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CASE REPORT
Year : 2016  |  Volume : 5  |  Issue : 1  |  Page : 39-41

Intentional chlorpyrifos poisoning in pregnant woman and subsequent fetal death


Department of Pharmacy Practice, JSS College of Pharmacy, JSS University, Mysuru, Ooty, The Nilgiris, Tamil Nadu, India

Date of Web Publication13-Jan-2016

Correspondence Address:
Sivasankaran Ponnusankar
Department of Pharmacy Practice, JSS College of Pharmacy, Rocklands, Post Box No. 20, Ooty - 643 001, The Nilgiris, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.173887

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  Abstract 

Organophosphate poisoning is an important medical emergency exist in agriculture-oriented countries such as India. This case report describes the treatment strategies followed for a management of suicidal intoxication of a pregnant woman by chlorpyrifos compound at a secondary care public hospital, Udhagamandalam, India. The patient was unable to perceive fetal movements and had classic clinical symptoms of organophosphate poisoning such as excess salivation and pinpoint pupil. The patient was administered with 2 g of pralidoxime and 10 ampoules of atropine sulfate (1.2 mg each). The fetotoxic evaluation showed fetal death. The antidote given to the patient was according to the criteria given by the World Health Organization. The late admission of the patient may be considered as a reason for fetal death. Psychosocial, educational programs are highly recommended for the population in this region to reduce the number of intentional poisoning attempts.

Keywords: India, management, organophosphate poisoning, pregnant woman, self-harm


How to cite this article:
Indu T H, Roopa B S, Ponnusankar S. Intentional chlorpyrifos poisoning in pregnant woman and subsequent fetal death. Int J Health Allied Sci 2016;5:39-41

How to cite this URL:
Indu T H, Roopa B S, Ponnusankar S. Intentional chlorpyrifos poisoning in pregnant woman and subsequent fetal death. Int J Health Allied Sci [serial online] 2016 [cited 2018 Jul 17];5:39-41. Available from: http://www.ijhas.in/text.asp?2016/5/1/39/173887


  Introduction Top


Organophosphate compounds are commonly used agrochemical agents, as well as potent suicidal agents. Recently, the World Health Organization (WHO) reported that among the pesticides, these agents cause a total of 30,000 deaths annually in developing countries, especially in the Asian countries.[1],[2] Most of the population in India depends on agriculture for earning daily wages and hence prone to pesticidal health issues such as dizziness, skin irritation, headache, and respiratory discomfort.[2] In rural areas, people tend to consume these agents for the purpose of self-harm, which may be due to the lack of legal policies and regulations to restrict their easy availability to public.[3]

Organophosphate compounds cross the placenta that can induce serious effects to both mother and fetus. Apart from this, the use of antidotes in pregnancy can also induce embryotoxic effects.[4] Thus, organophosphate poisoning management in pregnant women is quite complicated. The following case illustrates the treatment strategies employed on a young pregnant woman in the secondary care hospital who had an intentional consumption of chlorpyrifos pesticide.


  Case Report Top


A 26-year-old primipare woman (Gravida1, Abortion0) had consumed an unknown quantity of chlorpyrifos, an organophosphate pesticide, 8 h prior presenting to the Emergency Department of the Secondary Care Hospital, Udhagamandalam on November 24, 2014. The patient admitted that it was an intentional attempt due to her personal issues.

On presentation to the hospital, the patient was observed with excess salivation, frothy secretions, and fatigue with several episodes of vomiting and diarrhea. She was unable to perceive any fetal movements. Physical examination showed that the patient was conscious and oriented. Pinpoint pupils were observed and were not reacting to light. Her vitals were examined such as blood pressure: 90/70 mmHg (120/90 mmHg), pulse rate: 102 beats/min (72 beats/min), and respiratory rate: 18 breaths/min (22 breaths/min). All these symptoms and abnormal vitals were considered as the clinical manifestations of organophosphate poisoning.

The management started with oral gastric lavage using charcoal (50 g) mixed with saline water (200 ml/wash). Following this, airway support was provided by administering nasal oxygen at the rate of 5 L/min and a nasogastric tube (Ryle's tube) was inserted to aspirate the toxic contents from the stomach. Then the patient was administered with 1 g pralidoxime (intravenous [IV] bolus) as loading dose immediately and shifted to a maintenance dose of 1 g mixed with 200 ml sodium chloride solution as IV infusion for 1 h (200 drops/min). Furthermore, 10 ampoules (1.2 mg each) of atropine sulfate were administered with 500 ml sodium chloride solution as IV infusion at the rate of 16 drops/min. Vigilant monitoring of the pupil size was recommended every 30 min. Fluids (500 ml dextrose sodium chloride, 1000 ml ringer lactate, and 500 ml dextrose) were administered at the rate of 100 ml/h as the patient was restricted from the oral diet. Laboratory investigation showed the electrolyte levels were normal, and hepatic enzymes levels were elevated. Leukocytosis was observed, which may be due to cholinergic stimulation. The other laboratory investigation reports were shown in [Table 1]. Cholinesterase estimation was not performed.
Table 1: Laboratory investigations details

