaking, sneezing, or coughing
o Depending upon clinical presentation ofh1n1 patients are divided into
three categories:
o Category A – mild symptoms : fever, cough, sore throat with or without
bodyache, headache, diarrhea, and vomiting. The patients should be
monitored for their progress and re- assessed at 24-48 h by the doctor .
patient should confine at home and should avoid visiting public places.
Anti-viral therapy not recommended

5. Category B – all categories A symptoms in high risk group :
 Pregnant women fall under this category.
 Age <5 and > 65 years,
 comorbid conditions: lung disease, heart disease, liver disease , blood
disorders, diabetes, neurological disorders , cancers , HIV / AIDS and
immunosuppressed, on long – term steriod therapy.
 No testing is needed .
 One should start antiviral therapy.
 Home confinement and avoid public places.
Category C
 Category A and B with any of these: Chest pain , breathlessness ,
drowsiness, cyanosis , blood – stained sputum. Hypotension,
 testing is mandatory,
 admission to ICU,
 start antiviral therapy.

6. Complication
• Spontaneous abortions,
• preterm birth ,
• non- reassuring fetal tracing (Most commonly fetal
tachycardia), and febrile morbidity.
• Hyperthermia in early pregnancy has been associated with
neural tube defects and other defects and other congenital
anomalies.
• Fever during labor is risk factor for neonatal seizures ,
newborn encephalopathy, cerebral palsy, and death.

7. Management
• A] Drug Treatment :
Oseltamivir - safe drug both for prophylaxis and trearment.
Dose is 75 mg BD per oral for 5 days.
safe in pregnancy in all trimesters.
Supportive therapy - symptomatic treatment in the from of IV fluids,
parenteral nutrition,
oxygen therapy/ ventilatory supoort.
Paracetamol (Tab 500 mg PO 6 hourly) - fever , myalgia, and headache.
Salicylates and aspirin are contraindicated
antibiotics are to be given for treatment of any associated infection
Chemoprophylaxis : for contacts of suspected probable, and confirmed case.
Contacts include household/ social contacts, family members, workplace, school contacts
fellow travellers , and health – care personnel .
Dose – Tab Oseltamivir 75 mg OD for 10 days.

8. Specific Treatment at Time of Presentation
• A] Antenatal
 Triaging of influenza patients – having separate area for asymptomatic and
severely ill patients.
 Mechanism should be in place for triaging – signage, posters, and banners
should facilitate at arrival of health facility.
 Single patient room and
 Use of face mask when outside room.
 Perform diagnostic testing and
 Start empirical antiviral therapy immediately .Do not wait for test results.
• B] Intrapartum
 Mothers should use face mask throughout labor as tolerated
 Protect the infant from expose to respiratory secretions during or immediately
 after delivery.
 Immediately separate newborn to an open warmer by distance of > 6 ft.
 Bathe infant as soon as the temperature is stable.
 Birth companion should be free of infection.

9. Postpartum
Temporary separation of the infected mother from the
newborn within her room or in a separate room until the risk
of transmission is reduced, that is up 24-28 h after delivery -
in severely ill patient – thereafter mother can start
breastfeeds.
Patients with mild symptoms practice rooming in , initiation of
breastfeeding within 1 hour exclusive breastfeeding .
Discharge criteria – 48 h – short hospital stay in stable patients.

10. ZIKA VIRUS DISEASE IN PREGNANCY
Introduction
Zika virus disease is transmitted through the bite of an
infected Aedes mosquito.
Zika virus first identified in Uganda in 1947.
Zika virus disease has the potential for further international
spread given the wide geographical distribution of the
mosquito vector, a lack of immunity among population in
newly affected areas and the high volume of international
travel.
Mosquito that transmits Zika virus namely Aedes aegypti
also transmits dengue virus, is widely prevalent in India.

11. Causative Agent
• Zika virus which belongs to the genre Flavivirus.
• Zika virus is transmitted to people through the bite of an infected
mosquito from the Aedes genus, mainly Aedes aegypti which usually
bite during the morning and late afternoon hours.
• Transmission from an infected pregnant mother to her baby during
pregnancy or around the time of birth is also now being seen as a
distinct possibility .
• The incubation period of Zika virus disease is 2-7 days.
• Complications
1. Microcephaly (abnormally small head, which can be associated with
mental and developmental abnormalities in children) and
2. Guillan –Barre syndrome ( a neurological disorder manifesting as
paralysis)

12. Management
• Diagnosis
Zika virus is diagnosed through polymerase chain reaction (PCR) and virus
isolation from blood samples.
Positive test result for Zika during pregnancy signals close monitoring and
watch by health – care professional .
Antenatal ultrasound for growth and development of fetus and look for
sign of Zika virus infection during the pregnancy.
• Treatment
People sick with Zika virus - should get plenty of rest,
- drink enough fluids, and
- treat pain and fever with paracetamol.
- If symptoms worsen, they should seek
medical care and advice.

