What is the recommended course of action for a pregnant woman traveling to a location with a risk of rabies who has been bitten by a bandicoot rat on the toe, considering her pregnancy and potential need for rabies vaccination (Post-Exposure Prophylaxis, PEP)?

Rabies Post-Exposure Prophylaxis is Absolutely Required for This Pregnant Woman

A pregnant woman bitten by a bandicoot rat on the toe requires immediate rabies post-exposure prophylaxis (PEP) consisting of thorough wound washing, rabies immune globulin (RIG), and a 4-dose rabies vaccine series—pregnancy is NOT a contraindication to rabies PEP. 1, 2, 3

Why Pregnancy Does Not Change the Decision

• Rabies has a nearly 100% case fatality rate once clinical symptoms develop, making prevention through PEP the only life-saving intervention. 1, 3
• The American Journal of Obstetrics and Gynecology explicitly states that pregnancy should not be considered a contraindication to post-exposure prophylaxis given the uniformly fatal outcome of rabies. 1
• There is no evidence of increased risk of adverse pregnancy outcomes following rabies vaccination in pregnant women. 1
• Rabies cell-culture vaccines are safe and effective in pregnant women, and can be administered without concern for fetal harm. 4

Immediate Treatment Protocol

Step 1: Wound Management (Within Minutes)

• Immediately wash the wound thoroughly with soap and water for 15 minutes—this is the single most effective measure for preventing rabies infection. 2, 3, 5
• Follow with irrigation using a virucidal agent such as povidone-iodine solution if available. 3

Step 2: Assess Exposure Category

• A rat bite that penetrates the skin on the toe constitutes a Category III exposure (any penetration of skin by teeth), which requires both RIG and vaccine. 2, 5
• The location on the toe does not reduce the need for treatment—all bites represent potential rabies transmission risk regardless of body site. 6, 5

Step 3: Administer Post-Exposure Prophylaxis (Within 24 Hours)

For this previously unvaccinated pregnant woman:

• Rabies Immune Globulin (RIG): 20 IU/kg body weight administered on day 0, with the full dose infiltrated around and into the toe wound if anatomically feasible. 2, 3, 5
• Rabies Vaccine: 4 doses of 1.0 mL each, administered intramuscularly in the deltoid muscle on days 0,3,7, and 14. 2, 3
• RIG must NOT be administered in the same syringe or at the same anatomical site as the vaccine. 3
• Never use the gluteal area for vaccine administration—this produces inadequate antibody response and is associated with vaccine failure. 3

Critical Considerations for Rodent Bites

• While small rodents (rats, mice, squirrels, hamsters) almost never require rabies PEP in most geographical areas of developed countries, the decision depends heavily on the rabies epidemiology of the specific location being traveled to. 6, 5
• In developing countries and rabies-endemic regions, the risk assessment changes significantly—local public health officials must be consulted to determine if rats are known rabies vectors in that specific area. 5
• If traveling to a rabies-endemic region where animal rabies surveillance is poor or rats have been documented as rabies vectors, err on the side of caution and administer PEP. 5, 7

Common Pitfalls to Avoid

• Do not delay PEP while waiting to determine if the rat was rabid—in rabies-endemic areas, treatment should begin immediately and can be discontinued only if the animal tests negative. 3, 5
• Do not withhold treatment based on pregnancy status—this is a critical error that could result in maternal and fetal death. 1, 4
• Do not assume all rodent bites are low-risk without knowing the specific epidemiology of the travel destination. 6, 5
• Do not exceed 20 IU/kg for RIG dosing, as higher amounts suppress active antibody production. 3

Special Pregnancy Considerations

• The same vaccine dose volume (1.0 mL) and RIG dose (20 IU/kg) are used in pregnant women as in non-pregnant adults. 3
• No serologic testing is required after completing the vaccine series in immunocompetent pregnant women. 3
• Lactation is not a contraindication to rabies vaccination if the woman is breastfeeding. 4

Location-Specific Risk Assessment Required

The final decision hinges on the rabies epidemiology of [LOCATION]:

• Contact local or state public health officials in the destination country immediately to determine if rats are documented rabies vectors in that region. 5
• In areas where rabies surveillance is robust and rats have never transmitted rabies to humans, PEP may not be necessary. 6, 5
• In areas with poor surveillance, endemic dog rabies, or documented rodent rabies transmission, initiate PEP immediately. 5, 7