Influenza

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What is flu, and why do we care about it in pregnancy? 

  1. We reviewed the flu vaccine in pregnancy previously, but we have never talked specifically about flu itself! 

    1. Flu is a contagious respiratory illness caused by the influenza virus 

    2. The virus is a negative sense RNA virus 

    3. There are multiple strains, including A, B, C, D

      1. We have probably heard about A and B, but C and D also can infect people 

        1. A and B are known to cause more severe illness, while C can cause can cause a mild infection 

        2. D can infect humans, but is not known to cause illness 

    4. Transmission is through aerosols and contaminated surfaces 

  2. Why do we care about flu so much? 

    1. In typical years, as much as 5-15% of the population will contract flu

    2. This leads to 3-5 million severe cases annually and up to 650,000 flu deaths a year in the world 

    3. In the US, on average, 8% of the population gets sick from the flu, per the CDC 

  3. Who is most likely to get sick? 

    1. Children are most likely to get sick from flu and people 65 and older are least likely to get sick 

    2. However, pregnant and postpartum individuals are at significantly higher risk of serious complications related to seasonal and pandemic influenza infections compared to non pregnant people 


How is flu prevented? 

  1. Vaccination 

    1. The CDC recommends that all adults receive an annual influenza vaccine and that individuals who are pregnant during the season receive an inactivated or recombinant influenza vaccine as soon as possible 

    2. Timing: end of October is ideal, but any time during flu season vaccination should be encouraged 

    3. Remember that it is safe to give the flu vaccine with other inactivated vaccines that may be needed in pregnancy (ie. Tdap, RSV, or COVID vaccines) 

    4. It is also safe for lactating individuals to receive the flu vaccine 

    5. Of note, the vaccine also benefits the newborn when it is given during pregnancy 

      1. Randomized controlled trials and observational studies have shown neonatal protection from maternal influenza vaccination 

    6. Importantly, studies show that when recommendations for the flue vaccine during pregnancy come from the patient’s Ob/Gyn or other obstetric health professional, and the vaccine was available in the office, the odds of vaccine acceptance and receipt are 5x-50x higher! 

    7. For more information on the flu vaccine, check out our previous episode: https://creogsovercoffee.com/notes/2019/5/26/vaccines-i-tdap-and-influenza

  2. Masks 

    1. This is probably familiar to all of us now with the COVID-19 pandemic 

    2. Mask wearing can help prevent transmission of many respiratory infections, particularly when community levels of circulating viruses are elevated 

    3. When to wear a mask 

      1. Local public health guidance and recommendations based on community-centered risks 

      2. Individual’s specific vulnerability due to health conditions 

      3. Clinical and health care professional recommendations 

  3. Other methods 

    1. Hand washing 

    2. Cleaning surfaces regularly 

    3. Make sure to to use usual techniques to minimize contamination/spread of disease 


How should we evaluate for influenza in pregnancy? 

  1. Assess for symptoms 

    1. Fever >100.4 F (38 C) and one of the following 

      1. Cough, runny nose, sore throat, headache or body aches, fatigue, difficulty breathing or SOB 

    2. If these symptoms are present, test for COVID and flu 

    3. Also assess for illness severity 

      1. Difficulty breathing or shortness of breath 

      2. Chest pain/pressure 

      3. Unable to keep down liquids 

      4. Dehydration signs and symptoms 

      5. Less responsive, confused

      6. Symptoms are worsening 

    4. If yes to any of the above, then encourage patient to go to emergency room or equivalent location to be treated 

    5. If no, if there are other morbidities (ie. cardiovascular or pulmonary issues, immunosuppression, obstetric issues like preterm labor) → should be seen in a clinical setting as moderate risk 

    6. Otherwise, patient is considered low risk and patient can be treated outpatient or even over the phone, with follow up in 24-48 hours 


How to Treat Respiratory Infection in Pregnancy 

  1. Empiric treatment 

    1. Oseltamivir is the preferred treatment for pregnant individuals 

      1. Dosing: 75 mg orally twice a day for 5 days 

    2. Zanamivir can also be used (two 5 mg inhalations twice daily for 5 days) 

    3. Peramivir can also be given, but is 1 dose IV for 15-30 min 

    4. Do not delay treatment while respiratory infection test is running

  2. If suspected to have both COVID and flu, oseltamivir and Paxlovid can be prescribed and taken together 

  3. Post Exposure chemoprophylaxis for flu 

    1. Due to high potential for morbidity and mortality related to flu in pregnant and postpartum individuals, post exposure chemoprophylaxis can be considered for those who are pregnant and for those who are up to 2 weeks postpartum 

    2. Recommendation: oseltamivir 75 mg 1x/day for 7 days 

    3. Should be started within 48 hours of most recent exposure 

    4. At risk family members of patients with flu should be referred to health care professionals for consideration of chemoprophylaxis 


Impacted Fetal Head

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Reading: From SASCOG’s Pearls of Exxcellence - Cesarean Delivery with Deeply Impacted Fetal Head 

Imagine the scenario: 

You are called to do an urgent C-section as an intern for a patient with arrest of second stage of labor. Per sign out, the patient has been pushing for almost three hours and the fetal station has never made it below +1. There is significant caput. What are some of the things you should be thinking about to hopefully make this C-section easier? 

