Anthrax

Case reports have shown that anthrax during pregnancy can be successfully treated, but preterm delivery may be a complication.⁵ WGCB anthrax recommendations:⁶ Antibiotics: the primary classes, quinolines and doxycycline, are often avoided in pregnant and pediatric patients; however, they are recommended based on risk-benefit analysis in bioterrorism settings. The American College of Obstetricians and Gynecologists Committee on Obstetric Practice endorsed these recommendations and emphasized that prophylaxis be limited to women exposed to a confirmed environmental contamination or a high-risk source, as determined by local public health officials.⁷ Vaccine:⁸ Benefits appear to outweigh risks.

Botulism

Treatment is basically symptomatic and based on nursing care. The fetal prognosis is tightly correlated with the maternal status.

WGCB botulism recommendations:⁹ Children and pregnant women should receive standard therapy. Treatment with human-derived neutralizing antibody decreases the risk of allergic reactions posed by equine botulinum antitoxin, but availability of the investigational product, Botulism Immune Globulin Intravenous (Human) (California Department of Health Services [CDHS], Berkeley) may be limited to suspected cases of infant botulism.

Human botulism immune globulin intravenous (BIG-IV) for infants: Prompt treatment of infant botulism type A or type B with BIG-IV was safe and effective in shortening the length and cost of the hospital stay and the severity of illness.

BIG-IV, now licensed by the FDA to CDHS as BabyBIG, is a safe and effective treatment for infant botulism type A and type B. Treatment should be given as soon as possible after hospital admission and should not be delayed for confirmatory testing of feces or enema. BabyBIG is available as a public-service orphan drug in the United States. (Information on this drug may be obtained at www.infantbotulism.org and by telephone from the CDHS Infant Botulism Treatment and Prevention Program at 510-231-7600.)¹⁰

Hemorrhagic Fever Virus

The mortality among pregnant women with Ebola hemorrhagic fever (95.5%) was slightly but not significantly higher than the overall mortality observed during the Ebola epidemic in Kikwit, Democratic Republic of the Congo, (77%; 245/316 infected persons).¹¹ WGCB hemorrhagic fever virus (HFV) recommendations:¹² Although ribavirin is contraindicated in pregnancy for other indications and not approved in oral or parenteral form for children, the working group believes benefits outweigh risks with HFV.

Blood Transfusion in Pregnancy

If the degree of urgency calls for emergency transfusion of uncrossmatched blood, group O Rh-negative blood should be used. This is done to prevent antibody development in Rh-negative mothers. Autologous transfusion (e.g., from chest tube) should be considered whenever possible. One set of goals is to transfuse blood and crystalloid to maintain hematocrit at 25%-30% and urine output above 30 cc/hr. CMV is a concern with blood transfusion. Based on screened blood donors for antibody to CMV, more than 40% of healthy donors may have the potential to transmit CMV. The safest approach may be to use CMV antibody-negative products. If these are unavailable, use leukocyte-reduced products, because CMV is transmitted only by leukocytes. It is unclear which product provides the best protection against transfusion-associated CMV infection.¹³