Pregnancy ribavirin

Approximately 10-20% of patients experience a dose-dependent hemolytic anemia that may be dose-limiting. Other side effects are depression, fatigue, irritability, rash, cough, insomnia, nausea, and pruritus. Absolute contraindications to ribavirin therapy include anemia, end-stage renal failure, severe heart disease, and pregnancy. Ribavirin is both teratogenic in animals and mutagenic in mammalian cells. 

Use with ribavirin Ribavirin may cause birth defects and/or death of the fetus. Extreme care must be taken to avoid pregnancy in female patients and in female partners of male patients. Ribavirin causes hemolytic anemia. The anemia associated with ribavirin therapy may result in a worsening of cardiac disease. Ribavirin is genotoxic and mutagenic and should be considered a potential carcinogen. 

If pregnancy occurs in a patient or partner of a patient during treatment or during the 6 months after treatment cessation, such cases should be reported to the ribavirin tablet Pregnancy Registry at (800) 526-6367. 

D. Acyclovir is in pregnancy category B animal studies have shown no evidence of harm to the fetus, but no large, controlled studies of human outcomes have been performed. Cidofovir may be used to treat HSV that is resistant to acyclovir however, it is embryotoxic and teratogenic, and Ms. Doe should avoid it. Docosanol is used for cold sores and is not indicated for ophthalmic use. Fomivirsen is effective against CMV retinitis, not HSV keratitis. Ribavirin is indicated for RSV infection and is also mutagenic, teratogenic, and embryotoxic. 

Contraindications Autoimmune hepatitis, creatinine clearance less than 50 ml/min, hemoglobinopathies, hepatic decompensation, hypersensitivity to ribavirin products, pregnancy, significant or unstable cardiac disease... 

Adverse effects Side effects reported for oral or parenteral use of ribavirin have included dose-dependent transient anemia in Lassa fever victims. Elevated bilirubin has been reported. The aerosol may be safer, although respiratory function in infants can deteriorate quickly after initiation of aerosol treatment and therefore, monitoring is essential. Because of teratogenic effects in experimental animals, ribavirin is contraindicated in pregnancy. 

Significant ribavirin side effects include anemia and hyperbilirubinemia due to mild hemolysis and a reversible block of erythropoiesis. A published study in Sierra Leone and unpublished limited trials in West Africa reported that none of the patients with anemia required transfusions. Although ribavirin is contraindicated in pregnancy, pregnant women with confirmed Lassa fever should receive ribavirin because fetal death is nearly inevitable (95%) and because evacuation of uterine contents significantly increases the pregnant patient s chances of survival (48,56). Safety of ribavirin for children and infants is not well established (48). 

Pregnant women should not directly care for patients receiving ribavirin aerosol (FDA pregnancy category X). 

Clinical use and toxicity Ribavirin is used in aerosol form for respiratory syncytial virus infections. Early intravenous administration decreases mortality in Lassa fever and other viral hemorrhagic fevers. Ribavirin has recently been shown to have efficacy in treatment of hepatitis C viral infections. Aerosol ribavirin may cause conjunctival or bronchial irritation. Systemic use results in dose-dependent myelosuppression. Ribavirin is a known human teratogen. absolutely contraindicated in pregnancy. 

Roberts SS, Miller RK, Jones JK, Lindsay KL, Greene MF, Maddrey WC, Williams IT, Liu J, Spiegel RJ. The Ribavirin Pregnancy Registry findings after 5 years of enrollment, 2003-2009. Birth Defects Res A Clin Mol Teratol 2010 88 (7) 551-9. 

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