|Year : 2014 | Volume
| Issue : 2 | Page : 69-71
H1N1 in pregnancy: Experience in a tertiary care hospital
Department of Obstetrics and Gynaecology, Christian Medical College and Hospital, Ludhiana, Punjab, India
|Date of Web Publication||11-Jun-2014|
Department of Obstetrics and Gynaecology, Christian Medical College and Hospital, Ludhiana - 141 008, Punjab
Source of Support: None, Conflict of Interest: None
Introduction: The serious complication of influenza infection during pregnancy has been recognised for over a century. Because it is associated with high morbidity and mortality, we decided to undertake this study. Objectives: To assess maternal and perinatal outcome in women with H1N1 infection in pregnancy. Materials and Methods: This was a 1-year retrospective study conducted in Christian Medical College ( CMC) and Hospital, Ludhiana. All women infected with H1N1 virus anytime during pregnancy were included in the study. Results and Analysis: A total of 26 patients were included in our study. A majority of patients were in the age group of 20-25 years (84.61%). A total of 61.54% were primigravida and 69.23% were in the third trimester. Comorbidities like diabetes, asthma, and obesity were present in 19.23% patients. The commonest symptoms were cough (92.37%), sore throat, and breathlessness. The commonest maternal complication was preterm labor (30.76%), and fetal complication was intrauterine death (19.23%). The majority delivered vaginally (57.7%). There were seven maternal deaths in our study. Conclusions: H1N1 remains a grave risk in pregnancy, underlining the need for greater awareness, early diagnosis, and prompt treatment.
Keywords: Antenatal and perinatal complications, H1N1 infection, pregnancy
|How to cite this article:|
Dhar T. H1N1 in pregnancy: Experience in a tertiary care hospital. CHRISMED J Health Res 2014;1:69-71
| Introduction|| |
The serious consequences of influenza infection during pregnancy have been recognized for almost a century.  Influenza-related hospitalization of healthy pregnant women occurs at a rate of 1-2/1000.  Pregnant women with coexisting medical conditions are at an even greater risk of severe influenza-related morbidity.  Influenza-related hospitalization occurs mostly in third trimester, which is five times higher than postpartum control group. Influenza-related morbidity occurs in 10.5 of 10,000 pregnant women as compared with a rate of 1.91 in 10,000 nonpregnant controls. 
In view of this high morbidity and mortality associated with H1N1 during pregnancy, we decided to undertake a study to see the effect of H1N1 on the mother and fetus.
| Aims and Objectives|| |
The aim of this study was to assess the maternal and perinatal outcome in women with H1N1 infection in pregnancy.
| Materials and Methods|| |
This was a 1- year retrospective study conducted in Christian Medical College (CMC) and Hospital, Ludhiana from 1-7-2010 to 30-6-2011. All women infected with H1N1 virus anytime during pregnancy were included in the study. The Centers for Disease Control and Prevention (CDC) criteria for suspected H1N1 influenza was taken.
Onset of acute febrile respiratory illness within 7 days of close contact with a person who has a confirmed case of H1N1 influenza A virus infection
Onset of acute febrile respiratory illness within 7 days of travel to a community where one or more H1N1 influenza A cases have been confirmed
Acute febrile respiratory illness in a person who resides in a community where atleast one H1N1 influenza case has been confirmed.
A thorough history including history of contact with a patient of H1N1 disease and a detailed physical examination were carried out. All the necessary investigations like complete blood counts, coagulation profile, liver function tests (LFT), Renal function test, arterial blood gases, chest X-ray, and sonography for fetal well being were carried out. No polymerase chain reaction (PCR) testing was carried out in any patient.
The data were analyzed with respect to age, gestation at which H1N1 occured, parity, pregnancy complications, mode of delivery, and other maternal complications were noted. The details of fetal outcome including gestation at delivery, Apgar score, and birth weight were noted.
| Results and Analysis|| |
There were a total of 1250 deliveries in the study period of which 26 patients had H1N1 infection in pregnancy (2.08%). A majority of patients were in the age group of 20-25 years.
There were 16 primigravidas and 10 multigravida. A total of 69.23% of women were in third trimester, 23.07% in second trimester, and 7.70% in first trimester.
Only 19.23% had associated comorbidities like diabetes, asthma, and obesity.
The major symptoms included cough (92.37%), sore throat (84.6%), rhinorrhea (23.07%), shortness of breath (34.6%), and headache (30.7%) [Table 1].
The commonest complications in pregnancy were preterm labor (30.76%) followed by intrauterine death in 19.23%, PPH in 7.7%, and abortions and birth defects in 3.84%, respectively [Table 2].