How do I identify an impacted fetal head? 

  • What it is: 

    • There have been various definitions proposed - basically, most of the definitions center on having a fetal head becoming deeply engaged within the maternal pelvis resulting in difficult extraction 

    • Complicates 1.5% of cesarean births and up to 25% of emergent cesarean births 

  • Risk factors 

    • Fetal malposition - ie. occiput posterior and occiput transverse positions

      • OP positioning leads to a larger occipitofrontal diameter (11.5cm) passing through the pelvic outlet compared to OA (9.5 cm) 

      • See more on this in our malposition and malpresentation episode!

    • Prolonged second stage 

    • Failed operative vaginal delivery 

    • Basically, anything that can wedge the head into the pelvis 

  • Identifying an impacted fetal head 

    • There is not a 100% way of identifying that a fetal head will be impacted before you actually do the C-section and you reach down into the pelvis 

    • However, you should suspect it if there are any of the above risk factors 

    • Regarding fetal position: 

      • Can be known by palpating the sutures

      • In babies that are OP, the posterior fontanelle will be felt

        • This feels triangular, as it is formed by the junction of the sagittal and lamboidal sutures 

      • This is in contrast to babies that are OA, where the anterior fontanelle can be felt (shaped like a diamond) 

      • Other methods = using transabdominal ultrasonography to figure out position, as rate of error for digital vaginal exam can range from 30-65% depending on the study 

    • An impacted fetal head is usually identified during the cesarean delivery: when you place a hand beneath the pubic bone to lift the fetal head, it is often difficult due to how low the head is.

      • Possibly cannot get hand around the fetal head to elevate 

      • Or it is difficult to elevate and flex the head due to position or how low the head is 

Why do we care about IFH? 

  • What are risks to mom? 

    • Other than it being really hard to elevate the head and delivering the baby, there are multiple risks to both mother and infant at this stage 

    • Increased risk of: 

      • Maternal hemorrhage 

      • Hysterotomy extensions 

      • Bladder injury 

  • What are risks to baby? 

    • Neonatal hypoxia 

    • Traumatic injuries 

  • Therefore, important to identify this and anticipate how to resolve IFH 

What should you do if there is a suspected impacted fetal head? 

  • Let others know what you are thinking 

    • Tell nursing staff, anesthesia, and neonatology 

      • This way, everyone is prepared 

    • Call for help if needed - if you need another team member to come in for assistance, it’s better to have them and not need them than if no one is there 

  • Position the patient accordingly 

    • We tend to favor positioning patient in a modified lithotomy position 

      • Can either frog-leg 

      • Or place in lithotomy, but bend legs down so that the hip joint is not flexed during the initial part of the case

        • Can use yellow fin stirrups 

        • Easy to then flex at the hip joint into dorsal lithotomy if needed  

  • Place your hysterotomy accordingly 

    • Especially if the patient has entered second stage, the lower uterine segment will be distended 

    • Hysterotomy should be placed relatively high to avoid inadvertent entry through the cervix or vagina 

  • Maneuvers to resolve IFH 

    • Now that you have encountered an impacted fetal head and done all the right things up until now. How do you get the baby out? 

    • Vaginal hand or “push” technique 

      • Someone wears sterile gloves and inserts hand into vagina to elevate the fetal head 

      • They do not remove the hand until the head has been disimpacted by the surgeon from above or if this method has failed 

    • Breech delivery or “pull” technique 

      • Another technique is to deliver breech

      • Surgeon will extract feet from hysterotomy and proceeds to deliver the rest of the fetus 

        • Studies in low-resource settings show that this technique resulted in decreased maternal hemorrhage, hysterotomy extensions, and infection when compared to the “push” technique  — comparison of different methods via systematic review and meta-analysis

    • Extending your hysterotomy

      • If extraction is still difficult, can proceed with extension of the hysterotomy either via a J or a T extension 

      • These are done usually with two fingers beneath the area that you wish to extend to protect the baby, then cut the uterus with bandage scissors 

      • Can lead to more bleeding and will result in longer repair, but may lead to increased 

    • Devices 

      • Fetal Disimpacting System or cephalic elevation device; Fetal Pillow

      • Basically an inflatable device that is placed into the vagina that elevates the fetal head!

  • One randomized controlled trial at BWH in Boston that showed that this device led to 23-second reduction from hysterotomy to delivery compared with other methods 

    • Patients all received the device in the vagina, but were randomized to whether or not the device was inflated or not.

  • Other techniques 

    • Other techniques have been described, but not as well studied as the push or pull technique 

    • One = shoulder-first method, where the shoulders are initially delivered through the hysterotomy, followed by traction placed on axilla to facilitate delivery of the body and subsequently the head (Patwardhan maneuver)

  • Last thoughts 

    • If an IFH occurs, and it is particularly difficult, especially if it leads to need for multiple maneuvers, remember to debrief! 

