Managing pregnant women with suspected influenza

Guidance for clinicians

Pregnant women have a higher risk of severe disease than most other women following infection with influenza. These guidelines provide recommendations for managing pregnant women presenting with an influenza-like illness (ILI).

Influenza-like illness

For the purpose of these guidelines, ILI is defined as a fever (≥38˚C or a good history of fever), and either a cough or sore throat. Pregnant women should be encouraged to present early if they develop an ILI, or if they develop any respiratory symptoms after close contact with a person who has an ILI. They should be assessed, diagnosed and managed on clinical grounds, noting that there are a number of differential diagnoses for people presenting with an ILI. Influenza typically involves other symptoms such as fatigue, headache, muscle aches and pains.


In addition to following sensible good hygiene practices, it is strongly recommended that all women who are pregnant or considering becoming pregnant have the seasonal flu vaccine.


Antiviral prophylaxis is not generally recommended for well pregnant women, except in specific circumstances. A suggested approach for pregnant women who have had close contact with a patient with laboratory proven influenza is to provide information on the early signs and symptoms of influenza, and advise them to contact their doctor immediately for evaluation and possible early treatment if clinical signs or symptoms develop.


Consider laboratory testing for influenza where it will change clinical management or for severe illness requiring hospital admission. When a test is required, the request form should clearly state the reason for the test and the laboratory should be contacted to discuss prioritisation of the test if the patient is severely ill.


Treatment of patients with ILI should not be delayed while awaiting test results as there is generally little benefit if antiviral medication is started more than 48 hours after onset of symptoms. Treatment with anti-influenza medicine (either oseltamivir [Tamiflu] or zanamivir [Relenza]) may be offered to pregnant women at any stage of pregnancy. Although both drugs are classified as B1 (limited data indicating safety in pregnancy), use in pregnant women to date (mostly in second and third trimester), has not been associated with adverse fetal outcomes.

Experience of anti-influenza medication use in the first trimester of pregnancy remains very limited, so a careful discussion of the potential risks and benefits is essential before prescribing such agents. Experts have differing views as to the best drug to use in pregnancy. Oseltamivir is a capsule, has a systemic effect but causes nausea and vomiting in some patients. Zanamivir is inhaled, has a direct effect on the target organ (the lung) but can cause bronchospasm in some patients.

Considerations in the management of influenza in each trimester

First trimester

  • In the first trimester, the concern is largely about the effect maternal fever may have on the developing fetus, including miscarriage.
  • Symptomatic treatment with paracetamol is recommended to reduce fever.
  • Treatment with anti-influenza medicine should be discussed with the pregnant woman, taking into account other conditions that may increase her risk of severe disease.

Second and third trimester

  • In the second and third trimesters, the concern is largely for severity of illness in the pregnant woman, as well as the potential effects of maternal fever on the developing fetus.
  • Symptomatic treatment with paracetamol is recommended to reduce fever.
  • Assessment of maternal and fetal wellbeing is recommended at every presentation.
  • Treatment with anti-influenza medicine is strongly recommended to reduce the severity of disease in
    the pregnant woman.

Around the time of birth

  • Around the time of birth, the concern is about both the severity of illness in the pregnant woman and the risk of transmission to the baby
  • Symptomatic treatment with paracetamol is recommended to reduce fever.
  • Treatment of the pregnant woman with anti-influenza medicine is strongly recommended to reduce the severity of disease.
  • The pregnant woman should not be asked to wear a mask during labour and birth, but others in the room should follow infection control guidelines.
  • There is usually no advantage in expediting the birth of the baby.
  • While the baby is <3 months old, treatment of the mother is also recommended to reduce the risk of transmission to the baby.

Minimising the risk of infection from mother to baby

  • Breast feeding should be strongly encouraged
  • sensible efforts should be made to reduce the likelihood the baby will be infected, while minimising the effect on the mother-baby relationship. These include:
    • treating the mother to reduce the risk of transmission
    • the mother and baby should sleep at least 1 metre apart, in the same room (at least while in hospital), in separate beds
    • when breast feeding, bathing, caring for, cuddling, or otherwise being within 1 metre of the baby, the mother should wear a surgical mask and wash her hands thoroughly with soap and water before interacting with the baby.
  • the mother should avoid coughing and practice cough etiquette near the baby
  • although these measures can be ceased when the mother is no longer infectious, continued good hygiene should be encouraged at all times
  • the mother is considered non-infectious after 72 hours of treatment with anti-influenza medicine or if she remains afebrile for more than 24 hours without the use of anti-pyretic medication.
  • these measures should apply to any carer or family member with influenza
  • mothers requiring hospital care should not be prematurely discharged because they have influenza
  • if discharged while still infectious, mothers should be provided with a sufficient supply of surgical masks to take home.

Prophylaxis is not recommended for the baby. Should the baby develop symptoms, the baby should be isolated from other babies, assessed urgently by a paediatrician, who may consider treatment with anti-influenza medicine if influenza is diagnosed.

These guidelines are adapted and used with permission of NSW Health.

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