CDC Guidelines on the Prevention and Control of Influenza in Pregnancy

SUMMARY:  

The CDC provides guidance for managing pregnant women who have suspected or confirmed flu. Of note, pregnant women are considered to be in the high-risk category. ACOG has a committee statement that provides recommendations aligned with the CDC.

• Pre-delivery
• During delivery
• After delivery
• Nursery
• Treatment
• Visitors
• Before hospital discharge
• How flu spreads

Pre-Delivery 

Suspected or laboratory-confirmed influenza  

• Place in a private room on Droplet Precautions 
  • If patient is hospitalized, continue Droplet Precautions for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer 
  • Discharge patient from medical care when clinically appropriate, not based on the period of potential virus shedding or recommended duration of Droplet Precautions 
• Instruct patient to follow respiratory hygiene and cough etiquette, including wearing a facemask, if being transported outside of her room 
• Health care personnel entering rooms of pregnant women with suspected or confirmed influenza should adhere to Standard and Droplet Precautions, which include  
  • Donning a facemask upon entry into the room 
  • Performing hand hygiene 
  • Wearing gloves for any contact with potentially infectious materials 
  • Wearing gowns for any patient-care activity where contact with body fluids may occur 
• Patient and visitor education  
  • Inform regarding the risks of influenza virus transmission  
  • Instruct about adherence to respiratory hygiene and cough etiquette, hand hygiene, and use of personal protective equipment (PPE) according to current facility policy 

During Delivery 

Suspected or confirmed influenza, on labor & delivery floor  

• Patient should remain on Droplet Precautions 
• Health care personnel on labor & delivery should adhere to Standard and Droplet Precautions, including practicing hand hygiene before and after handling the newborn 

After Delivery 

To reduce the risk of influenza virus transmission to the newborn 

• Consider temporarily separating the mother who is ill with suspected or confirmed influenza from her baby following delivery during the hospital stay 
• Discuss the risks and benefits of temporary separation with the mother  
  • Ideal setting for care of a healthy term newborn while in the hospital is within the mother’s room 
  • Newborns infected with influenza virus are at increased risk for severe complications 
• Decisions about temporary separation should be made in accordance with the mother’s wishes 
• Throughout the course of temporary separation 
  • Feedings should be provided by a healthy caregiver if possible 
  • Mothers should be encouraged to express their milk to establish and maintain milk supply 
  • Expressed breastmilk should be fed to the newborn 
• Because the ideal length of temporary separation in the hospital is not yet established, assess on a case-by-case basis and consider the following in the decision process  
  • Risk/benefit factors  
  • If the mother has been afebrile without antipyretics for >24 hours 
  • Whether the mother can control her cough and respiratory secretions 
• If co-location (“rooming in”) of the newborn with his/her ill mother in the same hospital room, limit influenza-virus exposure of the newborn using the following strategies  
  • Use engineering controls like physical barriers (e.g., a curtain between the mother and newborn) 
  • Keep the newborn ≥6 feet away from the ill mother 
  • Ensure a healthy adult is present to care for the newborn 
  • If no other healthy adult is present in the room to care for the newborn 
    • Instruct the mother to put on a facemask and practice hand hygiene before each feeding or other close contact with her newborn 
    • Retain use of facemask during contact with the newborn  
    • Continue these practices while on Droplet Precautions in the hospital 
• Once contact between mother and newborn is resumed 
  • Droplet Precautions for influenza should continue to be observed in the hospital until at least 7 days after maternal illness onset 

Nursery 

If a newborn of a mother with suspected or confirmed influenza is in the nursery  

• Newborn care can be provided by a non-ill person using Standard Precautions and the newborn should be closely observed for signs of infection 
• Symptomatic mothers, care givers, and family members should not enter the nursery 
• If a newborn develops signs of the flu, place on Droplet Precautions and have the newborn examined by a physician 
  • Test for influenza  
  • Consider oseltamivir treatment 

KEY POINTS:  

Treatment  

• CDC considers women who are pregnant or postpartum (within 2 weeks after delivery) to be at high-risk
  •   CDC recommends starting oseltamivir treatment as soon as possible for confirmed or suspected influenza of any severity due to complication risks associated with pregnancy
• To reduce treatment delay
  • Inform patients regarding need for early treatment and signs and symptoms of influenza
    • Typical: Fever | Cough | Rhinorrhea | Sore throat | Headache | Shortness of breath | Myalgia
    • Other: Vomiting | Diarrhea | Conjunctivitis | Fever may be absent
  • Ensure rapid access to telephone consultation and clinical evaluation during pregnancy and postpartum
  • Consider empiric antiviral treatment based on telephone contact if hospitalization is not indicated and if this will substantially reduce delay before treatment is initiated
  • Antiviral treatment should not be delayed while awaiting respiratory infection test results, and a patient’s vaccination status should not affect the decision to treat
• Administer antiviral treatment as early as possible   
  • Ideally, within 48 hours of symptom onset  
  • Do not delay treatment even for a few hours while awaiting test results 
  • Treatment initiation even after 48 hours can still be beneficial   
• Preferred
  • Oseltamivir 75 mg orally twice daily for 5 days
• Alternative medications
  • Zanamivir: Two 5-mg inhalations (10 mg total) twice daily for
    5 days
  • Peramivir: One 600-mg dose IV over 15 to 30 minutes
  • Baloxavir: Not recommended for pregnant women
• Moderate risk of severe illness: Patient should be seen in an ambulatory setting for in-person evaluation as soon as possible
• High risk of severe illness: Patient should be seen in an emergency department or equivalent setting as soon as possible

