Α Royal College Guideline on Swine Flu for pregnant mothers

Guidance on Swine Flu (H1N1v) for pregnant mothers – a joint statement from the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives

Introduction
The Swine Flu (novel Influenza – H1N1) pandemic Phase 6 alert was declared by the World Health Organization (WHO) in June 2009. This meant that the flu virus was spreading rapidly both within and between countries.
In the UK, the Secretary of State for Health announced in July 2009 that the spread of flu in the United Kingdom had reached a level at which initial containment activities should now be replaced by a treatment response. The Chief Medical Officer sent information to doctors and health authorities, asking them to ensure that those suspected of having H1N1v will be treated immediately.
The WHO (on 2 July 2009) advised that pregnant women are at higher risk of complications from the virus and need to be monitored if they fall ill.
Experience so far shows that the H1N1v virus tends to affect the younger population, ie. those below the age of 60 years, and that the majority of people who suffer from it tend to experience mild flu symptoms. However, it can cause severe and complicated illness, and occasionally death, in people who have underlying health problems such as severe respiratory disease.
A few cases of severe illnesses among pregnant women and infants have been reported in the UK and from other countries. These have mostly affected women with pre-existing health problems. In previous pandemics, and in reports from some countries in this pandemic, there is evidence that pregnancy can increase the risk for influenza complications for the mother and the fetus.
Pregnant women are therefore included in the list of High Risk groups so that antiviral treatment can be provided as soon as their infection is diagnosed.
This document provides an updated guidance for pregnant women and mothers who have recently had their babies, in the light of the changing pattern of the outbreak of the H1N1 virus in the UK.

Prevention
Good personal and household hygiene measures are key to preventing the spread of the virus. Frequent handwashing or cleaning with a disinfecting hand rub is highly effective in preventing the spread of the virus on hands contaminated by droplets from the nose and throat. Parents should also ensure that they wash their babies’ hands.
Tissues should be used to cover the mouth and nose when sneezing and coughing, and all used tissues should be disposed of promptly (as described in the ‘Catch it, Bin it, Kill it!’ campaign) if these have been near the nose or mouth.
Work surfaces, children’s play areas, toys and changing mats should be cleaned frequently. Parents are also advised to limit the sharing of children’s toys, and to wash or wipe toys after use. Small non-electrical and battery operated plastic toys wash well in a 30 – 40oc washing machine cycle if enclosed in a fleecy ‘babygrow’ garment, among the normal laundry.

Treatment
Most of those people who have H1N1 flu, including pregnant women, will have mild symptoms, typical of seasonal (winter) flu. Common symptoms include a high temperature, sore throat, blocked or runny nose, body aches, tiredness, and occasionally diarrhoea and vomiting. In rare cases, the disease may rapidly progress to pneumonia.
The most important step to take in pregnancy is to treat fever (high temperature). This can be controlled by taking paracetamol which is known to be safe in pregnancy. The use of Non Steroidal Anti-Inflammatory Drugs (NSAIDs) such as Ibuprofen is not recommended in pregnancy.
Some women are prescribed low dose aspirin for specific conditions in pregnancy. If you have been prescribed with this, you should carry on with this medication unless advised by your doctor or obstetrician.
Women should consult their doctors or midwives for further advice and should avoid taking several over-the-counter medicines each day, since most popular flu medicines contain paracetamol, and their additive effect may lead to taking too much of this medicine.
If you are ill, or think you have flu, you will be advised to:
Stay at home Contact the national flu line service (Call the Swine Flu Information Line on 0800 1 513 513 for the latest advice on flu and its treatment.
If you have an assessment for flu (which will usually be done online or via the telephone), you will be asked if you are pregnant. If you have flu, you will receive an authorisation which a friend or carer can use to collect a course of antiviral medicine for you.
Follow self-care advice, including:
Drink plenty of fluids Take the antiviral medicine as prescribed Take medicines such as paracetamol if required
If your symptoms get worse after having your assessment or treatment, you should contact your GP directly.
To reduce risk of infection:
Wash or clean your hands frequently (particularly after contact with people who are ill) Cover your mouth and nose with a tissue while sneezing or coughing Dispose of used tissues promptly and carefully – bag and bin them Wash hard surfaces (eg. worktops, bathroom areas, play mats, changing mats, door knobs) with a domestic cleaner regularly Avoid unnecessary travel Avoid crowds where possible Ensure your children follow this advice.
These measures can greatly reduce the risk of spreading the infection. However, the pandemic virus is highly infectious and many people will be infected, so the measures do not completely prevent the spread of flu.

