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MRCOG PART 2 SBAs and EMQs

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notes	336
EMQ	1502
SBA	2115

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Essay 332 - malaria in pregnancy

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		Posted by Yazmin F. Thu Jul 29, 2010 11:16 pm
A healthy 35 year old woman attends the antenatal clinic at 16 weeks gestation. She is due to make an essential journey to a malaria endemic area. (a) What will you tell her about the available interventions to reduce the risk of contracting malaria? [5 marks] (b) She presents at 28 weeks gestation with a 24h history of fever with rigors and vomiting. Discuss your initial clinical assessment and investigations [10 marks]. Discuss the management of obstetric complications of malaria [5 marks] a) Ensure she fully understands the maternal and fetal risk associated with malaria and if she is not able to defer her journey then she must familiarise herself with the symptoms and signs that can suggest malaria (pyrexia, flu-like sumptoms) and seek medical help. Website addresses for specialist advice and specific resources for infectious diseases and tropical medicine should be given. Bites prevention by anopholine mosquito include skin repellents, sprays for room and clothing; mosquito nets; wearing of protective clothing including long sleeves may help in prevention. Also Chemoprophylaxis should be taken such as choroquine, if she is visting a chloroquine resistant area mefloquine can be taken. The importance of compliance must be emphsised. b) Malaria should be suspected until proven otherwise. Other non specific symptoms may include flu-like symptoms, malaise, fatigue, headache. Examination may identify tachypnea, hypotension, tachycardia, pyrexia , reduced oxygen saturation depending on the severity of malaria. Blood film is essential in establishing the correct diagnosis. A negative initial result does not exlude diagnosis, however 3 negative results 12-24hrs apart can rule out the diagnosis. Other investigations will include FBC to detect anaemia, thromocytopenia; U& Es, LFTs, Clotting as these can become impaired with multiple organ involvement. Blood culture is necessary to identify gram negative septicaemia and institute correct treament. Fetal assessment with CTG to ensure fetal well being is needed. c) Maternal Obstetric complications include: significant anaemia requiring blood transfusion, thromocytopenia however this can resolve as treament is completed; hypoglycaemia necessitating glucose infusion, infection needing antibiotics, and antipyretics. Severe disease can result in coma, respiratory distress, convulsions, DIC and patient will require managment in HDU setting involving Physician, Obstetician, anaesthetist, Neonatologist and Specialist advice from Hospital for Tropical Medicine. Fetal complications include preterm labour, fetal growth restriction, stillbirth, congenital infection. Where preterm delivery in anticipated steroids can be administered for lung maturity, and fetus can be monitored for growth, liqour and dopplers.
		Posted by A A. Thu Jul 29, 2010 11:54 pm
AA (a) I will tell her that malaria in pregnancy is a life threatening but preventable disease. I will advice to delay her travel plan, if it is impossible for her to postpone her journey, than she should get guidance from centre with expertise on malaria avoidance strategies. I will inform about symptoms of malaria like fever, chill, headache, cough general malaise, nausea vomiting and diarrhea. If she gets these symptoms she should seek medical advice as early as possible. I will inform her about prevention measures from mosquito bite. Advise use of mosquito repellents 50%NN diethyl m toulamide on exposed areas like legs and arms twice daily more often if sweaty climate. Sleep always under insecticide treated bed nets. She should wear long sleeves, trouser and socks after sunset. Use loose fitting clothes to prevent mosquito bite. Use of electrically heated pyrenthroids mats in her room. Avoid going outside from dusk till dawn because mosquito feeds at night. I will give her chemo prophylactic anti malarial drugs after getting information from Health protection Agency. Mefloquine 5mg/kg once weekly starting 2 to 3weeks before travel to establish tolerance and should be continued for month after leaving area. It is contraindicated in epilepsy and depression. (Malarone ) Atovaquone and Proguanil can be used after specialist consultation. It is not recommended due to lack of safety data. Inform her that malaria still can occur while taking chemoprophylaxis. I will give her written information on emergency treatment. (b) The patient should be admitted as emergency for prompt diagnosis and treatment. This patient needs a multidisciplinary team, including obstetrician, infectious disease physician. I will also ask her about her chemoprophylaxis and if so, than to stop at admission. I will get history of mosquito bites, I will take detailed history about her symptoms like sudden coldness followed by rigor than fever and sweating lasting for 4 to 6 hours is a classical presentation of malaria. Patient should also be asked about flue like symptoms, skin bruises, and heamaturia to exclude influenza and hemorrhagic fevers. To find out about severity of malaria, I will get history about convulsions, altered consciousness, any change in skin or urine color (to get information about Jaundice), difficulty in breathing or any abnormal bleeding. Also to exclude preterm labour I will ask about abdominal pain. Clinically patient should be examined for her conscious level and looked for any neck stiffness (meningitis / cerebral malaria), respiratory distressed, jaundice, and pallor. Check patient’s pulse, temperature and BP. Maintain her early obstetrics warning scoring chart. Look for JVP, dependent edema, skin bruises, and Chest examination to find out any evidence of pulmonary edema or ARDS. Per abdominal examination, looking for hepetosplenomegaly, uterine tightening and tenderness for preterm labour. Fundoscopy for retinal hemorrhages or whitening. Investigation includes FBC for hemoglobin, less than 8g/dl in severe anemia. Platelet count and clotting studies in abnormal bleeding in case of DIC. Serum glucose less than 2.2mmol/l in complicated malaria. Serum lactate level. Liver and Renal function test, arterial blood gases, in acidosis Ph less than. 7.3. Blood, urine, and stool culture for septicemia. Lumbar puncture to exclude meningitis. Chest x ray for pulmonary edema. Gold standard for malaria is microscopic examination of thick and thin film. Three negative blood films 12 to 24h apart will exclude malaria. Ultrasound and CTG for fetal assessment. After diagnosis, disease should be classified as uncomplicated or complicated malaria for treatment. (c) Obstetrics complications can be prevented by prompt treatment of malaria and fever. To follow unit protocol. Involve intensivist if patient admitted in HDU for maternal condition. Women\'s life comes first. Obstetrics complications include Stillbirth, preterm labour to be managed by betamethasone for lung maturity and tocolytic for pain. In case of IUGR, USG monitoring of fetal growth and Doppler study and CTG monitoring. Decision of delivery in case of compromised fetus. Thrombocytopenia needs active management of third stage of labour to avoid post partum hemorrhage. Use of thromboprophylaxis after risk assessment and if platelet count is more than 100. Hypoglycemia is an important complication ob both of malaria and its treatment (Quinine) and should be promptly addressed. Hypoglycemia alters CTG pattern and this should be kept in differential diagnosis of an abnormal CTG. Post delivery, cord blood film is recommended besides weekly blood film for parasites. Placenta should also be sent for histopathological analysis.
		Posted by H H. Fri Jul 30, 2010 01:06 am
HHH Will discus with her the urgency of her travel and if possible cancelling it. If travel is a must, will make her aware about malaria , its complications, and that it is transmitted by mosquitoes .I will make her aware of how to prevent mosquito bites,by repellants ,wearing long sleeve shirts and trousers, using electric kits that expell repellants in the rooms and using mosquito nets that are impregnated with repellant.I will tell her about chemoproprophylaxis ,which are drugs she will use before she travells there,Will and I will need to dicuss this with infectious disease physician. I will tell her that if she gets fever and rigors during her travell or after return back up to one year , to consider the possibility of malaria and to tell her physician about that. Will consider her past travell and consider malaria as a cause, but these symptoms might be due to urinary tract infection. Will ask of dysuria, frequency ,urgency or loin pain. Will ask of dyspnea and chest pain( thromboembolism, pulmonary edema), Examination for pulse(tachycardia in anemia,pulm embolism,), BP drop in associated infection and septicemia, temperature, level of consciousness (alert,reaction to voice,pain,non), respiratory rate, jaundice , anemia(pallor) ,cyanosis(ARDS), edema in lower limbs, chest examination for pulmonary edema,crepitations, petichal hemorrhages(DIC). Blood film (thick and thin) is taken to detect the parasite. If negative it is repeated every 24 hr for 3 samples to exclude malaria. Presense of parasite in >2% of blood cells considered complicated malaria. The type of malaria is known. Rapid malaria detection tests are not sensitive. FBC for anemia and thromboctopenia, clotting screen ,bleeding time and clotting time are easy bed side tests and can help detect DIC, urea and electroltes for renal function, liver function tests, blood glucose as hypoglycemia in complicated cases and will get worse with treatment with quinine, ABG(arterial blood gases) and chest Xray if chest involved with pulmonary edema or there is acute respiratory distress syndrome or pulmonary embolism. Will do CTG for fetal wellbeing. Mother here takes priority over fetus. If patient is comatossed ,has convulsions, jaundiced, has evidence of DIC, pulmonary edema, heart failure, parasites present in >2% of red cells or hypoglycemia, she considered to have complicated malaria and is admitted to ITU ,if not she is admitted to the ward. Department of infection control is notified. There is increased risk of miscarriage, this will be reduced by management of malaria with antimalarial drugs. Artesunate, quinine, chloroquine are safe to use during pregnancy. There is increased risk of preterm labour due to the fever, this could be reduced by antipyretics and proper hydration. Paracetamol as an antipyretic is the drug of choice, avoid NSIADS. There is increased risk growth restriction which will need follow up with growth scans. There is increased risk of intra uterine fetal death, reduced by proper management of malaria. In patients who develop DIC ,there is increased risk of bleeding in any operative intervention , so if patient is in labour ,there is risk of post partum hemorrhge, measures resuscitation,blood availability and senior help needed.
