Plague

In the preantibiotic era, plague was associated with significant maternal mortality. Among those surviving, stillbirths, spontaneous abortion, and fetal infection were common. Data are limited in the antibiotic era; however, treatment appears to be effective in improving outcomes. Because infection can be spread either transplacentally to the fetus or directly to the newborn during labor and delivery, induction of labor or cesarean delivery should be reserved for fetal distress indications as in any pregnancy. Infants of infected mothers can be treated empirically.¹⁴ WGCB plague recommendations:¹⁵ Antibiotics: the primary classes, streptomycin, gentamicin, quinolones, and doxycycline, are often avoided in pregnant and pediatric patients; however, they are recommended based on risk-benefit analysis in bioterrorism settings.

Smallpox

Pregnancy complicated by smallpox appears to have a significant overall case fatality incidence of miscarriage or premature birth. Vaccination before pregnancy reduced the risk for death.^16,17 Although fetal vaccinia may be a risk if mothers receive vaccine, all exposed mothers, as well as all infants and children, should be vaccinated within 4 days of first exposure.¹⁸

Tularemia

WGCB tularemia recommendations:19 Antibiotics: the primary classes, streptomycin, gentamicin, quinolones and doxycycline, are often avoided in pregnant and pediatric patients; however, they are recommended based on risk-benefit analysis in bioterrorism settings.

Organophosphates (Nerve Gas)

Infants and neonates have lower baseline cholinesterase activity and are at increased risk when exposed to equivalent amounts of organophosphorus compounds or carbamate.²⁰ Cholinesterase levels are also depressed during pregnancy, especially during the first two trimesters.²¹ Fetal death has been reported with maternal exposure.²²

Generally with early, proper treatment, outcomes for mother and child appear good.²³ However, some association of in utero organophosphate exposure and childhood attention deficit disorder exists.²⁴ There have been conflicting findings regarding in utero organophosphate pesticide exposure and fetal growth.^25,26 Shortened gestational duration was most clearly related to increasing exposure levels in the latter part of pregnancy. These associations with gestational age may be biologically plausible given that organophosphate

pesticides depress cholinesterase and acetylcholine stimulates contraction of the uterus. However, despite these observed associations, the rate of preterm delivery in this population (6.4%) was lower than in a U.S. reference population. Fetal death has been reported possibly resulting from fetal bradycardia and/or placental insufficiency because of maternal bradycardia.²⁷

Treatment for Nerve Agents (Tabun, Sarin, Soman, and VX)²⁸

Pregnant women and infants: For significant exposure, treatment is same as that given to other adults and pediatric patients with dosing of medications as described below. Nursing women requiring treatment (where the child is not exposed) must discontinue nursing while receiving medications.