The use of antivirals during pregnancy
The strategy for minimising the spread and effect of H1N1v is to treat people as soon as possible after they develop flu symptoms. It is important that you get an assessment and arrange for your ‘Flu Friend’ to collect your medicine as soon as you begin to feel ill.
Antiviral drugs are not a cure, but can shorten the illness and reduce the risk of complications, especially if the course is begun within 48 hours of symptoms developing. The H1N1 virus is known to be susceptible to two antivirals: oseltamivir (Tamiflu®) and zanamivir (Relenza®).
In the United Kingdom, pregnant women with flu symptoms will usually be given a course of Relenza. This medicine is inhaled, using a disk-shaped inhaler. It is recommended for pregnant women because it easily reaches the throat and lungs, where it is needed, and does not reach significant levels in the blood or placenta. This has the theoretical advantage of not affecting the pregnancy or the growing baby. However, if a doctor or midwifery specialist thinks that a different medicine is needed (for instance, for unusually severe flu), Tamiflu will be provided instead.
Any medicine can occasionally cause side effects. The most common one with Relenza is wheezing when the medicine is inhaled. Women who have asthma should keep their ‘reliever’ inhaler handy in case they need to take some treatment for this. All women should speak to their GP or midwife if symptoms persist or are severe. The antiviral medicine will be provided up to seven days after the onset of the illness, but you should make every effort to collect them within 48 hours of onset of symptoms.
The European Medicines Agency (EMEA) examined all of the accumulated evidence, since licensing some years ago, on the use of antiviral medicines in pregnancy, breastfeeding and in children under the age of one. They advised that the medicines are effective, and that there is no evidence of harm from their use, either for the pregnancy, the developing fetus or for babies below 12 months of age.
Pregnant women are reminded that the antiviral medicines used to treat H1N1 are highly purified and powerful drugs, available by prescription only. Women should not be tempted to buy and use drugs from the internet or mail-order sources. The effectiveness, purity and safety of these drugs cannot be guaranteed and many drugs purchased from these sources are not of the required strength to be effective.
According to the Royal Pharmaceutical Society of Great Britain, some counterfeit drugs have been manufactured using poisons, or chemicals which affect the normal immune response, and are potentially very harmful. The UK has the largest stockpile of antivirals in the world and pregnant women will be given priority treatment. They should therefore NOT obtain Relenza or Tamiflu from unknown suppliers.

Vaccines
At present, because the H1N1 virus is a new influenza strain and in the process of rapid development, there are no vaccines available yet. Scientists from around the world are working hard to develop a vaccine. It is anticipated that the first batches of vaccine may be available by late autumn of 2009.
The UK Joint Committee on Vaccination and Immunisation (JCVI) currently recommends immunisation against seasonal influenza for pregnant women with any condition known to cause increased risk from influenza, regardless of trimester. Women should make sure that they take up this vaccine as soon as it is offered.

Maternity services during a flu pandemic
The Department of Health, the Royal College of Obstetricians (RCOG) and Royal College of Midwives (RCM) have been closely involved in pandemic flu planning. Maternity services are expected to run as near normally as possible during a pandemic and there will be extra measures to ensure that service disruption is kept to a minimum.
In the event of a large pandemic, the whole health service will be mobilised, not just obstetricians, midwives and health visitors, but also GPs, community nurses, the ambulance and emergency services. A system is also in place for recently retired obstetricians, midwives and final-year medical trainees to boost services and support specialist health professionals. Women should stay in close contact with their local maternity services so that updated information can be relayed to them.