		Posted by Chitra.s M. Fri Jul 30, 2010 02:48 am
A.The woman is informed that malaria is spread by mosquito bite and bite prophylaxis is an important preventive measure.She is told about use of skin repellants like DEET 50% solution which has to be applied to exposed parts of arms and legs twice daily and more frequently in sweaty environment.She is advised about wearing clothing that covers arms and legs like long sleeved dresses and socks.She is advised about use of mosquito killing sprays(pyrethroid) and electrically heated repellant mats for room protection.She is informed that use of tear free,pyrethroid impregnated mosquito nets offers significant bite protection.The woman is given information about use of chemoprophylaxis-mefloquine tablet once a week is advised as it is the drug of choice and safe to use in 2nd and 3rd trimester.She advised to take mefloqiune during her stay and continued for 4 weeks after leaving the malaria endemic area.She is advised that chemoprophylaxis is not 100% protective and advised to seek help immediately if she develops fever/flu-like illness.She is provided written information regarding emergency standby treatment for malaria(quinine) in case of no immediate access to medical care.She is told that risks of malaria in pregnancy outweigh any possible adverse effects of chemoprophylaxis and adherence to preventive measures is advised. B.The woman is admitted to the hospital and assessed by a team of obstetrician ,physician and tropical medicine specialist.The aim of assessment is to establish an early diagnosis of possible malaria and prompt treatment to reduce maternal and fetal morbidity/mortality.Details of return from malaria endemic area, whether still on chemoprophylaxis is enquired.Chemoprophylaxis is stopped on admission.Details of the drug used,type of parasite prevalant in travel area are reviewed.Other associated symptoms like headache,muscle pain are enquired.Chest symptoms like cough, breathlessness and urinary symptoms like frequency and dysuria are enquired.History of any convulsions/impaired consciousness is taken from the accompanying person.The woman\'s level of consciousness is noted .She is examined for pallor and jaundice.Her temparature ,pulse(tachycardia) ,respiratory rate(tachypnoea) and BP(hypotension) are recorded.Oxygen saturation is monitored with pulse oximeter.Chest is examined for evidence of pulmonary edema.Abdominal examination is done to look for hepatosplenomegaly,uterine size,contractions and for fetal heart sound.An early warning obstetric chart is used . Investigations include a full blood count for anaemia,total and differential counts and thrombocytopenia.Clotting studies are done if platelet count is low.Thick and thin blood films are taken for malarial parasites-species and parasitemia.A rapid diagnostic test for malarial antigen is considered if blood films cant be immediately read.Blood sugar levels are done for evidence of hypoglycemia.Other tests include liver function tests for bilirubin and renal function tests for serum creatinine urea and electrolytes.Chest xray (with abdominal shielding),arterial blood gas analysis if there are signs and symptoms of pulmonary involvement.Other tests like lumbar puncture for meningitis,test for hepatitis and other travel related illness like dengue,typhus are done depending on the area of travel and clinical suspicion.CTG and ultrasound assessment of fetal well being is done. C.Malaria in pregnancy increases the risks of both maternal and fetal complications.The woman should be managed by a multidisciplinary team of obstetrician,tropical medicine specialist and neonatologist.There is an increased risk of preterm labour and still birth.These can be reduced by prompt treatment with antimalarials and antipyretics.Corticosteroids can be considered if there are no contraindications.Labour during malaria can be associated with fetal heart rate abnormalities.Treatment is with antipyretics like paracetamol,antimalarials and monitoring and correction of hypoglycemia.Role of caesarean delivery in the presence of fetal compromise is uncertain and has to be a consultant led decision.Mother\'s well being is the priority.There is increased risk of post partum haemorrhage in the setting of thrombocytopenia/DIC.This is managed by early liaison with haematologist and use of blood and blood products.Fetal growth restriction may be identified after recovery from malaria.This is managed by ultrasound scans for fetal growth,liquor volume and doppler studies for fetal well being .This helps in growth monitoring and planning delivery.Uncomplicated malaria is not an indication for labour induction.
		Posted by millionaire2004 A. Fri Jul 30, 2010 03:40 am
A healthy 35 year old woman attends the antenatal clinic at 16 weeks gestation. She is due to make an essential journey to a malaria endemic area. (a) What will you tell her about the available interventions to reduce the risk of contracting malaria? [5 marks] I will make her aware of her risk. I will give her contact information of center with expertise in prevention of malaria infection. I will tell her that travelling to malaria endemic are exposes her to malaria infection. Malaria infection has adverse risk to her pregnancy such as miscarriage,preterm delivery,stillbirth,fetal anaemia,intrauterine growth restriction and neonatal risk such as neonatal anaemia,neonatal death,congenital malaria,increased susceptibility to other infections and failure to thrive. I will tell her about mosquito-bite prevention. The risk of mosquito bite highest from dusk to dawn. Use mosquito repellent (50% DEET) on exposed arms and legs. Use knock down mosquito sprays containing permethrine. Advice her to use insecticide-impregnated mosquito net at night. Use long sleeve shirt and pants at night and it should not be tight to prevent mosquito bite. I will tell her about chemoprophylaxis such as Malarone and chloroquine. I will tell her that it should be started 1 week before travel (1-2 days if use Malarone) and used till 4 week after returning home (7 days if Malarone). It does not completely protect her from infection. Its use is safe in pregnancy. I will tell her about symptoms of infection such as flu-like illness,nausea,vomiting,headache which need urgent assessment. Think of malaria if symptoms occur even after 1 year after travel. I will tell her to see a GP to do blood smears if she suspect having malaria. (b) She presents at 28 weeks gestation with a 24h history of fever with rigors and vomiting. Discuss your initial clinical assessment and investigations [10 marks]. She most likely has malaria infection,but other causes of fever needs to be ruled out. Ask about history of usage/current usage of chemoprophylaxis for malaria. Stop chemoprophlaxis immediately as it will decrease malarial parasite count making it undetectable on blood smears. Obtain history from partner/family member about behavioural changes (could suggest CNS infection like meningitis ). Ask about loin pain with dysuria (suggest pyelonephiritis). Ask about any reduction in conscious level or loss of consciousness (suggest cerebral malaria) . Ask about any abnormal bleeding (suggest DIC in complicated malaria).Ask about presence of dark urine (suggest hemoglobinuria). Ask about shortness of breath which could suggest pulmonary oedema. Ask about abdominal contraction pain, looking for complication of preterm labour. On examination, assess patients conscious level, look for jaundice, pallor (suggest anaemia), hepatomegaly,splenomegaly which are present in malaria. Assess for presence of loin tenderness ( in pyelonephritis). Auscultate the lung fields for crepitation which suggest pulmonary oedema. Measure pulse, blood pressure (looking for circulatory collapse), temperature, pulse oxymetry. Investigation which will be taken are full blood count (for anaemia and thrombocytopenia), urea and electrolytes (deranged in renal impairment), blood sugar (hypoglycaemia in complicated malaria), coagulation profile (in DIC), blood and urine for culture and sensitivity. Thick and thin blood smears looking for malaria parasite and its density. 3 consecutive blood smears 12-24 hours apart rule out malaria. Sent urine for haemoglobin . (c) Discuss the management of obstetric complications of malaria [5 marks] Management should involve multidisciplinary team consisting of intensive care specialist, neonatologist, infectious unit specialist and obstetrician. Preterm delivery is a complication of malaria. Treat maternal fever promptly and treat malarial infection with anti-malarial drugs. Administer tocolytics and maternal corticosteroids to enhance fetal lung maturation. Fetal heart rate abnormalities are treated by treating maternal fever, identifying and treating maternal hypoglycaemia. Inform neonatologist if delivery is anticipated. Decision for caesarean section should take maternal condition into consideration and mother life comes first. Stillbirth could be prevented by treating malaria promptly. Post partum hemorrhage prevented by active management of third stage. Congenital malaria is a complication. Take cord blood smear to detect malarial parasite. Take neonates blood smear weekly till 28 days old. in the presence of positive cord blood smear, neonatal fever suggest malarial infection.
		Posted by A- N. Fri Jul 30, 2010 04:09 am
a. Risk of contacting malaria can be reduced by primary prevention like avoiding visiting to this place unless its absolutely necessary, next will by bite prevention by using repellants, mosquio nets, heated mosquito repellent coils, cleaning floors by insecticides like di ethyl tolumid. I will give information regarding the availabality of chemoprophylaxis like mefloquine, proguanil. I would explain that no chemoprophylaxis is 100% effective. The type of chemoprophylaxis depend on the place she is visiting with respect to the type of parasite, weather it is a chloroquine resistant varity or nor and with respect to her gestational age. I would direct her to the health protection agency websit where she and her G.P can look up at the recent guidelines to decide on most appropriate type of chemoprophylaxis. If she is using the antimalarial like proguanil she has to continue for 7 days after leaving the malaria endamic area as this works on liver schizont stage and takes 7 days. She will have to seek early medical opinion if she develops flu like symptoms as early treatment would reduce morbiity and mortality. B) I would take complete history including the duration of fever, weather associated symptoms like headache, malaise, cough, vomitting. I would enquire if the fever is cyclical that is comming every 3 days or 4 days as this will indicate either falciparum malaria or malaria. I would explore the posiballity of UTI by asking about history of Dysurea, lower abdominal pain, increase in frequency of urine, loin pain. I would like to assess if there is any presence of chorio amnionitis by asking history of rupture of membranes, foul smewlling vaginal discharge, fetal movements and abdominal pain. On examination I will check for vital signs as Tachycardia, pyrexia to grade the severity of malaria. history of oliguria and Physical eximation findings as hypotension, presence of pallor, jaundice, altered consciousness, petichial haemorrhage, hepatosplenomegaly all will indicate severe malarial infection. Presence of renal angle tenderness, supra pubic tenderness will suggest Urinary tract infection. Presence of chest signs as dulness on percussion, increased vocal resonence and presence of crepitations will suggest pneumonea. Presence of altered sensoriumwith neck stiff ness may suggest meningitis. Investigations include full blood count to check for Haemohlobin levels to assess anaemia and platelet count which may be low due to thrombocytopenea in malaria. Presence of neutophilia may indicate other cause than malaria as the cause if infection. Peripheral blood smear is most vital to diagnose, typing of malaria and to assess severity of parasitemia. If there are 3 consecutive negative smears taken 12- 24 hours apart will rule out malaria. I would also check urine for infection by doing microscopy and requesting culture and sensitivity. I would request Liver and renal function tests and blood glucose levals if clinical features are suggestive of malaria. If suspecting pneumonia clinically i would request chest X-Ray, if meningitis is a possibality I will request urgent medical opinion with aim of performing Lumbar puncture after giving Broad spectrum antibiotics Intravenously. I would perform CTG to assess fetal well being. Rapid detectyion tests for malaria are available however they are not very sensitive if there is low parasitemia and mis not useful in plasmodium vivax infection. C) The main complications include, hypogylcemia, pulmonary edema with ARDS, Convulsions, coma, hepatic and acute renal failure, anaemia and DIC. She has to be managed in critica;l care unit by a multidisiplinary team including Internsivist, microbiologist, obstetrician specialist in tropical medicine. The main aims include stabilization and treatment of malarial infection. The later is done by Intravenous Arsenuate is the drug of choice in severe malaria. Quinine and clindamycin is used when Arsenuate is not available. Hypoglycaemia is to be monitered regularly to promptly detect and managed. central venous pressure is to be monitored and should be kept less than 10cms of water to prevent pulmonary edema. I.V furosemide may used to treat pulmonary edema. Anaemia is treated with packed cells. If hypotension occours then secondary bacxterial infection is suspected and treated with broad spectrum antibiotics. Preterm labour and still birth is best managed by prompt treatment of malaria.
