Management of snakebite envenomation in pregnancy with prolonged coagulopathy in a resource-constrained setting: a case report

Abstract

Snakebite envenomation (SBE) during pregnancy is a rare but important obstetric emergency. Accounting for 0.4–1.8% of all cases of SBE, it is associated with serious foeto-maternal complications; miscarriage, teratogenesis, intrauterine foetal demise, preterm births, abruptio placentae and maternal mortality often arise from venom-induced consumption coagulopathy. We report a case of protracted coagulopathy following a third-trimester SBE and the dynamics of management in a resource-constrained setting. A 36-year-old Gravida 7 para 5 (all alive) + 1 spontaneous abortion at 32 weeks +1 day gestation was referred to our facility on account of coagulopathy from envenomation following a 5-day history of snakebite. Prior to referral, she had received 5 vials of polyvalent anti-snake venom. On arrival, the patient was generally stable. Cardiopulmonary systemic examination was unremarkable. Abdominal examination revealed a non-tender gravid uterus, with a symphysiofundal height of 32 cm and foetal heart rate of between 124 and 152 beats per minute. Her left lower limb was swollen from the foot to the knee and tender with pitting pedal oedema. Bedside clotting time far exceeded 20 min, and an obstetric scan done prior to the referral showed a single live intrauterine gestation at 29 weeks + 6 days with no evidence of placental abruption. She was started on intravenous antibiotics, analgesics and a total of 4 vials of polyvalent anti-snake venom. Two units of fresh whole blood initially transfused did not correct the coagulopathy. However, subsequent transfusion of fresh frozen plasma normalised bedside clotting time (within 6 min), with clinical improvement in foeto-maternal condition. We presented a case report of SBE with protracted coagulopathy. SBE during pregnancy can be challenging for healthcare providers. Prompt recognition, initiation of anti-venom and administration of blood products guided by basic coagulation studies prove beneficial to the management and prevention of foeto-maternal complications. We propose that further large-scale research be pursued on the effects, efficacy, and safety of antivenom use in pregnancy to inform treatment protocols that improve maternal and foetal outcomes, especially in cases with prolonged coagulopathy.