Malaria & Zika In Pregnancy Flashcards by Siba Kherbek

Malaria / Zika
Are caused by…?

Malaria:
Bit of female anopheles mosquito /
NIGHT
Zika :
Aedes / daylight- mid morning- late afternoon

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Why maternal infection with malaria is important?

Because it is life threatening infection BUT preventable
⚠️ NO PROPHYLAXIS REGIMEN 100% PROTECTIVE

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What are the maternal risks of malaria infection?

1- high mortality
2- high morbidity
3- miscarriage
4- preterm labour DOUBLED 🚩🚩

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What are the fetal risks of maternal infection with malaria?

1- IUFD
2-IUGR malaria is:
[responsible for >50% of FGR]
*Most babies will be normal birth
weight
3- abnormal CTG
4- hydrops

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How to prevent the maternal infection with malaria?

A B C D
A : awareness of risk :
( postponing a trip to endemic countries ) + inform about any fever or flu like upon returning home up to 1 year
B : bite prevention
C : chemoprophylaxis
D : diagnosis & treatment

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What are the countries that have the risk of contracting malaria infection during stay in without chemoprophylaxis?

1- Oceania 1 /20 ( Solomon islands)
2- Africa 1/50
3- India 1/500
4- south America 1/2500
5- Caribbean / Mexican 1/10,000

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Afro Caribbean with Duffy negative blood group antigen are less susceptible to a particular bacterial infection, what is it?

Plasmodium vivax

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Women with sickle cell trait are less susceptible to a particular bacterial infection, what is it?

Plasmodium falciparum

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Women with G6PD deficiency are less susceptible to a particular bacterial infection, what is it?

Plasmodium falciparum

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Why is p. Falciparum the most risky kind of malaria in pregnancy?

Because: parasite sequestration in placenta 👉 evade host defense
* most malaria mortality caused by falciparum

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What is the mortality rate in malaria? What is the sign correlate with mortality?

0.5 - 1 % [ 79% due to falciparum]
2 - 10 times higher in pregnant
⚠️LACTETAMIA correlate with mortality

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How to prevent bites to reduce the risk of malaria during traveling?

1- use insect repellent regularly
DEET[ SAFE IN PREGNANCY ]
/ Picaridin
2- wear light colored clothes covering the body
3- physical barriers: window screens
4- cover water containers / flower pots

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What is the role of vit B12 / garlic / tea tree oil… as insect repellents?

NOT RECOMMENDED
Only DEET 50%
( MAY Lower sun protection factor 👉 use higher sun cream)

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What is the role of citronella oil as insect repellent ?

Very short duration of action

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What is the duration of action for nets impregnated with permethrin?

6 months
Efficiency 50%

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What are the cautions about conceiving while on chemoprophylaxis of malaria ?

⚠️ADVICE: wait for complete exertion of the drug before pregnancy
ℹ if pregnancy occurs while taking these drugs 👉 NOT TOP
( low risk of Teratogenicity)

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What are the duration of exertion for each drug: Mefloquine- doxycycline- malarone ( atorvaquine/proguanil)- proguanil ?

Mefloquine 3 months
Doxycycline 1 week
Malarone(atorvaquine/proguanil)
2 weeks
Preguanil 1 week

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What are the malaria chemoprophylaxis protocols ?

🚩Causal prophylaxis: against liver stage: MALARONE ( atorvaquone- proguanil) to be continued 7 days after leaving a malarious area

🚩Suppressive prophylaxis: against RBCs stage: Mefloquine 5mg/ week
: to be continued 4 w after leaving a malarious area

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What is the drug of choice for chloroquine resistant?
Ist it safe during pregnancy?
What are the contraindications ? What is the substitute?

MEFLOQUINE 5mg / kg / week
* safe in 2nd&3rd trimester(also 1st)
* NOT ⬆️ stillbirth or CMFs
* contraindications: current or previous depression/ neuropsychiatric/ epilepsy
* alternatives: Malarone ( proguanil- atorvaquone)

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Which drugs of malaria chemoprophylaxis are contraindicated in pregnancy?

1- Doxycycline: 👉 irreversible teeth coloration + congenital cataract ( 3rd trimester)
2- Primaquine : hemolysis (esp:G6PD deficiency )

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If the pregnant woman feels flu like symptoms or temperature > 38 in a travel to malarious area, what is the management?

