Snakebite envenomation (SBE) is a life-threatening disease that typically results from the injection of toxins following the bite of a venomous snake. It affects people in predominantly poor, rural communities in tropical and subtropical countries. About 50%–55% of all snakebites result in envenoming.1 Snakebite is a common neglected public health issue. In Burkina Faso, the snake species belong to six families, among which Elapidae and Viperidae are the most venomous. A retrospective study showed that the total number of snakebite cases recorded from 2010 to 2014 was 114 126 with an average annual incidence of (136 ± 9) bites per 100 000 people.2 With over 20 000 snake bites, of which nearly 15 000 envenomations, treated in health facilities about 300 deaths reported every year. Woman is more frailty to envenomation with high risk of complication than other group of population. Snake bite induced coagulopathy is the most life-threatening complication with poor maternal and perinatal outcome.3 Literature to guide management of this rare obstetric complication remains limited. We report a case of a 3 gravida of 36 weeks of gestation with snakebite who was succesfully managed. Written consent for the use of case presentation and figures, and consent for publication in print and electronically has been given by the patient.
A 21 years old patient, gravida 3, para 2 was bitten by a snake at around 4 PM while she was looking for wood in the vicinity of her house. She experienced severe pain on the outside of her left foot. After calling for help, she tried unsuccessfully to kill the snake that fled into the bundles. Ten minutes after the bite, she felt palpitations, dizziness, and nausea and in 30 minutes the family drove her on a moped to the near health facility located 15 km from their residence. During the travel, women suffered an abrasion by the motorcycle's rays from the toes of the bitten foot. She was admitted to the health center at 6 PM (2 hours after the bite) and the clinical examination revealed prostration, blood pressure at 100/60 mm Hg, apyrexia, fetal heart sounds present, but gums bleeding and bleeding at the bite points. She received isotonic saline, 4 mg dexamethasone per os, 1 g amoxicillin per os and was evacuated the referral hospital at 6:55 PM. She was admitted to medical emergencies at 3 hours after bite and the clinical signs were blood pressure at 90/60 mm Hg, chest pain, agitation, multiple bleeding (bite marks, puncture marks, bleeding of gums, traumatic wounds). After a compression dressing of the lesions and administration of 1 g of paracetamol, the patient was transferred to the maternity ward at 7:50 PM for vomiting and severe pain. She then received 500 mL of gelatin, 500 mL of Ringer lactate, 2 g of ceftriaxone, 1 g of paracetamol.
At 8:45 PM the intensive care physician observed drowsiness, Glasgow coma scale of 10, and shock (pulse at 134 bpm, and blood pressure at 90/60 mm Hg). Multiple of bleeding with significant edema of the left lower limb, extending to the root of the thigh (Figs. 1–3). The dry tube coagulation test showed an absence of thrombus after 20 minutes. Laboratory tests showed hemoglobin was 112 g/L, hyperleukocytosis was 17 × 109/L, and platelet count was 490 × 109/L, creatinemia was 84 μmol/L; hypoglycemia was 3.2 mmol/L. Fetal activity was detected with heart rate of 148 bpm.
The treatment were intravenous infusion of 1 500 mL of saline and 500 mL of gelatine, 10 mg of intravenous vitamin K. One dose of anti-venom diluted in 500 mL of glucose serum was given. Management has been completed by a second peripheral venous access, nasal oxygen therapy, 4 mg ondansetron, 1 g tranexamic acid by intravenous injection followed by 1 g tranexamic acid infused every 8 hours, ceftriaxone 2 g. A permanent urinary catheter was placed. The fresh plasma requested was not available in this hospital. After 30 minutes of resuscitation, a spectacular clinical situation was observed: sudden awakening on call, followed by an unmotivated smile, a sitting position with consistent verbal communication. Glasgow scale 15 points with blood pressure 110/60 mm Hg; stop vomiting, stop bleeding, change functional signs. The coagulation test done had come-back negative. Despite the favorable evolution, an evacuation to Ouagadougou was taken due to the unavailability of fresh frozen plasma (FFP).
After 2 hours of driving in a nonmedical ambulance under 4 L/min oxygen, she was admitted to intensive care and with Glasgow 15 scale; stopped bleeding, clinical anemia, severe edema of the left lower limb, tense, shiny, and painless. Biology reports a prothrombin time 89%, a hemoglobin level of 100 g/L, platelet count 168 × 109/L, leukocytes 13 × 109/L, a normal blood ionogram, creatinemia, normal alanine aminotransferase and aspartate aminotransferase and normal fibrinemia, the Table 1 give reports of clinical examinations and laboratory tests. A second dose of antivenom was given; Exacyl 1 g then 6 g/24 hours, paracetamol 1 g infusion every hour. An initiated FFP transfusion was interrupted due to a transfusion-related event (generalized edema with vertigo, nausea, pruritus) treated with hydrocortisone 100 mg with oxygen.
An obstetrical ultrasound showed a progressive pregnancy of 36 weeks with a heart rate at 178 bpm. Biology showed anemia at 90 g/L, platelets at 164 × 109/L and a prothrombin level at 100%. The woman is transferred to obstetric ward where she received a transfusion of 2 units of red blood cell on 2017.09.02 for anemia at 70 g/L. Spontaneous labor occurred with the vaginal delivery (7 days after envenomation) of a female newborn baby Apgar 7-9-10 and birth weight 2 500 g (Fig. 4). The newborn was seen by a pediatrician and the woman was discharged from hospital 10 days after envenimation. At the follow-up consultation at 14 days postpartum the mother and baby exam were normal.