		Posted by sonu P. Fri Jul 30, 2010 07:25 am
a) I will give her general advice about avoiding rural and forest area camping and stay mainly in urban area if possible. She should avoid going outdoors in the evening and use mosquito repellent creams, impregnated mats and nets. I will advise her about the malaria prophylaxis available in the form of choroquin, mefloquin, and pyrimethamine (for choloroquin resistant areas). I will advise her that prophylaxis is not guaranteed to protect against malaria. Therefore all the other precautions mentioned above are very important. She needs to start prophylaxis a week before leaving, through all her stay and four weeks after coming back and that malaria can present upto a year of returning back. b) The initial clinical approach includes the general assessment of mother and the fetus.The first differential diagnosis will be malaria but ,I will take a history of urinary symptoms and loin pain; diarrhoea, if she is passing urine normally and any fluid leaking form the vagina to rule out other causes of her symptoms like pyelonephritis, gastroenteritis or choriamnionitis. I would like to know the exact travel history to anticipate the most likely species of plasmodium ( i.e falciparum or vivax )responsible, because falciparum malaria is more acute and serious with high rate of complications like cerebral malaria. On examination, I will assess her general condition, consciousness level, hydration, pallor, jaundice, organomegaly. I will check her pulse rate, BP, temperature and any supine hypotension. On abdominal examination, I will measure the SFH to look for growth of the fetus, look for signs of threatened preterm labour and perform a CTG for fetal wellbeing(the interpretation will be cautious due to early gestation );If there are signs of preterm labour a speculum examination should be done to look for dilatation and fetal fibronectin test performed to rule out impending preterm delivery. I will do a urine dipstick test to rule out UTI and check for ketones. I will do FBC, CRP, U&E, LFT and MSU to look for electrolyte imbalance, hepatic complication of malaria and rule out UTI..A fluid balance chart may need to be maintained in case of severe dehydration and to ascertain response to fluid management. `A peripheral blood film and malaria serology test will be done to confirm the diagnosis. If three consecutive blood films are negative, malaria can be practically ruled out. c) Obstetric complications could be maternal and/or fetal. The mother is at increased risk of multiorgan failure especially in falciparum malaria and therefore should be managed jointly with the infectious disease consultant in an HDU/ITU setting. Intravenous quinine or artemether, if chloroquin resistant strain suspected, are the drug of choice. A major side effect of the drug is severe hypoglycaemia; so it is given in 10% dextrose and blood glucose levels monitored regularly. There is an increased risk of preterm labour and delivery with increased perinatal and maternal morbidity and mortality; decision of tocolysis should be taken cautiously at consultant level. Neonatologist should be informed of this patient’s admission. The fetus is at risk of IUGR and fetal distress. Therefore regular monitoring for fetal well being in the form of ultrasound scan for growth and CTG should be instituted. Once the patient’s condition improves, she should be regularly followed up in the antenatal clinic with an aim of vaginal delivery at term. Caesarean section is for obstetric indications only. At delivery, the placenta is sent for microbiology and histology along with cord blood to look for the parasite or plasmodium vasculitis and microthrombi. The neonate should be monitored for symptoms of malaria and peripheral blood film is done as for adults and three negative smears needed to rule out congenital malaria.
		Posted by Syamala H. Fri Jul 30, 2010 09:13 am
syamalah ansa: As the lady is 16wks pregnant and has to make an essential journey to malaria endemic area she should be told that in case she aquires malaria she is a very high risk case as malaria is known to cause increased maternal morbidity and mortality. malaria increases risk of preterm delivery and the fetus is at risk of intrauterine growth restriction and stillbirth. guidance has to be sought from centre with expertise on malaria risk and avoidance strategiesabout her risk of being exposed to malaria depending upon area she is travelling to.she should be told that fever and any flu like illness while travelling andupon returning home upto 1yr or more may indicate malaria and requires urgent medical attention. strategies to reduce the risk is increased awareness of risk depending upon level of transmission,time of year,drug resistance,length of travel rural urban sleepovers and uptake of malaria prevention programme.bite prevention by applying 50%DEET,knock down mosquito spray with permethrin and pyrethroids inside tent and hotel room,longlasting pyrethriods net to used while sleeping(protetive efficacy 50%) room protection byelectrally heated mats of pryethriods and wearing loose fitting long sleeves clothes and long trousers with socks.chemoprophylaxis in the form of tab mefloquine 5mg/kg (250mg) once a week and should be continued for 4 weeks after leaving the area.it is only drug safe in pregnancy and does not cause increased risk of still birth and congenital malformation. if it is not tolerated can be given atovaquone and prouganil(malarone)afterconsultation with specialist. chemoprophylaxis is not 100% protective.if she develops flu like illness with fever she should urgently seek medical attention.in case if access to medical care is not available within 24 hrs she should have emergency standby malaria treatment available with written instruction.full medical evaluation should be done at the earliest opportunity and other causes of fever should be ruled out.provide written information. ans b: At 28 wks she comes with fever rigors and vomitting. history should be taken regarding duration of fever, its diurenal variation,associated symptoms like headach,disturbed vision altered conciousness may suggest meningitis. other symptoms like breathless,cough as it may be a signs of seasonal flu or may indicate serious condition like pulmonary edema and ARDS.presence of nasuea vomitting diarrhea may be present with flu or malaria or indicate gastroenteritis. ask for urinary symptoms like frequency colickypain and dysuria to rule out urinary tract infection.alteration in color of urine could be suggestive of hemoglobinuria or jaundice as in malaria other hemmorhagic fevers.confirm history of chemoprophylaxis, its compliance.obstetric condition like chorioamnionitis may cause similar symptoms so rule out premature rupture of memberane. examintion would include pulse, blood pressure, temp,hydration oxygen saturation .look for cynosis ,anemia,jaundice,clubbing. look for signs of rashes over body which might suggest viral illness.see for lymphadenopathy. examine chest to rule out pneumonia and pulmonary edema.per abdomen examination would include fundal height,any contraction and fetal heart rate.lower extremity should be examined for signs of deep vien thrombosis. per speculum examination if h/o suggestive of leaking. investigation include complete blood picture to look for anemia and thrombocytopenia,thick and thin blood film for malaria,peripheral smear for signs of hemolysis.liver fuction for jaundice,coagulation profile for DIC,urea electrolyte. urine microscopy for puscells hemoglobinuria.if initial investigation are unconclusive a bloodculturewould be required.CSF examination maybe required if signs of meningitis.serology for dengue, leptospirosis,and throat swab for H1N1 may be required depending on clinical suspicion. ansc: preterm labour.fetal growth restriction and fetal heart rate abnormality can occur.efficacious and prompt treatment of malaria reduces adverse effect on fetus and mother.in case of fetal distress in presence of fever give paracetamol1gm iv every 4-6 hrs(max4gm/day) hypoglycemia should be corrected. tocolytic therpy andsteriods can be prescribed.anemia corrcted if required with bloodtranfusion to improve oxygen saturation.increased risk of PPH due to thrombocytopenia and DIC.If delivery imminent notify pediatrician and NICU.multideciplinary approach with intensivist infectious disease specialist for managment ofsevere malaria.uncomplicated malaria i s not reason for induction of labour.thromboprophylaxis should be weighed against risk of hemmorhage..placental histology with cord and baby blood film for peripartum malaria.once recovered antenatal assesment with haemoglobin platlet glucose and growth scan.if growth restriction identified manage according to doppler studies.inform patient about risk of relapse and clear plan if she has symptom reccurence.babies should be screened by thick and thin film at birth and weekly till 28 days.disease should be reported to Health protection agency.