13. EBOLA
Introduction
• Ebola virus disease (EVD) (Ebola hemorrhagic fever) - severe,
often fatal illness, with a death of up to 90 %.
• The illness affects humans and non – human primates
(Monkeys, gorillas, and chimpanzees).
• EVD is a filovirus infection, transmitted to humans from an
unknown animals reservoir.
• Human-to – human transmission efficiently propagates EVD
through mucosal contact with infected body fluids.
• The incubation period up to 21 days (Median 5-9 days)
• Transmission is only recognized from symptomatic patients.

14. Complications
• EVD in pregnancy is associated with:
• high rate of obstetric complications and poor maternal and perinatal
outcome including SPONTANEOUS ABORTION PRE – LABOR ,
RUPTURE OF MEMBRANCES,
PRETERM LABOR / PRETERM BIRTH ,
ANTEPARTUM AND POSTPARTUM HEMORRHAGE ,
INTRAUTERINE FETAL DEATH,
STILLBIRTH AND NEONATAL DEATH.
MATERNAL DEATH
• Diagnosis
Suspected Case – Patient having history of travel or close contact with
symptomatic persons travelling from Ebola virus disease affected areas in the
past 21 days with high grade fever more than 101 F , along with one or more of
following symptoms – headache, body ache, abdominal pain, diarrhea , and
vomiting.

15. Investigations for EBOLA
• Confirmed Case – A case with above features and laboratory – confirmed
evidence of Ebola virus infection at BSL -3 facility by any one of the
following : IGM (ELISA), antigen detection, or RT- PCR.
• Screening and Triaging of Pregnant Women
Careful clinical and epidemiologic history - pregnant women to
determine any EVD contact history or EVD signs and symptoms.
A higher level of suspicion for Ebola infection should apply to women
with the following EVD – associated pregnancy complications.
• Treatment – 1. Supportive with particular focus given to the
replacement of electrolytes and fluids and the management of
distressing symptoms.
2. Iron supplementation is recommended

16. • Mortality rates from EVD - 50% - 70%.
• Causes of death - poorly understood - septic shock and multi-organ
failure.
• The Ebola virus is able to cross the placenta and infect the amniotic fluid
and fetus
• Ebola virus is able to survive for prolonged periods within decomposing
human tissue, it remains prudent to treat the POC (including a full – term
fetus) with full infection control precautions.
Management
Current practice for Ebola confirmed pregnant women has been to
manage the infection first, and the pregnancy after the woman has tested
NAAT negative.
It is considered safer to plan the delivery once viremia has resolved to
reduce the risk of EVD – associated disseminated intravascular
coagulopathy (DIC), which may result in greater blood loss during and
after delivery.

17. Safety of Health – care Workers - Trained personnel
entering high – risk area.
Training should focus on the donning and doffing of full
personnel protective equipment (PPE) and knowledge of
the limits of PPE. The option of termination of pregnancy
may also be discussed with patient at an appropriate time.
Termination of Pregnancy - Use of mifepristone/
misoprostol – oral drugs or manual vacuum, Aspiration in
the first trimester. Minimal invasive procedure and
exposure of health Care worker. All deliveries (at an
gestation and whether during or after illness) should take
Place inside a high – risk area.
Intravenous access should be gained at the earliest time,
ideally prior to labor.

18. DELIVERY
• Surgical delivery for the sake of the fetus is likely to be futile , given the
probability of neonatal death.
• Where surgery is considered for maternal reasons, a multi – disciplinary
team should decide on the risk versus benefit ratio, ideally consulting
with a medical ethical opinion.
• Vaginal examinations are not necessary and
• Artificial rupture of membranes should be avoided to reduce the risk of
body fluid exposure.
• Episiotmies and other surgical interventions should not be performed
• Vaginal tears should have pressure applied to stop bleeding, but not be
sutured
• Active management of the stage is recommended.

19. Postnatal
• Lactation is suppressed with medication and is offered contraception at
the time of discharge .
• Lactating EVD survivors whose breast milk is PCR positive or has not
been tested should practice good hand personal hygiene by immediately
and thoroughly washing with soap and water after any contact with
breast milk.
• Management of Pregnant EVD Cases Contacts, and Survivors -
 Comprehensive Ebola IPC precautions must be used during childbirth
and / or management of complications to prevent exposure to infections
intrauterine contents (i.e., amniotic fluid, placenta, and fetus).
 The neonates of such women should also be managed using Ebola IPC
precautions for 21 days following birth.

20. EVD survivors
• There is no evidence that women who become
pregnant after recovery from EVD are at risk of EVD
transmission .
• Standard obstetric IPC precautions should be used
when exposure to bodily fluids is possible during
childbirth and/or management of complications.

21. Vaccinations
• When vaccinating a pregnant woman, multiple lives are at stake, not just
one.
• H1N1 - Both the injected vaccine (flu shot) and nasal spray forms of
the vaccine against the 2009 H1N1 virus were produced and licensed by
the Food and Drug Administration. The vaccine first became available in
early October, and more doses are becoming available every week.
• EBOLA - In December 2016, a study found the VSV-EBOV vaccine to be
70–100% effective against the Ebola virus, making it the first
proven vaccine against the disease.
• ZIKA - Travelers should take steps to prevent getting Zika during travel as
there is no effective drug to treat—or vaccine to prevent—Zika infection
is licensed and available. Dec 1, 2019