1. ANTHRAX IN PREGNANCY CASE REPORTS AYTEN KADANALI İSTANBUL-TURKEY AYTEN KADANALI İSTANBUL-TURKEY

2. UNKNOWN MATTERS IN ANTHRAX DURING PREGNANCY Is there a difference in the course of anthrax during pregnancy? Are the risks of adverse pregnacy outcomes increase in anthrax during pregnancy?

3. THE GEOGRAPHIC LOCALIZATION OF OUR CASES

4. REPORTED HUMAN CASES OF ANTHRAX IN TURKEY 1960-1969 10724 1970-1979 5377 1980-1989 4423 1990-1999 4220 2000-2005 2210 2005-2010≈850 1960-1969 10724 1970-1979 5377 1980-1989 4423 1990-1999 4220 2000-2005 2210 2005-2010≈850

5. CASE-1 33 years old pregnant women 32 weeks of pregnancy History: She had flayed a dead cow 7 days earlier

6. -Submandibular eschar -Surronding vesicles -Extensive edema (face, neck, upper thorax) -Difficulties in respiration -Fever(38 ˚C) -Submandibular eschar -Surronding vesicles -Extensive edema (face, neck, upper thorax) -Difficulties in respiration -Fever(38 ˚C) Clinical findings

7. Obstetrical Examination -Ultrasound examination Fetal biometry appropiate for 32 weeks of pregnancy, amniotic fluid volume and placenta normal, -Cervix : no signs of dilatation -No uterine contraction NO SIGNS OF PRETERM LABOR

8. LABORATORY EVALUATİON - WBC count 28.300 cells/mm 3 -Large gram- positive on direct microscopic examination -Blood culture was taken -Routine biochemical tests were in normal limits -B.anthracis was isolated from the lesion - WBC count 28.300 cells/mm 3 -Large gram- positive on direct microscopic examination -Blood culture was taken -Routine biochemical tests were in normal limits -B.anthracis was isolated from the lesion

9. CLINICAL PROGRESSION -Penicillin G 8 x 3 million units/day IV was administered immediately (at the 4th day of disease) for 10 days -Prednisolone 100 mg/ day ( 75 mg morning- 25 mg evening) was also administered with antibiotic. Dose was gradualy decreased and stopped at day 6 of therapy -Signs and symptoms of anthrax were gradually disapperad except local scarring.

10. CLINICAL PROGRESSION -Rapid preterm labor was begun and resulted in preterm delivery at the 13th day of hospitalization. -APGAR score of baby was 8. -No signs and evidence of congenital infection. BOTH MOTHER AND BABY DISCHARGED IN GOOD CONDITION

11. CASE-2 -29 years of pregnant women -33 weeks of gestational age -History: Handled ill cow 12 days ago İncubation period was 7 days -29 years of pregnant women -33 weeks of gestational age -History: Handled ill cow 12 days ago İncubation period was 7 days

12. -Swelling of right arm -Weeping lesion at the right elbow -2 cm open sore with surrounding erythema -Induration, oozing serous fluid -Fever (38.5 ˚C) -Swelling of right arm -Weeping lesion at the right elbow -2 cm open sore with surrounding erythema -Induration, oozing serous fluid -Fever (38.5 ˚C) Clinical findings

13. Obstetrical Examination -Ultrasound examination Fetal biometry appropiate for 33 weeks of pregnancy, amniotic fluid volume and placenta normal, -Cervix : no signs of dilatation -No uterine contraction NO SIGNS OF PRETERM LABOR

14. LABORATORY EVALUATION - WBC count 19.600 cells/mm 3 -Large gram-positive on direct microscopic examination -Blood culture was taken -Routine biochemical tests were in normal limits -B.anthracis was isolated from the lesion - WBC count 19.600 cells/mm 3 -Large gram-positive on direct microscopic examination -Blood culture was taken -Routine biochemical tests were in normal limits -B.anthracis was isolated from the lesion

15. CLINICAL PROGRESSION -Procaine Penicillin 2 x 800.000 units/day IM was administered immediately (at the 5th day of disease) for 7 days -Prednisolone 75 mg/ day ( 50 mg morning- 25 mg evening) was also administered with antibiotic. Dose was gradually decreased and stopped at the 6th day of therapy -Signs and symptoms of anthrax were gradually disapperad except local scarring.

16. CLINICAL PROGRESSION -On the day of discharge from the hospital (8th day), preterm labor was begun -Tocolytic therapy was unsuccessful and patient was delivered at 34 weeks -APGAR score of baby was 8. -No signs and evidence of congenital infection. BOTH MOTHER AND BABY DISCHARGED IN GOOD CONDITION

17. PEARLS FROM THE CASES - 1 Anthrax during pregnancy can be successfully managed as in nonpregnant women Clinical progression of the anthrax is similar to nonpregnant women Prompt clinical suspicion and rapid administration of effective antimicrobials are essential.

18. PEARLS FROM THE CASES - 2 Penicillin is still the drug of choice in the theraphy of anthrax during pregnancy High dose prednisolone therapy may be beneficial Preterm delivery could be expected Increased plasma volume of pregnancy should be taken into consideration in the dosing of antibiotics

19. PEARLS FROM THE CASES - 3 In these cases, the evaluation of preterm delivery would be worthwhile; - It was at the end of the anthrax therapy -Sudden onset of preterm delivery -Unresponsiveness to tocolysis -Occurence without PROM

20. PEARLS FROM THE CASES - 4 We may also be interest on the effects of high dose prednisolone therapy: -Clinical outcome reducing mortality ??? -Pregnancy outcome delaying pretem delivery ??? -Benefits to newborn Reducing RDS and ventricular hemorrhage