Malaria in Pregnancy, Diagnosis and Treatment Flashcards
(32 cards)
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
