A 19‑week pregnant woman was scratched by a stray cat; what immediate management and prophylaxis should be undertaken?

Immediate Management of Cat Scratch in 19-Week Pregnant Woman

Immediately wash the scratch thoroughly with soap and copious water for 15 minutes, apply povidone-iodine solution if available, ensure tetanus prophylaxis is current, and consult local public health officials regarding rabies risk assessment—but do NOT routinely initiate rabies post-exposure prophylaxis for a stray cat scratch unless the cat shows signs of rabies or cannot be observed. 1

Wound Care (First Priority)

Perform immediate thorough wound cleansing:

• Wash and flush the scratch for approximately 15 minutes with soap or cleansing agent and copious amounts of water 1
• Apply an iodine-containing or similarly viricidal topical preparation to the wound if available 1
• This wound cleansing alone markedly reduces the likelihood of rabies transmission in animal studies 2

Tetanus Prophylaxis Assessment

Verify tetanus immunization status and provide booster if indicated 1, 3. Cat scratches can transmit tetanus even in previously immunized patients 4, so this should not be overlooked despite pregnancy.

Rabies Risk Assessment (Critical Decision Point)

The key question is whether rabies post-exposure prophylaxis (PEP) is needed:

For stray/unknown cats that escape or cannot be observed:

• Consult public health officials immediately 1
• The FDA label states "Unknown (e.g., escaped): Consult public health officials" for dogs, cats, and ferrets 1
• If the cat is healthy-appearing and the scratch was provoked, risk is lower
• If the cat appeared ill, acted strangely, or the encounter was unprovoked, consider initiating PEP while awaiting public health guidance

If rabies PEP is indicated:

• Both human rabies immune globulin (HRIG) and vaccine are safe and indicated in pregnancy 2, 1
• HRIG dose: 20 IU/kg body weight, infiltrated around the wound if anatomically feasible, with remainder given intramuscularly 2
• Vaccine: 1.0 mL doses intramuscularly on days 0,7, and 21 or 28 1
• The sooner treatment begins after exposure, the better 1
• Rabies is universally fatal once symptomatic, so pregnancy is NOT a contraindication to PEP

Antibiotic Prophylaxis

Consider amoxicillin-clavulanate as first-line antibiotic prophylaxis 3, 5:

• Cat scratches, particularly on hands, carry high infection risk 5
• Pasteurella multocida is isolated in over half of cat bite wounds and can cause serious infection 5
• Capnocytophaga canis can cause cellulitis and bacteremia from cat scratches 6
• Amoxicillin-clavulanate is safe in pregnancy and recommended for cat bite/scratch wounds 3, 5

Cat Scratch Disease Monitoring

Be aware that cat scratch disease (Bartonella henselae) may develop:

• Typically presents with regional lymphadenitis 1-3 weeks after exposure 7
• In a 19-year surveillance study of 8 pregnant women with cat scratch disease, 6 delivered healthy newborns without complications 7
• One early spontaneous abortion occurred, but causality could not be established 7
• Close monitoring during pregnancy is advisable if cat scratch disease develops 7

Common Pitfalls to Avoid

• Do not delay wound cleansing—this is the single most important intervention
• Do not assume pregnancy contraindicates rabies PEP—rabies is fatal, and both HRIG and vaccine are safe in pregnancy
• Do not dismiss minor scratches—cat scratches cause deeper puncture-type wounds than they appear and have high infection rates 3
• Do not wait for symptoms before consulting public health—rabies PEP must begin before symptom onset to be effective

Documentation

Document:

• Circumstances of the scratch (provoked vs. unprovoked)
• Appearance and behavior of the cat
• Neurovascular examination of the affected area
• Tetanus immunization status
• Public health consultation and recommendations