Skip directly to site content Skip directly to page options Skip directly to A-Z link Skip directly to A-Z link Skip directly to A-Z link
Volume 13, Number 12—December 2007
Letter

Rabies Prophylaxis for Pregnant Women

Cite This Article

To the Editor: Rabies poses a 100% risk for death to pregnant women and an indeterminate risk to the fetus (1,2). Although a theoretical risk exists for adverse effects from rabies immune globulin and killed rabies virus vaccines, several studies assessing the safety of this treatment have failed to identify these risks (36). Indeed, the consensus is that pregnancy is not a contraindication to rabies postexposure prophylaxis (PEP) (7). Despite this concensus, healthcare providers resist treating pregnant women with rabies PEP. We describe a case of a pregnant woman with uncertain rabies exposure.

A 35-year-old pregnant woman (at 34 weeks gestation) sought treatment 3 weeks after being exposed to a bat. The patient reported awakening at 3:00 am to find a bat flying in her bedroom. She attempted to confine the bat to 1 section of the home and then called for help. A relative trapped and retrieved the bat, then disposed of the animal without further incident. The patient denied being bitten by the bat, and she had no obvious bite marks after the event. Initially, the patient sought information from online resources, her primary care physician, and her obstetrician. She was uncertain whether rabies PEP was warranted, given what she believed to be the low probability of the bat being rabid and the low likelihood of her having had direct exposure to the bat. The patient did express concern about the safety of rabies PEP in pregnant women. Because no unequivocal recommendations were made by either her primary care physician or obstetrician, she sought further advice from the Infectious Diseases Department at the University of Michigan on how best to proceed.

The 1999 recommendations of Centers for Disease Control and Prevention Advisory Committee on Immunization Practices state, “... postexposure prophylaxis can be considered for persons who were in the same room as the bat and who might be unaware that a bite or direct contact had occurred ...” (8). Bat bites may not be apparent when they occur, even with careful examination. In fact, most of the recent human rabies patients have no known history of exposure to a rabid animal (9,10). Of the 21 cases of bat-associated rabies in the United States during 1980–1999, 12 (57%) occurred in persons with apparent bat contact but no detectable bites (8). Our patient woke up with a bat flying in her room and did not know how long it had been there. The best course of action would have been to test the bat for rabies. However, because the animal had already been disposed of, laboratory testing for rabies was not possible. Furthermore, given that 5%–9% of bats tested in Washtenaw County, Michigan, are positive for rabies (www.mdch.state.mi.us/pha/epi/cded/cd/batcoframe.htm), the exposure risk was not insignificant. Therefore, it was our opinion that this patient qualified for rabies PEP.

Several studies of the safety of rabies PEP for pregnant patients demonstrated no association between treatment and adverse outcomes (36). In 1 study, tissue culture-derived vaccines and human immune globulin did not lead to an increased risk for congenital anomalies; no effects were observed on intrauterine or infant growth or development with a follow-up period of 1 year postpartum (6). Although these studies are not comprehensive in their assessment of all reproductive outcomes, they do suggest that PEP is generally safe.

On the basis of the exposure and our literature review, we recommended that the patient receive rabies PEP. After discussing options with her husband, the patient chose not to receive treatment, citing continued concern about the effect of rabies PEP on the fetus. There must be a greater public health effort to educate clinicians and the public about proper response to bat exposures, particularly undetectable bite exposures such as this case. Had public health authorities been contacted to collect and test the captured bat for rabies, there would have been no ambiguity as to the appropriate course of action.

Top

Acknowledgment

This research was supported by University of Michigan Medical Scientist Training Program Grant No. GM0786.

Top

Mohamed E. Abazeed* and Sandro Cinti†Comments to Author 
Author affiliations: *University of Michigan Medical School, Ann Arbor, Michigan, USA; †University of Michigan Hospitals/Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA

Top

References

  1. Sipahioglu  U, Alpaut  S. Transplacental rabies in humans. Mikrobiyol Bul. 1985;19:959.PubMedGoogle Scholar
  2. Muller-Holve  W, Leitritz  H, Knorr  E. Early development of a child following rabies of the mother during pregnancy. Infection. 1977;5:4950. DOIPubMedGoogle Scholar
  3. Chutivongse  S, Wilde  H. Postexposure rabies vaccination during pregnancy: experience with 21 patients. Vaccine. 1989;7:5468. DOIPubMedGoogle Scholar
  4. Chutivongse  S, Wilde  H, Benjavongkulchai  M, Chomchey  P, Punthawong  S. Postexposure rabies vaccination during pregnancy: effect on 202 women and their infants. Clin Infect Dis. 1995;20:81820.PubMedGoogle Scholar
  5. Figueroa Damián  R, Ortiz-Ibarra  FJ, Arredondo-Garcia  JL. Post-exposure antirabies prophylaxis in pregnant women [in Spanish]. Ginecol Obstet Mex. 1994;62:136.PubMedGoogle Scholar
  6. Sudarshan  MK, Madhusudana  SN, Mahendra  BJ. Post-exposure prophylaxis with purified vero cell rabies vaccine during pregnancy—safety and immunogenicity. J Commun Dis. 1999;31:22936.PubMedGoogle Scholar
  7. American College of Obstetricians and Gynecologists. ACOG Committee opinion. Immunization during pregnancy. Obstet Gynecol. 2003;101:20712. DOIPubMedGoogle Scholar
  8. Centers for Disease Control and Prevention. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Human rabies prevention–United States. MMWR Recomm Rep. 1999;48(RR-1):121.
  9. Rupprecht  CE, Gibbons  RV. Clinical practice. Prophylaxis against rabies. N Engl J Med. 2004;351:262635. DOIPubMedGoogle Scholar
  10. Messenger  SL, Smith  JS, Rupprecht  CE. Emerging epidemiology of bat associated cryptic cases of rabies in humans in the United States. Clin Infect Dis. 2002;35:73847. DOIPubMedGoogle Scholar

Top

Cite This Article

DOI: 10.3201/eid1312.070157

Related Links

Top

Table of Contents – Volume 13, Number 12—December 2007

EID Search Options
presentation_01 Advanced Article Search – Search articles by author and/or keyword.
presentation_01 Articles by Country Search – Search articles by the topic country.
presentation_01 Article Type Search – Search articles by article type and issue.

Top

Comments

Please use the form below to submit correspondence to the authors or contact them at the following address:

Sandro Cinti, Infectious Diseases, University of Michigan Hospitals/Ann Arbor VA Health Systems, 2215 Fuller Rd, Ann Arbor, MI 48105, USA;

Send To

10000 character(s) remaining.

Top

Page created: July 06, 2010
Page updated: July 06, 2010
Page reviewed: July 06, 2010
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
file_external