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Fetoscopic examination recorded with no active fetal heart rate and fetal movements. Consequently, the gynecologist suspected intrauterine death and ordered for emergency fetal ultrasonography. The result showed the dead fetus at 16 weeks of pregnancy. Hence, the patient was requested for consent of the expulsion of dead fetus. Next day, she was administered with two units (10 IU/ml) of oxytocin for 6 h and misoprostol (600 µg) through intravaginal route for 4 h. The physician suggested continuing pralidoxime (500 mg) tid as IV bolus and atropine sulfate infusion at the rate of 4 drops/min

along with fluids. She delivered a baby. The patient complained of excessive vaginal bleeding on the 3rd day. Misoprostol 400 µg and one unit of oxytocin were prescribed along with the usual treatment to control bleeding. Pralidoxime administration was stopped, and atropine was advised to be administered until the cholinergic symptoms subsided. A semisolid diet was also advised. She has also given injection cefotaxime 1 g bd and injection ranitidine 50 mg bd which continued for the next 3 days along with fluids. A keen watch on vitals and fluid input-output chart was also suggested. On the day 7, vaginal bleeding subsided. She was discharged from the hospital with a prescription of Vitamin B complex tablet (Vitamin B1-2 mg, Vitamin B2-2 mg, niacinamide - 25 mg, and calcium - 1 mg), ferrous sulfate tablet (333 mg) bd, and ranitidine tablet 150 mg bd for 15 days and urged her to come for follow-up visits.


  Discussion Top


Chlorpyrifos (trade name: “Tricel”) is a type of organophosphate compound predominantly used in agriculture to control insects. This is easily available in this region, and the WHO reports that this compound belongs to the category II, which is described as moderately hazardous.[5] Since they can cross the placenta, fetotoxic effects in pregnant women even in nonlethal doses are very common.[1] This may be due to a slow rate of metabolism in the fetus and alterations in absorption, distribution, and detoxification system of pesticides in the fetus when compared with adults.[6],[7]

Pralidoxime and atropine (category C) were the drugs prescribed for this patient.[8],[9] The WHO supported the use of pralidoxime with a specific dose of 30 mg/kg bolus loading dose over 10-20 min followed by an 8-10 mg/kg/h infusion in pregnant women for seven days or until recovery.[4] The pralidoxime dose given to this patient was found in accordance with the above criteria. Being a nonteratogenic drug, the use of atropine is not restricted in pregnancy.[1] The mydriatic manifestation–a significant characteristic feature of excess atropinization was not observed in this patient.[1],[10]

The prescribed treatment was found in accord with standard criteria. As the early identification and quick management is very important to save the baby in pregnant cases, the late arrival of the patient at the hospital may account for the reason for fetotoxicity.[2] Estimation of cholinesterase enzyme would have led to a better optimization of treatment. Fruitful psychosocial education programs could prevent such intentional attempts to some extent, especially in young adults.

Acknowledgment

The authors acknowledge the support provided by the Government Headquarters Hospital, Udhagamandalam. Authors also acknowledge the Department of Science and Technology, New Delhi, India, for providing INSPIRE Fellowship to the first author (Ms. TH Indu, Research Scholar, JSS University, Mysore, India).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Solomon GM, Moodley J. Acute chlorpyrifos poisoning in pregnancy: A case report. Clin Toxicol (Phila) 2007;45:416-9.  Back to cited text no. 1
    
2.
Sun L, Li GQ, Yan PB, Liu Y, Li GF, Wei LQ. Clinical management of organophosphate poisoning in pregnancy. Am J Emerg Med 2015;33:305.e1-3.  Back to cited text no. 2
    
3.
Abhilash PC, Singh N. Pesticide use and application: An Indian scenario. J Hazard Mater 2009;165:1-12.  Back to cited text no. 3
    
4.
Bailey B. Are there teratogenic risks associated with antidotes used in the acute management of poisoned pregnant women? Birth Defects Res A Clin Mol Teratol 2003;67:133-40.  Back to cited text no. 4
    
5.
World Health Organization. International Programme on Chemical Safety. The WHO Recommended Classification of Pesticides by Hazard and Guidelines to Classification. Geneva, Switzerland: World Health Organization (WHO); 2009.  Back to cited text no. 5
    
6.
Samarawickrema N, Pathmeswaran A, Wickremasinghe R, Peiris-John R, Karunaratna M, Buckley N, et al. Fetal effects of environmental exposure of pregnant women to organophosphorus compounds in a rural farming community in Sri Lanka. Clin Toxicol (Phila) 2008;46:489-95.  Back to cited text no. 6
    
7.
Sebe A, Satar S, Alpay R, Kozaci N, Hilal A. Organophosphate poisoning associated with fetal death: A case study. Mt Sinai J Med 2005;72:354-6.  Back to cited text no. 7
    
8.
Jafarzadeh M, Nasrabadi ZN, Sheikhazadi A, Abbaspour A, Vasigh S, Yousefinejad V, et al. Is there a role for progesterone in the management of acute organophosphate poisoning during pregnancy? Med Hypotheses 2013;80:804-5.  Back to cited text no. 8
    
9.
Kamha AA, Al Omary IY, Zalabany HA, Hanssens Y, Adheir FS. Organophosphate poisoning in pregnancy: A case report. Basic Clin Pharmacol Toxicol 2005;96:397-8.  Back to cited text no. 9
    
10.
Shah AM, Chattopadhyay A, Khambadkone SM, Dixit KM, Irani SF. Neonatal mydriasis due to effects of atropine used for maternal Tik-20 poisoning. J Postgrad Med 1995;41:21-2.  Back to cited text no. 10
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