Malaria in Pregnancy, Diagnosis and Treatment Flashcards
Malaria burden in UK Cases per year % due to plasmodium falciparum deaths per year % moratlity
- 1500 per year
- 75 % falciparum
- 5-15 deaths per year
- 0.5 -1 % mortality
Malaria burden in UK in pregnancy
prevalence
death in pregnancy
- unknown
- no reported in last 10 yeaars
adverse effects of malaria on pregnancy
A- systemic infection = any febrile illness 1 - Maternal/fetal morbidity 2 - Miscarriage 3 - Still birth 4 - Premature birth
B- Parasitization itself 1 - FGR 2 - LBW 3 - Fetal anemia 4 - Interaction with HIV 5 - Susceptibility of infant to malaria
Why falciparum greater morbidity & mortality
( principally LBW & Anemia)
1- Cyto-adherence (infected erythrocytes) and rosetting (adherence of uninfected erythrocytes)-microccirculation of vital organs.
2- placental sqequestration
UK definition of complicated malaria
- <2 % complicated malaria or - No sins of severity or -m no complications
severe and complicated malaria
- severe signs non specific
- diagnosis of exclusion
- parasetemia degree: can be <2 %,
- > /=2 %
higher risk of severity so severe malaria protocol
congenital malaria
in utero or during delivery not by anopheles bite
clinical manifestation of severe or complicated malaria
GENERAL: prostration
RESPIRATORY the commonest in pregnant severe/complicated: Resp distress (acidotic breathing, ARDS) Pulmonary edema (including radiological)
CNS: impaired consciousness, multiple convulsions
CVS: shock (BP<90/60), abnormal bleeding, DIC
LIVER: jaundice
KIDNEY: hemoglobinuria (without G6PD deficiency)
Laboratory criteria of severe or complicated malaria
Blood suagr: < 2.2mmol/l (commonest in pregnant severe/complicated)
Algid malaria: Gram -ve septicemia (commonest in pregnant severe/complicated)
CBC: Hb < 8 g/dl, Thrombocytopenia
ABG: pH <7.3, Hyperlactemia (correlates mortality)
KIDNEY: Oliguria <0.4 ml/kg/hour or creatinine >265 mmol/l
LP: to exclude menigitis
challenges in diagnosis of malaria
- no specific s/s, may like flu
- Hx of travel may be > 1 year in PUO
- rapid detection test: may miss low parasetemia, >pregnant . rel insensitive to P. vivax
- taken prophylaxis: parasetemia below detection
- High immunity: -ve thick film, but parasetemia, unexplained anemia from endemic
diagnosis of malaria
- microscopic thin/thick smear
In febrile: 3 -ve smears 12-24 hoursapart rule out diagnosis
symptoms of malaria
History and examination –in malaria
- no symptoms or sign can accurately predict malaria.
GENERAL:
- Flu-like illness with fever/chills/sweats,
- headache
- muscle pain
- malaise
GIT:
- Nausea/ vomiting
- diarrhea
Respiratory:
- Cough
signs of malaria
GENERAL
- elevated temp
- perspiration
HEMOLYSIS:
- pallor
- jaundice
- splenomagally
RESP:
- resp distess
prognostic indicators of malaria and advantage
- clinical condition most important indicator of severity
- parasetemia
- Aid to MX & predicts fatality
- Other important prog indicators
- &count of mature trophozoite & schzonts PFalci
- malaria pigment >5 % of PMN leukocyte in smear
case fatality of malaria
- non-falciparum rarely fatal but caution
FACIPARUM
- Uncomplicated: 0.1 %
- severe: 15 -20 % in non-pregnant, 50 % in pregnant
- 2 -10 times higher in pregnant >non pregnant, in endemic areas
where to admit malaria in pregnancy
- Treat malaria in pregnancy as an emergency.
- uncomplicated malaria: to hospital
- severe complicated: intensive care unit.
Do not persist with oral therapy if vomiting is persistent.
Treat the fever with antipyretics.
Screen women with malaria for anaemia and treat appropriately.
Write a management plan for follow-up, to ensure detection of relapse.
Drug treatment in malaria
severe falciparum malaria:
- Intravenous artesunate
- Intravenous quinine if artesunate not available.
uncomplicated P. falciparum (or mixed, ( P. falci& P. vivax). - quinine and clindamycin
P. vivax, P. ovale or P. malariae
- chloroquine
Primaquine should not be used in pregnancy.
Seek advice from infectious diseases specialists, especially for severe and recurrent cases.
severe falciparum malaria treatment or any species
- Artesunate IV 2.4 mg/kg at 0, 12 and 24 hours, then daily thereafter.regardless of EGA
- Well enough: switch to oral artesunate 2 mg/kg (or IM artesunate 2.4 mg/kg) once daily,……………………plus clindamycin.
