This document discusses the risks of influenza in pregnancy and recommendations for vaccination and treatment. Key points: - Pregnant women are at higher risk of severe complications from influenza compared to non-pregnant women. This risk is highest in the second and third trimesters. - Influenza vaccination is recommended for all pregnant women during any trimester to protect both mother and baby. However, vaccine uptake among pregnant women remains low. - Early treatment with oral oseltamivir is recommended for pregnant women with suspected or confirmed influenza, regardless of trimester. Treatment should begin within 48 hours of symptom onset.

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4. Are The Risks of Flu in
Pregnancy Really that Serious
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5.  Pregnant women are especially vulnerable to develop
severe complications& death frominfluenza compared
with the general population, as well as higherrate
of obstetrics complications .
 Pregnancy does not predispose women to an increased
riskof acquiring influenza infection.
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6.  Data fromprevious pandemics (including the pandemics
of 1918 Spanish Flu,1957 Asian Flu,1968 Hong
Kong Flu, and 2009 Pandemic Flu) & virulent flu
seasons suggest that pregnant women have higherrates
of morbidity and mortality.

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 Pregnant women, both healthy pregnant women & those
with chronic medical conditions, are at increased riskof
influenza related complications & hospitalization.
 The riskof severe infection in pregnancy is exacerbated
by the presence of co-morbid conditions such as
asthma, diabetes mellitus, and obesity.

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 Pregnant women with comorbid conditions were >3
times more likely to be hospitalized forrespiratory
illness during influenza season than
women without these comorbid conditions.

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 A normally healthy woman who is pregnant has a similar
riskforcomplications frominfluenza as non pregnant
women who have co-morbidities. This risk increases
with gestation.
 Pregnant women with influenza were five times more
likely to be hospitalised than non-pregnant women.

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 The highest rate of hospitalization was during the third
trimesterof pregnancy, at which time pregnant women
were five times more likely to be hospitalized with a
cardiopulmonary illness during influenza season
compared with postpartumwomen.
 When pre-existing medical conditions are superimposed
on pregnancy the risks become even higher.

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 The highest riskforsevere complications appeared
to be in the second and especially the third
trimesters of pregnancy, although intensive care unit
admissions and deaths occurred in all 3 trimester
 Pregnant women are seven times more likely to be
admitted to ICU than theirnon-pregnant
counterparts.

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15.  It seems that the increased severity of influenza in
pregnancy is due to physiological changes that occur
during pregnancy :
1)The increase in minute ventilation & cardiac output ,both
of which significantly tax the cardiopulmonary reserve .
2)A shift away fromT-cell-mediated immune response, to
accommodate the developing fetus .

17.  While humoral (antibody mediated) immunity appears to
be enhanced, the cellular arm of the immune system is
temporarily suppressed.
 This is to prevent harmful immune responses being
directed at the growing baby, which is genetically foreign
to the mother.
 These changes can leave a pregnant women more
vulnerable to some intracellular pathogens including viral
infections.

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23.  The physiological changes that occurduring pregnancy
have largely returned to normal within a couple of
weeks afterdelivery.
 It’s important to rememberthat immediately
postpartum, pregnant women can be severely affected,
particularly if they have had multifetal pregnancies
orotherpregnancy complications.

25. The flu is a serious dangerforpregnant women
 Pregnant women hospitalised at five times the rate of
non-pregnant women & seven times more likely to be
admitted to ICU than theirnon-pregnant
counterparts.
 “If someone has the flu in pregnancy they have five
times the riskof losing that pregnancy through
miscarriage, stillbirth orneonatal death.

26. Riskto the women
 During pregnancy influenza can impose serious health
implications forboth the motherand the child.
 Maternal Complications of influenza include:
1. Miscarriage and stillbirth
2. Premature birth
3. Birth defects
4. Maternal pneumonia
5. Maternal death

27.  The mechanismby which the influenza virus infection
can cause poorobstetric outcomes seems to be more
due to hyperthermia & inflammation, ratherthan their
trans-placental transmission .

28.  Infection induces the synthesis of pro-inflammatory
cytokines that stimulate the amnion and the decidual
tissue to produce prostaglandins, which can stimulate
myometrial contractions, leading to miscarriages and
spontaneous pretermdelivery .

29. Riskto the growing baby
 Viremia appears to occurvery infrequently during
influenza illness; therefore, transplacental (direct
vertical) transmission of influenza virus from
motherto the embryo orfetus is expected to be
extremely rare .