		Posted by NIRMALA M. Fri Jul 30, 2010 11:10 am
Nirmala a. She should be educated about the risks involved with malarial infection in pregnancy especially due to falciparum infection like miscarriages, fetal growth restriction, preterm labour, still birth along with increased maternal morbidity and mortality. The best way to avoid contracting malaria is to avoid traveling to the malarial endemic area while pregnant. Advice from specialist with current experience in malaria treatment and prophylaxis should be sought. Website addresses and department of health publication leaflets about malaria prevention and treatment should be made available to the patient in her language. She should be informed that prophylaxis is not 100% effective. She should be educated that female anopheline mosquitoes which are the cause for malaria, bites during the night time. Therefore she should be advised to stay indoors after sunset, possibly in an air-conditioned room, if not, in a room with well protective windows with screens. She could be advised to apply mosquito repellent creams like 50% DEET on the exposed body parts, to spray mosquito repellent sprays containing permethrin and pyrethroids which could repel and kill the mosquitos, use repellent coated nets for sleeping and use mosquito repellent mats. She can be advised to wear fully covered garments which protects her from mosquito bites. She can be given chemo prophylaxis mefloquine 100mgs once a week which should be continued till one week after she left the area. If Mefloquine could not be given due to any psychiatric problems, atovaquone- proguanil 1 tablet per day to be continued for 4 weeks after she left the area. b. General symptoms like fever, rigors, sweats, vomiting, diarrhoea, headache, malaise are all non specific symptoms which might represent uncomplicated malarial infection. Any symptoms and signs pertaining to severe malaria should be looked for such as prostration, impaired consciousness, convulsions, breathing difficulty presenting with tachypnoea, decreased oxygen saturation, shock manifesting with hypotension, tachycardia, reduced capillary refill. Jaundice, renal failure and abnormal bleeding also signs of severe malaria. MOEWS chart is used to assess her vitals, input and output which shows the severity of her clinical situation and suggests any deterioration. Once malaria is suspected in pregnancy, she has to be hospitalized for further investigations and management as uncomplicated malaria will progress to severe form if treatment delayed. Severe malaria should be treated in ITU. She has to be treated by MDT involving ITU consultant, Infectious disease specialist and Obstetric Consultant. Investigations to include FBC including haematocrit to look for anaemia and thrombocytopenia, LFT to look for any liver function derangements, UEC to note any renal shut down, Clotting to rule out DIC, Blood glucose to look for hypoglycaemia, central venous line to maintain hydration and to maintain right heart pressure < 10mmhg, CXR if clinical situation warrants with abdominal shield, ECG if tachycardia, ABG to know lactate levels and blood cultures if algid malaria is suspected. Diagnostic investigation for malaria is thick and thin blood films to quantify the parasitaemia as 2% of parasitized RBCs suggest severe infection and to identify the species which direct the treatment, results to be obtained urgently with in one hour of admission. If the smear is negative, 2 more repeat smears to be done in 12-24 hours. If three consecutive smears are negative for malaria, then it is very unlikely that she has malaria and other infectious causes should be looked for. Even one smear is positive, she has to be treated for malaria. Once malaria is confirmed, blood film and other blood tests like FBC, LFT, UEC, clotting, Blood films repeated daily to note improvement to treatment or to identify any deterioration. c. Obstetric complications of malaria includes fetal growth restriction due to placental parasitaemia, still birth due to multiple factors including lactic acidosis, pre-term labour due to pyrexia, fetal distress due to pyrexia and hypoglycaemia, PPH due to maternal anaemia and thrombocytopaenia. She should be managed by MDT including Obstetric Consultant, ITU Consultant in severe malaria, Infectious control Specialist and Neonatology Consultant. Obstetric complications are prevented by promptly treating with IV Artesunate 2.4 mgs/ kg per day followed by IM or oral artesunate along with clindamycin 450 mgs tds for 7 days in severe falciparum malaria. In uncomplicated falciparum malaria she could be treated with quinine 600 mgs tds with clindamycin 450 mgs tds for 7 days. In non falciparum malaria, treatment is with chloroquine 600 mgs followed 6-8 hours by 300mgs of chloroquine, repeated on day 2 and 3. She should be treated supportively with anti pyretics and fluids. Pyrexia is controlled with IV paracetamol 1 gm 4-6 hourly to a max of 4 gms / day. Hypoglycaemia should be controlled with 25% or 50% dextrose and frequent monitoring to look for hypoglycaemia is necessary. Usually fetal distress due to pyrexia and hypoglycaemia settles with symptomatic treatment. Tocolysis and steroids could be used in threatened preterm labour if there are no contraindications. Serial growth scans should be done in order to identify FGR if symptoms settle and pregnancy continues. Prompt treatment of maternal anaemia and thrombocytopaenia in order to avoid PPH and active management of third stage of labour. Severe malaria is not an indication for induction or Caeserean section. Mode of delivery is based on obstetric and fetal indications. Thromboprophylaxis can be given if there are no contraindications.
		Posted by MR R. Fri Jul 30, 2010 12:23 pm
MR A healthy 35 year old woman attends the antenatal clinic at 16 weeks gestation. She is due to make an essential journey to a malaria endemic area. (a) What will you tell her about the available interventions to reduce the risk of contracting malaria? [5 marks] I will ask her about the duration of the travel,time of the year and places of travel.I will advice her to avoid going out between dusk and dawn as the mosquito bites are more predominant during this time.I will ask her to wear loose fiiting garments and cover all the exposed areas to avoid bites.I will tell her to use repellents like 50% DEET on her skin atleast twice daily and more frequentlt if sweaty.If she is not tolerant to this ahe can use a lesser effective alternative.I will ask her to use knock down sprays like pyrethroids or permethine in her room.She can also use pyrethroids impregnanted nets.Electric mats vaporising pyrethroids can be used in th room and should be changed everyday.(coils are less effective) I will advise her that taking chemoprophylaxis prevents contacting malaria but this is not 100%.She can use one of the two available option 1. casual (continued for 7 days after leaving the endemic area) 2. suppressive ( continued for 28 days) eg.mefloquine 250 mg once weekly dose or other alternatives.If vomiting in 30 mts to repaet the whole dose or after 1 hour to repeat half the dose.I will counsel that the benefits outweigh the risks of taking chemopropylaxis.I will educate her regarding malaria symptoms like fever with chills and rigors and to seek medical help immedaitely.If unable to reach help I will advice her to take stand by treatment. (b) She presents at 28 weeks gestation with a 24h history of fever with rigors and vomiting. Discuss your initial clinical assessment and investigations [10 marks]. A history of associated symptoms like dark urine,jaundice and cyclical ocuurence should raise the suspicion of malaria.A history of ruptured membranes,abdominal pain+/- bleeding can suggest chorioamnionitis.Dysuria,frequency and loin pain can suggest UTI /Acute pyelonephritis.Associate diarrhoea and abdominal pain can be due to gastroenteritis.Productive cough and dyspnoea can be associated with URTI.Examination should include her Temperature,Pulse rate,Blood pressure and oxygen saturation.Jaundice,anaemia & haemoglobinuria can suggest malaria due to red cell haemolysis.Presence of seizures,laboured breathing,oliguria,altered conscious level can suggest more severe complicated malaria.Retinal assessment can yeild whitening of the retinain sever cases.I will do thick and thin blood film to confirm diagnosis.Rapid antigen assays are available but less sensitive.Three negative blood films 12- 24 hours apart is taken as negative test.Full blood count can reveal anaemia and thrombocytopenia.ABG can show metabolic acidosis in severe malaria.Blood glucose levels are checked regularly< 2.2 mmol /l can suggest severe malaria.Stool cultures,sputum sample,CXR and urinalysis done to rule out other causes of fever with vomiting.A ctg is done to assess fetal well being. Discuss the management of obstetric complications of malaria [5 marks] This should be manged in liasion with ifectious disese specialist.Antimalrial treatment oral/IV based on the severity reduces the complication(IV artesunate/quinine/choloroquine)Preterm labour can be due to underlying pyrexia and adequate oral /IV paracetamol should be used to reduce this < 38 c.Antenatal steroid cover with appropriate tocolysis should be used to reduce the incidence of RDS.Anaemia should be corrected with packed red cells with or without IV frusemide to reduce the incidence of pulmonary edema.Non reasuring CTG can be due to pyrexia or hypoglycemia due to quinine therapy and treatment should be aimed at correcting this.In ongoing pregnancies there is risk of IUGR and regular 2- 4 weekly scan are arranged for growth,liquor volume and umbilical artery dopplers.Regular antenatal follow ups are arranged after discharge for checking Hb ,platelets,blood films if required and fetal wellbeing.Thromoprophylaxis cover after considering other risk factors should be considered.Third stage of labour should be manged actively if coexisting thrombocytopenia.Congenital malaria can happen if the placenta is sequetrated with parasites and the neonate should be followed up woth blood test every week till 28 days.Placenta should be sent for histopathology.
		Posted by nazia M. Fri Jul 30, 2010 06:38 pm
a) Malaria can be life threatening but it is preventable. Consider postponing her trip unless travel is unavoidable. Written and verbal information should be provided about effective anti-mosquito measures. Education about the symptoms of malaria is beneficial it enables her to realize that she needs to seek medical attention without delay. Bite prevention measures including skin repellent containg 50% DEET, knock- down mosquito spray (premethrin and pyrethoids sprays), insecticide-treated bed nets (pyrethoid-impregnated bed nets), clothing that covers the body and room protection by electrically heated mats. Chemoprophylaxis with mefloquine once a week and take during her stay continue for 4 weeks. It is safe in second and third trimester but it is not 100% protective. Tell about website for her to learn about malaria for traveller. b) Patient should be admitted in hospital for assessment urgently. There are no specifics sign and symptom of malaria and can mimic influenza and other common virul infection. Febrile pregnant women with a history of travel in a malaria area should be asked about symptoms like fever with chill, sweats, headaches, muscle pain, nausea vomiting, diarrhea, chest symptom like cough and any urinary symptom. Women should be asked about details of prophylaxis taken for malaria because parasitemia supress below the level of microscopic detection. Examination should be done to exclude jaundice, pallor and increase temperature. Respiratory examination for respiratory disstress and abdominal examination to exclude hepato and spleno megaly should be done. Investigations include microscopic examination of thick and thin blood films for parasites and malaria rapid antigen test- it is less sensitive than blood film, send to lab immediately and ask for result in 1 hour, full blood count so exclude anemia and thrombocytopenia, blood glucose for hypoglycemia, urea and electrolytes for renal impairment, liver function test for liver impairment, blood culture, urine dipstick, if indicated stool test, x-ray test (precaution apply) and obstetric ultrasound for estimated gestational assessment and iugr. Single negative blood film doesn\'t include malaria repeat daily 2 days. Malaria is unlikely if 3 negative blood films. Women with malaria should have the severity of the condition assessed and documented whether complicated or uncomplicated malaria so that prompt treatment should be instituited. c) Obstetrics complications of malaria are preterm labor, iugr, fetal disstress and iud. Patient should be managed by multi-disciplinary team approach which include obstretician, neonatologist, infectious disease specialists, intensive care specialists. Fever is associated with premature labor and fetal disstress prompt treatment with antipyretic (paracetomal at the standard dose). Still birth and premature delivery are best prevented with prompt and effective antimalarial treatment. Tocolytic therapy and steriod therapy should be considered.maternal hypoglycemia should be excluded as the cause of fetal distress and if present treated.uncomplicated malaria is not a reason for labour induction.Regular antenatal care including assessment of hb,platelets,blood glucose,fetal growth scan is advised.If iugr is identified routine obstetric management for this condition is applied.
