Q Fever in Pregnancy Risk Management

Authors: James Yew 1, David Watson 2, Robert Norton 2

1Mackay Base Hospital, Mackay, Queensland, Australia
2The Townsville Hospital, Townsville, Queensland, Australia

Introduction Discussion
North Queensland has one of the highest rates of Q fever in Australia with In pregnant women, Coxiella burnetti colonize and multiply in the uterus,
clustering of cases ranging from 6.7 - 24.9 per 100,000 population1. Most do not have mammary glands and placenta2. Transplacental transmission has also been
any occupational exposure to cattle. Native mammals are more likely to be documented through identification of the organism in infected placenta and fetal
seropositive for Q fever than cattle. Geographic mapping of cases in the region has viscera3. Although infection with C. burnetti has not been associated with
shown clustering of cases around newer suburbs bordering on bushland. Q fever teratogenicity, it can result in obstetric complications such as spontaneous
complicating pregnancy presents a number of specific challenges. abortion, intrauterine foetal death, intrauterine growth retardation, oligohydramnios
and premature delivery (see Table 1)4. These complications are more likely to
occur in women who are infected in their first trimester of pregnancy, compared to
Cases
those infected later. In addition, there is an increased rate of spontaneous abortion
Over the last 10 years, there have been 107 cases of proven Q fever seen at
associated with C. burnetti strains harboring the QpDV plasmid5.
The Townsville Hospital. 27 (25%) were female, of which two were pregnant during
Doxycycline is the antimicrobial of choice in treating Q fever, but should be
time of diagnosis.
avoided in pregnancy. Cotrimoxazole, although only bacteriostatic against C.
burnetti, has been shown to prevent obstetric complications when administered as
Case 1
JD was diagnosed with acute Q fever in the first trimester of her pregnancy in a prolonged course (>5 weeks) to treat Q fever in pregnancy4,5.
early 2007. She was treated with 2 weeks of ciprofloxacin, and an amniocentesis Women infected with C. burnetti during pregnancy are prone to develop
showed no evidence of Q fever by nucleic acid testing (NAT). She proceeded to have chronic Q fever, and this appears to correlate with the duration of infection during
a normal pregnancy and delivered a health baby. pregnancy. One study demonstrated that most women infected during the first six
In June 2008, at the 6-month post-natal follow up, she had developed a Ph1 IgG months of pregnancy developed chronic Q fever, regardless of treatment during
(immunofluorescence) of 1280 accompanied by symptoms of lethargy and pregnancy2. It is therefore recommended that when postpartum, women who
intermittent night sweats. A transoesophageal echocardiogram (TOE) revealed no develop a serological profile suggestive of chronic Q fever should be commenced
evidence of endocarditis. She successfully completed 20 months of treatment with on the treatment recommended for Q fever endocarditis. The aim of treatment is
doxycyline and hydrocychloroquine, with a concomitant decline in her Ph1 IgG to 160 twofold to prevent the development of endocarditis and to prevent recurrence of
in July 2010. Q fever during subsequent pregnancies2,3.
Breastfeeding by mothers with Q fever is not recommended as C. burnetti
Case 2 has been isolated from breast milk2,3.
RD suffered from an undiagnosed febrile illness in the first trimester of her
pregnancy in July 2012. She presented to hospital in December 2012 at 26/40 weeks
gestation with an episode of self-limiting painless antepartum haemorrhage. Fetal Summary
ultrasonography demonstrated intrauterine growth retardation and redistribution of When faced with a compatible illness in a pregnant woman, local
blood flow. epidemiology and a history of contact with native mammals should alert the
Blood tests revealed a Q fever Ph1 IgG and Ph2 IgG of 1280, with a Ph2 IgM of treating clinician to consider Q fever in pregnancy. As illustrated in our second
40; a single Q fever serology was negative in July 2012. She was commenced on case, an initial negative Q fever serology should not dissuade the clinician from
cotrimoxazole and amniocentesis did not detect Coxiella burnetti by NAT. Her baby pursuing this diagnosis, as 10-12 days is required to develop an antibody
was delivered at 28/40 weeks gestation by C-section; histological examination of the response to C. burnetti. A repeat serology taken 12-25 days after onset of illness
placenta revealed multiple infarcts in the placenta and C. burnetti was detected by would be indicated.
NAT. C. burnetti was not detected by NAT in the babys blood and the baby has Timely and appropriate management of Q fever in pregnancy with a
progressed well. prolonged course of cotrimoxazole decreases the risk of obstetric complications
A transthoracic echocardiogram (TTE) demonstrated a mobile echogenicity on and subsequent maternal morbidity.
her aortic valve, and she was therefore commenced on doxycycline and
hydroxycholoroquine immediately post-partum. A delayed TOE more than 6 weeks
later failed to show the lesion seen on the TTE. She currently remains on treatment. References
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Premature delivery 25% 19% 27%