Tetanus in Pregnancy

Tetanus remains a leading cause of maternal and neonatal morbidity and mortality in developing countries. It is caused by the release of two toxins produced by Clostridium tetani, a noninvasive gram-positive anaerobic bacillus. Tetanospasmin is taken up by the neuronal end plates and prevents neurotransmitter release at the synaptic junction. This leads to spasms and is irreversible. Recovery requires the formation of new neurons and may take months. Generalized muscle spasm, respiratory compromise, and autonomic dysfunction are all common clinical manifestations. Diagnosis is based mainly on history and clinical examination. The management of the pregnant woman is similar to the nonpregnant individual. The main objectives are prompt prevention of further toxin absorption, wound debridement, antibiotic therapy, and aggressive supportive care. Primary and secondary prevention protocols are important worldwide because tetanus is a preventable disease. The tetanus toxoid vaccine can be given in pregnancy.

KEYWORDS

Tetanus - pregnancy - Clostridium tetani

REFERENCES

• 1 Cate T R. Clostridium tetani (tetanus). In: Mandell GL, Douglas RG, Bennett JE Principles and Practice of Infectious Diseases. New York/London; Churchill Livingston 1990: 1842-1846
• 2 Smith J WG. Bacterial diseases. In: Topley-Wilson's Principles of Bacteriology, Virology, and Immunity. 7th ed. Vol. 3. Baltimore; Williams & Wilkins 1983: 345-368
• 3 Orenstein W A, Wassilak S G. Tetanus. In: Evans AS, Brachman PS Bacterial Infections of Humans. New York; Plenum 1991: 707-720
• 4 Sanders R KM. The management of tetanus 1996.  Trop Doct. 1996;  26 107-115
• 5 Million A. Diagnosis, treatment and prevention of tetanus.  Prim Care Update Obstet Gyn. 1997;  4 75-79
• 6 Sanford J P. Tetanus-forgotten but not gone.  N Engl J Med. 1995;  332 812-813
• 7 Kefer M P. Tetanus.  Am J Emerg Med. 1992;  10 445-448
• 8 Bleck T P. Clostridium tetani . In: Mandell GL, Bennett JE, Dolin R Principles and Practice of Infectious Diseases. New York/London; Churchill Livingston 2000: 2537-2543
• 9 Cecil S. Tetanus. In: Wyngaarden JB, Smith LH Cecil Textbook of Medicine. Philadelphia; WB Saunders 1988: 1634-1636
• 10 Fauveau V, Mamdani M, Steinglass R, Klobinsky M. Maternal tetanus: magnitude, epidemiology and potential control measures.  Int J Gynaecol Obstet. 1993;  40 3-12
• 11 Centers for Disease Control and Prevention .Tetanus. Available at: http://www.cdc.gov/nip/publications/pink/tetanus.pdf. Accessed February 1, 2004
• 12 Centers for Disease Control and Prevention . Summary of reportable diseases.  MMWR Morb Mortal Wkly Rep. 2000;  49 22-23
• 13 Gergen P J, McQuillan G M, Kiely M, Ezzati-Rice T M, Sutter R W, Virella G. A population-based serologic survey of immunity to tetanus in the United States.  N Engl J Med. 1995;  332 761-766
• 14 Buekens P, Tsui A, Kotelchuck M, Degraft-Johnson J. Tetanus immunization and prenatal care in developing countries.  Int J Gynaecol Obstet. 1995;  48 91-94
• 15 Tunkel A R, Pradhan S K. Central nervous system infections in injection drug users.  Infect Dis Clin North Am. 2002;  16 589-605
• 16 Bennett J, Schooley M, Traverso H, Agha S B, Boring J. Bundling, a newly identified risk factor for neonatal tetanus: implications for global control.  Int J Epidemiol. 1996;  25 879-884
• 17 Kumar V, Kumar R, Mathur V N, Raina N, Bhasin M, Chakravarty A. Neonatal tetanus mortality in a rural community in Haryana.  Indian Pediatr. 1988;  25 167-169
• 18 Kerr J H, Corbett J L, Prys-Roberts C, Smith A C, Spalding J M. Involvement of the sympathetic nervous system in tetanus: studies on 82 cases.  Lancet. 1968;  2 236-241
• 19 Veronesi R, Focaccia R. The clinical picture. In: Veronesi R Tetanus: Important New Concepts. Amsterdam; Excerpta Medica 1981: 183-206
• 20 Salimpour R. Cause of death in tetanus neonatorum: study of 233 cases with 54 necropsies.  Arch Dis Child. 1977;  52 587-594
• 21 Creasy R, Resnik R. Maternal-Fetal Medicine: Principles and Practice, 3rd ed. Philadelphia; WB Saunders 1999: 1104
• 22 Speroff L. Bacterial shock in obstetrics and gynecology with emphasis on the surgical management of septic abortion.  Am J Obstet Gynecol. 1966;  95 139-151
• 23 Trujillo M H, Castillo A, Espana J, Manzo A, Zerpa R. Impact of intensive care management on the prognosis of tetanus: analysis of 641 cases.  Chest. 1987;  92 63-65
• 24 Queenan JT, Hobbins JC Protocols for High Risk Pregnancies. Cambridge; Blackwell Science 1996: 324-325
• 25 Silveira C M, Caceres V M, Dutra M G, Lopes-Camelo J, Castilla E E. Safety of tetanus toxoid in pregnant women: a hospital-based case-control study of congenital anomalies.  Bull World Health Organ. 1995;  73 605-608
• 26 Dietz V, Milstein J B, van Loon F, Cochi S, Bennett J. Performance and potency of tetanus toxoid: implications for eliminating neonatal tetanus.  Bull World Health Organ. 1996;  74 619-628
• 27 Gendrel D, Richard-Lenoble D, Massamba M B, Picaud A, Francoual C, Blot P. Placental transfer of tetanus antibodies and protection of the newborn.  J Trop Pediatr. 1990;  36 279-282
• 28 Englund J A, Mbawuike I N, Hammill H, Holleman M C, Baxter B D, Glezen W P. Maternal immunization with influenza or tetanus toxoid vaccine for passive antibody protection in young infants.  J Infect Dis. 1993;  168 647-656
• 29 Fischer G W, Ottolini M G, Mond J J. Prospects for vaccines during pregnancy and in the newborn period.  Clin Perinatol. 1997;  24 231-249
• 30 Centers for Disease Control and Prevention . Diphtheria, tetanus and pertussis: guidelines for vaccine prophylaxis and other preventive measures.  Ann Intern Med. 1985;  103 896-905