Download Emerging Infections and Medical Procedures

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
• Review unique features of
pregnant women
• Comprehensive review of
reported clinical experience
with anthrax in pregnancy
and the postpartum period
Pregnant and Postpartum Women
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Approximately 7 million pregnancies/year
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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.
Considerations for Infectious
Disease in Pregnancy
Maternal
Fetal
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• Complications from
maternal infection
• Congenital infection
• Risks from diagnostic
testing and treatments
Susceptibility
Severity
Obstetrical Issues
Access to appropriate
treatment
• Adherence
Major Physiologic
Characteristics of Pregnancy
Organ System
Physiologic Change
Immunologic
shift away from cell-mediated immunity and
toward humoral immunity
Respiratory
increased tidal volume
decreased maternal oxygen reserve
decreased lung compliance
Cardiovascular
increased blood volume
decreased intravascular oncotic pressure
increased volume of distribution
Gastrointestinal
decreased function and motility
Renal
increased glomerular filtration
Increased renal secretion
Jamieson et al. Emerg Infect Dis ; 2006: 12:11
Cono et al. Emerg Infect Dis; 2006: 12:11
Choice of Antimicrobial Agents in
Pregnancy
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Efficacy of drug
Pharmacokinetics
Maternal risks
Fetal risks
Other concerns
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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
What do we know about
anthrax in pregnancy?
Systematic Review of Worldwide
Experience
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Extensive search dating back to 1886
14 articles
7 articles translated from Italian and German
Submitted to Obstetrics & Gynecology for
publication
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
Anthrax by Location
Location
Author(Year)
# of Cases
Turkey
Kadalani(2003)
2
India
Sujatha(2002)
1
Poland
Tomasiewicz(1998)
1
Iran
Handjani(1976), Dutz(1971),
Deneshbod (1970),
Kohout(1964),
5
U.S.
Regan(1923)
1
Germany
Rostowzew(1897), Eppinger
(1888), Paltauf(1888), Vogt
(1927), Marchand (1886)
8
Italy
Romano(1888), Morisani(1886)
2
Anthrax
Anthrax Form
# of cases
Suspected Exposure
Inhalation
(3)
Unknown
Cutaneous
13
“flaying a dead cow”, “slaughtering a
sick cow”, wool sorting, contact with
infected “rags”
Gastrointestinal
2
Ingestion of spores, ingestion of
improperly cooked beef
Uterine
1
Attempted abortion with
contaminated instrument
Unknown
1
“Horse-hair sorting”
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
Clinical Presentations
Gastrointestinal
• Abdominal pain, vomiting, bloody
diarrhea, abdominal bloating, ascites,
pallor, hypotension, vaginal bleeding,
vulvar edema, anuria
Uterine
• Endometritis, massive hemorrhage,
ascites
Case
Author
Age
Gestational Age
Form
Maternal
Death
Fetal or
Neonatal
Death
1
Kadalani (2003)
33
32 weeks
cutaneous
N
N
2
Kadalani (2003)
29
33 weeks
cutaneous
N
N
3
Sujatha (2002)
44
NR
gastrointestinal
Y
Y*
4
Tomasiewicz (1998)
NR
31 weeks
cutaneous
N
N
5
Handjani (1976)
20
16-20 weeks
gastrointestinal
Y
Y
6
Dutz (1971)
NR
NR
uterine
Y
Y
7
Kohout (1964)
30
9 months
cutaneous
Y
N
8
Regan (1923)
22
5-6 months
cutaneous
Y
Y
9
Rostowzew (1889)
34
8 months
cutaneous
Y
Y
10
Rostowzew (1889)
36
7 months
cutaneous
Y
Y
11
Rostowzew (1897)
35
4 months
cutaneous
Y
Y
12
Eppinger (1888)
NR
NR
(inhalation)
Y
Y
13
Eppinger (1888)
NR
NR
(inhalation)
Y
Y
14
Paltauf (1888)
NR
5 months
(inhalation)
Y
Y
15
Romano (1888)
20
“full term”
cutaneous
Y
Y
16
Morisani (1886)
40
“full term”
cutaneous
Y
Y
17
Marchand (1886)
32
“full term”
Unknown*
Y
Y
Postpartum Cases
Case
Author
Age Time from
Delivery ( at
Presentation)
Maternal
Death
Fetal/Neonatal
Death
18
Daneshbod
(1970)
NR
3 days
Y
N
19
Daneshbod
(1970)
