Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Malaria in pregnancy

6,043 views

Published on

Management of of Malaria in pregnancy

Published in: Science
  • Dating for everyone is here: ❤❤❤ http://bit.ly/2F4cEJi ❤❤❤
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Follow the link, new dating source: ❶❶❶ http://bit.ly/2F4cEJi ❶❶❶
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Who Else Wants To Cure Their uterine fibroids, Regain Their Natural Inner Balance and Achieve LASTING Freedom From PCOS Related Symptoms? ◆◆◆ https://bit.ly/2ONPXxg
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • DOWNLOAD THAT BOOKS INTO AVAILABLE FORMAT (2019 Update) ......................................................................................................................... ......................................................................................................................... Download Full PDF EBOOK here { https://urlzs.com/UABbn } ......................................................................................................................... Download Full EPUB Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download Full doc Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download PDF EBOOK here { https://urlzs.com/UABbn } ......................................................................................................................... Download EPUB Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... Download doc Ebook here { https://urlzs.com/UABbn } ......................................................................................................................... ......................................................................................................................... ................................................................................................................................... eBook is an electronic version of a traditional print book that can be read by using a personal computer or by using an eBook reader. (An eBook reader can be a software application for use on a computer such as Microsoft's free Reader application, or a book-sized computer that is used solely as a reading device such as Nuvomedia's Rocket eBook.) Users can purchase an eBook on diskette or CD, but the most popular method of getting an eBook is to purchase a downloadable file of the eBook (or other reading material) from a Web site (such as Barnes and Noble) to be read from the user's computer or reading device. Generally, an eBook can be downloaded in five minutes or less ......................................................................................................................... .............. Browse by Genre Available eBooks .............................................................................................................................. Art, Biography, Business, Chick Lit, Children's, Christian, Classics, Comics, Contemporary, Cookbooks, Manga, Memoir, Music, Mystery, Non Fiction, Paranormal, Philosophy, Poetry, Psychology, Religion, Romance, Science, Science Fiction, Self Help, Suspense, Spirituality, Sports, Thriller, Travel, Young Adult, Crime, Ebooks, Fantasy, Fiction, Graphic Novels, Historical Fiction, History, Horror, Humor And Comedy, ......................................................................................................................... ......................................................................................................................... .....BEST SELLER FOR EBOOK RECOMMEND............................................................. ......................................................................................................................... Blowout: Corrupted Democracy, Rogue State Russia, and the Richest, Most Destructive Industry on Earth,-- The Ride of a Lifetime: Lessons Learned from 15 Years as CEO of the Walt Disney Company,-- Call Sign Chaos: Learning to Lead,-- StrengthsFinder 2.0,-- Stillness Is the Key,-- She Said: Breaking the Sexual Harassment Story That Helped Ignite a Movement,-- Atomic Habits: An Easy & Proven Way to Build Good Habits & Break Bad Ones,-- Everything Is Figureoutable,-- What It Takes: Lessons in the Pursuit of Excellence,-- Rich Dad Poor Dad: What the Rich Teach Their Kids About Money That the Poor and Middle Class Do Not!,-- The Total Money Makeover: Classic Edition: A Proven Plan for Financial Fitness,-- Shut Up and Listen!: Hard Business Truths that Will Help You Succeed, ......................................................................................................................... .........................................................................................................................
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Malaria in pregnancy

