Acog committee opinion, number 268, february 2002

This document reflects emerg-ing clinical and scientific ad- vances as of the date issued andis subject to change. The infor- mation should not be construedas dictating an exclusive course of treatment or procedure to be followed. ABSTRACT: Anthrax infections are diagnosed by isolating Bacillus anthracis from body fluids or by measuring specific antibodies in the blood of persons suspected to have the disease. It is recommended that asymptomatic pregnant and lactating women who have been exposed to a confirmed environmental contamination or a high-risk source as determined by the local Department of Health (not the women’s health care provider) receive prophylactic treat- ment. A variety of antimicrobial regimens are available. Although some of tem, or transmitted, in any formor by any means, electronic, these drugs may present risks to the developing fetus, these risks are clearly outweighed by the potential morbidity and mortality from anthrax. Guidelines for prophylactic treatment of anthrax and treatment of suspected active cases of anthrax are changing continually, and the Centers for Disease Control and Prevention web site should be consulted for the latest recommendations. Anthrax is an infection caused by Bacillus anthracis, an aerobic, gram- positive, spore-forming, nonmotile bacillus species. There are three primary clinical manifestations of the disease: 1) cutaneous, 2) inhalational, and 3) Cutaneous: This is the most common presentation, accounting for 95% of naturally occurring infections. The organism’s portal of entry is a cut or abrasion on the skin. The areas of greatest exposure are the hands, arms,face or neck. Potential sources of the organism include wool, hides, and The American College of
Obstetricians and Gynecologists
leather and hair products of infected animals, particularly goats. Exposure also may result from a bioterrorist act (eg, a contaminated letter). Incubation periods may be as long as 12 days. Skin infection begins as a raised prurit- ic papule, resembling an insect bite. Within 1–2 days a vesicle develops, fol-lowed by a painless ulcer 1–3 cm in diameter with a characteristic black necrotic eschar in the center. Localized lymphangitis and painful lym- nant or lactating women exposed toanthrax. ACOG Committee Opinion phadenopathy may occur. Although antibiotic therapy does not appear to change the course of eschar formation and healing, it does decrease the risk of systemic disease. Mortality rates are 20% if untreated, but less than 1% Inhalational: This is the most serious presentation, evolving. For the latest recommendations consult resulting from deposition of spore-bearing particles the Centers for Disease Control and Prevention of 1–5 μm into the alveolar spaces. Macrophages ingest the spores that are then transported to the pul- monary lymphatics where they germinate. Theasymptomatic incubation period usually is 1–7 days Exposure
after exposure, but spores may germinate in the medi- For asymptomatic individuals with low-risk expo- astinal lymphatics for up to 60 days. Once germina- sure, antimicrobials are not warranted until there is tion occurs, replicating bacteria release toxins leading an evident risk of actual exposure based on microbi- to hemorrhage, edema, and necrosis. Initial symp- ologically documented anthrax as determined by toms resemble a flulike illness with fever, cough, and law enforcement and public health authorities. The headache, but without rhinitis, followed by progres- woman’s health care provider is not the party to val- sive dyspnea that rapidly progresses to respiratory failure and death within hours. Case-fatality estimates In the current crisis, when screening for expo- are extremely high, even with supportive care and sure is deemed necessary, it is conducted by nasal swab. The resultant secretions can be examined byGram stain and culture. However, given the lack of Gastrointestinal: The relatively rare intestinal form of reliability of nasal swab screening, postexposure anthrax follows ingestion, deposition, and subsequent prophylaxis is indicated only after confirmed or germination of spores in the upper or lower gastroin- high-risk suspected exposure. In the latter cases, testinal tract. The former leads to the oral-pharyngeal treatment can be stopped if anthrax is not docu- form of the disease marked by oral-esophageal ulcers and regional lymphadenopathy. The latter results in For adult postexposure prophylaxis against acute inflammation of the intestinal tract with symp- anthrax infections, the CDC currently recommends toms that include anorexia, malaise, nausea, vomit- 500 mg of ciprofloxacin orally every 12 hours for 60 ing, and fever. Subsequently patients infected with days or 100 mg of doxycycline orally every 12 hours gastrointestinal anthrax develop abdominal pain; hematemesis; severe, bloody diarrhea; and sepsis.
Intestinal anthrax may be fatal in 25–60% of cases;the effect of early antibiotic therapy is unknown.