NR
3 days
Y
N
20
Vogt (1927)
32
5 months
N
N
Maternal Outcomes
n=4
Maternal Death Proportion = 80%
Case
Year
Form
Gestational
Age
Treatment
Fetal Death
3
Sujatha (2002)
GI
unknown
Cefotaxime
metronidazole
Y
5
Handjani (1976)
GI*
16-20 weeks
Penicillin/Streptomycin
Y
6
Dutz (1971)
U
NR
NR
Y
7
Kohout (1964)
C
9 months*
Penicillin
N (transient
asphyxia)
8
Reagan (1923)
C
5-6 months
Antiserum in wound,
disinfectants
Y
9
Rostowzew (1897)
C
8 months
NR
Y
10
Rostowzew (1897)
C
7 months
NR
Y
11
Rostowzew (1897)
C
4 months
NR
Y
12
Eppinger (1888)
(I)
NR
NR
Y
13
Eppinger (1888)
(I)
NR
NR
Y
14
Paltauf (1888)
(I)
5 months
NR
Y
15
Romano (1888)
C
“full term”*
Incision, cautery,
disinfectants
N
16
Paltauf (1886)
C
“close to
term”
Cautery
Y
17
Marchand (1886)
U
“full term”
NR
Y
Fetal/Neonatal Deaths among Pregnancy
Cases
n=6
n=11
Fetal Death Proportion = 64.7%
Preterm Deliveries (PTD)
Author/Year
Anthrax
Gestational Age
Clinical
Kadalani/2003
Turkey
Cutaneous
32 weeks/34 weeks
(submandible)
Preterm delivery
13 days after
presentation and 3
days after
“infection resolved”
with antibiotics
Kadalani/2003
Turkey
Cutaneous
(elbow)
33 weeks/34 weeks
Preterm delivery 7
days after
presentation
despite tocolysis,
treated with
antibiotics
Tomasiewicz/1998
Poland
Cutaneous
(eyelid)
31 weeks/34 weeks
Preterm delivery 3
weeks after
presentation
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
Anthrax in Fetal Tissues
Author
Maternal Anthrax
Fetal Tissues
Regan (1923)
Cutaneous
Placenta, amniotic
fluid, lungs, liver, heart
Rostowzew (1897)
Cutaneous
Placenta, umbilical
vessels, liver
Rostowzew (1897)
Cutaneous
Placenta, umbilical
cord liver, spleen,
kidneys, adrenals
Rostowzew(1897)
Cutaneous
Placenta, liver, spleen
adrenals
Paltauf (1888)
(Inhalation)
Placenta, lungs heart
Marchand (1886)
Unknown*
Blood, lungs, kidneys,
adrenals, liver, spleen
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
Results Summary
• 20 cases of naturally-occurring anthrax in pregnant and
postpartum women
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Most were cutaneous
High maternal mortality proportion overall and higher than expected with
cutaneous infections
• Obstetrical complications
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–
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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
Limitations
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All naturally-occurring
Very old case reports
Few women received antibiotics
Delays (or failure) to make diagnosis
until autopsy
Discussion
Are pregnant and postpartum women more or less susceptible to anthrax than the general
population?
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Unclear from this review
Is anthrax infection more severe in pregnant and postpartum women than in the general population?
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High proportion of maternal deaths but limited antibiotic use
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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?
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Deliveries- both preterm and full term
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High proportion of fetal death
Is there a risk of congenital infection in infants whose mothers are infected with anthrax?
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Evidenced of anthrax in fetal tissues
Is there a risk of anthrax transmission through breast milk?
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No evidence to date
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
Acknowledgements
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Denise Jamieson
Marianne Zotti
Sonya Rasmussen
Tracee Treadwell
Reina Turcios-Ruiz
George Wendel
Sean Shadomy
Deborah Dee
Willie Bower
Etobssie Wako
Mirelys Rodriguez
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)
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