ALTERNATIVELY:
- Quinine IV 20 mg/kg loading dose (no loading dose if already quinine or mefloquine) in 5% dextrose over 4 hours and then
- 10 mg/kg IV over 4 hrs/ 8 hours + clindamycin IV 450 mg every 8 hours (max. dose quinine 1.4 g). (vomiting with noncomplicated falciparum)
- well enough: switch to oral quinine 600 mg 3 times a day to complete 5–7 days and oral clindamycin
450 mg 3 times a day 7 days
- If oral artesunate is not available, for severe complicated malaria
or
Uncomplicated malaria P. falciparum
Resistant P. vivax
7-day course of
- Oral quinine 600 mg 8 hourly and clindamycin at 450 mg 3 times a day 7 days.(after EGA <13 weeks)
3-day course of
- Riamet®(GSK) 20 mg/120 mg artemether & lumefantrine 4 tablets/dose for weight > 35 kg, twice daily for 3 days (with fat)
or
- atovaquone-proguanil (Malarone®, Novartis) 4 standard tablets daily for 3 days.or
quinine dosing if
- IV therapy extends more than 48 hours
- renal or
- hepatic dysfunction.
- reduced to 12-hourly
- severe and recurrent hypoglycaemia in late pregnancy.
- Preventing relapse (P. vivax/ovale) after treatment DURING pregnancy
- Preventing relapse AFTER delivery
- Chloroquine oral 300 mg weekly until delivery
- Postpone until 3 months after delivery & G6PD testing
primaquine
- P. ovale
- P. vivax
- Oral primaquine 15 mg single daily dose for 14 days
- Oral primaquine 30 mg single daily dose for 14 days
G6PD (mild) for P. vivax or P. ovale
Primaquine oral 45–60 mg once a week for 8 weeks
suspect malaria
- Febrile or ill pregnant with history of travel or residence in malaria area (tropics or sub-tropics) should be assessed urgently (incubation for non-falciparum malaria may occasionally be > 6 months)
● Recent return (3 weeks): check infection control requirements with microbiologist e.g. viral
haemorrhagic fever, avian influenza or severe acute respiratory syndrome
● Chemoprophylaxis is not 100% effective, (parasetemia below detection)
● Pregnant women with malaria can deteriorate very rapidly,( take as emergency)
● Expert advice specialist with current experience: MX strongly advised
● Notify all cases to local health protection unit, send blood film to reference laboratory
How to avoid mortality
- Early diagnosis,
- assessment of severity and
- treatment
is vital to avoid malaria deaths
Urgent investigations in malaria
- thick and thin blood films and
- malaria rapid antigen tests. Send to a laboratory immediately and ask for a result in 1 hour.
- FBC,
- blood glucose (imparied consciousness or seizures),
- U&E,
- LFT,
- blood culture,
- urine dipstick;
if indicated,
- stool test,
- chest X-ray (precautions apply),
- obstetric ultrasound (EGA)
No evidence of malaria in blood film
- (Single negative test does not exclude malaria)
- Stop prophylaxis until malaria excluded
- Avoid empirical therapy unless severe illness:
- seek expert advice
- Repeat blood film daily 2 days
- Malaria unlikely if 3 negative blood films
- Finish chemoprohylaxis
Complicated malaria:
one or more of following:
1 ● Impaired consciousness ( GCS & NSQ) or seizures
2 ● Hypoglycaemia
3 ● Pulmonary oedema or ARDS
4 ● ≥ 2% parasitised RBC but can lower severe malaria
5 ● Severe anaemia (Hb < 8.0 g/dl)
6 ● Abnormal bleeding/DIC
7 ● Haemoglobinuria (without G6PD deficiency)
8 ● Renal impairment/electrolyte disturbance ( pH < 7.3)
9 ● Hyperlactataemia (correlates with mortality)
10 ● Shock (algid malaria) – consider Gram negative
septicaemia
Non-falciparum malaria treatment
- Chloroquine (base) 600 mg orally
- followed by 300 mg 6–8 hours later.
- Then 300 mg day 2, and again day 3
what are 4 complications more common & severe in pregnant than non pregnant
- hypoglycemia
- pulmonary edema
- severe anemia
- sec. bacterial anemia
hypoglycemia in malaria in pregnancy
- commonly asymptomatic, may with fetal bradycardia
(other signs of FD). - most severely ill, associated with lactic acidosis & high mortality
QUININE INDUCED HYPOGLYCEMIA
- usual manifestations: abnormal behaviour, sweating &
sudden loss of consciousness are the .
- caused by hyperinsulinaemia and
- most common and important adverse effect of drug.
- profound, recurrent and intractable SO regular
monitoring
- may present late in d/z, Pt recovering.
- treatment doses: not induce abortion or labour.
Pulmonary oedema in malaria in pregnancy
- may be present on admission or
- may develop suddenly and unexpectedly
- immediately after childbirth.
- grave complication of severe malaria,
- high mortality of over 50%.
- first indication of impending PE: Tachypnea before any chest signs
Iatrogenic fluid overload: monitor CVP & urine output.
- In some: ARDS addition to PE
- Once develops, fluidrestriction
