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Clinical Considerations for Anthrax in Pregnant and Postpartum Women

Clinical Considerations for Anthrax in Pregnant and Postpartum Women. Dana Meaney-Delman, MD MPH Assistant Professor of Gynecology and Obstetrics Emory University School of Medicine Consultant Division of Reproductive Health Centers for Disease Control and Prevention. Overview.

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Clinical Considerations for Anthrax in Pregnant and Postpartum Women

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  1. Clinical Considerations for Anthrax in Pregnant and Postpartum Women Dana Meaney-Delman, MDMPH Assistant Professor of Gynecology and Obstetrics Emory University School of Medicine Consultant Division of Reproductive Health Centers for Disease Control and Prevention

  2. Overview • Review unique features of pregnant women • Comprehensive review of reported clinical experience with anthrax in pregnancy and the postpartum period

  3. Pregnant and Postpartum Women • Approximately 7 million pregnancies/year • Population that is not well studied • Recent H1N1 pandemic experience • Complex clinical management decisions • Pre-event planning essential to ensure an efficient public health response and minimize the burden of disease Ventura et al. National Vital Statistics Report 2009: 58(4): 1-13 Cono et al. Emerg Infect Dis 2006;12:11 1631-1637. Pandemic and All-Hazards Preparedness Act. Public Law 109-417. December 19, 2006.

  4. Considerations for Infectious Disease in Pregnancy Maternal • Susceptibility • Severity • Obstetrical Issues • Access to appropriate treatment • Adherence Fetal • Complications from maternal infection • Congenital infection • Risks from diagnostic testing and treatments

  5. Major Physiologic Characteristics of Pregnancy Jamieson et al. Emerg Infect Dis ; 2006: 12:11 Cono et al. Emerg Infect Dis; 2006: 12:11

  6. Choice of Antimicrobial Agents in Pregnancy • Efficacy of drug • Pharmacokinetics • Maternal risks • Fetal risks • Other concerns • Availability • Tolerability • Adherence Cono et al. Emerging Infectious Diseases; 2006: 12:11 1631-1637 Lagoy et al. J Women’s Health;2005:14: 104-110

  7. What do we know about anthrax in pregnancy?

  8. Systematic Review of Worldwide Experience • Extensive search dating back to 1886 • 14 articles • 7 articles translated from Italian and German • Submitted to Obstetrics & Gynecology for publication

  9. Findings • 20 cases total • 17 pregnant , 3 postpartum • 9/20 cases reported in the 19th century • Anthrax reported in 8 countries • 1 in US • Poland, Iran, Iraq, Turkey, India, Italy • Greatest number in Germany

  10. Anthrax by Location

  11. Anthrax

  12. Clinical Presentations Cutaneous • Red painless papule black eschar • Significant edema including facial and neck respiratory compromise • Fever, increased WBC • Enlarged regional lymph nodes • Difficulty swallowing • IUFD, labor

  13. Clinical Presentations Gastrointestinal • Abdominal pain, vomiting, bloody diarrhea, abdominal bloating, ascites, pallor, hypotension, vaginal bleeding, vulvar edema, anuria Uterine • Endometritis, massive hemorrhage, ascites

  14. Postpartum Cases

  15. Maternal Outcomes n=4 Maternal Death Proportion = 80%

  16. Fetal/Neonatal Deaths among Pregnancy Cases n=6 n=11 Fetal Death Proportion = 64.7%

  17. Preterm Deliveries (PTD)

  18. Anthrax and Breastfeeding • Vogt et al. 1927 • Maternal case 5 months postpartum • Cutaneous anthrax on hand fever debridement  sepsis • Continued breastfeeding • No evidence of transmission despite the lack of antibiotic treatment and severe disease

  19. Anthrax in Fetal Tissues

  20. Maternal & Neonatal Anthrax 32 year old P2 experienced spontaneous labor, resulting in the delivery of a male infant who appeared healthy at birth. Two hours after delivery, the patient developed weak pulse and lethargy, and experienced 1 episode of vomiting. Her respiratory status rapidly deteriorated and she expired 7 hours after delivery. Maternal autopsy revealed mesenteric edema, ascites and mesenteric lymph glands infiltrated with anthrax bacilli. On day of life 3, infant developed “blue-red” rash over entire body, lethargy, a bloated abdomen and ultimately respiratory failure. Fetal autopsy revealed “enormous numbers of anthrax bacilli” in fetal blood, liver, spleen, kidneys adrenal glands and lungs. Marchand 1886

  21. Results Summary • 20 cases of naturally-occurring anthrax in pregnant and postpartum women • Most were cutaneous • High maternal mortality proportion overall and higher than expected with cutaneous infections • Obstetrical complications • High fetal/neonatal death proportion • PTD reported • Labor coincided with presentation in 3 cases • Delayed diagnosis may have contributed to disease severity • Perinatal Transmission • 6/11 fetal/neonatal deaths demonstrate anthrax in fetal tissues • No evidence of passage of anthrax via in one case of anthrax sepsis

  22. Limitations • All naturally-occurring • Very old case reports • Few women received antibiotics • Delays (or failure) to make diagnosis until autopsy

  23. Discussion Are pregnant and postpartum women more or less susceptible to anthrax than the general population? • Unclear from this review Is anthrax infection more severe in pregnant and postpartum women than in the general population? • High proportion of maternal deaths but limited antibiotic use • Higher rate of death in cutaneous anthrax than reported for general population Is there an increased risk of adverse obstetrical outcomes in women infected with anthrax? • Deliveries- both preterm and full term • High proportion of fetal death Is there a risk of congenital infection in infants whose mothers are infected with anthrax? • Evidenced of anthrax in fetal tissues Is there a risk of anthrax transmission through breast milk? • No evidence to date

  24. Implications • Anthrax has substantial morbidity and mortality in the obstetrical population • Medical countermeasures for pregnant and postpartum women • should maximize maternal (and fetal) survival • may involve the use of medications that are not typically used this population • may need to include antimicrobials with transplacental passage

  25. Acknowledgements • Denise Jamieson • Marianne Zotti • Sonya Rasmussen • Tracee Treadwell • Reina Turcios-Ruiz • George Wendel • Sean Shadomy • Deborah Dee • Willie Bower • Etobssie Wako • Mirelys Rodriguez

  26. Animal Data On Anthrax in Pregnancy • Paucity of data • Reports of increased rates of spontaneous abortions in cattle (F de Lalla 1992) • Reports of maternal to fetal transmission in guinea-pigs, dogs, pigs (Regan 1923) • Reports of anthrax detected in milk from dairy cattle (WHO 1993)

  27. Anthrax in the 1880s • 1829 Regnier describes “anthrax” transmissibility from mother to fetus • 1855 Pollender discovered bacilli • 1858 Brauell, Davaine & Koch 1867 innoculated pregnant animals--> no fetal infections • 1882 Strauss/Chamberland & Koubassoff innoculated pregnant animals: fetal infections • Other studies documenting perinatal transmission in animals • Perroncito, Walley 1889, Simon1889, Malvoz 1888, Rosenblath 1889, Latis 1891, Lubarsch, Birch-Hirschfeld 1891

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