SBE is not a common during pregnancy but the obstetrical consequences are severe and related to severity of envenomation. Studies reporting SBE are rare in developed countries while present in developing countries.4 In Burkina Faso, snakebites are among the five leading causes of consultations in health districts.2 The notification of snakebites is operational in Burkina Faso since 2010, which helped in clarifying and mapping their incidence and mortality. The snake bite took place near the woman's family during the wintering period. This is a period with a high risk of poisoning with weeding, cutting down shrubs and humidity. Several authors have reported cases of envenimation occurring mainly during the wintering period.2,5 In this case, haemorrhage is observed in the lower third of the leg and most studies have described a similar result.6 Complications observed were shock, hemorrhage, digestive and neurological disorders. These signs are described differently depending on the series of cases reported.4,6,7 Management consisted of hydroelectrolytic equilibration and hematologic resuscitation and the use of polyvalent anti-venom. This management does not differ from the recommendations.5,8 A transfusion of FFP resulted in an urticaria-like reaction that was successfully managed with corticosteroids.
The mother-fetal prognosis was good in this case with the birth of a healthy newborn. The rapidity of care and the use of the anti-venom saved the mother and her child. Snake bite when it occurs; is associated with fetal and maternal complications depending on the degree of envenomation5 and time to have care. Langley in his review of literature on snakebite in pregnancy reported maternal case-fatality of 4.2% and fetal death rate in the range of 43%–58% when there is envenomation.
The maternal and obstetric complications observed were obstetric hemorrhage, preterm labour and delivery, disseminated intravascular coagulation, hypotension, hypovolemic shock, and anemia; while fetal and neonatal complications included tachycardia, prematurity, neonatal jaundice, anemia, and sepsis according to literature.5,9 Maternal and fetal survival with late presentation and systemic envenomation in low resource setting is uncommon, and this probably because snake venom was slow-acting, the amount of venom injected was small or the bite site location limited rapid absorption of snake venom. A combination of several factors may have played out.10
In developing countries where blood products are not readily available, when transfusion with clotting factors are required; fresh whole blood is transfused alternatively especially in patients with or at risk of anemia. In most rural areas in developing countries where there are no hematologists, clinicians rely on 20-minute whole blood clotting test; a simple and rapid test of blood coagulability which can be done by the bedside and has been found to correlate well with fibrinogen concentration.
Anti-snake venoms (ASV) are scarce, expensive.5,7,11 Its use in pregnancy should therefore be with caution and only when there is threat to life as seen in this patient with local and systemic envenomation. Scarcity of ASV in rural areas of developing countries results in high morbidity and mortality following envenomation while many die before arrival to the hospital. With free care for pregnant women and children since 2016 in Burkina Faso, women receive ASV free of charge. This access makes it possible to reduce morbidity and mortality linked to poisoning.
This report of SBE of women successfully delivered showed that early consultation and administration of ASV can change outcome. It is necessary to sensitize people for early consultation during prenatal care.
Conflicts of Interest
. World Health Organisation. Global Snakebite Burden: Report by the Director - General. 2018. Available at: https://apps.who.int/iris/handle/10665/276406
. Gampini S, Nassouri S, Chippaux JP, et al. Retrospective study on the incidence of envenomation and accessibility to antivenom in Burkina Faso
. J Venom Anim Toxins Incl Trop Dis 2016;22(1):1–5. doi:10.1186/s40409-016-0066-7.
. Harshavardhana HS, Pasha I, Prabhu NCS, et al. Snake bite induced coagulopathy: a study of clinical profile and predictors of poor outcome. Int J Sci Study 2014;2(1):2–5.
. Mittal R, Dhiman B, Sood N, et al. Case report. A rare case of pregnancy
complicated by snake bite. Int J Reprod Contraception, Obstet Gynecol 2016;5(1):243–245. doi:10.18203/2320-1770.ijrcog20151635.
. Adewole AA, Ugiagbe OA, Onile TG, et al. Snake bite in third trimester of pregnancy
with systemic envenomation and delivery of a live baby in a low resource setting: a case report. Case Rep Womens Health 2017;16:14–17. doi:10.1016/j.crwh.2017.10.001.
. Hariprasad S, Sukhani N. Assessment of clinical parameters among patients with snake poison induced coagulopathy. Int J Adv Med 2018;5(6):1374–1379. doi:10.18203/2349-3933.ijam20184209.
. White J, Alfred S, Bates D, et al. Twelve month prospective study of snakebite in a major teaching hospital in Mandalay, Myanmar; Myanmar Snakebite Project (MSP). Toxicon: X 2019;1:100002. doi:10.1016/j.toxcx.2018.100002.
. Ainsworth S, Slagboom J, Alomran N, et al. The paraspecific neutralisation of snake venom induced coagulopathy by antivenoms. Commun Biol 2018;1(1):1–144. doi:10.1038/s42003-018-0039-1.
. David A, Padmaja. Snake bite in pregnancy
-case report and review of literature. Int J Pregn Chi Birth 2017;2(1):21–23. doi:10.15406/ipcb.2017.02.00010.
. Kumar S, Ambikavathy M, Lakshmaiah V, et al. Snake bite in the third trimester of pregnancy
: a rare case report and review of literature. Int J Biol Med Res 2011;2(3):820–821.
. Keikhaiel KR, Kahkhaie LR. Maternal and perinatal outcome, a case report of disseminated intravascular coagulation following snakebite after treatment with polyvalent anti-snake bites
. J Biol Today's World 2018;7(1):27–29. doi:10.15412/J.JBTW.01070105.