The RCOG and RCM recommend that pregnant women have a Flu Friend to call upon should they become too ill or require further assistance. This person will collect antiviral medicines and may help to act as the woman’s contact with the GP or maternity services.

Antenatal clinics
Women without flu symptoms are advised to attend their usual antenatal appointments unless different arrangements have been made by their local maternity service. The progress of the pregnancy is monitored at these sessions and information on pregnancy care is provided. Low risk women may be monitored differently, eg. by a telephone consultation with their midwife, to avoid the need to travel to a hospital or clinic.
The availability of antenatal clinics and classes may be compromised during a pandemic because of staff shortages. Antenatal screening may be postponed or modified, eg. Down’s syndrome screening with nuchal translucency scans may be replaced by blood tests if there is a shortage of ultrasonographers. Local maternity services are examining ways to ensure minimal disruption of clinical services and will provide up-to-date information on their services regularly, in most cases via their hospital or Trust websites.

Birth in hospital
Careful planning needs to take place and some procedures such as a planned induction of labour or an elective caesarean section may be rescheduled at short notice. Some women may also be assigned to another hospital for the birth if their maternity unit of choice is under severe pressure due to flu cases or staff shortages. Women will be sent home from hospital as soon as possible, to reduce their exposure to infection.
Women will be informed by their maternity service should such contingency plans be put in place and need not worry about contacting other maternity units. Most maternity units will work closely together to ensure continuity of service as far as possible.

Birth at home
Staff shortages, or illness of a family member may mean that planned home births cannot be offered during a pandemic. If this is the case, mothers may need to have a hospital birth, which may mean a change to family arrangements. Women planning a home birth should discuss their options with their midwife.

Postnatal care and support
During a pandemic, women are advised to limit the number of visitors they receive at home in the first two months after the birth, to prevent themselves or their baby catching the disease from someone with the flu. If a member of the family has H1N1, they should keep apart from the mother and baby, in a different room if possible.
Similarly, midwives may not be available for home visits during a pandemic. Alternative arrangements will be made and women should check with their local maternity services on the availability.
If your baby is found to have the H1N1v flu and requires further treatment, it may be cared for in a neonatal unit. Or, if you have H1N1v and your baby is well, it may be expedient to have your baby cared for away from you for a short space of time, until you recover. The need for a mother and baby to be separated will be rare, and you will be encouraged to be in close contact with your baby as far as possible.

Caring for the infant
To prevent mother-to-baby transmission of the flu, mothers are reminded about the need for good personal hygiene. Hands must be washed and kept clean at all times when in contact with infants. Clothes which may be contaminated from used tissues or runny noses, should be changed and washed. Mothers should also take special care over their baby’s hygiene, and keep surroundings, cots and other equipment clean. Provided these basic steps are taken, mothers and fathers are encouraged to have frequent skin-to-skin contact with their babies.
How do I know if my baby has H1N1v flu?
The symptoms in newborns will be similar to the ordinary flu and includes fever, cough, cold and the loss of appetite. In addition, your baby will be tired and irritable and will need help during feeding. If you spot that your child has a high temperature or is having difficulty breathing (short rapid breaths) and a repetitive cough, contact your GP immediately for further advice.

Breastfeeding
Women who are breastfeeding will usually be given Tamiflu if they need an antiviral medicine. This is because there is no longer a risk to the placenta or developing baby. It also is safe for women to breastfeed while using Relenza. Mothers are encouraged to breastfeed as they would normally.
If a mother is too ill to breastfeed, or the baby is too ill to suckle, then expressed milk should be used. The risk for swine flu influenza transmission through breast milk is unknown, but good nutrition, with breast milk where possible, is important for recovery from flu and other infections.

