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MRCOG Part 2 > Malaria in Pregnancy - GT 54a and 54b > Flashcards

Malaria in Pregnancy - GT 54a and 54b Flashcards

1
Q

How many cases/year of malaria are reported in the UK?

A

1500

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2
Q

What % of cases are due to Plasmodium falciparum?

A

75%

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3
Q

What is the overall mortality rate from malaria?

A

0.5-1%

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4
Q

What is rosetting in malaria?

A

Adherence of non-infected RBCs interfering with microcirculatory flow

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5
Q

What is the hallmark of Falciparum infection in pregnancy?

A

Sequestration of parasites in the placenta - evade splenic filtering and processing
Does not happen in benign types of malaria

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6
Q

From what do the adverse effects of malaria in pregnancy result?

A
  • Systemic infection, i.e. the same as any severe febrile illness in pregnancy
  • Parasitisation itself - FGR/LBW, mat anaemia,interaction with HIV, infant susceptibility to malaria
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7
Q

Which subtype of malaria is not as benign as previously thought?

A

Plasmodium vivax

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8
Q

At what % parasitised blood cells should women be treated as severe malaria?

A

> 2% (otherwise - uncomplicated malaria if less and no signs of severity)

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9
Q

What are the clinical manifestations of severe malaria?

A
  • Prostration
  • Impaired consciousness/convulsions
  • Resp distress/pul oedema**
  • Circulatory collapse
  • DIC
  • Jaundice
  • Haemoglobinuria (without G6PD deficiency)
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10
Q

What are the lab tests with severe malaria?

A
  • Hb <8
  • Thrombocytopenia
  • BM <2.2**
  • pH <7.3, raised lactate
  • Oliguria or Creat >265
  • Hyperparasitaemia >2%
  • Gram neg septicaemia**

Should perform LP to exclude meningitis

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11
Q

What is algid malaria?

A

Associated with gram neg septicaemia

Often involves GI viscera

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12
Q

How is malaria in pregnancy diagnosed?

A

Microscopy - thick and thin blood films (gold standard)

Rapid diagnostic test - may miss low parasitaemia

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13
Q

What is the fatality rate from severe malaria in pregnant and non-pregnant?

A

Pregnant - 50%

Non-pregnant- 15-20%

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14
Q

Where should patients be admitted with malaria in pregnancy?

A

Uncomplicated - to hospital

Severe - to ITU

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15
Q

What is the treatment for severe falciparum malaria in pregnancy?

A

IV artesunate 2.4mg/kg at 0, 12, 24 then OD
Then when well PO/IM artesunate + clindamycin
IV quinine if not available (but doesn’t kill sequestered parasites)

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16
Q

What is the treatment for uncomplicated falciparum (or combined) malaria in pregnancy?

A

Quinine 600mg TDS and clindamycin 450mg TDS PO for 7/7

Give IV if vomiting ++

17
Q

What is the treatment for P vivax, ovale or malariae?

A

PO chloroquine

18
Q

Which antimalarial should be avoided in pregnancy and why?

A

Primaquine

Can induce methaemoglobinaemia and haemolysis in the fetus

19
Q

Which antimalarial is associated with severe recurrent hypoglyacaemia in late pregnancy?

A

Quinine

20
Q

What are the alternative antimalarials for falciparum malaria?

A

Riamet

Malarone (Atovaquone-proguanil)

21
Q

What is chinconism and which drug causes it?

A

Quinine 7/7

Tinnitus, headache, nausea, diarrhoea, altered auditory acuity and blurred vision

22
Q

When does most recurrence occur with malaria?

A

Day 28-42 but can see late recurrence unique to pregnancy - 85-121 days

Therefore weekly blood films until delivery

23
Q

What is the treatment for recurrence of malaria in pregnancy?

A

Atovaquone-proguanil (Malarone)
Dihydroartemisinin-piperaquine

Particularly if quinine/clinda failed as first line

24
Q

What is the treatment of severe anaemia in severe malaria in pregnancy?

A

Slow blood transfusion

Ideally with 20mg frusemide IV

25
Q

What should be suspected if a patient with severe malaria becomes hypotensive?

A

Secondary bacterial infection

26
Q

Which antimalarials should be used to prevent relapse during and after pregnancy?

A

During - Chloroquine 300mg PO weekly

After- postpone 3/12 and after G6PD testing (provides resistance)

27
Q

What are the obstetric complications of malaria?

A

Preterm labour
FGR
Fetal heart rate abnormalities
Thrombocytopenia if acute

28
Q

When should placental histology be sent in malaria?

A

Peripartum malaria

Also send cord and baby blood film

29
Q

What antenatal care should be given following an episode of malaria in pregnancy?

A

Regular Hb
Platelets
Glucose
Growth scans

30
Q

When does vertical transmission occur in malaria?

A

Either during pregnancy or at time of birth

31
Q

How often should a neonate be screened if malarial parasites are identified in the placenta?

A

Weekly until 28/7

32
Q

By how much does IV artesunate reduce mortality compared to quinine?

A

35%

Not resistance - but kills the sequestered parasites

33
Q

What is premunition?

A

The degree of naturally acquired host immunity to malaria - low in UK residents and high susceptibility

Depends on repeated exposure to infectious anopheline bites

34
Q

What is the risk of contracting malaria without chemoprophylaxis during a 1 month stay in:

1 Oceania
2 Subsaharan Africa
3 Indian subcontinent/southeast Asia?

A

1 Oceania 1:20
2 Subsaharan Africa 1:50
3 Indian subcontinent/southeast Asia 1:500

35
Q

In what % of cord bloods was DEET detected following application in pregnancy?

A

8% no apparent adverse effects

36
Q

How long should chemoprophylaxis be continued after leaving an endemic area for malaria?

A

If causal Rx - 7/7 (eg Malarone)

If suppressive Rx - 4/52 (e.g. Mefloquine)

37
Q

What is the recommended chemoprophylaxis for malaria in pregnancy?

A

T2/T3 Mefloquine; may be justified in T1
Caution re: neuropsychiatric effects

Atovaquone and proguanil (Malarone®) potentially good but insufficient safety data

38
Q

Which malarial chemoprophylaxis is contraindicated in pregnancy?

A

Doxycycline - bone growth, teeth discoloration in T3, congenital cataract
Primaquine - haemolysis especially in G6PD deficiency

MRCOG Part 2 (97 decks)

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