About 57.70% had vaginal delivery, 34.61% underwent a cesarean section, and 3.84% each had forceps delivery and abortion, respectively. Eight patients required intensive care unit (ICU) admission. All women were initiated on antiviral treatment for H1N1, i.e. Oseltamivir (75 mg b.i.d.) and other antibiotics on clinical suspicion itself. There were seven maternal deaths during this period [Table 3]. Mostly women who presented late after the onset of symptoms like fever, cough, breathlessness, and low saturation and were hence initiated late on antiviral therapy succumbed to the illness.
Of the 25 babies born, 20 were live births and five were stillborn. There was one neonatal death and one baby was born with neural tube defects.
| Discussion|| |
During seasonal influenza epidemic and ongoing pandemics, pregnancy places otherwise healthy woman at an increased risk for serious complications from influenza. In a series of 1350 pregnant women reported in 1918 pandemic, above 50% developed pneumonia and of these more than half died with a case fatality rate of 27%,  which is similar to our study where 26.9% case fatality rate occurred in pregnant women.
The majority of patients in our study were in the age group of 20-25 years and in third trimester, which is similar to the study conducted by Jiminez et al.  Pregnancy and underlying medical conditions have been reported in women who were hospitalized with influenza and they included diabetes, cardiovascular, neurological, and pulmonary diseases like asthma.  Our study also showed comorbidities like diabetes, asthma, and obesity in 19.23%, and the study by Jiminez et al.,  had associated comorbidities in 22.8%.
Pregnancy-related complication of novel H1N1 infection includes nonreassuring fetal heart rate (fetal tachycardia), febrile morbidity, and hyperthermia. Hyperthermia in early pregnancy has been associated with neural tube defects and other congenital anomalies, and fever during labor is a risk factor for neonatal seizures, encephalopathy, cerebral palsy, and death,  and our study showed similar results.
During the current pandemic, low-risk nonpregnant women with mild illness do not need to be tested. However, all pregnant women should be regarded as high risk and should be treated because the potential benefits outweigh the risks to the fetus.  It has been reported that a significant delay in the initiation of treatment during pregnancy led to higher morbidity and mortality.  Treatment should ideally be started as soon as possible and preferably within 48 h of symptoms onset for maximum benefit and current CDC guidelines also suggest this. 
| Conclusions|| |
"Knowledge Gaps" in women and their health care providers must be addressed to improve the pre- and post-conception vaccination status. Vaccines that are now available can go a long way to prevent complications.
Communication messages aimed at pregnant women and their health care professionals should aim at providing information of H1N1 disease, the use of early antiviral therapy, and the benefits of early therapy and the risks of influenza complications in pregnant women.
| References|| |
|1.||Tamma PD, Ault KA, del Rio C, Steinhoff MC, Halsey NA, Omer SB. Safety of Influenza vaccination during pregnancy. Am J Obstet Gynecol 2009;201:547-52. |
|2.||Mak TK, Mangtani P, Leese J, Watson JM, Pfeifer D. Influenza vaccination in pregnancy: Current evidence and selected national policies. Lancet Infect Dis 2008;8:44-52. |
|3.||Neuzil KM, Reed GW, Mitchel EF, Simonsen L, Griffin MR. Impact of influenza on acute cardiopulmonary hospitalisations in pregnant women. Am J Epidemiol 1988;148:1094-102. |
|4.||Graves CR. Pneumonia in pregnancy. Clin Obstet Gynecol 2010;53:329-36. |
|5.||Kosmak GW. The occurrence of epidemic influenza in pregnancy. Am J Obstet Gynecol 1919;79:238-51. |
|6.||Jimenez MF, El Beitune P, Salcedo MP, Von Amelin AV, Mastalir FP, Braun LD. Outcomes for pregnant women infected with influenza A (H1N1) virus during the 2009 pandemic in Porto Alegre, Brazil. Int J Gynecol Obstet 2010;111:217-9. |
|7.||Carlson A, Thung SF, Nowitz ER. H1N1 influenza in pregnancy: What all obstetric care providers ought to know. Rev Obstet Gynecol 2009;2:139-45. |
|8.||Jamieson DJ, Honein MA, Rasmussen SA, Williams JL, Swerdlow DL, Biggerstaff MS, et al. Novel Influenza A (H1N1) pregnancy working Group. H1N1 2009 Influenza Virus Infection during pregnancy in the USA. Lancet 2009;374:451-8. |
[Table 1], [Table 2], [Table 3]