Information resources
If pregnant women fall ill and suspect they may have the H1N1 flu, they should make sure that they get a phone or on-line assessment immediately. Reliable information information is available from the following sources:
Department of Health
http://www.dh.gov.uk/en/Publichealth/Flu/Swineflu/index.htm
http://www.dh.gov.uk/en/Healthcare/Children/Maternity/Maternalandinfantnutrition/DH_099965 NHS Choices http://www.nhs.uk/AlertsEmergencies/Pages/Pandemicflualert.asp DirectGov http://www.direct.gov.uk/en/Swineflu/DG_177831 Relenza http://www.relenza.com/

RCOG/RCM 9 July 2009

HPV and Genital Warts

Human papilloma virus (HPV) is the most common sexually transmitted infection and it is likely that most of us have had HPV at some time in our lives — although we may not have known it. So what is HPV, how can it be prevented and treated, and what does papilloma mean anyway?

Papilloma means a growth or wart, which is why HPV is also known as the 'wart virus'. In practical terms, however, only about 10% of people with HPV develop warts. The vast majority of people with HPV don't, and are therefore unlikely to know that they are infected or that they may be passing the virus to their sexual partner(s).

Young sexually active people are at greatest risk of getting genital HPV, with the highest rate of infection in those between the ages of 20 and 24. Recent research suggests that many young women may become infected with the virus during their first sexual experience, and the risk of infection increases with the number of sexual partners. HPV prevalence seems to decrease with age.

What is HPV?

There are thought to be more than 100 types of human papilloma virus that can infect the body. Some strains lead to common warts on people's hands and feet, but these are different from genital warts and cross-infection is extremely rare. About 30 types of HPV affect the genital area. Some types cause genital warts, others cause changes in cervical cells that may lead to cervical cancer, but most HPV infections cause no symptoms at all and go away on their own.

How is the virus spread?

Genital HPV is highly infectious, particularly when warts are present, and is spread mainly through direct skin-to-skin contact with the infected area. Genital HPV is passed on during sexual contact, including vaginal and anal sex, oral sex and, while less risky, non-penetrative sex play. It is also possible for sex toys to carry an infection from one person to another. In rare cases, HPV may be spread without direct sexual contact. It may be possible, for example, to pick up the virus if you use a towel to wipe your genitals after it has been used by someone who has HPV or genital warts.

How do I know if I have HPV?

Genital warts are the only visible sign of HPV infection, but they may not appear for weeks, months or even years after infection occurs, if they appear at all. Women are more likely than men to develop warts, and they can grow on the lips of the vulva, around the clitoris, inside the vagina, around the urethra, on the cervix, on the area between the vagina and the anus (perianal region), and in and around the anus itself. In men, warts tend to develop on the tip and shaft of the penis, on the scrotum, as well as in and around the anus. Although rare, genital warts may develop in a person's mouth or throat if infected through oral sex.

Warts may appear as small red or white bumps, they may grow alone or in cauliflower-like clusters, or they may be flat and barely visible.

Genital warts are generally not painful, but may be itchy or uncomfortable. You may not realise you have warts, particularly if they are small, inside the vagina or on your cervix.

How is HPV diagnosed?

HPV is usually diagnosed based on the presence of genital warts. If there are no obvious warts, but infection is suspected (because a partner has warts, for example), the doctor may apply a solution that turns warts white, making very small or flat warts more visible.

An abnormal smear result may be a sign that you have been exposed to HPV, but not all cervical smears can detect current HPV infection. If your smear result suggests HPV might be present, you may be scheduled for another smear, or for a colposcopy. During a colposcopy, we look at your cervix through a microscope (the colposcope) for signs of HPV and we may take a sample (biopsy) of cervical tissue for further investigations. If you don't have visible genital warts and your smear result doesn't show signs of HPV, there is currently no other way of knowing whether or not you have the virus.

HPV — prevention and new developments

Fortunately there is now an effective way of preventing HPV aside from not having sex or sexual contact. The recently developed vaccine reduces the risk of cervical cancer up to 70%. It is important to vaccinate young girls aged 12-13. At this age the immune response is stronger and sexual contact of the virus is not an issue yet. The vaccination schedule at 0,2 and 6 months is currently applied in all major Health Services worldwide.

