Management of Dog Bite in a 12-Week Pregnant Woman
A pregnant woman at 12 weeks gestation with a dog bite should receive immediate wound care, prophylactic antibiotics (amoxicillin-clavulanate), tetanus prophylaxis if indicated, and rabies post-exposure prophylaxis (both rabies immune globulin and vaccine) if rabies risk exists—pregnancy is NOT a contraindication to any of these interventions. 1, 2
Immediate Wound Management
Thoroughly wash and irrigate the wound immediately with soap and copious water for approximately 15 minutes, followed by application of a virucidal agent such as povidone-iodine solution. 1, 3, 4
Avoid damaging skin or tissues during cleansing, as proper wound care alone can markedly reduce the risk of both bacterial infection and rabies transmission. 1
Debride devitalized tissue carefully while preserving viable tissue to optimize healing and reduce infection risk. 3
Avoid primary wound closure (suturing) when possible, especially in high-risk wounds, as this increases infection risk. 1, 5
Antibiotic Prophylaxis
Prophylactic antibiotics are strongly recommended for pregnant women with dog bites, particularly given the immunologic changes of pregnancy and potential for serious complications. 1, 3
Amoxicillin-clavulanate 875/125 mg orally twice daily is the first-line antibiotic for 3-5 days, as it provides coverage against both aerobic and anaerobic bacteria commonly found in dog bite wounds. 1, 3, 5
Alternative oral options if amoxicillin-clavulanate is contraindicated include doxycycline 100 mg twice daily (though generally avoided in pregnancy after first trimester) or penicillin plus dicloxacillin. 1, 5
For severe infections requiring IV therapy, options include ampicillin-sulbactam 1.5-3.0 g every 6-8 hours or piperacillin-tazobactam 3.37 g every 6-8 hours. 1, 5
Tetanus Prophylaxis
Tetanus prophylaxis should be administered based on vaccination history and wound characteristics. 1, 3
If the last tetanus-containing vaccine was >5 years ago, administer Td (tetanus-diphtheria) vaccine as part of wound management. 1
Pregnant women with unknown or incomplete tetanus vaccination history should be considered unvaccinated and may require both tetanus toxoid and tetanus immune globulin (TIG) for wound management. 1
Vaccination during the second or third trimester is preferred to minimize perception of association with adverse pregnancy outcomes, though first trimester administration is not contraindicated when indicated. 1
Rabies Post-Exposure Prophylaxis (PEP)
Rabies PEP is a medical urgency and should be initiated promptly if rabies risk exists—there are NO contraindications to rabies PEP in pregnancy. 1, 2, 6
Risk Assessment for Rabies PEP
Consult local health officials immediately to determine if rabies vaccination should be initiated based on regional rabies epidemiology and the dog's status. 1, 4
A healthy domestic dog should be confined and observed for 10 days. If the dog remains healthy throughout this period, it was not shedding rabies virus at the time of the bite and PEP is not needed. 1, 4
If the dog is rabid, suspected rabid, unavailable for observation, or shows signs of illness during observation, immediately initiate rabies PEP. 1, 4, 7
An unprovoked attack is more likely to indicate rabies than a provoked attack (e.g., attempting to feed or handle the animal). 1, 7
Rabies PEP Regimen for Previously Unvaccinated Pregnant Women
For pregnant women never previously vaccinated against rabies, PEP consists of BOTH rabies immune globulin (RIG) and vaccine. 1, 4, 7
Rabies immune globulin (HRIG) should be administered once at the beginning of prophylaxis (day 0), with as much as possible infiltrated around the wound site and the remainder given intramuscularly at a site distant from vaccine administration. 1, 4, 7
HRIG can be given up to and including day 7 of the vaccine series if not administered initially; beyond day 7, it is not indicated as antibody response to vaccine is presumed to have occurred. 1
Rabies vaccine should be administered intramuscularly in the deltoid muscle on days 0,3,7, and 14 (4-dose schedule for previously unvaccinated persons). 1, 4, 8
The 4-dose vaccine schedule (days 0,3,7,14) is safe and effective when used with appropriate wound care and HRIG administration. 8
Safety of Rabies PEP in Pregnancy
Rabies vaccines are safe and effective in pregnant women, and pregnancy should never delay or prevent PEP administration. 2, 9, 6
No failures of rabies PEP have been documented in the United States when current biologics are properly administered, including in pregnant women. 1
Available data indicate that administering rabies vaccines during pregnancy is safe and effective, with no documented adverse effects on the fetus. 6
Fear of risk to the fetus is a dangerous misconception—multiple deaths have occurred in pregnant women who delayed or avoided PEP due to unfounded concerns about fetal safety. 2
Rabies is essentially 100% fatal once clinical signs develop, making PEP administration critical regardless of pregnancy status. 2, 9, 10
Follow-Up Care
Reassess the wound within 48-72 hours to evaluate for signs of infection (erythema, warmth, purulent drainage, increasing pain, fever). 3
If the dog remains healthy after 10 days of observation and rabies PEP was initiated, prophylaxis can be discontinued. 1, 4
Hand injuries and facial injuries require particularly vigilant follow-up due to higher risk of infection and functional/cosmetic complications. 1, 3
Critical Pitfalls to Avoid
Never delay rabies PEP due to pregnancy—this is a fatal misconception that has resulted in preventable maternal deaths. 2
Do not administer HRIG beyond day 7 of the vaccine series, as it can suppress active antibody production. 1
Do not exceed the recommended dose of HRIG (20 IU/kg), as excess can partially suppress active antibody response. 1
Do not substitute Tdap for Td in pregnant women previously vaccinated with Tdap—use Td for wound management in this scenario. 1