Rabies is associated with 100% fatality rate among all infectious disease and makes a risk for maternal death and an indeterminate risk to the fetus.

Let us review the statement of the Advisory Committee on Immunization Practices (ACIP) for rabies immunization that is applied to pregnancy and breast feeding women as well. First of all, clean the wounded site by soap and water and begin rabies post-exposure prophylaxis.

Secondly, if it is an owned dog, cat or a stray animal that is available for testing, the suspected animal should be observed for 10 days. If the animal remains alive, vaccination will be ceased. Thirdly, being bitten by wild-life animals that are not available warrants initiation of post-exposure prophylaxis (PVRV and HRIG) and vaccine is administered to deltoid area.

Currently, rabies post-exposure prophylaxis is a method of choice for prevention of rabies. Any pregnant woman who is bitten by stray animal is at risk. They need proper post-exposure management. Vaccination is not contraindicated in pregnancy and breast feeding. Different studies confirm that anti rabies vaccination are safe during pregnancy. One study has reported that no maternal or fetal side effects were seen among 21 pregnant women who received post exposure prophylaxis.

Another study has confirmed the safety of vaccination in post-exposure pregnant women and has emphasized that treatment should never be withheld or delayed if the patient is possibly exposed to rabies. One case study from Mexico reported two patients with rabies exposure during the second and third trimester of pregnancy who received immunization.

There were no side effects in mothers who were attributed to prophylaxis, which appears safe when it is given during pregnancy. Because of the fatal risk following a rabid animal bite, this case recommends that pregnancy not be a contraindication to rabies post- exposure prophylaxis.

Current vaccines provide an acceptable antibody response within 7-10 days but passive immunization by immunoglobulin (with 21 days, half-life) is used for filling this 7-10 days gap. We have to point that rabies is endemic in Iran however safety of rabies post-exposure prophylaxis in pregnant women had been mentioned in different studies, we are going to assess the efficacy of rabies antibody in pregnant women and newborns in Iran and correlation of antibody levels between them as well.

Several studies have demonstrated the safety of anti-rabies vaccination during pregnancy and there is no association between treatment and adverse outcome, and public health authorities recommend the pregnancy not be considered a contraindication to rabies post-exposure prophylaxis.

The policy of our department is the same: Still some clinicians and patients are reluctant to vaccination as Abazeed reported about a pregnant woman whom was exposed to bat and refused to receive treatment, but fortunately the bat was not infected.

In a case study, among 21 pregnant women who received rabies post-exposure prophylaxis, no adverse effect was seen in the mother and the child. According to our recent report we also have not seen any serious side effects following the use of PVRV and HRIG.

Regarding the immunogenicity of rabies post-exposure vaccination in pregnant women, Sudarshan assessed antibody levels in infants whom their mothers received PVRV during pregnancy after being bitten by suspected animals, and found that PVRV had an effective immunity in the mother and the child and it was also safe during pregnancy.

Another point is that vaccination not only makes an acceptable protection, but also it causes no side effects in a mother and her child, and immunity will be achieved in the infant as well. There are many reports that confirm the safety of rabies immunization during pregnancy, but our aim was to determine the rabies antibody level and the immunization efficiency in mothers and newborns as well.

Rabies poses a 100% risk for death to pregnant women and an indeterminate risk to the fetus. 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. Indeed, the consensus is that pregnancy is not a contraindication to rabies postexposure prophylaxis (PEP). 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.

Most of the world’s estimated 60,000 annual rabies deaths occur in countries where canine rabies is endemic and where PEP is often inaccessible to bite victims (4). When PEP is available, documentation of vaccination hesitancy for prevention of rabies is rare. This investigation identified six rabies deaths among breastfeeding or pregnant women.

Based on information provided by family members, these deaths might have been associated with unfounded concerns about vaccine-associated risks to the fetus or breastfed child. A previous U.S. report also documented refusal to receive PEP by a pregnant woman with a potential rabies exposure because of concerns about the effect of PEP in the fetus; that patient did not develop rabies (5). Studies have found no increased risk for spontaneous abortions, premature births, or fetal abnormalities among pregnant women after receiving PEP

Several studies of the safety of rabies PEP for pregnant patients demonstrated no association between treatment and adverse outcomes. 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. Although these studies are not comprehensive in their assessment of all reproductive outcomes, they do suggest that PEP is generally safe.

A growing body of literature documents peripartum rabies cases. Including the six cases reported here, case reports and a literature review found 20 documented probable or suspected peripartum rabies cases reported during the 114-year period, 1902–2016 (8,9). A total of 17 neonates survived, and were reported to be healthy, including eight who did not receive vaccine or immunoglobulin after caesarean or vaginal delivery (8). Among the three neonates who did not survive, one acquired rabies, and the other two died from complications unrelated to rabies

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.

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