    • Both with the team - what happened, what went well, what could have been improved, and take home points 

    • Talk to the patient 

      • Often, this can be traumatic for both the provider and the patient 

      • The baby may need to go the NICU, there may need to be a hysterotomy extension 

      • Discuss what occurred with the patient and if maneuvers resulted in certain complications 

        • Discuss extensions, baby going to NICU

        • Discuss if need for future C-section if T incision has occurred 

Espresso: Zuranolone for Postpartum Depression

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We’re back! While we’ll operate for a bit on a reduced schedule (new episodes every-other-week), we are so excited to get back to podcasting and covering the need-to-know in OB/GYN. Thanks for all the love and support over the last few months! <3 Nick & Fei

Reading: Zuranolone for the Treatment of Postpartum Depression (ACOG Practice Advisory)

What is zuranolone and why is it important? 

    • We know that postpartum/perinatal mental health conditions and some of the leading causes of preventable maternal mortality 

      • PPD affects approximately 14% of women 

      • Understanding/discussing/recommending medication and treatment can potentially decrease maternal morbidity and mortality 

  • Medication type

    • Neuroactive steroid gamma-aminobutyric acid (GABA) A receptor positive modulator 

    • Oral medication  

    • Recent FDA approval for use in PPD 

Why is zuranolone recommended, and what else is out there? 

  • Why is it recommended? 

    • Two phase 3 randomized double-blind, placebo-controlled multicenter studies 

    • Primary endpoint in both: change in depressive symptoms in the Hamilton depression rating scale (HAMD-17) 

      • 17 point scale 

      • Assesses somatic (physical ie. loss of appetite), affective (mood ie. sadness), cognitive (thinking, ie. difficulty concentrating), and behavioral (ie. social withdrawal) symptoms of depression 

      • Reliable and valid method of assessing and measuring depression 

    • In both studies, those on Zuranolone showed significantly more improvement in their symptoms compared those in placebo 

      • Treatment effect maintained at day 42 (4 weeks after last dose of zuranolone) 

  • Why the HAMD-17? 

    • More used in research settings, but anticipated that other validated tools (like EPDS or PHQ9) will be used in clinical settings 

  • What else is out there? 

    • Brexanolone - first FDA approved medication specifically for postpartum depression

      • However, unlike zuranolone which is oral, brexanolone consists of a 60 hour in-hospital IV infusion, which may not be readily accessible 

        • May be difficult to arrange inpatient admission 

        • May also be difficult for patients to leave their newborns for 60 hours to get infusion 

    • SSRIs 

      • Not specific for postpartum/perinatal depression 

      • Can be effective, but also may be difficult to find the correct SSRI

      • Many SSRIs also require uptitration of dosage 

  • What to consider when prescribing zuranolone 

    • Consideration of zuranolone in the postpartum period (within 12 months postpartum) for depression that has onset in the third trimester or within 4 weeks postpartum

    • Benefits: 

      • Significantly improved and rapid resolution of symptoms 

    • Risks: 

      • Potential suicidal thoughts or behavior 

      • Sedation - can make it so you can’t drive 

      • Lack of efficacy data beyond 42 days 

  • How to prescribe and take zuranolone 

    • Daily recommended dose is 50 mg 

      • Take in evening with fatty meal (400-1000 calories, 25-50% fat) for 14 days 

      • Can reduce dose to 40 mg if CNS depression effects occur 

      • If hepatic or renal impairment, start dose at 30 mg 

    • Can be used alone or as an adjunct to other oral antidepressant therapy like SSRIs 

    • Recommendation is to have effective contraception during treatment and for 1 week after final dose. There is a registry if pregnancy occurs 

    • Warn patients about adverse reactions 

      • Impaired ability to drive 

      • CNS depressant effects 

      • Increased suicidal thoughts and behaviors 

    • Zuranolone does pass into breastmilk, but relative infant dose is smaller than that of SSRIs 

Physiologic Changes of Pregnancy: Part 2

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10/08/2023
As part of our brief break for parental leave, we’re revisiting some of our most popular episodes! Today we’re revisiting Physiologic Changes of Pregnancy, part II.

We’re continuing “Fei and Nick’s Fabulous Adventure Through Pregnancy” today!

Need a refresher on all those lung volumes? So did we. There are a number of resources online to review them, however a nice quick video review can be found here.

These two episodes have covered a lot of ground on a lot of systems. We tried to come up with a quick-view table encompassing all of these changes. Let us know what you think!

Physiologic Changes of Pregnancy: Part 1

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10/01/2023
As part of our brief break for parental leave, we’re revisiting some of our most popular episodes! Today we’re revisiting Physiologic Changes of Pregnancy - almost five years to the day since we released it! Check out our reprisal of part II next week with the all-encompassing table of changes.

As promised, our first episode on pregnancy! Join us on “Fei and Nick’s Fabulous Adventure Through Pregnancy!”

Today we tackled the changes of the immunologic and hematologic systems seen in pregnancy. There’s quite a bit of information there! If you feel like we’ve missed anything, feel free to reach out via email or social media.

Next week, we’ll release Part 2 and have some more resources ready for your studying!