4 ch 4 pp infec&malaria preg aa copy
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Infection
International
MALARIA IN PREGNANCY
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Infection
International
Objectives
• Describe epidemiology of malaria
• Describe maternal and fetal complication
• Principle of management and preventive
strategies
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Infection
International
Global Effect
• Affects 300-500 million people yearly
• a!ses " to #$% million deat&s
• '0( of deat&s occ!r in )!b -)a&aran
Africa
*appro+imately 3000 deat&s eac& day,
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Infection
International )ie of problem in Africa
*./O "''',• Pop!lation 512
• Ann!al birt&s #2$%• E+posed to malaria '3(
• A coverage 13(
• 4o birt& eig&t "1(• 6alaria attrib!table fraction to 47."#-50(
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Infection
International
INDONESIA
• Annual Paracite Inciden pertahunmasih tersebar di Seluruh Propinsi
• Bali s/d Papua
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Infection
International
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Infection
International
Scope of Focused ANC
Majority ofpregnant women needthese services only
Some pregnant womenrequire these servicesalso
Fewer pregnant women requirethese services
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Infection
International
Anopheles Mosquito
Anopheles mosquitoes differ from other mosquitoes in the waytheir body is positioned. The body of the Anopheles points up in the
air in one line, but in other mosquitoes, the rear end is bent and
points down.
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Infection
International
Malaria Ecolog and Burden!linical Manifestations
InfectedMosquito
Infected
Human
Chroniceffects
AnemiaNeurologic/cognitiveDevelopmental
Impairedgrowth anddevelopment
Malnutrition
Acutefebrileillness
Severeillness
Hpoglcem
iaAnemia
Cerebralmalaria
Death!espiratordistress
"regnanc
#etus
Maternal
Acute
illnessAnemia
Impairedproductivit
$ow birthweight
Infantmortalit
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Infection
International Factors Aecting
Transmission• Breeding sites
• Parasites
• Climate
• Population
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Infection
International
Insecticide-Treated Nets%ntreated Nets
• Provide a high level ofprotection against
malaria• Kill or repel mosquitoesthat touch the net
• educe num!er ofmosquitoes in"outside net
• Kill other insects such
as lice and !ed!ugs• #re safe for pregnant
women$ young children andinfants
Insecticide&'reated Nets
• Provide some protectionagainst malaria
• %o not &ill or repelmosquitoes that touchnet
• %o not reduce num!er ofmosquitoes
• %o not &ill other
insects li&e lice and!ed!ugs
• #re safe for pregnantwomen$ young childrenand infants
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Infection
International
Insecticide-Treated Nets
ITN tucked under a bed ITN tucked under a mat
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Infection
International
Effect of malaria on pregnancy
Related to Level of transmission and
immunity of individual exposed
• In areas of high transmission
endemi! or sta"le malaria area#
• In areas of lo$ transmission or
non endemi! or unsta"le areas
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Infection
International
6aternal complication
In Endemi! areas
• malaria related
anaemia• %e"rile illness
• Pla!ental
se&uestration
In non'Endemi! areas
• Greater ris( of
severe disease
• )igher ris( of death
• Anaemia
hypogly!emia
pulmonary oedema
renal failure
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Infection
International
Anaemia
6!lti factorialaffects 50-10( pregnant omen in
)!b-)a&aran region
• /aemolysis• 8ncreased imm!ne clearance of infected and non
infected 97s
• 6alarial &yperactive splenomegaly• !tritional : &oo;orm infestation
• 8ncreased ris; in pregnancy to Post -part!m
/emorr&age : /eart fail!re
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Infection
International
)evere malaria
• erebral malaria <nro!sable coma
it& ase+!al perip&eral parsitaemia or
placental infection$• /ypoglycemia
• P!lmonary edema *A9D),
• Ac!te renal fail!re
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Infection
International
=etal complications
8n endemic areas
• 4o birt& eig&t