30.  Maternal influenza infection within the first trimester
of pregnancy has been associated with congenital
anomalies .
 Feverthat often accompanies influenza virus infection
has been shown to increase the riskforcongenital
anomalies.
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31.  An association between maternal hyperthermia and
congenital anomalies (eg, congenital heart defects and
orofacial clefts in particular, cleft lip with orwithout
cleft palate and neural tube defects ) has also been
observed.
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Riskforyoung babies
 infants born to women who were hospitalized for
respiratory illness during influenza season at any
time during pregnancy were more likely to be born
small forgestational age and to have lowermean
birthweight than infants born to women who were
not hospitalized.

33.  Infants less than 6 months old are at increased risk
forinfluenza-associated complications , a high rate
of excess hospitalization and even death than
other age groups .
 90% of influenza-related pediatric deaths occurin
unvaccinated children .
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 Influenza vaccines are not approved foruse in
children <6 months old.
 Thus, influenza vaccination during pregnancy and
influenza vaccination of household contacts and
caregivers of infants <6 months old can prevent
influenza in these vulnerable infants who are
too young to receive influenza vaccination.

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36. Influenza vaccination during pregnancy is a key strategy to
prevent influenza and influenza-related complications
in pregnant women and theirinfants 36

37. “When meditating overa disease,
I neverthinkof finding a remedy
forit, but instead, a means of
prevention.”
Louis Pasteur
A Vision to future of humanity
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Immunizations are one of the world's biggest public health success stories.
But not all communities have the same access to vaccines .”
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43.  To lowerthe riskof complications fromthe flu, all
pregnant women are urged to receive an inactivated
seasonal influenza vaccine. The benefits of receiving
the flu shot outweigh any theoretical risks to the
fetus.
 Furthermore, maternal influenza vaccination offers
protection to the baby afterbirth until the child can
receive his orherown vaccine at six months of age.43

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It is Safe to Receive Flu Shot During Pregnancy
September 13, 2017
 “ACOG continues to recommend that all women receive the influenza
vaccine. This is particularly important during pregnancy.
 Influenza vaccination is an essential element of prenatal care
because pregnant women are at an increased risk of serious illness
and mortality due to influenza.
 In addition, maternal vaccination is the most effective strategy to
protect newborns because the vaccine is not approved for use in
infants younger than six months.

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59.  In fact, influenza immunization during pregnancy is one
of the Healthy People 2020 objectives, aiming foran
80% overall uptake.
 Unfortunately, this is not practiced nearly widely
enough, despite the collective recommendations of CDC
, ACOG, AAFPAnd AAP.
 Despite these recommendations, the uptake of influenza
vaccination by pregnant women remains alarmingly low.

60. Increasing influenza vaccine uptake by pregnant
women should be a priority forall women’s
health providers.

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73.  Although we recommend universal influenza
vaccine during pregnancy, influenza vaccines are
not 100% effective.
 Thus, a history of influenza vaccination should not
preclude clinical suspicion of influenza infection.
 In addition to antigenic drift, infection eitherjust
before, orwithin 10-14 days after, vaccination can
still result in clinical infection .

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77. Annual influenza Vaccination should occurbefore the
onset of influenza activity in the community .
Health care providers should offervaccination as soon
as it becomes available .
Vaccination should be offered as long as influenza
viruses are circulating i.e. Octoberthrough May .

78. 1) Inactivated (Killed) , (TIV) = Flu Shot
 Intramuscular
 Trivalent
 Annual
1) Live attenuated vaccine (LAIV) = Flu Mist
 Intranasal
 Trivalent
 Annual
Traditional Seasonal Influenza Vaccines

79. Seasonal Influenza Vaccines:
Something Old, Something New
The “Flu Shot“
o Traditional trivalent inactivated influenza vaccine protected
against 3 influenza virus strains (2 influenza A and 1
Influenza B)
o Since 2013-14 Quadrivalent vaccine protects against 4
strains (2 influenza A and 2 influenza B)
– Old nomenclature: Trivalent Inactivated Vaccine = TIV
– New nomenclature: Inactivated Influenza 3 = IIV3
– New Quadrivalent Vaccine: Inactivated Influenza 4 =
IIV4

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 Influenza vaccines are updated annually to include the
viral strains that are predicted to circulate in winter.
 Influenza vaccine is most effective when circulating
viruses are well-matched with viruses contained in
vaccines.
 Immunity developed in one influenza season may not
provide protection in future years mainly because of
changes in circulating strains, antigenic drift, and
waning immunity.

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Trivalent inactivated Influenza vaccine is considered safe for
use in pregnant women at all stages of pregnancy, in any
trimester , regardless of gestational age
Pregnant women should receive inactivated vaccine (flu shot)
but should NOT receive the live attenuated vaccine (nasal
spray).
There is no evidence that influenza vaccine causes any harm
to mother or baby when administered to a pregnant woman.

