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Bushra's obstetrics > Malaria in Pregnancy, Diagnosis and Treatment > Flashcards

Malaria in Pregnancy, Diagnosis and Treatment Flashcards

1
Q 
Malaria burden in UK 
Cases per year
% due to plasmodium falciparum
deaths per year
% moratlity
A
  • 1500 per year
  • 75 % falciparum
  • 5-15 deaths per year
  • 0.5 -1 % mortality
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2
Q

Malaria burden in UK in pregnancy
prevalence
death in pregnancy

A
  • unknown

- no reported in last 10 yeaars

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3
Q

adverse effects of malaria on pregnancy

A 
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
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4
Q

Why falciparum greater morbidity & mortality

A

( principally LBW & Anemia)

1- Cyto-adherence (infected erythrocytes) and rosetting (adherence of uninfected erythrocytes)-microccirculation of vital organs.

2- placental sqequestration

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5
Q

UK definition of complicated malaria

A 
- <2 % complicated malaria
or
- No sins of severity
or
-m no complications
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6
Q

severe and complicated malaria

A
  • severe signs non specific
  • diagnosis of exclusion
  • parasetemia degree: can be <2 %,
  • > /=2 %
    higher risk of severity so severe malaria protocol
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7
Q

congenital malaria

A

in utero or during delivery not by anopheles bite

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8
Q

clinical manifestation of severe or complicated malaria

A

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)

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9
Q

Laboratory criteria of severe or complicated malaria

A

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

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10
Q

challenges in diagnosis of malaria

A
  • 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
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11
Q

diagnosis of malaria

A
  • microscopic thin/thick smear

In febrile: 3 -ve smears 12-24 hoursapart rule out diagnosis

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12
Q

symptoms of malaria

History and examination –in malaria

A
  • 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

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13
Q

signs of malaria

A

GENERAL

  • elevated temp
  • perspiration

HEMOLYSIS:

  • pallor
  • jaundice
  • splenomagally

RESP:
- resp distess

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14
Q

prognostic indicators of malaria and advantage

A
  • 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
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15
Q

case fatality of malaria

A
  • 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
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16
Q

where to admit malaria in pregnancy

A
  • 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.

17
Q

Drug treatment in malaria

A

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.

18
Q

severe falciparum malaria treatment or any species

A
  • 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
19
Q
  • If oral artesunate is not available, for severe complicated malaria
    or
    Uncomplicated malaria P. falciparum

Resistant P. vivax

A

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

20
Q

quinine dosing if

  • IV therapy extends more than 48 hours
  • renal or
  • hepatic dysfunction.
A
  • reduced to 12-hourly

- severe and recurrent hypoglycaemia in late pregnancy.

21
Q
  • Preventing relapse (P. vivax/ovale) after treatment DURING pregnancy
  • Preventing relapse AFTER delivery
A
  • Chloroquine oral 300 mg weekly until delivery

- Postpone until 3 months after delivery & G6PD testing
primaquine

22
Q
  • P. ovale

- P. vivax

A
  • Oral primaquine 15 mg single daily dose for 14 days

- Oral primaquine 30 mg single daily dose for 14 days

23
Q

G6PD (mild) for P. vivax or P. ovale

A

Primaquine oral 45–60 mg once a week for 8 weeks

24
Q

suspect malaria

A
  • 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
25
Q

How to avoid mortality

A
  • Early diagnosis,
  • assessment of severity and
  • treatment
    is vital to avoid malaria deaths
26
Q

Urgent investigations in malaria

A
  • 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)
27
Q

No evidence of malaria in blood film

A
  • (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
28
Q

Complicated malaria:

A

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

29
Q

Non-falciparum malaria treatment

A
  • Chloroquine (base) 600 mg orally
  • followed by 300 mg 6–8 hours later.
  • Then 300 mg day 2, and again day 3
30
Q

what are 4 complications more common & severe in pregnant than non pregnant

A
  • hypoglycemia
  • pulmonary edema
  • severe anemia
  • sec. bacterial anemia
31
Q

hypoglycemia in malaria in pregnancy

A
  • 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.
32
Q

Pulmonary oedema in malaria in pregnancy

A
  • 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

Bushra's obstetrics (54 decks)

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