Malaria In Pregnancy.pptx
•Download as PPTX, PDF•
0 likes•238 views
Malaria in Pregnancy and treatment in Papua New Guinean women
Recommended
More Related Content
Similar to Malaria In Pregnancy.pptx
Similar to Malaria In Pregnancy.pptx (20)
Recently uploaded
Recently uploaded (20)
Malaria In Pregnancy.pptx
- 1. Malaria in Pregnancy and other febrile illnesses M. TENO 27th July 2023
- 2. Outline Malaria • Prevalence and Incidence • Risk Factors • Mode of Transmission • Clinical Presentation • Pathogenesis • Hematological Abnormalities • Treatment • Prevention • Complications
- 3. Malaria • Prevalence rate: 7.1% (Annual Report. April 2018) • WNBP – 30.8% • Oro – 20.&% • Madang – 18.4% • New Ireland – 16.2% • ENBP -11.4% • Endemic in Papua New Guinea – first cause of mortality and out-patient visits
- 4. Risk factors • Gravidity – Primigravidae • Maternal Age • HIV infection
- 5. Why is it common in primigravida’s? • Lack immunity to ‘pregnancy- specific’ variants of P.F, that selectively accumulate in the placental intervillous space leading to placental malaria • Massive sequestration of infected erythrocytes in placenta
- 6. Etiology Caused by four species of plasmodium: • P. falciparum - risk increases due to placental cytoadherence • P. Vivax • P. Ovale prevalence and effect in pregnancy are unknown. • P. Malariae • P. Knowlesi – commonest cause of malaria in Malaysia
- 7. Mode of transmission • Bite from an anopheles • Blood transfusion from an infected donor • Sharing of infected needles and syringes • Congenital transmission from mother to child
- 8. PATHOGENESIS
- 11. In pregnant women: infected erythrocytes bind to chondroitin sulphate. A receptor present in the intervillous space of the placenta, whereas in non-pregnant women infected erythrocytes adhere to CD36 and also exhibit rosette formation and agglutination
- 12. Clinical manifestations Uncomplicated Malaria Patients who present with symptoms of malaria with +ve test but with no features of severe malaria • Fever • Shivering/chills • Headaches • Muscle/joint pains • Nausea/vomiting • False labour pains Complicated (Severe) Malaria • Impaired consciousness (GCS<11/15) • Prostation: GBW, unable to sit, stand or walk • Multiple convulsions • Severe Anaemia • Jaundice • Significant bleeding: haematemesis or malaena • Pulmonary edema: chest indrawing with crepitations on auscultation • Metabolic: hypoglycaemia (<2.2mmol/L), acidosis (base deficit > 8mEq/L or alctate > 5mmol/L) • Shock • Hyperparasitaemia (P.f > 10%)
- 13. Complications Maternal Complciations • Cerebral malaria • Massive hemolysis • Anaemia • Renal failure • Metabolic: Acidosis, Hypoglycaemia Fetal complications • Spontaneous abortion • Stillbirth • Preterm delivery • Low Birth Weight • Congenital malaria • Neonatal & infant mortality • Poor developmental/behavioural outcome
- 14. Outcomes cont… Complicated malaria • Cerebral Malaria • P.F blocks small vessels in the brain, induces fever, irritability, convulsions, and sometimes episodes of coma • Acute renal failure • sudden reversible loss of function (days – weeks) • ↓ GFR/perfusion: ↓ plasma vol, cardiogenic or septic shock • Hyperkalaemia: due to ↓ GFR & acidosis) • Intravascular hemolysis → Anaemia
- 15. What are the 3 components of a RED BLOOD CELL??? GLOBIN HEME IRO N
