The pregnancy and neonatal periods create unique challenges for medical providers in disaster settings. Maternal physiology is altered during the gestational period, and toxic and teratogenic potential to the fetus are a significant concern. As in the nondisaster setting, a basic principle to be followed is maintaining maternal survival in order to maximize fetal survival.

According to the CDC, “Decisions about the treatment or prophylaxis of emerging infections must take into account effect on mother’s health and potential risks for the embryo or fetus. Although limiting fetal exposure to treatments that may pose unknown risks is optimal, protecting the life of the mother is key in protecting the fetus. In an emergency setting with a high risk for life-threatening exposure to an infectious pathogen, recommendations likely will call for the use of vaccination and prophylactic medications, when they are available, for pregnant women, despite unknown risks to the fetus. Other measures that can protect persons who are unable or choose not to receive vaccination or prophylactic medications include limiting exposure to persons who may be infectious, avoiding public gatherings, and restricting travel to affected areas.”¹

This article will address disaster agents and unique risks and management issues for the pregnant woman, her fetus, and the neonate.

Refer to the Perinatal Disaster Management tool on www.ACEP.org. This tool, which corresponds to sections in this following article, summarizes key management issues. It can be used as a standalone tool in its paper format. This can become essential in a disaster setting where rapid resource access is critical and electronic technology may be compromised.

A number of recommendations are drawn from the Working Group on Civilian Biodefense consensus for measures to be taken by medical and public health professionals following the use of biological weapons against a civilian population. These will be referred to as WGCB in this article.

Emerging Infections

According to the CDC, “Planning for a future influenza pandemic must include specific considerations for pregnant women. Because pregnancy has been shown to increase the risk for influenza-associated complications, pregnant women are considered a high-risk group and are recommended to receive influenza vaccination during inter-pandemic years. This vaccine is inactivated and is considered safe for pregnant women. It is reformulated each year to include the anticipated viral strains of the upcoming influenza season. Pregnant women also should be considered at increased risk from influenza infection in the event of pandemic influenza.”²

Antivirals

Although zanamivir can be used in pregnancy, oseltamivir is preferred for treatment of pregnant women because of its systemic absorption. Theoretically, higher systemic absorption might suppress influenza viral loads more effectively in sites other than the respiratory system (e.g., placenta) and might provide better protection against mother-child transmission.^3,4

The drug of choice for chemoprophylaxis is less clear. Zanamivir may be preferable because of its limited systemic absorption; however, respiratory complications that may be associated with zanamivir because of its inhaled route of administration need to be considered, especially in women at risk for respiratory problems.

For infection, oseltamivir treatment should be initiated as soon as possible – ideally within 48 hours of onset of symptoms. In addition, any pregnant woman hospitalized with confirmed, probable, or suspected pandemic virus infection should receive oseltamivir, even if more than 48 hours have elapsed since onset of illness. Begin treatment as early as possible.

Dosing is as follows: Oseltamivir: 75 mg BID × 5 days for acute infection, Q day × 10 days for prophylaxis. Zanamivir: Two 5-mg inhalations (10 mg total) BID × 5 days for acute infection, Q day × 10 days for prophylaxis.

SARS

According to the CDC, “Reports suggest that the clinical course and outcomes of SARS might be more severe for pregnant than for non-pregnant women. On the basis of more recent data, the efficacy of ribavirin and corticosteroids in the treatment of patients with SARS has been questioned. Other medications, such as interferons, have been proposed for use in future SARS outbreaks, but use of these medications in pregnant women may also be of concern.”

Monkeypox

According to the CDC, “Because of the high death rate associated with monkeypox on the African continent and lack of experience with monkeypox in the United States, CDC recommended smallpox (vaccinia) vaccination (about 85% effective against monkeypox). Smallpox vaccination during pregnancy poses a low risk for fetal vaccinia, which can lead to preterm birth, and fetal and neonatal death. However, women who were exposed were advised to receive the smallpox vaccine regardless of their pregnancy status, given the life-threatening risk associated with monkeypox infection.”

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

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.