Visitors

• Visitors should be limited to persons who are necessary for patient’s care/wellbeing   
• Visitors who have been in contact with an infected patient before and during her hospitalization are a possible source of influenza for other patients, visitors, and staff 
• Screen all visitors for acute respiratory illness  
  • Only allow asymptomatic individuals to visit 
  • Instruct visitors to limit their movement within the facility 
• Facilities should provide instruction, before visitors enter patients’ rooms, on proper hygiene and procedures 

Before Hospital Discharge 

• Strongly encourage and, if possible, provide the flu vaccination to 
  • Any unvaccinated family members aged 6 months and older  
  • Caregivers in contact with the newborn 
• Advise caregivers that they should 
  • Contact their health care provider promptly if the newborn develops signs that suggest a flu infection 
  • Isolate any individuals in the home who become ill to protect the newborn 
  • Ensure that the ill postpartum woman follows hand hygiene and respiratory hygiene and cough etiquette when having contact with her newborn 
• Caregivers, if possible, should be limited to vaccinated non-ill adults until the mother’s flu resolves 

How Flu Spreads

Person to Person

• Flu viruses spread mainly by droplets made when people with flu cough, sneeze, or talk
• Most common
  • Droplets can land in the mouths or noses of people who are nearby (usually within about 6 feet away) or possibly be inhaled into the lungs
• Less often
  • Touching a surface or object that has flu virus on it and then touching their own mouth, nose, or possibly their eyes

When Are People with Flu Contagious?

• Flu viruses can usually be detected one day before symptoms develop and up to 5 to 7 days after becoming sick
• People with flu are most contagious in the first 3 to 4 days after illness begins
  • In theory, possible for an infected person to spread flu viruses to close contacts while still asymptomatic
• Symptoms typically begin approximately at 2 days (range from 1 to 4 days) following infection of the respiratory tract
• Asymptomatic individuals can spread virus to close contacts

Note: Those with weakened immune systems may be contagious for >7 days

Postexposure Antiviral Chemoprophylaxis

• Due to high risk for complications, postexposure antiviral chemoprophylaxis should be considered for pregnant and postpartum (up to 2 weeks postpartum including after pregnancy loss) individuals who have been in close contact with infectious individuals
  • Oseltamivir 75 mg daily for 7 days

Influenza and COVID-19

• Influenza and COVID-19 have overlapping signs and symptoms
  • Consider both infections in symptomatic pregnant women
• If a patient tests positive for SARS-CoV-2 infection, Paxlovid can be taken together with oseltamivir

Learn More – Primary Sources:  

CDC Guidance for the Prevention and Control of Influenza in the Peri- and Postpartum Settings

CDC: Information for Health Professionals – Influenza

CDC: Recommendations for Obstetric Health Care Providers Related to Use of Antiviral Medications in the Treatment and Prevention of Influenza

CDC: Influenza Antiviral Medications: Summary for Clinicians

CDC: How Flu Spreads

ACOG Practice Advisory: Influenza in Pregnancy: Prevention and Treatment

How to Tell the Difference Between the Flu and a Cold?

SUMMARY:  

The CDC provides information on how to discriminate between the flu and the ‘common cold’. Both conditions are viral in origin. Co-infection with bacteria is possible and in the case of infection with influenza virus, can lead to significant and serious complications.  

‘Signs and Symptoms’ Comparisons

KEY POINTS:  

Flu Symptoms  

Patient may experience just a few or many 

• Fever or feeling feverish/chills 
• Cough 
• Sore throat 
• Runny or stuffy nose 
• Muscle or body aches 
• Headaches 
• Fatigue (tiredness) 
• Some people may have vomiting and diarrhea, though this is more common in children than adults

Note: Not everyone with flu will have a fever

Flu Complications 

• Moderate complications 
  • Sinus and ear infections  
• Serious flu complications (can result from either influenza virus infection alone or from co-infection of flu virus and bacteria) 
  • Pneumonia 
  • Heart inflammation (myocarditis) 
  • Brain inflammation (encephalitis)  
  • Muscle inflammation (myositis, rhabdomyolysis)  
  • Multi-organ failure (e.g., respiratory and kidney failure) 
  • Sepsis 
  • Exacerbation of chronic medical problems  
    • Asthma attacks  
    • Worsening of heart disease  

High Risk Categories  

The following are at high risk of complications related to influenza virus infection 

• Young children 
• Adults aged 65 years and older  
• Pregnant women are at especially high risk 

Note: To see the comprehensive list of high risk flu categories (and more), see the CDC Emergency Advisory below in the ‘Related ObG Topics’ section

Learn More – Primary Sources:  

CDC: What is the difference between a cold and the flu?

CDC: Information for Health Professionals