CDC looks to improve H1N1 obstetric guidance

Sep 29, 2009 (CIDRAP News) – As more pregnant women enter hospital delivery rooms sick with pandemic H1N1 flu, health professionals and their patients are struggling with some of the elements in federal guidance—such as having patients wearing masks during labor—that will soon be revised, experts from the US Centers for Disease Control and Prevention (CDC) said today.

Two CDC experts who spoke in teleconferences for clinicians today said today that women and their healthcare providers are also struggling with some other aspects of the guidance, such as the recommendation to separate a mother who is sick with the flu from her newborn.

The guidance, issued Jul 6, urged women who are sick with the pandemic H1N1 virus to wear a surgical mask during labor and delivery to avoid transmitting secretions to her baby, the healthcare team, others in the room, and surfaces.

Kevin Ault, MD, associate professor of gynecology and obstetrics at Emory University School of Medicine in Atlanta, who spoke during the conference call said, "Masks are problematic for obvious reasons. It's difficult to wear a mask during birth," he said.

Ault also said some hospitals are having problems separating babies in nurseries who have been exposed to the pandemic H1N1 virus from the ones who haven't been. He said his facility has room to develop a separate space, but others have had to use plexiglass or other ways to divide the two groups.

Ault and the experts from the CDC also said it's difficult to separate moms from babies, because close contact is important for bonding and breastfeeding. According to federal guidance, a mother who is sick should consider avoiding close contact with her baby until she has been on antiviral medication for 48 hours, is free of fever, and can control coughing and sneezing.

So far there have been no reports of babies becoming infected from their sick mothers after delivery, he said. However, the babies delivered to mothers with the flu are considered potentially infected.

Denise Jamieson, MD, MPH, a medical officer in the CDC division of reproductive health, told clinicians that the CDC is revising its guidance on how to manage sick women in labor and delivery settings.

The CDC's experts today also addressed the urgency of early treatment for pregnant women who have pandemic H1N1 flu and the importance of vaccines for this group, who typically have the lowest vaccine uptake, about 15%, of any group recommended to receive flu vaccines.

Pregnant women are at higher risk of severe flu complications and death and are at the front of the line to receive the nation's first doses of pandemic H1N1 vaccine as it becomes available in the coming weeks.

About 5% of pandemic flu deaths have occurred in pregnant women, though they make up about 1% of the population. According to Aug 20 CDC data, 24 of 484 flu deaths in the United States occurred in pregnant women.

Sonja Rasmussen, MD, a senior scientist in the CDC's division of birth defects and developmental disabilities, said healthcare providers should not wait until tests come back to treat a pregnant woman who has a suspected case of pandemic flu.

She also emphasized that physicians should not base their treatment decisions on the results of a negative rapid test. She added that the use of oseltamivir outweighs any risk to the baby and that fevers during pregnancy are linked to adverse outcomes.

Ault said 11 published studies over the past 40 years have shown no maternal or fetal problems from seasonal flu vaccination and that one recent study has shown health benefits for babies of mothers who received their seasonal flu shots.

A survey of Georgia woman who declined the seasonal flu vaccine in 2006 found that about 45% said their physicians didn't mention the shot, while about 28% said they worried about the effect it might have on their babies. About a quarter of the women said they wouldn't receive it because they were only in their first trimester. (Recommendations have since been revised to say women in any trimester should receive a seasonal flu shot.)

To improve flu vaccination rates in pregnant women, Ault recommends that physicians establish standing orders for all pregnant women to be offered the vaccine. He also said broadcasting e-mails to medical practice employees and offering professional education on the topic to staff may help boost rates.

Other tactics he mentioned include incorporating vaccinations for pregnant women into best practices reviews or appointing a vaccine "champion" to handle all of the medical office's vaccine paperwork and management issues.

Clinical trials of the pandemic H1N1 vaccine in pregnant women began around Sep 15 and should wrap up in about 2 weeks, the experts said today.

See also:

Jul 6 CDC guidance on novel H1N1 flu in obstetric settings

COCA conference call information

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