- 16. Oxidized Diglucoronide Monoglucoronide RBCs Globins Irons Cleared by mononuclear Phagocytic system Fe + transferrin Hepatoglobin Heme Oxygenase Biliverdin Reductase Hemes Biliverdin Unconjugated Bilirubin Conjugated Bilirubin Urobilinogen Bilirubin + Albumin Bilirubin + Glucoronic Acid SPLEEN LIVER GALL BLADDER Responsible for the colour of urine and stools Urobilin
- 17. Oxidized Diglucoronide Monoglucoronide RBC s Globin s Irons Cleared by mononuclear Phagocytic system Fe + transferrin Hepatoglobin Heme Oxygenase Biliverdin Reductase Heme s Biliverdin Unconjugated Bilirubin Conjugated Bilirubin Urobilinogen Bilirubin + Albumin Bilirubin + Glucoronic Acid SPLEE N LIVER GALL BLADDER Responsible for the colour of urine and stools Urobilin How does malaria affect the break down of RBCs? Hepatocellular Damage Splenomegaly & splenic rupture Jaundice (hemolytic) Hyperbilirubinaemia Pale stools Urine appears dark brown Increased Sequestration Hemolytic Anaemia
- 18. PATHOGENESIS OF FETAL OUTCOMES
- 19. Management
- 20. Principles of Management 1. Diagnosis 2. Treat Malaria 3. Manage Complications 4. Prevent Recurrence
- 21. Investigations: • Rapid Malaria Test • Detects Specific Malaria antigens (proteins) in blood • Can detect one or multiple malaria species • Contains a strip made of filter paper & nitro- cellulose: antibody binds to parasitic antigen • Malaria Parasite Blood Slide (MPS) • Involves staining and direct visualization of parasite under microscope • Others: Fluorescent Staining, PCR based Assay and Antibody tests. • Full Blood Examination
- 22. Treatment • Depends on severity of the disease • Uncomplicated • Complicated or Severe • Gestational Age: first, second and third trimester • Aim: treat or resolve pyrexia.
- 23. WHO Guidance for Prevention and Treatment of Malaria in Pregnancy • Intermittent Preventive Treatment in pregnancy (IPTp) • Sulfadoxine-pyrimethamine (fansidar) • Commenced in the 2nd Trimester • Each SP dose is given at least one month apart • IPTp is administered as directly observed therapy (DOT) • Insecticide-Treated nets (ITNs) • Provided to women as early in the pregnancy
- 24. Treatment (P. falciparum or P. Ovale) Uncomplicated Malaria Trimester 1 Trimester 2 & 3 Quinine 600mg IMI/PO TDS + Clindamycin 10mg/kg IMI BD x 7/7 If Treatment fails: Artesunate + clindamycin x 7/7 If clindamycin is unavailable, use quinine as a monotherapy Artemisinin-based combination therapy (ACT) • Artesunate + amodiaquine • Artesunate + mefloquine • Dihydroartemisinin + piperaquine • Artesunate + sulfadoxine-pyrimethamine (SP) • Artemether +lumefantrine Coartem/Mala-1 3tabs PO stat, 3tabs PO after 8h, then BD x 3/7 Severe or Complicated Malaria Artesunate IMI/IVI x 24hrs If artensunate is not available, use quinine or artemether Artesunate IMI/IVI x 24hrs then Artemether & lumefantrine 3tabs PO stat, 3tabs PO after 8h, then BD x 3/7 If a woman is either toxic or vomiting, use parenteral/rectal suppositories of coartem/artesunate or injections of quinine. Avoid fansider before 16 weeks and after 34 weeks
- 26. Mixed Infection (p.falciparum, ovale, malariae) • Add primaquine 200mg PO dly x 14 days to the standard treatment. • Only to be commenced after delivery provided the baby does not have G6PD deficiency.