  1. 1. MANAGEMENT OF MALARIA IN PREGNANCY Dr Kimambo Elisonguo Resident OBGY Muhimbili University of Health and Allied Sciences (MUHAS)
  2. 2. Contents  Introduction  Pathophysiology Placental malaria  Clinical presentation  Complications  Management  Prevention  Conclusion  References
  3. 3. Why should malaria in pregnancy be a special agenda?
  4. 4. Introduction  Malaria is more common in pregnancy compared to the general population.  The non- immune, primigravidae are usually the most affected(prevalence & complications)  The increased risk of contracting malaria may be due to  Decreased immunity  Hormonal changes
  5. 5. Introduction cont..  Malaria and pregnancy are mutually aggravating conditions. The physiological changes of pregnancy and the pathological changes due to malaria have a synergistic effect on the course of each other Thus making the life difficult for the mother, the child and the treating physician.
  6. 6. Introduction cont..  In pregnancy, malaria tends to be more atypical in presentation. This could be due to the hormonal, immunological and hematological changes of pregnancy
  7. 7. Introduction cont..  Some anti malarial drugs are contraindicated in pregnancy and some may cause severe adverse effects.  Therefore Choice of medication becomes difficult.  Management of complications of malaria may be difficult
  8. 8. Pathophysiology  Pathogenesis of malaria relates to the various host and parasite factors  Starts by inj of Plasmodium sporozoites via a bite from an infected mosquito  The sporozoites travel through the bloodstream of the host to the liver, where they invade hepatocytes.  These cells divide many 1000-fold until mature tissue schizonts are formed, each containing thousands of daughter merozoites.  This exoerythrocytic stage is asymptomatic
  9. 9. Pathophysiology cont..  The liver schizonts rupture after a week or so  This event releases thousands of merozoites into the bloodstream, where they invade red blood cells (the erythrocytic stage)  At the completion of the schizogony within the red cells,(48hrs for P. falciparum) newly developed merozoites are released by the lysis of infected erythrocytes  Along with them, numerous waste substances are also released into the blood.  These include red cell membrane products, hemozoin pigment, and other toxic factors such as glycosylphosphatidylinositol (GPI)
  10. 10. Pathophysiology cont..  These products, particularly the GPI, activate macrophages and endothelial cells to secrete cytokines and inflammatory mediators such as TNF-alpha, IFN-γ, Il-1, IL-6, IL-8, MCSF, and lymphotoxin, as well as superoxide and nitric oxide (NO).  The systemic manifestations of malaria have been largely attributed to these cytokines
  11. 11. Pathogenetic Characteristics of Severe Malaria  Cytoadherence  Sequestration  Rosetting
  12. 12. Placental Malaria  Caused by P. falciparum–infected erythrocytes that bind to placental tissue.  Binding is mediated by VAR2CSA, a parasite antigen which interacts with chondroitin sulfate A (CSA) on the syncytiotrophoblast  The VAR2CSA is coded by the var2csa gene  By this process, the parasites avoid being filtered through the spleen  Also it impairs movements of nutrients across the placenta
  13. 13. Placental Malaria cont..  Consequences include maternal anemia and fetal growth retardation.  Antibodies against VAR2CSA occur during pregnancy after exposure to infected erythrocytes sequestering in the placenta  Concentrations of these antibodies increase with parity.  Placental changes due to malaria infxn (hemozoin deposition & increased monocyte deposition) also contribute to placental
  14. 14. Clinical presentation  Includes  Fever  Headache  Joint pains  Malaise  Nausea +/-vomiting, +/- diarrhea  Abdominal pain  Poor appetite  Palor  Splenomegally
  15. 15. Clinical presentation cont…  Severe malaria  Presence of one or more of the following  Prostration (extreme weakness),  Impaired consciousness/coma  Change of behavior  Convulsions  Jaundice  Vomiting everything  Circulatory collapse/shock  Hyperparasitemia  Bleeding tendency (DIC)  Respiratory distress
  16. 16. Complications  Anemia  Abortion and its complications  Premature labour  Cerebral malaria  AKI  Pulmonary edema  IUGR  Congenital infection To the newborn  Premature delivery  Low birth weight and its complications  Congenital/neonat al malaria To the mother To the fetus
  17. 17. Management  Includes  Investigations  Treatment of malaria  Management of complications  Prevention  Treatment of malaria in pregnancy should be  Energetic :  Don't waste any time.  Careful  Choose drugs and dosage carefully  Anticipatory  One should always be looking for any complications by regular monitoring
  18. 18. Investigations  Includes  Antigen detection techniques : - MRDT-(HRP- 2/pLDH(PfPAN))  Peripheral blood smear for MPs( thin & thick films)  PCR based assay  Antibody test  Placental blood smear(postpartum)  Others depending on the clinical presentation
  19. 19. Treatment of malaria in pregnancy  Depends on  Severity  Gestational age
  20. 20. Treatment cont… A: Uncomplicated malaria  In the first trimester, Pregnant women with uncomplicated malaria should be treated with quinine tablets for seven days The dose is 10 mg/kg every 8 hours for 7days Do not exceed a maximum dose of 600mg per dose
  21. 21. Treatment cont..  In the second and third trimester  Artemether-Lumefantrine should be used as medicine of choice  The dose is 4 tabs stat then 8hours after the first dose then 12hourly for 2days (a total of three days)  Alternatively  Dihydoartemisinin-Piperaquine (DPQ)  Artesunate-Amodiaquine