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Children aged <6 months are not eligible to receive currently
licensed influenza vaccines and should be protected against
influenza through vaccination of their mothers during
pregnancy (via passive transfer of antibodies across the
placenta and through breast milk).
The benefit of vaccination far outweighs any possible risk
from the vaccine itself.. The risk is actually in not getting
a flu shot .
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The trivalent inactivated vaccine (TIV) is also safe for breast
feeding mothers and their babies (via breast milk)
Women who are breast feeding may receive either either
inactivated vaccine or live attenuated vaccine (nasal spray)

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Standard Technique forInjection

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The current recommendation is to
offerand encourage routine flu
vaccinations during pregnancy
regardless of the trimesterof
pregnancy.”
Flu vaccine is safe and effective
during pregnancy.

101.  There are numerous barriers to optimal
immunization during pregnancy.
 Substantial percentage of pregnant women continue
to decline influenza vaccinations because of safety
concerns.
 Obstetric providers often do not view vaccination as
theirprimary responsibility.

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As a healthcare provider, yourrecommendation
and offerof flu vaccine are critical motivators for
pregnant women to be vaccinated.
Healthcare providers should informpregnant women
of theirincreased riskof developing influenza-
related complications and encourage themto get
vaccinated.

103. The Ob-Gyn’s Role in Immunization
 Studies continue to show that a provider
recommendation is the most influential factorin a
patient’s decision to receive an immunization .
 Pregnant women see theirob-gyn regularly throughout
the course of theirprenatal and postpartumcare allowing
formultiple opportunities foreducation & vaccination.

104.  It is thus important that obstetric care providers have
to educate pregnant women about the potential
impact of influenza infection during pregnancy and
review the signs and symptoms forwhich they should
promptly report forevaluation.
 Ob-gyns should integrate immunizations into their
routine assessment and practice with both pregnant
and non-pregnant patients .
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107. The best way to have a healthy
baby is to have a healthy

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While influenza vaccination is the first and best way to
prevent influenza illness, a history of influenza
vaccination does not rule out the possibility of
influenza virus infection in an ill patient with clinical
signs & symptoms compatible with influenza.
A history of influenza immunisation does not exclude
influenza as a possible diagnosis.

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TreatmentTreatment
RecommendationsRecommendations

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115.  Pregnant women might be reluctant to take antiviral
medications, and health care providers might be
reluctant to prescribe such treatment forinfluenza
during pregnancy.
 Treatment delay often was associated with adverse
outcomes in pregnant women .
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116.  Available information on influenza antiviral medications
during pregnancy is reassuring ,howeveradequate well-
controlled studies of pregnant women are not available .
 Neuroaminidase inhibitors e.g Oseltamivirare considered
to be pregnancy category C by FDA .

117.  Pregnant women are considered to be at higherrisk
of influenza complication by the Advisory Committee
on Immunization Practices, and thus, empiric
treatment is recommended.
 Treatment decisions, especially those involving
empiric treatments, should be informed by knowledge
of influenza activity in the community.
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118.  Yourdecision to treat should be based on yourclinical
evaluation ratherthan on diagnostic testing because
of the limited sensitivity of rapid influenza diagnostic
tests and the time required to complete more
definitive testing.
 Decisions to start antiviral treatment should not wait
forlaboratory confirmation of influenza .

119.  Ideally, antiviral treatment should begin within 48 hours
of the onset of symptoms. Forthat reason, pregnant
women with symptoms of influenza should be
encouraged to seekcare early in theirillness.
 However, treatment of pregnant women appears to be of
clinical benefit, even when that treatment is started more
than 48 hours aftersymptomonset.

120.  Currently, the majority of circulating influenza viruses
are resistant to the adamantanes and WHO
recommends neuraminidase inhibitors as the first-line
treatment forpeople requiring influenza antiviral
therapy.
 Oral oseltamiviris preferred fortreatment of pregnant
women because it has the most studies available to
suggest that it is safe and beneficial.

122.  Pregnant women and Postpartumwomen, who are in
transition to normal immune, cardiac, and respiratory
function, should be considered to be at increased risk
of influenza-related complications up to two weeks
postpartum(including following pregnancy loss).
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123.  Treatment with antiviral medications is recommended
forpregnant women orwomen who are up to 2 weeks
postpartum(including following pregnancy loss) with
suspected orconfirmed influenza and can be taken
during any trimesterof pregnancy.
 Pregnancy should not be considered a
contraindication to oral oseltamiviruse.
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Informing pregnant and up to 2 weeks postpartum (including following
pregnancy loss) women of signs and symptoms of influenza and the need
for early treatment , as soon as possible after onset of symptoms.

