Malaria In Pregnancy 2

Malaria in pregnancy Management options Preventive care Curative care 10/14/08

presented by Dr Omoregie

Preventive care Behavioural modification - Protective clothing - Insect repellant Insecticide-treated bednets (ITBN) Chemoprophylaxis Malaria vaccine

10/14/08

presented by Dr Omoregie

chemoprophylaxis Advantages Chemoprophylaxis + folic acid + fesolate is life saving – prevents the adverse effect of malaria in pregnancy. Promotes growth in teenage pregnancy

10/14/08

Drawback High cost of implementation Emergency of resistant strains (low compliance rate).

presented by Dr Omoregie

Types of chemoprophylaxis Absent or Low C/Q Moderate C/Q resistance resistance area (West area (Central and Africa, the Arab South America, Papua states, Pakistan, India New Guinea, etc). Bangladesh, eastern India). Booking visit – 3-day standard course of Single oral dose of chloroquine followed sulfadoxine + by daily oral proguanil pyrimethamine followed 200mg throughout by daily oral proguanil pregnancy. 200mg throughout pregnancy. 10/14/08

presented by Dr Omoregie

Areas with high C/Q resistance (East and Central Africa, southeast Asia: Thailand, Cambodia, Laos and Vietnam) Single oral dose of mefloquine 250mg once weekly – commenced in the 2nd trimester of preg to avoid teratogenicity and embryotoxic effects. 10/14/08

Intermittent sulfadoxine and pyrimethamine treatment – 2 or 3 doses after 16wk GA. Unsuitable for chemoprophylaxis – pyrimethamine alone, mepacrine, maloprim, and quinine – due to adverse side effects.

presented by Dr Omoregie

Special circumstances Non-immune visitors to endemic areas. Non-immune women living in endemic areas Start chemoprophylaxis a Long-term anti-malarial week before visit and chemoprophylaxis b/4 continue for at least 4 they become pregnant weeks after return and continue on same home. If mefloquine is drug throughout preg. the drug, 2 wks is - If mefloquine is the drug sufficient b/c of long used exclude the first half-life. trimester. 10/14/08

presented by Dr Omoregie

Antepartum malaria in preg Uncomplicated malaria Acute attack Clinical presentation Myalgia, athralgia, headache, poor or reduced appetite, nausea with or without vomiting, pruritus, abdominal pain, fever which may or may not be paroxysmal in nature. 10/14/08

Malaria in preg may be asymptomatic. Clinical evaluation Lethargic, restless or prostrate, pyrexia, dehydrated, tinge of jaundice, ? Pallor, hepato-splenomegaly.

presented by Dr Omoregie

investigations General Haematocrit (FBC) Hb-electrophoresis Mid-stream urine for m/c/s LFT* Ultrasonography*

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Specific Blood smear – thick and thin film. Blood picture – hypochromia, anisocytosis, poikilocytosis, micro or megalocytosis, hyper/hypochromasia

presented by Dr Omoregie

diagnosis NON-MICROSCOPIC METHOD Fluorochrome staining – c acridine orange - Positive result – differential staining of DNA (green) and cytoplasmic RNA (red). Antibodies – quantification against malaria parasite. RNA or DNA polymerase chain reaction (most sensitive) can detect as low as 5 asexual forms/µl of blood. Parasite produces specific enzyme – pLDH (parasite lactate dehydrogenase) which is electrophoretically distinct from the human LDH. Histidine rich protein 1 and 2. 10/14/08

MICROSCOPIC METHOD Blood film - Thick film – quantification of parasitaemia (counting parasites relative to leucocytes) - Thin film – identification of species. - Using Giemsa or field stain.

presented by Dr Omoregie

Patterns of drug resistance in falciparum malaria Chloroquine – most p.falciparum endemic countries, only exception is Haiti, central America and Egypt. Pyrimethamine (25mg) with sulfadoxine (500mg) – widespread in Asia, parts of East, Central and Southern Africa; south America. Drug is contraindicated in those with hx of sulphonamide allergy. Mefloquine – south-east Asia, some African countries. In other places it is used to treat pf resistant to quinine, c/q or sp. Quinine – detected in south-east Asia (generally only partial). Multi-drug resistance – pf fails to respond to c/q, sp and mefloquine in parts of south-east Asia; here, artemisinin is either used alone or in combination with mefloquine. 10/14/08

presented by Dr Omoregie

Treatment of uncomplicated mf C/Q sensitive p.falciparum, p.vivax, ovale or malariae Oral c/q 600mg base on days 1 and 2, 300mg on day 3 Analgesic – paracetamol Antipyretic/tepid sponging Fluid therapy Input/output chart Temp chart Blood sugar level Urea level 10/14/08