		Posted by Bee N. Sat Jul 31, 2010 02:23 am
A healthy 35 year old woman attends the antenatal clinic at 16 weeks gestation. She is due to make an essential journey to a malaria endemic area. (a) What will you tell her about the available interventions to reduce the risk of contracting malaria? [5 marks] (b) She presents at 28 weeks gestation with a 24h history of fever with rigors and vomiting. Discuss your initial clinical assessment and investigations [10 marks]. Discuss the management of obstetric complications of malaria [5 marks] (Bee) A) I will advice her that their are centers with expertise in the field of prevention of diseases such as malaria that can be contacted for clarification and details in preventive methods of contracting malaria. General information like avoiding rural areas, water logged areas where mosquitoes breed and travellling during a time of the year when malaria is less prevalent may be helpful. I will inform her that putting on cloths that will cover the body as much as possible will be helpful especially at night when the mosquitoes are more likely to bite. I will inform her of the availabilty of creams such as DEET which are mosquitoe repellants. I will also inform her to use insecticides to spray the rooms she will be residing such as permethrine containing insecticides. I will also inform her that their are electric mats which vapourise insecticides which can be used as well as bed nets to cover her bed so as to prevent mosquito access. Their are also drugs which can be used for chemoprophylaxis. At 16 weeks mefloquine is safe as long as she doesnt have contraindications to it such as depression or other psychiatric illness in which case Atovaquone and proguanil (malarone) can be used. I will inform her that giving information about where she is travelling to will help to know what kind of chemoprophylaxis that can be precribed (some areas are chloroquin resistant). B)I will start by asking about the onset, severity, frequency of fever to have an idea of what the origin is since malaria fever could be cyclical but so are abscesses. I will ask about her vomitingseverity, frequency and nature. This will give an idea if she will be needing IV fliuds if not tolerating orally. I will ask about any abdominal pain or diarrhoea help rule out bowel related problems. I will ask about presence of dysuria, frequency and urgency to rule out urinary pathology. I will ask about history of travel and to what region as malaria, hepatitis A and B, yellow fever and heamorrhagic fevers need to be considered. I will ask about neurological symptoms such as photophobia and severe continuos headache and altered consciuosness which may be a sign of meningitis or encephalitis. I will then ask about chest symptoms such as cough and chest pain to rule out chest pathology. I will ask about foul smelling vaginal discharge to rule out chorioamnionitis and ask about fetal movements to ensure that baby isnt been adversely affected by illness. I will start examination by taking her BP, Pulse and temperature. I will check for anaemia and jaundice which will indicate possible hemolysis associated with malaria. I will also check for petechial rashes which is a sign of coagulopathy. I will examine her chest to rule out consolidations found in pulmonary oedema. I will do a neurological examination which will not only help rule out space occupying lesions such as abscesses but also check for her sensorium which can be altered in cerebral malaria. I will examine her abdomen to check for hepatosplenomagaly which cn be enlarged in malaria. I will put on a cardiotocograph to monitor fetal heart trace. I will take urine for urinalysis which may show blood/hemoglogin as in hemolysis. I will send urine off for culture if indicated. I will take blood for FBC to show presence of anaemia CRP which may show signs of infection on going. I will also check the LFT and E&U which are organss whose functions may also be deranged in malaria. I will do a thick and thin blood film to check for malaria parasites and also do random blood sugar to rule out hypoglyceamia which may be a complication of plasmodium infection. Further imaging such as chest-X ray will be performed if their is suspicion of pulmonary involvment. C)Management of obstetric complications is best done under a multidisciplinary setting involving the obstetrician, pediatrician, ITU specialist and hematologist. Complicated malaria should be managed in ITU/HDU but this does not necessarily imply obstetric complications such as IUGR. Anaemia should be treated promptly with blood transfusion if severe enough and thrombocytopaenia which is associated with blood loss at delivery will necessitate active management of third stage of labour. Hypoglyceamia is more likely in pregnancy and can be treated with dextrose infusion and prompt treatment of malaria. Fetuses are prone to Intra uterine growth restriction and should have regular clinic appointment with growth scans for abdominal circumference, liquor volume and doppler. Preterm labour should be managed with steriods and tocolysis though prompt treament of fever will reduce risk. Prompt manegement of malaria will also help prevent still birth which is more common in pregnancy associated with malaria. Fever in pregnancy can cause CTG abnormalities and delivery will be necessary if it persists. The peadiatricians will need to be involved if this occurs and maternal health considered as priority in such instance. Baby should be monitored after birth especially in cases of placental infection for congenital malaria and treated appropriately. Primaquine is contraindicated in pregnancy.
		Posted by Kiran J. Sat Jul 31, 2010 05:11 am
a:She is informed regarding mosquito bite prevention.Skin repplellants like 50% DEET can be applied to exposed areas of her body and frequent applications in hot and sweaty milieu.She is to be told to wear loose clothing and socks and long sleeves to protect from mosquito bites and avoid going out from dusk till dawn.She can use mosquito sprays like prethyroids and permethrin or electrical device using vaporisation of pyrethroids mat.Bed nets impregnated with pyrethoid insectiside can offer 50% protection from mosquito bites. I will tell her that chemoprophylaxis is not 100% effective and despite on it she can still contrat malaria and if any symptoms of fever or rigors she needs to seek medical aid urgently.The regime commonly used in chloroquine resistant malaria endemic are mefloquine 5mg/kg body wieght per week .If cannot tolerate this than she can have atovaquone and proguanil.She should also be made aware that before any chemoprophylaxis is imparted advice from infectious disease physician will be taken. I will tell her about risks of travel to malaria endemic countries and that if possible to postpone.If travelling is extremly important she can seek guidance from from a centre with expertise on malaria risks and avoidance strategies and provide her written information regarding these centres. b) I will check her pulse for tachycardia and blood pressure for hypotension if she has septicimia.Her temperature for pyrexia,general physical examination to inspect for jaundice and pallor and raised JVP as they may be a sign of hepatic sequestration of parasite and severe aneamia.Chest inspection and breathing rate as first sign of pulmonary edema is increased respiratory rate,chest ausculatation for any decreased air entry or added sounds.Abdominal examination for spleenomegaly and symphsiofundal hieght as malaria can cause IUGR.Fetal heart auscultation and CTG as in acute malaria there can be fetal distress.Her oxygen saturations and cappliary refill as it can be reduced if she is hypotensive and collapsed due to circulatory shock and any signs of meningism( neck rigidity ,rash) Investigations consist of thick and thin blood smears for microscopic examination These are sent urgently by courier or taxi to hospital of tropical medicine or HPA malaria referance labs.A rapid detection test can also be done but it may be negative if recently on chemo prophylaxis.The microscpic examination will reveal parasitimia,type of plasmodium and which stage of life cycle the plasmodium would be at this particular time.In addition to this I will do an FBC to detect aneamia and thrombocytopenia as it will guide me whether she needs pack cells transfusion or not and should thromboprophylaxis be avoided if platelets are less than 100..U&E to assess renal functions and involve intesivitists and haemodylasis if creatinine >250.Her BMs should be done to check for hypoglyceamia and dextrose infusion if <2.2mmol/l.Blood cultures are done to detect 2ndasy bacterial septicimia and Lumbar puncture if s/o meningism.ABG to detect metaboloc acidoses and serum lactate levels to detect hyper lacticimia as it has high associated mortality risk. c> There is a risk of preterm labour and fetal distress hence effecacious treatment of malaria by I/V artesunate or Quinine coupled with clindamycine and symptomatic supportive management with antipyretics and hypoglycaemia if present.Prophylactic steroids and inform SCBU ,Consultant paediatrician and infectious disease specielist.Tocolysis can be considered and BMs every 1/2 hour if on I/V quinine(as it can cause hypoglycaemia).The mother should be informed of the risks of congenital malaria of the baby and that babys blood film and placental histology will be sent to detect for parisitaemia and that baby in case of having symptoms will require antimalarials after birth.In case she recovers from preterm labour I would follow her up with 2 weekly scans to see growth velocity of the fetus and regular assessments of maternal HB,platelets and glucose and a clear plan in notes in case of relapse.
		Posted by R v P. Sat Jul 31, 2010 06:05 am
healthy 35 year old woman attends the antenatal clinic at 16 weeks gestation. She is due to make an essential journey to a malaria endemic area. (a) What will you tell her about the available interventions to reduce the risk of contracting malaria? [5 marks] Available interventions to reduce the risk include bite prevention methods and chemoprophylaxis. Mosquito repellents containing 50% DEET have shown to be effective against Anopheles. Knock down mosquito sprays containing permethrin have also been shown to be effective in killing the vector. Insecticide impregnated bed nets without tears and well tucked under the beds have also been shown to be effective in prevention of transmission. Appropriate clothing covering trunk and limbs can also reduce mosquito bites. Chemoprophylaxis could be causal or supressive. Malarone which targets the liver schizont stage belongs to former and needs to be taken for 7days after return. Mefloquin is supressive and needs to be taken for 28days up on return as it targets the RBC stage. Quinine resistance is very common and may be of limited use. (b) She presents at 28 weeks gestation with a 24h history of fever with rigors and vomiting. Discuss your initial clinical assessment and investigations [10 marks]. Malaria is likely to be the cause of her symtoms. Malaria in pregnancy is a medical emergency. Patient should be admitted to the hospital as she could deteriorate rapidly. If features of severe malaria such as altered consciousness, respiratory distress, or shock are present, she needs to be admitted to the ICU. Initial assessment should be systamatic with the ABCD approach. She is likely to maintain her airway on her own at this stage. If not anaesthetic help should be called. Tachypnoea is likely to be present and may be secondary to respiratory distress. Chest should be auscultated to exclude pulmonary oedema. Blood pressure and pulse rate should be assessed. Raised temparature shoud be promptly treated with antipyretics. MEOWS charts should be used to document observations. Large bore IV access should be obtained and fluid resuscitation instituted. Anti ematics such as Metaclopromide may control vomiting. Hourly urine output should be monitored to detect acute renal failure. Investigations and treatment should be done by a multi deciplinary team. This should include an expert with current experience in treating malaria, senior obstetrician, intensivitist and anaesthetist. Blood should be obtained for thick and thin film. This may help to identify the species, quantify parasithaemia and the stage of the disease. Repeat films may be required every 24hrs and be urgently sent to a reference laboratary. If rapid testing is used results should be confirmed with blood films as above. Anaemia and thrombocytopenia should be excluded. Baseline renal and liver functions should be assessed as both liver and kidneys could be damaged with severe malaria. DIC is also a complication of severe disease. Therefore clotting assay is important. Group and save should be done in case transfusion is required. Chest X ray could exclude pulmonary oedema. Urine dipstick and MSSU is indicated if pyelonephritis is considered in the differential diagnosis. Haemoglobinurea may be present in renal involvement. If severe malaria is suspected, IV artesunate is the tratment of choice. Dosage is 2.4mg/kg at 0/12/24hrs and then daily. If it is unavailable, IV Quinine should be used. Discuss the management of obstetric complications of malaria [5 marks] Obstetric complications of malaria include miscarriage, pre term labour(PTL), small for gestation age (SGA), still birth and congenital malaria in the neonate. Iatrogenic fetal anomalies is also a recognised complication with some anti malerial drugs. SGA should be managed according to the current guidelines. This includes serial growth scanning and fetal wellbeing assessment if indicated. Steroids should be administered in threatened PTL. Tocolysis may be necessary to complete steroids or to help intra uterine transfer. Optimum maternal tratment and treatment of relapses are associated with a favourable obstetric outcome. This may reduce the risk of SGA and PTL. Cord blood should be obtained at birth and neonatal blood films checked at birth and then weekly until 28days to detect congenital malaria. Premaquin is not used in pregnancy due to the risk of congenital anomalies.