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136. Early Treatment is Important forPregnant Women
 If a pregnant woman becomes sickand is suspected of
having influenza, it's important that she receives
prompt antiviral treatment.
 Pregnant women with confirmed orsuspected influenza
should be treated with oseltamiviras soon as possible,
regardless of pregnancy trimester.
 Pregnant women are recommended to receive the same
antiviral dosing as nonpregnant women.

137.  Fortreatment of pregnant women orwomen who are
up to 2 weeks postpartumwith suspected or
confirmed influenza, oral oseltamiviris currently
preferred.
 The standard duration of antiviral treatment is 5 days
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138.  Considerempiric treatment of pregnant women and
women who are up to 2 weeks postpartum(including
following pregnancy loss) at home based on clinical
evaluation formild uncomplicated illness , especially
if hospitalization is not indicated .
 Health care providers should develop methods to ensure
that treatment can be started quickly aftersymptom
onset , rapid access to antiviral medications is

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140.  Hospitalized patients with severe infections e.g those
with prolonged infection orwho require intensive care
unit admission) might require longertreatment courses.
 Some experts have advocated use of doubled doses of
oseltamivirforsome severely ill patients
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142.  Feverin pregnant women should be treated because of
the riskthat it appears to pose to the fetus , it has been
shown to increase the riskforcongenital anomalies.
 Acetaminophen (Paracetamol ) appears to be the best
option fortreatment of feverduring pregnancy
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The American College of Obstetricians and Gynecologists and the Society for Maternal–Fetal Medicine.
February 2017.

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145.  Oseltamiviris recommended by the World Health
Organization (WHO) foruse in the clinical management of
pandemic and seasonal influenza of varying severity, and as
the primary antiviral agent fortreatment of avian H5N1
influenza infection in humans.
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147. What should I do if I come into
close contact with someone
who has the flu while I am
pregnant?
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148.  Post-exposure influenza antiviral chemoprophylaxis can
be considered forpregnant women and women who are
up to 2 weeks postpartum(including following
pregnancy loss) who have had close contact with
someone likely to have been infectious with influenza
(CDC).
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Post exposure Chemoprophylaxis
 Post exposure Antiviral chemoprophylaxis is not
generally recommended if more than 48 hours have
elapsed since the last contact with an infectious person.

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Those receiving post exposure chemoprophylaxis
should be informed that chemoprophylaxis lowers but
does not eliminate the riskforinfluenza, that
susceptibility to influenza returns once the antiviral
medication is stopped .

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Patients receiving post exposure chemoprophylaxis
should be encouraged to seekmedical evaluation as soon
as they develop a febrile respiratory illness suggestive of
influenza because influenza virus infection still can occur
while a patient is on antiviral chemoprophylaxis .

153.  An emphasis on close monitoring and early initiation of
antiviral treatment is an alternative to chemoprophylaxis
forsome pregnant women and women who are 2
weeks postpartum(including following pregnancy
loss)who have had contact with someone likely to have
been infectious with influenza.
 Clinical judgment is an important factorin treatment
decisions. 153

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Indiscriminate use of antiviral chemoprophylaxis might
promote resistance to antiviral medications orreduce
antiviral medication availability fortreatment of
persons at higherriskforinfluenza complications or
who are severely ill.

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CDC does not recommend widespread orroutine use of
antiviral medications forchemoprophylaxis so as to limit
the possibilities that antiviral resistant viruses
could emerge.
Antiviral chemoprophylaxis is currently NOT recommended
by the WHO.

156.  Chemoprophylaxis with antiviral medications is not a
substitute forinfluenza vaccination (Oseltamiviris not
a substitute forthe flu shot) .
 Annual influenza vaccination is the best way to
prevent influenza because vaccination can be given
well before influenza virus exposures occur, and can
provide safe & effective immunity throughout the
influenza season. 156

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Otherimportant things in protecting yourself from
getting influenza?
1.Wash yourhands often and thoroughly with soap and
warmwater, oruse a hand sanitizer.
2.Avoid touching youreyes, nose ormouth. You can get
infected by touching something that is contaminated with
influenza and then touching youreyes,nose, ormouth.
3.Avoid close contact with people who are sick.
4.Follow good health habits.

167. Road Map

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175.  All pregnant women should be counseled about the
early signs and symptoms of influenza infection
and advised to immediately call forevaluation if
clinical signs orsymptoms develop while these
women are pregnant orare in the first two weeks
afterdelivery orpregnancy loss.
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