Management of envenomations during pregnancy
Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque , NM , USA.Clinical Toxicology (Impact Factor: 3.67). 01/2013; 51(1). DOI: 10.3109/15563650.2012.760127
Context. Envenomations during pregnancy pose all the problems of envenomation in the nonpregnant state with additional complexity related to maternal physiologic changes, medication use during pregnancy, and the well-being of the fetus. Objective. We review the obstetric literature and management options available to prevent maternal morbidity and mortality while limiting adverse obstetric outcomes after envenomation in pregnancy. Methods. In January 2012, we searched the U.S. National Library of Medicine Medline/PubMed, Toxline, Reprotox, Google Scholar and Micromedex databases, core surgery and internal medicine textbooks, and references of retrieved articles for the years 1966 through 2011. Search terms included "envenomation in pregnancy," "stings in pregnancy," "antivenom use in pregnancy," "anaphylaxis in pregnancy," and variants of these with known venomous animals. Reference lists generated further case reports and articles. We included English language articles and abstracts. Levels of Evidence (LOE) for the reports cited and Grades of Recommendations (GOR) based on LOE for our recommendations use the National Guidelines Clearinghouse metric of the US DHHS. Results. Recommendations for the management of envenomation in pregnancy are guided primarily by studies on nonpregnant persons and case reports of pregnancy. Clinically significant envenomations in pregnancy are reported for snakes, spiders, scorpions, jellyfish, and hymenoptera (bees, wasps, hornets, and ants). Adverse obstetric outcomes including miscarriage, preterm birth, placental abruption, and stillbirth are associated with envenomation in pregnancy. The limited available literature suggests that adverse outcomes are primarily related to venom effects on the mother. Optimization of maternal health such as management of anaphylaxis and antivenom administration is likely the best approach to improve fetal outcomes despite potential risks to the fetus of medication administration during pregnancy. Obstetric evaluation and fetal monitoring are imperative in cases of severe envenomation. Conclusion. The medical literature regarding envenomation in pregnancy includes primarily retrospective reviews and case series. The limited available evidence suggests that optimal management includes a venom-specific approach, including supportive care, antivenom administration in appropriate cases, treatment of anaphylaxis if present, and fetal assessment. The current available evidence suggests that antivenom use is safe in pregnancy and that what is good for the mother is good for the fetus. Further research is needed to clarify the optimal management schema for envenomation in pregnancy.
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- "The antivenom should confront as much venom as has entered the body. Therefore, for children and pregnant women, dose adjustment is not recommended. However, for children less than 10 kg, the total volume of fluid for dilution of antivenom should be adjusted. "
ABSTRACT: Snakebite in Iran has been a health concern. However, management of snakebite is not standardized and varies from center to center. This study is aimed at devising an evidence-based comprehensive protocol for snakebite management in Iran, to reduce unnecessary variations in practice. A narrative search in electronic databases was performed. Fifty peer-reviewed articles, guidelines, and textbooks were reviewed and practical details were extracted. Our currently used protocol in the Mashhad Toxicology Center was supplemented with this information. Consequently an improved wide-range protocol was developed. The protocol was then discussed and amended within a focus group comprised of medical toxicologists and internal medicine specialists. The amended version was finally discussed with expert physicians specialized in different areas of medicine, to be optimized by supplementing other specific considerations. During a one-year process, the protocol was finalized. The final version of the protocol, which was designed in six steps, comprised of three components: A schematic algorithm, a severity grading scale, and instructions for supportive and adjunctive treatments. The algorithm pertains to both Viperidae and Elapidae snakebite envenomations and consists of a planned course of action and dosing of antivenom, based on the severity of the envenomation. Snakebite envenomation is a clinical toxicologic emergency, which needs to be treated in a timely and organized manner. Hence, a multi-aspect protocol was designed to improve the clinical outcomes, reduce unnecessary administration of antivenom, and help physicians make more proper clinical judgments.
Article: Land Envenomations[Show abstract] [Hide abstract]
ABSTRACT: Envenomation by reptiles, spiders, and insects are a common worldwide occurrence. Tens of thousands of bites occur each year, with most victims seeking treatment in emergency rooms. Many envenomations, however, occur in environments where athletes train and compete. As a result, sports physicians may find themselves on the front lines of treating bites and stings. This article reviews the most common types of envenomations seen in the United States.
Article: Anaphylaxis to insect venom[Show abstract] [Hide abstract]
ABSTRACT: Insects responsible for allergic reactions almost exclusively belong to Hy-menoptera and include honey bee (Apis mellifera), bumblebee (Bombus), wasp (Vespula vulgaris, Vespula germanica), hornet (Vespa crabro). Insect venom comprises 10-50 kDa glycoproteins and enzymes responsible for the allergic reaction, numerous small-molelcule chemicals and locally toxic peptides. The lifetime risk of being stung is 30%. Insect stings are the third most frequent cause of anaphylaxis in adults (preceded only by food and drugs anaphylaxis), and the second one in children (preceded only by food). Insect venom hypersensitivity is based primarily on IgE-dependent mechanism. In majority reports generalized allergic reactions (anaphylactic), are rare, reaching frequency 7.5% in adults, while more than ten times less (0.5-6.5%, this higher frequency is reported in atopic children and in some ethnic groups) in children. Fatalities due to insect stings comprises 0.246 deaths/1 milion people/year. In beekeepers and other professions of high insect sting exposure, both local and generalized reactions are more frequent in comparison to general population. Additional agents and cofactors may contribute to higher risk of episode of anaphylaxis and/or more severe course of insect sting reaction. Diagnosis of anaphylaxis is clinical in its character. Classification of general reaction is based on 4-grade Mueller's scale. Intramuscular administration of epinephrine (to antero-lateral part of quadriceps muscle), oxygen supplementation, intravenous fluid resuscitation are the mainstay of medical intervention in anaphylaxis. All patients with a history of insect sting anaphylaxis should be supplied with autosyringe of epinephrine for self-medication. The goals of allergist consultation are diagnosis, establishing indications and contraindications to venom allergen immunotherapy, as well as patient's education on prevention and self-medication.
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