Treatment of poisoning in pregnancy

Frequently, questions arise about the developmental toxicity of both a particular toxicant and the treatment with antidotes. In general, it can be assumed that the fetus is more endangered by the toxicant than by the treatment. For instance, this was observed with poisoning by methanol (Hantson 1997) as well as with overdoses of paracetamol and iron compounds.

On the other hand, there are practically no epidemiological studies focusing on fetal outcome after antidote use during the first trimester. There are only case reports and case series which until now have not indicated any teratogenicity, the only exception being the chelating agent penicillamin, ethanol, and methylene blue (after intra-amnotic injection).

With regard to the chelating agent dimercaprol (2,3-dimercapto-propanol, also known as British Anti-Lewisite, or BAL), there are several case reports regarding the treatment of poisoning with arsenic and lead, and these do not reveal any embryotoxic risk (Bailey 2003). The chemically related chelating agent 2,3-dimercapto-1-propansulfon acid (DMPS) can be evaluated similarly. However, any chelate therapy has to take into account that essential components of nutrition, such as zinc and copper, are also eliminated, so deficiencies can result for the fetus.

Most expcricncc exists with antidotes which arc mainly used for other than toxicological indications (e.g. atropine, pyridoxine).

Concerning paracetamol overdose, which is frequently described in pregnancy, there is a risk of liver toxicity in both mother and fetus. Therapy with the antidote acetylcysteine is either determined by the amount of paracetamol which the woman (pregnant or not) has probably taken, or by the concentration of paracetamol in her blood (McElhatton 1996). Acetylcysteine crosses the placenta and functions as antidote for the fetus, too (Horowitz 1997).

To refrain from therapy with deferoxamine antidote in the case of iron poisoning would endanger mother and child (McElhatton 1991, Olcnmark 1987).

Recommendation. Generally, every pregnant woman suffering from an intoxication should be treated in the same way as a non-pregnant woman, which means that all the therapeutic measures that are clinically and toxico-logically indicated should be applied. Treatment, however, should follow updated guidelines. As a result of recent findings, the recommendations for therapy have in parts been changed substantially in the last few years. As it would go beyond the scope of this book to integrate these, in the case of necessity, competent Poison Control Centers or relevant textbooks (e.g. Brent 2005) should be consulted. The following case reports do not necessarily follow actual guidelines, because they are in parts "historical".

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