Adverse birth outcomes in women exposed to Syrian chemical attack
Authors: Omar Hakeem, Sawsan Jabri
Journal: The Lancet Global Health (2015)

The city of Moadamyah, Syria, is one of the areas affected by a chemical attack on Aug 21, 2013. While the acute exposure resulted in several deaths, the long-term consequences are still unfolding. One of the observations we are witnessing is adverse effects on pregnant women and their offspring. Our review of the medical records of the last months of 2014 has shown a high rate of spontaneous miscarriages, stillbirths, and birth defects among children born to women who had past exposure to the chemical warfare gases used in the attack. Of the 211 pregnant women who visited Al Ghouta Hospital during September, October, and November of 2014, 110 had a history of self-reported exposure to the chemical attack; 101 were not exposed. There were 49 miscarriages (45%) in the exposed group (38 in the first trimester, 11 in the second trimester) compared with 14 (14%) in the non-exposed women. The usual proportion of known pregnancies ending in spontaneous miscarriage is 10–15%.2ADAM Medical EncyclopediaMiscarriage.http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002458/Google Scholar There were four premature births (<37 weeks' gestation; two of them died shortly after birth) and three stillbirths (≥28 weeks' gestation) in the group of women with a history of exposure to gases, compared with none in the unexposed group. According to WHO statistics, the rate of stillbirth in Syria in 2009 was 12·4 per 1000 births;3WHOCountry stillbirth rates per 1000 total births for 2009.http://www.who.int/pmnch/media/news/2011/stillbirths_countryrates.pdfGoogle Scholar our findings (three of 211 births) equates to a rate of 14·2 per 1000 births, all of which were among the exposed group (which makes the rate 27·2 per 1000 births). Congenital anomalies and birth defects affect an estimated one in 33 infants globally.4WHOCongenital anomalies: fact sheet no 370.http://www.who.int/mediacentre/factsheets/fs370/en/Google Scholar Seven women exposed to the attack delivered neonates with malformations during the same 3-month period, of whom five died after a few hours to a few days and the other two survived—one with cardiac abnormalities and the other with cerebral oedema. Clinical findings among the babies who died included multiple malformations of the head and spinal cord, absence of the occipital and parietal bones of the skull, small brain size with a large amount of fluid between the skull and scalp, dissecting skin in many areas of the body, and many clots in the umbilical cord. Although many factors intertwine in the cause of spontaneous abortion, stillbirth, and birth defects, our data suggest an increased incidence of these complications in women exposed to chemical attacks compared with women who were not exposed, and to the previous available statistics on Syria. Although the immediate life-threatening effects of chemical gases used in the chemical attack were easy to identify, the long-term consequences are harder to recognise.1Yanai J Pinkas A Seidler FJ et al.Neurobehavioral teratogenicity of sarin in an avian model.Neurotoxicol Teratol. 2009; 31: 406-412Crossref PubMed Scopus (7) Google Scholar These consequences could be seen in particular among pregnant women and young children because of the higher vulnerability of the developing brain to neurotoxic insult.1Yanai J Pinkas A Seidler FJ et al.Neurobehavioral teratogenicity of sarin in an avian model.Neurotoxicol Teratol. 2009; 31: 406-412Crossref PubMed Scopus (7) Google Scholar Detection is even harder because of the limited resources for laboratory examinations and environmental detection of the chemical warfare agent's residue5Tak V Purohit A Pardasani D Goud DR Jain R Dubey DK Simultaneous detection and identification of precursors, degradation and co-products of chemical warfare agents in drinking water by ultra-high performance liquid chromatography-quadrupole time-of-flight mass spectrometry.J Chromatogr A. 2014; 1370: 80-92Crossref PubMed Scopus (15) Google Scholar that the area is suffering from. We will keep closely monitoring the maternal record and update our information. We declare no competing interests.