A case of Malaria in pregnancy UCTH, Nigeria

1. MALARIA IN PREGNANCY CASE
MANAGEMENT PRESENTATION
BY
DR EFFIOM, VICTOR E.
HO FIRM 1

2. BIODATA
 Mrs. S.C.N
 Hosp. No: 367404
 31 years
 Public servant
 30 level of education (B.sc)
 No. 4 Akai Effa Street, Calabar.
 Hails from Imo state, Igbo Tribe.
 Christian of Christ Embassy denomination.

3.  G2P1
+0 (1 Living Child)
 LMP - 13/07/13
 EDD – 20/04/14
 EGA: 35 wks + 5 days.

4. History
 PC:
She presented to the emergency clinic on 20th/3/2014 @
GA 35wks + 5days with fever X 4/7.
 HPC:
Fever was insidious in onset, moderate grade,
intermittent, with associated chills and rigors
accompanied by copious sweating.
 No cough, catarrh, dyspnea
 No frequency, urgency, dysuria, changes in urine
output or any other associated urinary symptoms.

5. History Of Presenting Complaint contd.
 There was associated history of vomiting. Patient had
vomited 2x on same day prior to presentation at the
emergency clinic.
 Vomitus consisted of recently ingested meals, post prandial
onset, non-bilious, non-projectile.
 There was associated history of loss of appetite.
 No headache. neckpain or visual disturbances.
 No abdominal pain, +ve associated joint pains.
 Nil bleeding per vaginam or drainage of liquor.
 No abnormal vaginal discharge.
 No Prior treatment at home, thus she presented in
emergency clinic for expert mgt.

6. HISTORY OF THE INDEX PREGNANCY
 Pregnancy was spontaneously conceived and desired.
 It was suspected following 8 weeks of amenorrhea and
subsequent blood pregnancy test turned out to be
positive.
 Booked at GA of 30wks + 4 days.
 Booking parameters showed Height: 1.72m, Weight: 94kg
Blood pressure: 110/60 mmHg, Urinalysis: NAD
 Had TT X 2 at 30wks and 34 wks GA.

7.  Serology: Non-reactive
 Booking PCV: 32%
 VDRL: Non-reactive
 Blood group and Genotype: O+, AA
 She had received 1 dose of sulfadoxine +
Pyrimethamine for IPTp in this pregnancy @
GA 32weeks.
 On hematinic, caps Ranferon-12 once daily
 Vitamin C 100mg TDS.

8. HISTORY OF THE INDEX PREGNANCY
CONTD.
 Regular at ANC attendance (2 visits),
complaint with medications.
 Pregnancy has been uneventful so far prior
to presentation at the emergency clinic @
GA 35wks + 5days, With above stated
complaint.

9. PAST OBSTETRICS HISTORY
 Her first confinement was in 2012.
 Spontaneous conception & desired
 Antenatal care at UCTH, uneventful antenatal period.
 Spontaneous onset of Labour at term.
 SVD of live male Neonate, Apgar 81 95, Wt: 2.7kg.
 Exclusive breastfeeding/immunised for age.
 Puerperium was uneventful.

10. PAST GYNAECOLOGICAL HISTORY
 Menarche 14, K = 3/28
 LMP (as stated above 13/7/13).
 No dysmenorrhea, menorrhagia nor dyspareunia
 No history of STIs
 Male partner uses condom occasionally.
 Has knowledge of pap smear but has never done it.

11.  PAST MED/SURG HISTORY:
o Not a known diabetic, hypertensive or asthmatic,
epileptic, sickle cell disease
o Nil surgery
o No hx. blood transfusion
 Drug Hx: Patient was on Haematinics (Caps Ranferon
once daily) and Vit. C 100mg TDS.
 Allergy Hx: No known hx of allergy.

12. FAMILY AND SOCIAL HISTORY
• Patient is third in a family of 7, 6 females and 1
male, all alive and well.
• Both parents are alive and well.
• No known family history of HEADS.
• She is married to a 40 year old self-employed
Businessman in a monogamous union and they
both live in a 2-bedroom apartment setting.
• Water source is from Bore-hole system

13. FAMILY AND SOCIAL HX. cont.
• Sewage disposal via water cistern and
drainage in her area of residence is fairly
good.
• Does not sleep in Insecticide treated Nets
• She and her husband neither drink
alcohol nor use tobacco in any form. No
illicit drug use also.
• There is a family history of twin
pregnancy.

14. SUMMARY
I have presented the case of Mrs S.C.N a 31 year old
booked G2P1+0 (1A) who presented to the emergency clinic
at GA 35wks + 5 days, with a 4-day hx of fever, with
associated vomiting and joint pains.

