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21 - Maternal Infections > Malaria & Zika In Pregnancy > Flashcards

Malaria & Zika In Pregnancy Flashcards

1
Q

Malaria / Zika
Are caused by…?

A

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

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2
Q

Why maternal infection with malaria is important?

A

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

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3
Q

What are the maternal risks of malaria infection?

A

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

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4
Q

What are the fetal risks of maternal infection with malaria?

A

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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5
Q

How to prevent the maternal infection with malaria?

A

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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6
Q

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

A

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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7
Q

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

A

Plasmodium vivax

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8
Q

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

A

Plasmodium falciparum

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9
Q

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

A

Plasmodium falciparum

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10
Q

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

A

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

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11
Q

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

A

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

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12
Q

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

A

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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13
Q

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

A

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

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14
Q

What is the role of citronella oil as insect repellent ?

A

Very short duration of action

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15
Q

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

A

6 months
Efficiency 50%

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16
Q

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

A

⚠️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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17
Q

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

A

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

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18
Q

What are the malaria chemoprophylaxis protocols ?

A

🚩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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19
Q

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

A

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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20
Q

Which drugs of malaria chemoprophylaxis are contraindicated in pregnancy?

A

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

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21
Q

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

A

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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22
Q

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

A

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

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23
Q

How to suspect infection with malaria?

A

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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24
Q

What is the most common reason of death from malaria?

A

Misdiagnosis & delay of treatment

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25
Q

What are the symptoms of malaria?

A

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

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26
Q

What is the gold standard investigation of malaria?

A

Malaria blood film ( thick & thin )

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27
Q

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

A

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

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28
Q

When to rule out diagnosis of malaria?

A

Afebrile + 3 negative smears
12 - 24 hours apart

29
Q

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

A

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

30
Q

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

A

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

31
Q

What is the drug treatment for Uncomplicated malaria?

A
  • P falciparum:
    Oral Quinine + oral clindamycin
    ( standby treatment)
    7 DAYS
    ⚠️ vomiting + no signs of severity or complicated 👉 IV Quinine + IV clindamycin
32
Q

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

A

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

33
Q

What is the drug treatment of severe & complicated malaria?

A

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

34
Q

What are the features of complicated malaria?

A

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

35
Q

Where to manage a pregnant woman with malaria?

A

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

36
Q

What are the side effects of Quinine?

A

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

37
Q

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

A

🚩 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

38
Q

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

A

90 % hb < 10 👉 ferrous sulfate + folic acid

39
Q

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

A

MDT to plan optimal management

40
Q

How to monitor the fetus in maternal sever malaria?

A

By CTG
Particularly in the presence of fever

41
Q

How acute malaria affects mean blood loss ?

A

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

42
Q

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

A

Uncomplicated malaria NOT indication of IOL

43
Q

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

A

UNPROVEN

44
Q

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

A

If PLT count < 100,000
Or is falling

45
Q

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

A

*🚩 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

46
Q

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

A

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

47
Q

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

A

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

48
Q

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

A

Thick & thin blood film at birth
WEEKLY for 28 days

49
Q

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

A

ADMISSION + IV artesunate

50
Q

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

A

Falciparum placental sequestration

51
Q

What does Algid malaria mean?

A

Malaria + G positive septicemia
Or collapse
Or hypotension

52
Q

Which antimalarial drug is contraindicated in G6PD deficiency?

A

Primaquine

53
Q

How long the immunity against malaria last?

A

2 years

54
Q

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

A

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

55
Q

What are the symptoms of Zika virus infection?

A

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]

56
Q

What is the fatality rate of Zika virus infection?

A

Low
Hospitalization is uncommon

57
Q

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

A

MICROCEPHALY
10% of pregnant with confirmed Zika infection

58
Q

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

A

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

59
Q

What is the drug treatment of Zika virus?

A

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

60
Q

Does Zika virus transmit through breastfeeding?

A

NO EVIDENCE

61
Q

When to suspct Zika virus infection?

A

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

62
Q

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

A

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

63
Q

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

A

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

64
Q

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

A

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

65
Q

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

A

🚩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

66
Q

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

A

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

67
Q

How to make neonatal assessment where Zika virus is suspected?

A

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

68
Q

Diagnosis of Zika fever include…?

A

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

21 - Maternal Infections (13 decks)

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