Management of Exposed Asymptomatic
Pregnant or Lactating Women
Evaluation and Management of Possible
At this time, the Committee on Obstetric Practice Anthrax Exposure Caused by
recommends that prophylaxis of asymptomatic Bioterrorist Acts
pregnant and lactating women be limited to thosewomen who have had exposure to a confirmed envi- The risk of anthrax exposure is remote for people not ronmental contamination or who are exposed to a in direct contact with the contaminated object or site high-risk source as determined by the local and is greatest for those present in the immediate Department of Health. Prophylaxis for asympto- vicinity of contamination. The disease is not spread matic pregnant or lactating women is 500 mg of by casual contact or by coughing and sneezing. ciprofloxacin orally every 12 hours for 60 days (6).
Ciprofloxacin and other fluoroquinolones gen- Active Infection
erally are not used during pregnancy and lactation Anthrax infections are diagnosed by isolating B because of suggested irreversible drug-induced anthracis from the blood, cerebrospinal fluid, skin arthropathy associated with such treatment in a vari- lesions, or respiratory secretions or by measuring ety of species of adolescent animals (1–5). However, specific antibodies in the blood of persons suspected no clear evidence of teratogenicity has been demon- to have the disease. Rapid diagnostic immunoassays strated in humans (1–5). Despite these concerns, the and polymerase chain reaction are available at potential morbidity and mortality from anthrax national reference laboratories. Strategies of antimi- clearly outweighs these risks. Thus, if the bacteria crobial treatment of active anthrax infection are are shown to be sensitive to penicillin, the treatment should be switched to 500 mg of amoxicillin orally 2. Friedman JM, Polifka JE. Doxycyclicne. In: Teratogenic effects of drugs: a resource for clinicians (TERIS). 2nd ed.
Baltimore: The Johns Hopkins University Press, 2000: If a woman has been prescribed ciprofloxacin and is found to be pregnant, she should continue her 3. Center for Drug Evaluation and Research. U.S. Food and course of antibiotics for the full 60 days (6) unless Drug Administration. CIPRO (Ciprofloxacin) use by the bacteria are shown to be penicillin-sensitive. She pregnant and lactating women. Available at http://www.
should then be switched to amoxicillin. A 1999 fda.gov/cder/drug/infopage/cipro/cipropreg.htm.
Retrieved November 2, 2001 expert review of published data on experiences with 4. Center for Drug Evaluation and Research. U.S. Food and ciprofloxacin concluded that therapeutic doses dur- Drug Administration. Drug preparedness and response to ing pregnancy are unlikely to pose substantial ter- bioterrorism. Available at http://www.fda.gov/cder/drug atogenic risk, but the data are insufficient to state prepare/default.htm. Retrieved November 2, 2001 that there is no risk (1). In the case of penicillin- and 5. Center for Drug Evaluation and Research. U.S. Food and Drug Administration. Doxycycline (Vibramycin, ciprofloxacin-allergic patients, treatment should Monodox, Doryx, Doxy, Atridox, Periodox, Vibra-Tabs) consist of doxycycline or penicillin desensitization use by pregnant and lactating women. Available at should be considered if the organism is proved sen- http://www.fda.gov/cder/drug/infopage/penG_doxy/doxy sitive (6). In this situation, the risks of anthrax would far outweigh the risks of doxycycline to the 6. Updated recommendations for antimicrobial prophylaxis among asymptomatic pregnant women after exposure to fetus (ie, dental staining of the primary teeth and bacillus anthracis. MMWR Morb Mortal Wkly Rep 2001; possible depressed bone growth and defective den- The guidelines for prophylactic treatment of anthrax and treatment of suspected active cases of Resources
anthrax are continually evolving. Please refer to Inglesby TV, Henderson DA, Bartlett JG, Ascher MS, Eitzen E, www.bt.cdc.gov and www.cdc.gov/mmwr for any Friedlander AM, et al. Anthrax as a biological weapon: medical updates in CDC treatment guidelines.
and public health management. Working Group on CivilianBiodefense. JAMA 1999;281:1735–1745[erratum JAMA2000;283:1963] References
Update: investigation of anthrax associated with intentionalexposure and interim public health guidelines, October 2001.
1. Friedman JM, Polifka JE. Ciprofloxacin. In: Teratogenic MMWR Morb Mortal Wkly Rep 2001;50:889–893 effects of drugs: a resource for clinicians (TERIS). 2nd ed.
Baltimore: The Johns Hopkins University Press, 2000: Use of anthrax vaccine in the United States. MMWR Morb

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