Standby treatment ( emergency treatment) if malaria is suspected *
🚩Quinine + clindamycin 🚩
[ in the bag😊]
Commence Mefloquine 1 week after the last dose ( prophylaxis)

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If the pregnant woman has vomiting after the oral dose of standby treatment, of malaria, ( Quinine + clindamycin) how to manage?

<30 min 👉 primprane + full dose
30 - 60 min 👉 primprane + half dose

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How to suspect infection with malaria?

1- Pyrexia of unknown origin PUO
+ history of travel to endemic areas
2- history of travel > 1 year of onset of symptoms
3- taking prophylaxis + compliance 👉 not rule out malaria

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What is the most common reason of death from malaria?

Misdiagnosis & delay of treatment

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What are the symptoms of malaria?

No specific specific symptoms - flu like symptoms - fever- chills- night sweats - muscle pain- cough - NVH

What is the gold standard investigation of malaria?

Malaria blood film ( thick & thin )

What is the role of rapid detection tests for specific parasite AG & enzyme in diagnosing malaria?

1- may miss : low parasitaemia 2- insensitive in VIVAX 3- less sensitive than blood film ℹ if rapid test positive 👉 microscopy to confirm species, stage of parasite, quantify parasitaemia

When to rule out diagnosis of malaria?

Afebrile + 3 negative smears 12 - 24 hours apart

Why it is necessary to repeat smears to make sure the patient doesn't have malaria?

1- patients who are taking prophylaxis may their parasitaemia suppressed below the level of microscopic detection 2- pregnant may have negative blood thick films but parasites remain sequestered in the placenta

When to diagnose Uncomplicated Malaria? What is the fatality rate ?

1- < 2 % parasitized RBCs 2- no signs of severity & no complicating features ℹ fatality rate 0.1 % for falciparum

What is the drug treatment for Uncomplicated malaria?

* P falciparum: Oral Quinine + oral clindamycin ( standby treatment) 7 DAYS ⚠️ vomiting + no signs of severity or complicated 👉 IV Quinine + IV clindamycin

When to diagnose severe & complicated malaria? What is the fatality rate?

1- parasitaemia >= 2% of RBCs OR --- 2- high risk of developing severe malaria: (anaemic/ HIV+) even if < 2% ℹ fatality rate 15 - 20 % non pregnant 50 % in pregnancy

What is the drug treatment of severe & complicated malaria?

Artesunate IV Switch to oral artesunate + clindamycin ONCE able to oral * ALTERNATIVE: IV Quinine in 5% dextrose+ IV clindamycin

What are the features of complicated malaria?

M A L A R I A M : metabolic acidosis ⬆️ lactate A: anaemia Hb < 8 L: lungs: pulmonary edema/ ARDS A: altered consciousness: confusion R: reduced Glucose I: Infant death A: acute renal failure⬇️ urine output Black urine

Where to manage a pregnant woman with malaria?

1- falciparum 👉 admission Uncomplicated: hospital Severe: ICU 2- non falciparum: out patient admission only for compliance: vomiting

What are the side effects of Quinine?

Cinchonism: tinnitus- headache- nausea- vomiting- diarrhea. * blurred vision * altered auditory acuity * low focus * hypoglycemia

What is the management in a pregnant woman with malaria in each case : - severe falciparum - Uncomplicated falciparum - mixed ( falciparum + other type) - vivax / ovale/ malaria

🚩 blood film every 24h ( clinical deterioration is an indication for repeat blood film) * severe falciparum: IV artesunate ( IVQuinine if artesunate not available) * Uncomplicated falciparum: Quinine + clindamycin * mixed : Quinine + clindamycin * others: chloroquine

What is the prevalence of anaemia in pregnant women with falciparum malaria?

90 % hb < 10 👉 ferrous sulfate + folic acid

If fetal compromise has happened in a woman with malaria,how to manage?

MDT to plan optimal management

How to monitor the fetus in maternal sever malaria?

By CTG Particularly in the presence of fever

How acute malaria affects mean blood loss ?

Acute malaria 👉 thrombocytopenia 👉 ⬆️ mean blood loss ⚠️ NO CONFIRMED ⬆️ risk of PPH

Is malaria an indication of IOL ( induction of labour)?