C/Q resistant p.falci or sensitivity unknown Oral sulfadoxine (500mg) and pyrimethamine (25mg) 3 tablets – single dose OR oral quinine 600mg tds for 7 days OR oral mefloquine 25mg/kg up to a max of 1000mg given as 2 doses, 8-24hrs apart.

presented by Dr Omoregie

Rx of complicated malaria Medical emergency Prompt assessment to detect complications early Note state of hydration Coma – lumbar puncture to R/O bact meningitis. Also R/O eclampsia (Rx are diff) Good nursing care (ABC of life)

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WHO 2000 C/Q sensitive p. falcip c/q by iv infusion – 25mg base/kg diluted in isotonic fluid by continuous ivf over 30 hrs (or 5mg/kg over six hours every 6hrs – a total of 5 doses) OR c/q by im or sc inj. Total dose 25mg/kg given either as 2.5mg/kg four hourly or 3.5mg/kg 6hly

presented by Dr Omoregie

C/Q resistant p.falcip or sensitivity unknown Quinine – loading dose is 20mg/kg diluted in 10ml isotonic fluid per kg body wt given i.v over 4hrs. Maintenance dose – 8hrs after loading dose. 10mg/kg in isotonic fluid admin over 4hrs repeated every 8hr until patient can swallow. Subsequent maintenance – tab 10mg/kg 8hly to complete a 7-day course of Rx OR quinine as above + subsequent maintenance with fansidar (3 tab single doses) 10/14/08

OR Artesunate 2.4mg/kg (loading dose) i.v followed by 1.2mg/kg at 12 and 24hr, then 1.2mg/kg daily for 6 days. Daily dose orally if able to swallow. OR Artemether 3.2mg/kg (loading dose) i.v, followed by 1.6mg/kg daily for 6 days. The daily dose can be given orally if able to swallow.

presented by Dr Omoregie

Mx of complications Acute pulm oedema – frusemide Convulsions – diazepam/phenobarb Acute renal failure – fluid restriction, frusemide, correct electrolyte imbalance/ dialysis Anaemia – bld transfusion. Hypoglycaemia – intermittent infusion of 50 ml of 50% dextrose solu via NG tube 10/14/08

Cerebral oedema – mannitol

presented by Dr Omoregie

Mx in labour Outcome/ course of lab not affected by mild infection. Severe malaria requires parenteral therapy, may result in spurious f/distress with increase C/S rate. There may be need to shorten the 2nd stage with Vacuum extraction. Active mx of 3rd stage to prevent PPH

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Mx in puerperium A major problem in diagnosis especially in the unbooked.

HIV a threat to prevention of malaria in preg**

presented by Dr Omoregie

Recent advances Malarial vaccines – the gene responsible for the sporozoite coating has been identified and cloned using monoclonal antibody and hybridoma techniques. The anti-sporozoite vaccine developed was unsuccessful in clinical trials. However, a synthetic tripeptide vaccine SPf66 developed by Pataroyo and colleagues have been found to be partially effective, following clinical trials in Columbia – had less than 50% efficiency. Further clinical trials are currently going on to identify a more efficient vaccine for malaria. 10/14/08

presented by Dr Omoregie

Types of vaccines Antisporozoite – RTS,S/ASO2 clinical trial in Gambia (2001) – to prevent all malarial clinical manifestation. Erthrocytic stage – SPf66 – reduce incidence of severe malaria and malaria mortality. Transmission blocking vaccine – reduce transmission in low endemic area. 10/14/08

presented by Dr Omoregie

conclusion Malaria in pregnancy is a recurring factor in maternal and perinatal mortality and morbidity. It remains an important hindrance to our attainment of the goals of safemotherhood. We hope this presentation would reenergize us towards acting to reduce or eliminate the adverse effects of malaria in pregnancy. 10/14/08

presented by Dr Omoregie