• 8ntra-!terine grot&retardation
8n non-endemic areas
• Abortions
• preterm delivery• ongenital malaria
• 4o birt& eig&t
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Infection
International
Malaria Diagnosis
• 'sually !ased on signs and symptoms ofthe patient$ clinical history andphysical e(amination and"or la!oratory
confirmation of the malaria parasite$if availa!le)
• Prompt and accurate diagnosis leads to*
+ ,mproved differential diagnosis of fe!rile
illness+ ,mproved management of non-malarial illness
+ .ffective case management of malaria
"#
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Infection
International Indications for
Diagnostic Testing• For pregnant women$ a parasitological diagnosisis recommended prior to starting treatment*+ /hose who live in or have come from areas of unsta!le
transmission are the most li&ely candidates forsevere malaria$ which can !e life-threatening
• #s a test of cure in clients who have !eentreated for malaria !ut still have symptoms*+ ,f treatment was adequate$ clients may have !een
reinfected or have another pro!lem causing similarsymptoms
+ Counterfeit or poor quality drugs may also !e a thecause of treatment failure
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Infection
International
Clinical Diagnosis
• Based on the patient9s symptomsand on physicalfindings at e(amination
• /he first symptoms of malaria andphysical findings are often not
specific and are common to otherdiseases
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Infection
International
Types of Malaria
• 'ncomplicated*
+ Most common
• Severe*+ :ife-threatening$ can affect!rain
+ Pregnant women more li&ely toget severe malaria than non-pregnant women
i i M l i i
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Infection
International
ecogni!ing Malaria in"regnant #omen
%ncomplicated Malaria
• Fever
• Shivering"chills"rigors
• 6eadaches
• Muscle"joint pains
• ;ausea"vomiting• False la!or pains
Severe Malaria
Signs of uncomplicated malaria P:'S one ormore of the following*
• Confusion"drowsiness"coma• Fast !reathing$
!reathlessness$ dyspnea
• <omiting every meal"una!le toeat
• Pale inner eyelids$ inside ofmouth$ tongue$ and palms
• =aundice
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Infection
International
Com$ination Therapy
• Plasmodium falciparum has !ecomeresistant to single-drug therapy$resulting in ineffective treatment andincreased mor!idity and mortality
• 562 now recommends that countries use acom!ination of drugs to fight malaria
•%rug resistance is far less li&ely withcom!ination therapy than with single-drug treatments
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Infection
International
Types of Com$ination Therapy
Artemisinin-based Combination Therapy(ACT):
• /he simultaneous use of drugs thatincludes a derivative of artemisininalong with another anti-malarial drug
• /his com!ination is currently the mosteffective treatment for malaria
• For second and third trimesters$ #C/sshould !e the first-line treatment ifavaila!le and in line with localprotocol
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Infection
International
Selecting Treatment
• Follow local guidelines regardingwhich com!ination therapies to use 0if
any1 and how to use them• For uncomplicated malaria in the >sttrimester and for severe malaria inany trimester$ quinine is the drug of
choice• ,f #C/s are the only effectivetreatment availa!le$ they can !e usedin the first trimester
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Infection
International
Treating %ncomplicated Malaria
#irst trimester(
• ?uinine >7 mg salt"&g !ody weight three times daily@ clindamycin >7 mg"&g !ody weight twice daily for A
days+ ,f clindamycin is not availa!le$ use quinine only
• #C/ can !e used if it is the only effectivetreatment availa!le
Second and third trimesters(
• 'se the #C/ &nown to !e effective in thecountry"region$ 2
• #rtesunate @ clindamycin 0>7 mg"&g !ody weight twicedaily1 for A days$ 2
• ?uinine @ clindamycin for A days
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Infection
International
Treating %ncomplicated Malaria• 2!serve client ta&ing anti-malarial drugs
• #dvise client to*+ Complete course of drugs
+ eturn if no improvement in hours
+ Consume iron-rich foods
+ 'se ,/;s and other preventivemeasures
$#
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