Radiologic or Nuclear Event

Potential health effects of prenatal radiation exposure:²⁹ Exposures at less than 5 rads appear to be safe for the developing fetus. About 5% of the energy from a nuclear explosion is released as radiation. The prompt radiation from a Hiroshima-sized explosion would expose people within about 1.3 miles (2 km) of ground zero to a 500-rad dose of radiation. For 2 days after such an explosion at ground level, anyone within about 1.7 miles (2.75 km) of ground zero could be exposed to a 500-rad radiation dose from fallout.

Before about 2 weeks’ gestation (i.e., the time after conception): The health effect of concern from an exposure of more than 10 rads is the death of the embryo. If the embryo survives, however, radiation-induced noncancer health effects are unlikely, no matter what the radiation dose. In all stages of gestation: Radiation-induced noncancer health effects are not detectable for fetal doses below about 5 rads. From about 16 weeks’ gestation to birth: Radiation-induced noncancer health effects are unlikely below about 50 rads.

Potassium iodide (KI)30: After a ra­diologic or nuclear event, local public health or emergency management officials will tell the public if KI or other protective actions are needed.

Infants (including breastfed infants): Infants need to be given the recommended dosage of KI for babies. The amount of KI that gets into breast milk is not enough to protect breastfed infants from exposure to radioactive iodine. The proper dose of KI given to a nursing infant will help protect it from radioactive iodine that it breathes in or drinks in breast milk.

Pregnant women: Because all forms of iodine cross the placenta, pregnant women should take KI to protect the growing fetus. However, pregnant women should take only one dose of KI following internal contamination with (or likely internal contamination with) radioactive iodine.

Breastfeeding Women: Should take only one dose of KI if they have been internally contaminated with (or are likely to be internally contaminated with) radioactive iodine. Because radioactive iodine quickly gets into breast milk, the CDC recommends that a woman internally contaminated with (or likely to be internally contaminated with) radioactive iodine stop breastfeeding and feed her child baby formula or other food if it is available. If breast milk is the only food available for an infant, nursing should continue.

Bone Marrow Recovery

Neupogen³¹: Children and pregnant women should take Neupogen with caution. It is not known if Neupogen is excreted in human milk, so breastfeeding women should take Neupogen with caution as well.

Plutonium, Americium, and Curium

DTPA³²: Infants (including breastfed infants) and children younger than 12 years of age: Either Ca-DTPA or Zn-DTPA may be given to infants and children. The dosage of DTPA to be given should be based on the child’s size and weight.

Pregnant women: Unless a pregnant woman has very high levels of internal contamination with plutonium, americium, or curium, treatment should begin and continue with Zn-DTPA.

Ca-DTPA should be used in pregnant women only to treat very high levels of internal radioactive contamination. In this case, doctors and public health authorities may prescribe a single dose of Ca-DTPA, together with a vitamin and mineral supplement that contains zinc, as the first treatment. However, after the first dose of Ca-DTPA, treatment should continue 24 hours later with a daily dose of Zn-DTPA, as needed.

Breastfeeding women: Radioactive materials can and do get into breast milk. For this reason, the CDC recommends that women with internal contamination stop breastfeeding and feed the child baby formula or other food if it is available. If breast milk is the only food available for an infant, nursing should continue. Breastfeeding women who are internally contaminated with plutonium, americium, or curium should be treated with DTPA.

Cesium and Thallium

Prussian blue³³: Since the 1960s, Prussian blue has been used to treat people who have been internally contaminated with radioactive cesium (mainly Cs-137) and nonradioactive thallium (once an ingredient in rat poisons). Doctors can prescribe Prussian blue at any point after they have determined that a person who is internally contaminated would benefit from treatment. Prussian blue will help speed up the removal of cesium and thallium from the body. The drug is safe for most adults, including pregnant women, and children (2-12 years). Dosing for infants (0-2 years) has not been determined yet.

Women who are breastfeeding their babies should stop breastfeeding if they think they are contaminated with radioactive materials and consult with their doctors.

People who have had constipation, blockages in the intestines, or certain stomach problems should be sure to tell their doctors before taking Prussian blue. Before taking Prussian blue, people also should be sure to tell their doctors about any other medicine they are taking.

References

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