		Posted by zara A. Sat Jul 31, 2010 09:56 am
A]She should be made aware of riskof malaria depending on area of travel and ethinicity uk resident high risk,thematernal risks[ lifethreatening,morbidity,anaemia ] and foetal risks[miscarriage,stillbirth,preterm labour ,iugr.,and consequences in later life]She should consider the risk and try to postpone until delivery.IF not possible ,then refer for advice in centre with expertise.She should told strategies for bite prevention.Skin repellentslike50% deet solution applied to exposed arms and legs twice daily ,and more frequently in sweaty wheather.MOSQUITO knock own sprays containing pyretheriods and permethrines helpful to prevent from bitewhether stay inside or outside.IF OUTSIDE stay then use pyrethriods impregnated nets helpful for bite prevention.IF iINSIDE THEN room protection by using electric mats that vaporises pyrethriods will helpful\'.CHEMOprophylaxis should offered depending on chloroquine resistence in area of travel.Explain that benefits of taking prophylaxis out weighs risk.Mefloquinine 5mglkg body wt offered.and should continue 4 weeks after leaving endemic area and if mefloquinine resistence then atovaquone and proguanil given after advice from infectious disease physician..Tell her no prophylaxis 100%safe.EDucate her about symptoms of malaria [fever ,flu like symptoms ].emergencySTAND by treatment[quinine and clindamycin] should taken and advice urgently sought if have symptoms of malaria.WRITTEN information given and web site addresses provided.B]The patient should be admitted and prompt assessment done as symptoms suggestive of malaria .Asses ment should be done to assess the severity of malaria and exclude other possibilities like UTI,viral infections ,gastroenteritis.IF MALARIA SUSPECTED involve infectious diseae physcian and notify health protection unit.ASSESS her concious level.ASK ABOUT CHEMOPROPHYLAXIS and compliance[not100%preventive]HISTORY should taken of frequency of vomiting ,pattren of fever,head ache ,bodyache [constitutional symptoms]diarrhoea [gastroenteritis ]burning micturation freqency,loin pain[ uti] ,colour of urine hematuria [suggestive of hemoglobinuria due to hemolysis ,anuria [renal failure],breathlessness dyspnea COUGH[ARDS ;PULMONARY OEDEMA].ASK about bleeding from gums and from any site ,bruises[thrombocytopenia.DIC] ,Ask about abdominnal pain and vaginal loss.SYMPTOMS are nonspecific.EXAMINATION DONE pulse [tachycardia signof infections and shock].BP should be recorded .[hypotension] hydration status should be checked [dehydration in fever ,vomiting ] ,TEMP RECOrded pallor [indicate anaemia ]JAUNDICE , chest examination done respiratory rate [tachpnea ] auscultation [crepitation],OXYGEN SATURATION MEASURED by pulse oximetry,ABDOMINAL examination done to look for spenomegaly and hepatomgaly.symphysio fundal height measured .CTG done to record foetal heart and contraction.Investigations doneRAPIDantigenDETECTION TESTANDmicroscopic examinationof thick and thin blood films to look for parasitemia and identify species.if fim negative three films done 12 t0 24 hours rule out malaria.Ask labarotory to give result in 1 hour ,FULL BLOOD count haemoglobin[anaemia] platelet count [thrombocytopenia] ;seru m urea creatinine serum electrolytes done as possibility of renal involment.LIVER function tests done ,coagulation tests [DIC].Urine microscopy and culture [UTI, ANDFOR HAEMOGLOBINURIA],SERUM LACTATE DONE[HYperlactemia] ,arterial blood gases [ACIDOSIS]BLOOD culture[secondry bacterial infections].blood glucose[hypoglycemia].STOOL CULTURE SHOULD DONE,chest xray with abdominal shielding[pulmonary edema].lumber puncture if CNS invlement. abdominal usG done hepato megaly;spleenomegaly.oBSTETRICusG for foetus done [.C ]Obstetric complications are preterm labour,still birth ,, FETAL DISTRESS ctg abnormalities [bradycardia ,tachycardia,decelerations],IUGR,vertical transmission to foetus [congenital malaria]. ALL COMPLICATIONS PREVENTED BY EFFECTIVE antimalarial treatment,.MULTIDISCIPLINARY APPROACH invovling obstetrician,infectious disease physician,and neo natologist.IF FOETAL HEART abnormalities check temp and blood glucose .settle temp with paracetamol and correct hypoglycemia .FOETAL HEART USAULLY RECOVER if not recover then consider delivery decision based on standard principle life of mother comes first.IF PRETERM labour tocolysis ,steriods given .inform scubu .involve paediatrician ,counsel parents.FOR iUGR serial growth scans fortnightly and umblical artery doppler.FOR detection of congenital malaria send placenta and cord blood for blood film if positive then weekly thick and thin films of baby uptil28 days.
		Posted by zara A. Sat Jul 31, 2010 10:04 am
MATERNAL COMPLICTIONS PPH TO PREVENT it coagulation abnormalities corrected ;thromocytopenia corrected with platelet transfusion ,effective antimalarial drugs given.active management of third stage.VTE CAN ALSO occur thromboprophylaxis can prevent it.not given if platelet below100x106.
		Posted by Dr Dyslexia V. Sat Jul 31, 2010 09:02 pm
X a) She should be aware of the malaria disease are more sinister in certain countries such as plasmodium falciparum parasite which are more prominent in the African continent and more sinister. She could be asked to consider to postpone the trip if possible after the pregnancy. She should be informed in regards to the symptoms of the disease such as flue like illness, and recurrent fever and the prompt need to seek treatment. He should be informed that the vector of malaria is a female anopheles mosquito which usually bites from dusk to dawn. She could prevent the mosquito bites by using full covering clothes. She could also use mosquito repellant on the area exposed with compounds such as DEET(Di ethyl N-thoulamid). She could also use knock down mosquito sprays. She could use bed nets during sleeping time which could be impregnated with mosquito repellants such as permethrin. She could also use heated mats with permethrin. Apart from this, she could use a course of chemoprophylaxis such as mefloquine which could be started from one week before the travel to four weeks post travel. It is relatively safe in 2nd, 3rd trimester and during breastfeeding. She could also use Malarone which could be started one to two days prior to trip than 1 week post trip. She should be informed the contraindication of the drug such as neuropsychiatric disorders or hypersensitivity to quinine. She should also be informed that she still be able to get malaria inspite of chemoprophylaxis and if symptomatic to seek treatment. b) History in regards to recent travel to malaria endemic country is of importance but other infection are still need to be ruled out. History of shortness of breath, cough, sputum, coryzal symptoms, ear pain should be asked to ascertain upper or lower respiratory infection. Symptoms of vomiting with diarrhea could indicate gastrointestinal tract infection such as tropical sprue, giardiasis should also be ruled out. History of leaking liquor or vaginal discharge should be asked to rule any chorioamnitis as well. Urinary symptoms such as lower abdominal pain with dysuria, frequency, pyuria, with back pain could indicate urinary tract infection. The history of fever pattern of every 2 to 4 days could indicate malaria infection. Examination should be done to assess pulse rate, respiratory, spo2, temperature is of importance. Presence of pallor or jaundice could be present in malaria. Examination of the lung should be done to elicit to assess crepitation, rhonchi could indicate lung infection. Abdominal examination should include uterine size, tenderness which could be present in chorioamnitis or presence of renal angle tenderness in pyelonephritis. Presence of hepatosplenomegaly could indicate malaria. Sterile speculum examination done to assess leaking and vaginal discharge with swab taken for suspected chorioamnitis. Investigation of full blood count with presence of raised total white count, low hemoglobin could indicate malaria. Liver function test could be altered in complicated malaria. Renal function test must be done as baseline for renal disease. A rapid test for malaria should be done and if positive a peripheral blood film should be done taken three times 24 hours apart to assess the type of malaria parasite. Lumbar puncture should be done as well for suspected cerebral malaria. Ultrasound could be done to assess fetal well being and CTG as well. c) Obstetric complication of malaria to the mother include severe fever which could be treated with regular tepid sponging and the use of regular paracetamol. If severe anemia is present she could be transfused with packed cells. She should be monitored for hypoglycemia and treated with dextrose solution if it occurs. Malaria infection should be promptly identified and the type of malaria parasite and it’s sensitivity ascertained. Appropriate antibiotics should be administered such as IV Artesunate or Quinine. Regular ultrasound should be done to monitor presence of IUGR. Caesarean section is reserved only for obstretic indication and maternal health takes presedence over fetal wellbeing in such cases of DIC and fetal distress. Pre term labour could be treated with tocolytics and the use of corticosteroids for fetal lung maturation. Active 3rd state management with use of ergometrine should be done to minimize 3rd stage blood loss in a already anemic and thrombocytopenic mother. Cord blood film should be taken and monitored weekly for 4 weeks for presence of malaria parasites. Placental parasitaemia is associated with increased neonatal morbidity and mortality if not promptly treated.