15.  PHYSICAL EXAMINATION
o Young lady, febrile, not pale, anicteric,
acyanosed, mildly dehydrated.
o Temp: (37.90C).
 CARDIOVASCULAR SYSTEM
o PR - 78 bpm, regular, normal volume
o BP – 100/60mmHg,
o heart sounds were normal

16.  RESPIRATORY SYSTEM
o RR - 18 cpm,
o lung fields were clinically clear

17. ABDOMINAL EXAMINATION
 Gravidly enlarged, MWR
 No area of tenderness, L0, S0, K0
2
 SFH: 34CM
 Single foetus in Longitudinal lie.
 Presentation: Cephalic
 Position: ROA
 Descent: 5/5th palpable per abdomen
 FHR: 140bpm, regular

18. Diagnosis
• ?? Acute Malaria in a primiparous woman
@ 35wks GA.

19. Treatment
① The diagnosis was explained to the
patient and she was counselled on the
plan of management, which she
consented to.
②Admitted to ANW
③Carry out following investigations; MP,
urinalysis, FBC, RBS, USS, S/E,U,Cr

20.  Urinalysis ------------------- NAD
 Thick Blood film: Trophozoites of P.
falciparum ++
 Haematocrit estimation --- 34%
 WBC count: was within normal range
 RBS: 5mmol/l
 Serum Electrolytes: NAD

21. Ultrasound scan: normal findings
 Obstetric scan at 36wk GA showed a live foetus in
longitudinal lie & cephalic presentation with
adequate AF and placenta in posterio-fundal
location. Estimated foetal weight was 2.9kg ± 0.4
 Definitive Diagnosis: Uncomplicated Malaria in
Pregnancy @ 35wks GA

22. Treatment.
①IVF 5% D/S 1L 8hrly x 24hrs
②Intramuscular Paracetamol 600mg stat then
tabs Paracetamol II TDS x 3/7
③Intramuscular Metoclopramide 10mg Stat.
④Intramuscular Artemether 150mg daily x 3/7
⑤Close feto-maternal monitoring every 4
hours.

23.  Patient continued to improve clinically.
 Temperature normalised about 12 hrs. after
admission. (36.7 degrees Celsius)
 There was no further episode of vomiting
 Oral haematinics were recommenced.
 Feto-maternal vital signs remained stable.
 Thick blood film on 3rd day of admission did not
reveal peripheral parasitaemia.

24.  Patient completed intramuscular arthemeter while on
admission.
 Patient was counselled on preventive measures against
malaria and the need to be complaint with subsequent
Antenatal visits.
 She was also counselled on the signs of labour and
subsequently discharged home on oral haematinics.
 She was given 1wk appointment to the ANC.

25. SUBSEQUENT ANTENATAL MANAGEMENT
 Subsequent antenatal period was uneventful.
 Patient was seen weekly until she went into labour at
37wks + 6days gestation.
 PCV @ 37wks was 34%.

26. INTRAPARTUM MANAGEMENT
 She presented to the labour room in active phase labour.
 The labour was monitored with the use of partograph
 Labour was uneventful, lasted for ~ 8hrs.
 Delivery was by SVD
 Outcome was live male baby that weighed 3kg
 3rd stage of labour was managed actively
 Immediate post partum period was uneventful.

27. POSTPARTUM CARE.
 One hour post delivery, patient’s vital signs were normal
 She was transferred to the PNW.
 Lactation was well established on the 2nd day
 Uterine involution was good. Lochia was normal.
 She was advised on exclusive breastfeeding and
immunization for baby.

28. POSTPARTUM MANAGEMENT
 Counselled on contraception and child spacing.
 She was also counselled on preventive measures against
malaria.
 Antenatal Haematinics were continued X 6/52
 She was discharged home 2nd day post partum
 Reviewed in post natal clinic x 6/52

29. POSTPARTUM MANAGEMENT
 At postnatal visit, she had no complaint, baby was
exclusively breastfeed & was immunized for age.
 Findings on her general and systemic examination were
essentially normal.
 The uterus had completely involuted.

30. POSTPARTUM MANAGEMENT
 She was requested to do PAP smear and the result
subsequently received was normal.
 The need for contraception for child spacing was further
emphasized.
 She was encouraged to continue exclusive BF and ensure
immunization for baby
 Subsequently discharged to family planning clinic

31. SUMMARY
I have presented a 31 year old booked now Para 2+0 (2A)
who was treated for uncomplicated malaria at a GA of
35wks with intramuscular arthemeter.
The subsequent course of pregnancy was uneventful with
spontaneous onset of labour at term (GA 37wks + 6 days).
She was delivered of a live male infant, weight 3kg.
Puerperium was uneventful.

32. Thank you…