Uncomplicated malaria NOT indication of IOL

Is there a role of an early CS in severe malaria if the fetus is viable?

UNPROVEN

If thromboprophylaxis is indicated in pregnant with malaria, when to withheld the treatment?

If PLT count < 100,000 Or is falling

When is the recurrence of malaria usually happened, how to lower that risk , what is the treatment in pregnancy?

*🚩 most recurrence 28 - 42 days *🚩 to lower the risk: weekly blood film 👉 early detection Repeat blood film if fever returns *🚩treatment:Quinine +clindamycin If failed: artesunate + clindamycin For 7 days

How to monitor a pregnant woman who is undergoing treatment of malaria?

WEEKLY : 1-blood film 2- regular antenatal care 3- hb + plt + glucose 4- BP : increased risk of PET when the infection affects the placenta

What is the prevalence of congenital malaria in the case of maternal malaria infection ? What are the ways of transmission?

8 -33% Transmission: at the time of birth During pregnancy ⚠️ HIGHER RISK: infection at the time of delivery

If the mother developed malaria during pregnancy, how to monitor the neonate?

Thick & thin blood film at birth WEEKLY for 28 days

If circulatory collapse has happened in a pregnant with any species of malaria, what is the management?

ADMISSION + IV artesunate

Pregnant + arrived from endemic + malaria prophylaxis + unexplained anemia + negative blood film , what is the reason?

Falciparum placental sequestration

What does Algid malaria mean?

Malaria + G positive septicemia Or collapse Or hypotension

Which antimalarial drug is contraindicated in G6PD deficiency?

Primaquine

How long the immunity against malaria last?

2 years

What type of viruses is Zika? What are the ways of transmission of Zika virus?

Flavivirus 1- bite of Aedes mosquito ( same that transmits yellow fever) 2- sexual transmission ( presence in semen) male 👉 female ⚠️ dosen't spread by social contact ( shaking hands- kissing) 3- vertical transmission: mother to baby

What are the symptoms of Zika virus infection?

80 % asymptomatic ( 3 - 12 days for symptoms to develop ) 1- fever - joint pain - headache 2- ichy maculopapular rash 3- conjunctivitis + eye pain ( retrobulbar) [ for 2 - 7 days]

What is the fatality rate of Zika virus infection?

Low Hospitalization is uncommon

If the pregnant has Zika infection, what is the main fetal risk? What is the incidence?

MICROCEPHALY 10% of pregnant with confirmed Zika infection

Zika virus has been detected in semen up to ....? For how long infectious?

188 days after symptoms onset / 6 months Infectious: 69 days / 2 months

What is the drug treatment of Zika virus?

No specific treatment Symptomatic ⚠️ Aspirin & NSAID avoided until dengue can be ruled out to lower the risk of haemorrhage

Does Zika virus transmit through breastfeeding?

NO EVIDENCE

When to suspct Zika virus infection?

Travel history + symptoms within 2 WEEKS of travel 👉 Zika test

If the mother is confirmed for Zika infection, how to move the fetus?

REFERRAL to fetal medicine Growth scan every 4 weeks / MRI / AC (> 20 w)

When to make a diagnosis of microcephaly if the mother has Zika infection ?

28 w HC > 2 SD below Mean of gestational age 👉 suspected when significant brain abnormality Or microcephaly confirmed 👉 discuss TOP regardless of gestation

What is the advice for pregnant women who are traveling to areas with active Zika virus transmission or her partner is traveling only?

Barrier contraceptions for ALL pregnancy even in the absence of Zika symptoms

What is the advice for female planning a pregnancy who have visited country with active Zika transmission?

🚩avoid becoming pregnant 28 days Even if no experienced any Syria 🚩 avoid becoming pregnant 2 months when they have experienced any symptoms 🚩avoid becoming pregnant 3 months if the partner traveled

How often to monitor with US a suspected case with Zika but negative investigations?

Baseline US Every 4 weeks 18-20 w 28- 30 w

How to make neonatal assessment where Zika virus is suspected?

1- first assessment 3 months then every 3 months up to 1 year 2- hearing test 3 - 6 months of age 3- ophthalmology review at 6 months

Diagnosis of Zika fever include...?

Blood or body fluid test for the presence of Zika viral RNA ( PCR)