		Posted by Ir A. Sun Aug 1, 2010 06:11 am
Ir a) I will tell her about mosquito repellant creams containing 50% DEES which should be applied to all exposed body parts throughout the day. She should wear loose fitting clothes with long sleeves, trousers and socks to minimize exposed body surface. Mosquito knock down sprays containing permethrin are also available. Mosquito net screens impregnated with permethrin can be put up around the bed while sleeping. In addition to these bite prevention methods, the other option is chemoprophylaxis. She can take Mefloquinone 5mg/kg once a week or atovaquone 250 mg daily. These medications are considered safe in pregnancy. I\'ll still suggest that she should postpone her trip if possible as pregnant women have low premunition and are prone to develop serious complications of malaria. I\'ll provide her with the information website address that provides guidance to people travelling to malaria endemic areas. b)I\'ll enquire about symptoms of severe malaria like difficulty in breathing, bleeding from any site, severe headache, blurred vision and altered sensorium. I\'ll ask about any abdominal pain and whether fetal movements are felt or not. I\'ll examine her for jaundice, pallor and signs of dehydration. I\'ll note her temperature, pulse rate, blood pressure and respiratory rate. I\'ll auscultate her chest to see whether lungs are clear. I\'ll do abdominal examination for uterine size, symphysiofundal height, any palpable contractions and listen to fetal heart. I\'ll palpate the abdomen for hepatosplenomagaly though it may be difficult to assess in a 28 week pregnancy. I\'ll admit her in the antenatal ward and set an iv plug and send off blood for peripheral smear (both thick and thin films). I\'ll order full blood count, liver function tests, blood urea, serum creatinine, electrolytes and coagulation profile. Her oxygen saturation should be noted and urine should be tested for ketones. A cardiotocogram may be done to ensure fetal well being. c) Pregnant women are at high risk of developing complications with a case fatality rate of as high as 50% in severe malaria. the patient should be managed as an inpatient in consultation with consultant obstetrician and infectious disease specialist. Obstetric complications of malaria include miscarriage, severe maternal and fetal anemia, preterm labour, intrauterine growth restriction, low birth weight, still birth, DIC and increased maternal and perinatal mortality. All pregnant women with malaria should be admitted to hospital and those with signs of complicated malaria should be admitted to ICU. The patient should be screened for anemia and treated with oral/parenteral iron or blood transfusion depending on severity of anemia. Intravenous antimalarials should be started if vomitimg persists and patient is unable to tolerate oral therapy. Preterm labour should be managed as in other patients and steroids for lung maturity are not contraindicated. The patient should be monitored with serial growth scans to detect IUGR. Signs of fetal distress may be due to maternal pyrexia or hypoglycemia. So fever should be treated with antipyretics and blood glucose measured in case of nonreassuring fetal heart. The patient should be the patient should be manged together with ID physician. Complicated malaria like cerebral malaria, pulmonary edema should be treated with intravenous artesunate. Pulmonary edema may necessitate ventilatory support and should be managed in conjunction with anaesthetist.
		Posted by Arun D. Sun Aug 1, 2010 07:46 am
aruuuuu a) available interventions She should consider the risks of travel to malaria endemic countries and consider postponing their trip, unless travel is unavoidable. i will advise the woman to seek guidance from a centre with expertise on malaria risks and avoidance strategies. i shall advise her that a fever or flu-like illness while travelling or upon returning home, up to 1 year or more, may indicate malaria and requires medical attention. i shall advise her on the risk of being exposed to malaria at her intended area of travel.i shall also give her the copy of think malaria leaflet produced by the Department of Health.i shall inform her about bite prevention measures, including skin repellents, knock-down mosquito sprays, insecticide-treated bed nets, clothing and room protection. clothing that covers the body and forms a barrier from biting mosquitoes will reduce the risk of malaria.i will inform her (and their general practitioner) of the risks and benefits of chemoprophylaxis versus the risks of malaria.i will tell her n that there is no malaria prophylaxis regimen that is 100% protective. Mefloquine (5mg/kg once a week) is the recommended drug of choice for prophylaxis in the second and third trimesters for chloroquine-resistant areas. Written instructions should be given to a pregnant traveller regarding emergency standby malaria treatment in the event of suspected malaria without access to medical care. b) assesment and investigation i will ask for the symptoms of malaria like fever, headache, muscle pain, nausea, diarrhoea, cough and general malaise. i will watch for pyrexia, pallor, jaundice, perspiration, splenomegaly and respiratory distress.peripheral blood smear with thin and thick film will help diagnosis of malaria with species identification and estimation of parasitemia.rapid detection test may miss low parasitemia, more likely in pregnant women and insensitive in vivax malaria.In a febrile patient, three negative malaria smears 12–24 hours apart rules out the diagnosis of malaria. Women with malaria in pregnancy should have the severity of their condition assessed and documented as an aid to management.several clinical features like prostration, pulmonary edema, shock,excessive bleeding, hemoglobinuria, impaired consciousness,convulsions indicate severe malaria.full blood count should be done to rule out severe anemia and thrombocytopenia which indicates severe anemia.Random blood glucose to rule out hypoglycemia.blood gases to rule out acidosis,renal function tests, serum lactate, parasite count and blood culture ( to rule out septicemia ) are also to be done. c) prevent obstetric complications In severe malaria complicated by fetal compromise, a multidisciplinary team approach (intensive care specialist, infectious disease specialist, obstetrician, neonatologist) is required to plan optimal management of mother and baby. Stillbirth and premature delivery in malaria in pregnancy are best prevented with prompt and effective antimalarial treatment. Uncomplicated malaria in pregnancy is not a reason for induction of labour. Pharmacological thromboprophylaxis should be weighed up against the risk of haemorrhage and should be withheld if the platelet count is falling or less than 100, indicating thrombocytopenia. Peripartum malaria is an indication for placental histology and placenta, cord and baby blood films to detect congenital malaria at an early stage. Inform women of the risk of vertical transmission and, in the presence of positive placental blood films, that fever in the infant could indicate malaria; a blood film from the baby is required for confirmation. Regular antenatal care, including assessment of maternal haemoglobin, platelets, glucose and fetal growth scans, is advised following recovery from an episode of malaria in pregnancy. Regular fetal growth assessment is advised and, if growth restriction is identified, routine obstetric surveillance should be followed.i will inform the woman about the risk of relapse, try to prevent it and develop a clear plan with the woman in the event of symptom recurrence.preterm labour and fetal heart rate abnormalities should be treated as per routine protocol.
		Posted by Aruna R. Sun Aug 1, 2010 08:15 pm
Aruna A healthy 35 year old woman attends the antenatal clinic at 16 weeks gestation. She is due to make an essential journey to a malaria endemic area. (a) What will you tell her about the available interventions to reduce the risk of contracting malaria? [5 marks] (b) She presents at 28 weeks gestation with a 24h history of fever with rigors and vomiting. Discuss your initial clinical assessment and investigations [10 marks]. Discuss the management of obstetric complications of malaria [5 marks] a) I will advice her not to make the travel to malaria endemic area. If it is unavoidable i will advice her about the awareness of risks, bite prevention,chemoprophylaxis, and diagnosis and teatment.Awareness of the risk includes the length of travel, time of the year of travel, urban or rural sleepover planned,the type of resistant strains of malaria parasite available in that area and about the availability of medical interventions available in that area. Bite prevention using 50% DEET skin repellants, mosquito knok down sprays containing permithrine and pyrithroid,using pyrithroid impregnated nets and room with electrically heated pyrithroid mats. i will advise them to wear long sleeve cloths and avoid travelling out in dusk or dawn.Chemoprophylaxis using mefloquine 5mg/kg once a week in second and third trimester. If any fever or other symptoms occur seek early help from experts. b) clinical assessment : History of travel to endemic area , symptoms like fever vomiting, diarrhoea ,headace, jaundice ,and bleeding episodes.examination include paleness(anaemia),jaundice, temperature (38), dehydration, and purpuric spots. abdominal examination include spleenomegaly.cheat auscultation to rule out respiratory distress .Investigation include fullbloodcount to cheak anaemia and thrombocytopenia, renal function tests since renal failure can happen with malaria. liver function tests including bilirubin to rule out jaundice. thick and thin periphral smears for malarial parasite which is the most reliable test than rapid malarial test.chest xray to rule out respiratory diseases and pulmonary odema. blood sugar testing to rule out hypoglycaemia. c) Obsteric complications are managed by multidisciplinary team including intensive care specialists, infectious disease specialists, obstetrician,neonatologist to plan optimal management of the baby and the mother. preterm labour, stillbirth and fetal heart rate abnormality can occur with severe malaria. this can be best managed by prompt treatment of malaria. thromboprophylaxis should be weighed against the risk of haemorrhage and withheld if the platelet count is < 100x109 /l. placental histology and cord blood films if recurrence occur to find out the congenital malaria.
		Posted by Bobey B. Mon Aug 2, 2010 09:03 am
a) I will tell her about the available interventions starting with bite prevention measures including skin repellents containing 50% DEET. It should be applied to the exposed areas of the arms and legs twice daily in second and third trimesters. She should also use knock-down mosquito sprays like pyrethroids to clear the room from mosquitoes. Insecticide treated bed nets are recommended by the World Health Organization for all pregnant women in malaria-endemic areas. She should wear clothing covering most skin. After sunset, long sleeves, long trousers, loose-fitting clothing and socks must be used. Electrically heated mats that vaporize pyrethroids will protect room environment from mosquitoes. She should be informed of the risks and benefits of chemoprophylaxis versus the risks of malaria. There is no malaria prophylaxis regimen is 100 % protective. 250 mg Mefloquine one tablet weekly should be started 2-3 weeks before travel and should be continued 4 weeks after leaving the area. In case of mefloquine resistant or intolerance (250 mg Atovaquone and 100 mg proguanil ) one tablet daily should be started 1-2 days before travel and be continued for one week after leaving the area. She should be given written instructions in the event of suspected malaria. Treatment should be started in the presence of flu-like illness and temperature 38 C or over. b) The evaluation of such patient should include taking a comprehensive travel history. The clinical symptoms of malaria often resemble those of common viral infections. Her presentation with fever , rigors and vomiting are non-specific symptoms. History should be taken for the cyclical occurrence of sudden coldness followed by rigor and then fever and sweating. History of passage of dark urine and symptoms of anaemia may be present . Other common symptoms include malaise, muscle pain , abdominal pain , mild diarrhea and dry cough should be asked . General examination should be done for jaundice , pallor , Pulse for tachycardia , BP for orthostatic hypotension , raised temperature and perspiration. Pulse-oximetry for oxygen saturation .Fudus examination should be done to detect retinal whitening, indicator of retinal damage. Chest examination should be done for tachypnoea , decreased air entry , presence of crepitations and apical tachycardia. Abdominal examination should be done for hepatomegaly and splenomegaly.Uterus should palpated for its size and coincide with the gestation age. Investigations should be done include: Light microscopy of the thick and thin stained blood smears is the standard method for diagnosis of malaria. Three negative blood films 12-24 hrs apart will rule-out the diagnosis of malaria. One negative blood does not exclude malaria. Rapid diagnostic tests which detect specific parasite antigen or enzyme are less sensitive than malaria blood film. A positive rapid test should be followed by microscopy to quantify the parasitaemia and to confirm the species and the stage of the parasites. FBC should be done for thrombocytopenia ( is the most common laboratory abnormality ) and low haemoglobin . Blood should be tested for blood glucose level ( hypoglycaemia ) in severe cases ABG should be asked to detect acidosis. LFT should be done for elevated hepatic aminotransferase level. Hyperbilirubinaemia should be tested as a common finding. Urine microscopy and culture must be done for urinary tract infection. Urea and electrolytes must be done to detect any renal impairment. Chest X-ray should be done with abdominal shield to detect pulmonary oedema. Stool culture and blood culture to rule-out other causes of sepsis. Lumbar puncture may be done to exclude meningitis. c)Common obstetric complications are preterm labour , fetal growth restriction , fetal heart rate abnormalities, and stillbirth and low-birth weight. Multidisciplinary team including intensive care specialist , obstetrician and neonatologist is required for optimal management of mother and pregnancy. Stillbirth and preterm labour are best prevented by prompt and effective anti-malarial treatment. Tocolytics and corticosteroids should be considered if there are no contraindications. In severe malaria , fetal heart rate abnormalities are particularly in the presence of fever , hypoglycaemia and lactic acidosis . Regular paracetamol every 4-6 hrs is given for maternal pyrexia. Maternal blood glucose level must be checked regularly and the pediatrician should be alerted . Fetal growth restriction is common complication and serial growth scan with Doppler studies are important in antenatal care. Acute malaria can cause thrombocytopenia which increase risk of blood loss and postpartum haemorrhage . Thrombocytopenia usually recovers after treatment within 7-14 days. Maternal malaria close to delivery can result in congenital malaria and increased mortality. Placenta should be sent to histopathology , cord blood film is recommended and weekly screening of the neonate for 28 days is useful to allow early detection and treatment of congenital malaria.