  22. 22. Treatment cont..  B: Severe malaria  The primary objective of treatment in severe malaria is to prevent death.  The secondary objective is to prevent disabilities and to prevent recrudescent infection  In the first trimester  The medicine of choice for treatment of severe malaria in the first trimester is IV Quinine(dose)
  23. 23. Severe malaria Rx cont..  In the second and third trimester The medicine of choice for treatment of severe malaria in 2nd and 3rd trimester of pregnancy is Inj. Artesunate  The dose is dose 2.4 mg/kg given at time 0 hour, then at 12 hours and 24 hours  Followed by ALu for 3days  The first oral dose should start 8hrs after the last injection  Quinine should be used only if Artesunate injectable is not available.
  24. 24. Treatment cont…  According to WHO recommendation,  Treatment of severe malaria is with Inj Artesunate for both children and adults including infants, pregnant women in all trimesters and lactating women.  Inj Artesunate should be given for at least 24hrs and until patient can tolerate oral medication, then they should complete treatment with 3days of ACT  If Artesunate is unavailable, Inj Artemether (IM) should be given  If Artemether is unavailable, Inj Quinine should be given(loading dose 1st)
  25. 25. Artesunate for injection  Descpription  Artesunate is a water-soluble derivative of Artemisinin.  The only Artemisinin analogue that can be given intravenously  It produces rapid parasite clearance in falciparum malaria.  Superior to Quinine in preventing death
  26. 26. Artesunate for injection cont..  Three formulations are available:  30mg,  60mg and  120mg of Artesunate for injection.
  27. 27. Table 14: Artesunate for injection package by strength Strength 30mg 60mg 120mg Artesunate for injection 1 vial of 30mg 1 vial of 60mg 1 vial of 120mg 5% Sodium bicarbonate 1 Ampoule of 0.5mls 1 Ampoule of 1ml 1 Ampoule of 2.5mls Sodium chloride 1 Ampoule of 2.5mls 1 Ampoule of 5mls 1 Ampoule of 10 mls
  28. 28. Administration and dosage (60 mg strength)  Injectable Artesunate has 2-steps dilutions.  Step 1:  The powder for injection should be diluted with 1ml of 5% sodium bicarbonate solution (provided in each box) and shaken vigorously 2-3 minutes for better dissolving till the solution becomes clear.  Step 2:  For slow intravenous infusion (3-4 minutes): Add 5 ml of 5% dextrose or normal saline, to obtain a Artesunate concentration of 10 mg/ml  For deep intra-muscular injection: Add 2 ml of 5% dextrose or normal saline to obtain a Artesunate concentration of 20 mg/ml
  29. 29. Quantity for dilution of Artesunate for injection ROUTE IV INJECTION IM INJECTION STRENG TH 30mg 60mg 120mg 30mg 60mg 120mg 5% NaCO3 0.5mls 1ml 2mls 0.5mls 1ml 2mls NS/5% dextrose 2.5mls 5mls 10mls 1ml 2mls 4mls TOTAL (mls) 3mls 6mls 12mls 1.5mls 3mls 6mls Artesunate concentrati on (Mg/ml) 10 10 10 20 20 20
  30. 30. Caution;  The powder form for injection is difficult to dissolve, care should be taken to ensure that it is completely dissolved before parenteral administration.  If the solution is cloudy or a precipitate is present, the parenteral preparation should be discarded.  Dissolved artesunate should always be used immediately after 2nd dilution  Never store diluted Artesunate for further use
  31. 31. Supportive treatment in the Management of malaria in pregnancy  Treatment of anemia (BT, FA)  Correction of electrolyte imbalance  Oxygen + Diuretics in pulmonary oedema  Dialysis for ARF  Anticonvulsants  ICU care for CM  Monitoring of the fetal growth & health
  32. 32. Prevention  Available options are:-  Vector control  Insecticide Treated Nets (ITNs)  Residual house hold spraying  Environmental management  Drug prophylaxis  Intermittent preventive treatment (IPTp)  Alternative- DPQ (not yet adopted)  Vaccine?? –Still under development
  33. 33. Intermittent preventive treatment (IPTp)  The medicine of choice for IPTp is Sulfadoxine/Pyrimethamine (SP)  Reduses the risk of Placental malaria Low birth weight and Maternal illness  Dosing should start as early as possible in the sec trimester  Should be given at least 1 month apart, at least 3doses  SP can be administered up to the time of delivery
  34. 34. Conclusion  Diagnosis and Management of malaria during pregnancy can be challenging  The primary objective in the management of severe malaria is to prevent death  Malaria preventive package during pregnancy includes:  Intermittent preventive treatment with SP during antenatal clinic visits  Use of ITNs throughout pregnancy and in the postpartum period  Prevention must be complemented by effective case management of malaria for all women of reproductive age
  35. 35. References  National Guidelines for Diagnosis and Treatment of Malaria-December 2014  The diagnosis and treatment of malaria in pregnancy-Royal College of Obstetricians and Gynecologists-April 2010  A Review of Malaria Diagnostic Tools: Microscopy and Rapid Diagnostic Test (RDT)-American journal of tropical medicine and hygiene  http://www.uptodate.com/contents/pathogenesis-of-malaria  http://www.malariasite.com/pathophysiology/  https://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-7- 133  https://en.wikipedia.org/wiki/Pregnancy-associated_malaria  https://malariajournal.biomedcentral.com/articles/10.1186/s12936-015- 0576-8
  36. 36. References  https://malariajournal.biomedcentral.com/arti cles/10.1186/1475-2875-13-152  http://www.ncbi.nlm.nih.gov/pmc/articles/PM C3257207/  https://diagnosticpathology.biomedcentral.co m/articles/10.1186/1746-1596-8-59  http://www.mjhid.org/article/view/338/460  http://scialert.net/fulltext/?doi=jp.2015.120.12 6&org=10  http://jcm.asm.org/content/40/1/306.full
  37. 37. Thank you….!

×