Using condoms may help to prevent HPV, but because they do not cover the entire genital area, and are often put on after sexual contact has begun, the virus can still be passed on, even during 'safe sex'.

Using a condom for 3 to 6 months following treatment for warts may help prevent reinfection for you and your partner, and is usually recommended as part of a treatment programme. Risk factors, which, if avoided, may reduce your risk of getting HPV include: smoking, having multiple sexual partners and exposure to other sexually transmitted infections.

Fortunately, most HPV infections go away on their own within six months to two years without causing any complications or harmful long-term effects. For people with genital warts, the psychological and emotional impact of having warts is often the worst part of HPV. Some infections, however, may be linked to other problems, including recurring warts, other sexually transmitted infections (STIs) and cervical cancer.

Abnormal smear results and cervical cancer

Some types of HPV can lead to abnormal cell changes on a woman's cervix. These changes are known as CIN (cervical intra-epithelial neoplasia), which means 'new changes in the outer layer of the cervix'. In many cases, abnormal cells revert back to normal without treatment, but sometimes they do not. If left untreated, these cells may develop into cervical cancer, but it usually takes 10 to 20 years for this to happen. Fortunately, the progression to cervical cancer can be easily prevented if abnormal changes are found and treated early. Smear tests are currently the only way to detect abnormal cell changes, and are therefore the best way to protect yourself from cervical cancer. If you have been diagnosed with HPV, you may be scheduled for more frequent cervical screening — every 6 to12 months — to keep an eye on cervical cell changes. If the cells do not return to normal, or changes are severe, we will need to consider treatment options to remove the abnormal cells.

If you have visible genital warts, you probably do not have a type of HPV that is linked to cancer.

The two most common strains of HPV linked to cervical cancer are HPV 16 and 18, but most women with HPV, including those infected with type 16 or 18, do not develop cancer. Other strains of the HPV virus have also been linked to cervical and other more rare cancers, such as vulval and anal cancer.

What if I'm pregnant and have warts?

Warts tend to grow rapidly during pregnancy and may become numerous and large. This may be due to a weakened immune system, but there is some evidence to suggest that HPV is influenced by progesterone, which is high during pregnancy. In most cases warts will not interfere with pregnancy or birth but if the warts are very large, they may need to be removed.

The safest treatments during pregnancy are cryotherapy and surgery. In severe cases, if large warts cannot be removed, it may be necessary to have a caesarean section.

Although rare, HPV may be passed on to a baby through warts in the birth canal. This is not a serious condition, but it is possible for the baby to develop warts in the throat if exposed to the wart virus. Known as laryngeal papillomatosis, this can cause breathing problems in the baby, but the risk of this happening is extremely low and therefore is not, on its own, a reason to perform a caesarean section.

In summary:

· If we have ‘HPV changes’ described in a smear report, don’t panic, one in three young women at some point will have the virus. In the vast majority of women, the virus will just linger for a few months, usually up to a year, and will then be eliminated, exactly like when we get rid of a flu virus.

· We just do a colposcopy, to have a close look at the cervix under the microscope and confirm that the virus just ‘lingers’ but has not created a lesion deep in the cervix, and therefore is likely to persist.

· There are no tablets or creams to kill the virus. We wait for it to go spontaneously and we stop smoking, as it is documented to help HPV survive long-term.

· We don’t do contact tracing, blaming your ex, or warning him, the virus is far too common. It may be spread by non-sexual means, yet we don’t panic about our mother and sister and toilet seats. We just follow the basic hygiene rules at home.

· If you have visible warts, we will cauterise them under local anaesthetic at the Practice, and, alas, they recur and we may need to repeat these treatments a few times.

· If the virus persists in subsequent smear tests, it may eventually lead to pre-cancerous changes and cancer, this is usually a 10-12 year process. We will monitor with regular smear tests and colposcopies and when necessary, will remove the lesion with a cone biopsy, before it becomes cancerous.