- 27. • Supportive Treatment: • Fetal monitoring • Adequate calories • Correct electrolyte imbalance • Blood transfusion • Oxygen + diuretics in pulmonary edema • Anticonvulsants • Admission to Intensive care unit for complicated malaria • Dialysis for acute renal failure (ARF)
- 28. Complicated Malaria in Pregnancy • Maintain airway patency, insert guedals airway and nurse on lateral side • Insert an intravenous cannula and collect bloods: BSL, FBE, MPS, UEC/LFT, x- match, blood gases, lumbar puncture • Perform a detailed clinical examination including GCS • Insert an IDC – monitor fluid balance to avoid over or under hydration
- 29. Differential Diagnosis of fever in pregnant women • Bacterial Meningitis • Repiratory infections: Pulmonary TB or EPTB, pneumonia, URTI, Covid-19 • Cellulitis • Urinary Tract infections: cystits, pyelonephritis • Genital tract infections: vaginitis, cervicitis
- 30. Complicated Malaria in Pregnancy Treating Complications • IV Diazepam for convulsions • Transfusion for severe anaemia • Frusemide for pulmonary oedema • IV glucose for hypoglycemia • Fluid restriction, K-absorbing resins, IV potassium and insulin or dialysis for renal failure
- 31. Preventive Measures • Educate pregnant women to sleep under treated bed nets • Health Education • Health awareness during ANC regarding preventive strategies, i.e. Use of treated bed nets • Screened houses • Protective clothing when outdoors • Use of mosquito repellants • Consistent ANC visits for malaria prophylaxis • To seek medical attention if fever occurs. • Rid off pools of stagnant water around the vicinity of the house
- 32. Reference • Gyal, K. et al. Malaria in Pregnancy, Intech open: Chapter 3. Available [online]. www. http://dx.doi.org/10.5772/64611.com. Date Accessed [19th may 2019] • Mola, G. and Maurice King.(2008) Primary Mother Care and Population for Papua New Guinea. UPNG Press. • Mola, G. Manual of Standard Managements in Obstetrics and Gynaecology for Doctors, HEO’s and Nurses in Papua New Guinea. • Royal College of Obstetricians and Gynaecologists . (March 2009) .The Treatment and Prevention of Malaria in Pregnancy. Guideline No xx • WHO. How malaria RDTs work [Online] Available: https://www.who.who.int/teams/global-malaria- programme/case-management/diagnosis/rapid-diagnostic-tests/how-malaria-rdts-work Date accessed: 8.08.2022 • WHO (2007) Malaria in Pregnancy . Guidelines for measuring key monitoring and evaluation indicators • WHO. How malaria RDTs work [Online] Available: https://www.who.who.int/teams/global-malaria- programme/case-management/diagnosis/rapid-diagnostic-tests/how-malaria-rdts-work Date accessed: 8.08.2022 • WHO (2007) Malaria in Pregnancy . Guidelines for measuring key monitoring and evaluation indicators
Editor's Notes
- 1. HIV infection weakens the immunity and hampers the cytokine response to malaria.
- During pregnancy, women develop antibodies to the infected erythrocyte surface that may either block infected erythrocyte binding or coat them for destruction by monocytes, thereby reducing disease severity in subsequent pregnancies
- Anopheles injects its plasmodium sporozoites into the blood stream. Carried to the liver, invade hepatic parenchymal cells and undergo asexual reproduction A single sporozoite produces 10 000 to >30 000 merozoites. Liver cell eventually bursts, thus discharging motile merozoites into the blood stream. Merozoites invade RBCs and multiple 6-20 fold every 48-72hrs. Merozoites that enter the blood stream, invade erythrocytes and become trophozoites. By the end of the intraerythrocytic life cycle, the parasite has consumed all the haemoglobin, occupy most of the RBC, and is now called a schizont. RBC ruptures and releases 6-30 merozoites, capable of invading other RBCs and repeating the cycle. After a series of asexual cycles, some parasites develop into gametocytes that can transmit malaria.
- .
- Hypoglycemia: increased glucose metabolism and impaired glucose production caused by inhibition of gluconeogenesis Quinine and quinidine – stimulants of pancreatic insulin secretion. This causes hyperinsulinemic hypoglycaemia Lactic acidosis results from: Failure of hepatic and renal clearance anaerobic glycolysis in tissues Lactate production by parasites
- Acidosis: increased lactate production from anaerobic glycolysis and to a smaller extent from P.F
- RDT: also referred to as a lateral flow immuno0-chromatographic antigen detection test. Captures dye-labelled antibodies to produce a visible band on a strip of nitro-cellulose. Dye-labelled antibody binds to parasite antigen – resulting complex is shown as a strip by a band bound antibody forming a visible line (T-test line) A control line (c-control line) gives information on the integrity of the antibody-dye conjugate, but does not confirm the ability to detect parasite antigen Procedure: mix blood with lysing agent (ruptures the BC, releasing more parasite protein)
- There is not enough evidence for the alternative treatment using ACT in Trimester 1 Organogenesis occurs in T1, the period for potential teratogenicity. Hence antimalarials considered safe to use are quinine, chloroquine, clindamycin and proguanil.
- Main objective: prevent patient mortality/morbidity Secondary objective(s): prevent dissabilities and disease progression