Trimeresurus stejnegeri Envenoming during Pregnancy Yen-Chia Chen, Min-Hui Chen, Chen-Chang Yang, Yen-Wen Chen, Lee-Min Wang, and Chun-I Huang* Department of Emergency Medicine, Department of Medicine, and Division of Clinical Toxicology, Department of Respiratory Therapy, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China; Institute of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China; Center for Drug Evaluation, Taipei, Taiwan, Republic of China; Department of Environmental and Occupational Medicine, School of Medicine, National Yang-Ming University, Taiwan, Republic of China Abstract. Snake envenoming in pregnancy may cause fetal death and maternal mortality or morbidity. However, little is known about the toxic effects and optimal management of snake envenoming because of the rarity of cases. We report three cases in Taiwan in the past 15 years of pregnant women who were treated successfully after being bitten by Trimeresurus stejnegeri with local envenoming. Two of the three patients received treatment with equine-derived hemotoxic bivalent F(ab') 2 antivenom without development of any adverse effects. All three women recovered un- eventfully and subsequently had normal deliveries. Telephone follow-up of the three children 6–10 years later showed no developmental delay of the children. INTRODUCTION Snake bite is a common medical emergency worldwide. Much information is available regarding the effect of snake venom on non-pregnant women and treatment protocols. However, little is known about snake bite during pregnancy. To provide more information on snake envenoming during pregnancy, we report three pregnant women who were bitten by a green habu (Trimeresurus stejnegeri). The types of snake bites were documented on medical charts and originally clas- sified in emergency departments by identifying the snake brought by the patient or by snakes in pictures identified by the patients. CASE REPORT Case 1. A 32-year-old pregnant woman who was at 17 weeks of gestation was bitten by a green habu on the dorsal region of her left foot on July 10, 1995. She initially had severe local pain, followed by swelling and bruising of the foot. She visited a local hospital 2.5 hours after the venomous snake bite and had progressive swelling of the left leg and ecchy- mosis around the fang marks. She received treatment with toxoid and empirical antibiotics. She was referred to our toxi- cologic service nine hours after the snake bite. On arrival at the toxicologic service, the patient’s vital signs were normal; however, the swelling had progressed to her left thigh. Routine laboratory examinations showed leukocytosis with a white blood cell count of 13,400/mm 3 and a positive result on a urine pregnancy test. One vial of equine-derived hemotoxic bivalent F(ab') 2 antivenom was given 12.5 hours after the snake bite, and she was admitted to the clinical toxicology ward. She did not develop any adverse reactions to the antivenom, and the local swelling disappeared promptly after the administration of antivenom. On day two, her thrombin time and activated partial thromboplastin time were normal. Monitoring of the fetus did not find any evidence of hypoxia, and there was no vaginal bleeding. The patient was discharged uneventfully on the fourth day after admission and delivered a normal baby at 40 weeks of gestation (23 weeks after the snake bite). Telephone follow-up 10 years later showed no developmental delay of the child. Case 2. A 36-year-old pregnant woman who was at 8 weeks of gestation was bitten by a green habu over proximal part of her right middle finger on December 12, 1996. Thirty minutes later, she was sent to a community hospital with local pain, bleeding, and swelling around the fang marks. Antivenom was not administered at the community hospital because of the fear of possible adverse effects. She had persistent pain and progressive swelling of right hand and was transferred to our toxicologic service approximately four hours after the snake bite. On arrival, her vitals signs were normal. Physical examina- tion showed that bleeding had stopped at the bite site, but ecchymosis and swelling of right forearm were noted. Labo- ratory data, including liver enzyme levels, renal function, pro- thrombin time, activated partial thromboplastin time, and complete blood counts were unremarkable except for mild leukocytosis with a white blood cell count of 11,600/mm 3 and a positive result on a urine pregnancy test. Because mild local envenoming was suspected without evidence of further pro- gression, a clinical toxicologist recommended only supportive care. Her condition continued to improve, and she was dis- charged on the third day after admission. During hospitaliza- tion, monitoring of the fetus’s condition did not show any abnormality. The patient gave birth to a normal baby girl at 39 weeks of gestation (31 weeks after the snake bite). Tele- phone follow-up of the child eight years later showed no growth retardation or intellectual disabilities. Case 3. A 22-year-old pregnant woman who was at 28 weeks of gestation was bitten by green habu over right wrist on April 20, 1999. She came to a local hospital with swelling of right wrist and hand one hour after the snake bite and received one vial of equine-derived hemotoxic bivalent F(ab') 2 antivenom. However, the symptoms rapidly wors- ened, and she was transferred to our emergency department two hours after the snake bite. On arrival at the emergency department, physical exami- nation showed local erythema, bleeding from fang marks, and progressive swelling of right forearm. Laboratory examina- tions were remarkable for mild leukocytosis with a white blood cell count of 13,900/mm 3 and mild anemia with a he- moglobin level of 11.3 g/dL. Two vials of hemotoxic bivalent * Address correspondence to Chun-I Huang, Department of Emer- gency Medicine, Taipei Veterans General Hospital, 201, Shih-Pai Road Section 2, Taipei 112, Taiwan, Republic of China. E-mail: cihuang@vghtpe.gov.tw Am. J. Trop. Med. Hyg., 77(5), 2007, pp. 847–849 Copyright © 2007 by The American Society of Tropical Medicine and Hygiene 847