		Posted by Ida I. Mon Aug 2, 2010 10:11 pm
I. A) She should be advised to postpone her trip if possible unless unavoidable. She should be counselled regarding the high maternal and fetal risks that comes with malaria, which include miscarriage, stillbirth, and premature labour. She should be advised to prevent bites by wearing long and loose fitting clothes that would cover her amrs and leg, as well as the usage of insect repellant, preferably that contains 20% DEET which is safe in pregnancy. Pyrethroid impregnated bed nets shoud be used to prevent nighttime bites during sleep, and this should be tucked into the bed and matteress. Knock down mosquito repellants can also be used to kill mosquitoes. She should be advised to take chemoprophylaxis 1 week before travel until 1 week after she comes back home. Malarone and Mefloquine is usually taken in the second and third trimester and is safe in pregnancy. Advise on symptoms of malaria, with clear written instruction on emergency standby malaria treatment if there is no access tyo medical care. Written information and useful website address, such as the Health Proctection Agency and the Department of Health should be made available. B) The duration and severity of the symptoms has to be ascertained. History of travel to an endemic country, which includes the duration of stay, history of rural sleepovers and the time of year (rainy or dry season) would be beneficial. She should also be asked if she was given any chemoprophylaxis prior to her travel and if she had been compliant to the medications given. She should also be asked if she has any urinary symptoms, such as frequency or dysuria. She should also be asked if she had a previous history of PV discharge, and the nature of the discharge to exclude preterm premature rupture of membranes or chorioamnionitis. She shuold also be asked if she is producing any sputum, and the colour of her sputum that could point towards pneumonia. She should be examined for pallor and jaundice. Her blood pressure, pulse rate and oxygen saturation should be examined. Temperature measured to assess the severity of the fever. Her lungs should be auscultated to exclude crepitations that could suggest pneumonia. Her abdomen is examined for tenderness, hepatosplenomegaly and the symphisiofundal height. Loin tenderness examined to look out for pyelonephritis. She should have a full blood count to exclude anaemia and thrombocytopenia. A baseline renal profile and liver function test to exclude renal and liver impairments, respectively. A coagulation profile to exclude coagulopathy that could be present with DIC. Blood glucose taken to exclude hypoglycaemia. A HIV screening shuold be done as malaria is associated with HIV infection. Thick and thin blood films shoud be done to estimate, quantify and identify the parasite. Blood cultures taken to look for secondary bacterial infections that may be present. Urinalysis should be done to exclude urinary tract infection. Ultrasound of the fetus done to assess fetal growth and liquor volume. C) Obstetric complications of malaria is a medical emergency. She should be admitted to the intensive care unit under the care of a multidisciplinary team which consists of the obstetrician, anaesthetist, infectious disease specialist and the neonatologist. Malaria shuold be treated promptly to prevent stillbirth or premature labour. Fluid balance should be monitored using a central venous presurre, and the pressure maintained to less than 10 cmH2o. Fever is treated with antipyretics. Htypoglycemia shuld be monitored. Severe anaemia is treated with packed cell transfusion. Tocoloysis and corticosteroids considered if premature labour is present. Continous fetal monitoring essential as malaria is associated with fetal heart abnormalities. Serial ultrasound done to exclude growth restrictions. Aim is for vaginal delivery, and caesarean deliveries only done for obstetric indications only. Active management of third stage is necessary as anaemia is associated with postpartum haemorrhage.
		Posted by KWASI RICHARD A. Tue Aug 3, 2010 01:39 am
KRA a I would tell her about the risks of travelling to the endemic are and to consider postponing her trip. I would tell her available interventions include bite prevention measure, which include using skin repellents, knock-down mosquito sprays, insecticide - treated bed nets, Clothing and room protection. I would tell her about chemoprophylaxis, discuss the risks and benefits of chemoprophylaxis and risks of malaria. I would tell her chemoprophylaxis is not 100% effective and malaria could still occur while taking chemoprophylaxis. I would tell her there are different types of chemoprophylaxis, casual prophylaxis directed agains the hepatic phase of the disease and the drug should be continued for 7 days after leaving the endemic area and suppresive prophylaxis directed against erythrocytic phase and should be taken for 4 weeks after leaving the endemic area. I would advise her to seek medical attention as soon as possible if she thinks she has malaria and she would be given written instructions on emergency treatment if immediate access to medical care is not possible. B Admit her to the ward and establish intravenous access and start intravenous fluids in the form of 1 litre hartmans. I would enquire about any recent travel abroad and consider differentials like malaria, influenza, haemorrhagig fever. I would ask her about other symptoms like headache, joint pains, diarrhoea and dry cough. I would also ask about classical presentation of malaria of sudden coldness followed by rigor and then fever and sweating. Clinical signs on examination would include pyrexia, jaundice, hepatomegaly, splenomegaly and retina damage on fundoscopy. Clinical signs of severe malaria would include impaired consciousness and low blood pressure. Investigations I would arrange include microscopic examination of thick and thin blood films. A single negative blood film does not exclude malaria. Parasite levels may be suppressed by chemoprophylaxis hence negative results so it is advisable to stop prophylaxis on admission. A positive test should always be followed by a blood film examination. Other investigations include full blood count to exclude anaemia and thrombocytopaenia, blood glucose because of the risk of hypoglycaemia, renal and liver funtion test as a base line, chest xray, urine microscopy culture and sensitivity, stool culture, blood culture to exclude other causes of sepsis. C Obstectric complications include preterm labour, prompt treatment of which will reduce risks, administration of tocolytics, and corticosteroids would be required. Intrauterine growth restriction would require regular antenatal care with ultrasound monitoring. Still birth is prevented by prompt treatment of malaria. There is a risk of neonatal parasitaemia which will require cord blood being taken at delivery.
		Posted by Mohamed D. Tue Aug 3, 2010 11:45 am
Mohamed a) She should postpone her travel if possible as prophylaxis plans are not 100% efficient for prevention of malaria. Her risk will depend on her premunition, time of travel during the year (seasonal variation of malaria mosquettos), duration of stay, and place of stay either rural or urban. Bite prevention strategies should be used as; skin repellants with 50% DEET, clothes covering most of the body, knock down mosquettos sprays, and bed nets impregnated with permethrin. Room electric moquetto killers and cold room temperature will also reduce her risk of bites. All these are safe in pregnancy. Chemoprophylaxis using mefloquine is safe in pregnacy. If she felt unwell during her trip or up to 1 year or more after return; malaria should be suspected and medical help should be seeked. b) Any patient with flu like symptoms and history of travel to a malaria endemic area , is supected as malaria. This an emergency and hospital addmission or ICU addmission if severe condition is mandatory. Patient stabilisation by insuring airway and breathing with 10-15 litres of oxygen, IV line and bloods should be sent for FBC for anaemia and leucocytosis, LFT, U&Es for baseline investigations and to role out severe liver disease, and increased CRP and leucocytosis are non specific inflamatory markers with any infection, but help in follow up and respose to treatment. Blood sugar should be checked as hypoglycaemia is common and associated with fetal heart rate abnormalities. Peripheral blood with thick and thin blood film for parasitaemia and species identification is diagnostic of malaria. Films should be sent by corrier if not available to test in the local lab to infectious disease centre. Rapid antibody specific test are not accurate for malaria diagnosis with low parasitaemia especially in pregnancy. Three negative lood films 12-24 houres apart will exclude malaria. Swabs, blood cultures and MSU should vbe sent to role out other nfection causes. Multidisciplinary team with conultant obstetrician, ICU physician and infectious disease specialist should be involoved in severe cases as it is associated with maternal mortality. Examine the patient for signs of Jaundice in her mucous membranes, signs of respiratory distress with JVP, listen to chest to exclude basal crepitaions with pulmonary oedema, and examine her abdomen for organomegaly, FHS, and uterine tone to role out preterm labour or tender uterus with chorioamnionitis.CTG for detection of FHR abnormalities with malaria, and for uterine contractions with PTL. Oxygen saturation will be reduced in RDS or pulmonary oedema. Hypotension may indicate gram negative septicaemia. Start an obstetric early warning score chart for monitoring and early detection of problems. C) Malaria is associated with maternal and fetal morbity and mortality. Fetal growth restriction and preterm labour are common after malaria in pregnancy. Treatment with antimalarial drugs usually reduces these risks. Follow up with fetal growth scans and if FGR is diagnosed; mangement should follow obsteric indication for delivery as any case of FGR. Uncomplicated malaria is not an indication for IOL. Maternal hypoglycaemia is common especially with the use of quinine therapy and will lead to fetal heart rate abnormalities. Measurement of blood sugar levels and treat hypoglycaemia with dextrose. MDT with neonatologist in case of fetal compromise with sever malaria for optimal management. Cogenital malaria and vertical transmission is suspected with malaria close to time of delivery. Placental, cord and baby blood films should be sent for dection of parasitaemia. Any fever devlops in the baby, malaria should be role out first. Anaemia is common with malaria and FBC to check Hb concentration should be done. treatment with Iron theray is the first line unless severe anaemia and packed RBCs transfusion with frusemide should be used or exchange transfusion if pulmonary oedema risk is very high.