2b ch 4 pp infec&malaria preg

8/17/2019 2B CH 4 PP Infec&Malaria Preg

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Infection

International

PP Infection


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Infection

International

Objectives• definition

• predisposing factors

• pathophysiology

• clinical features

• sites of postpartum infection

• treatment

• prevention


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Infection

International

• Denition:

Any patient with fever of 38.5°C 48!"hours following a vaginal or forcepsdelivery with uterine tenderness


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Infection

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Incidence and scope:

• #a$or cause of maternal death in emergingcountries

• %ess fre&uent with vaginal 'irths

• Complications include( shoc)* pelvica'scesses and pelvic throm'osis


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Infection

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Pathophysiology

• +ormal flora of genital tract contains

potential pathogens

• Amniotic fluid and increase in white'lood cells during la'our


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Infection

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Predisposing factors

• ,rauma and tissue necrosis following delivercreates a culture medium for ascending

• Cesarean section is most importantpredisposing

• -rolonged la'our and ruptured mem'ranes

• -overty and poor hygienenutrition


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Infection

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Bacteria polymicro'ial

most common(

/scherichia coli* 0el'siella* -roteus and1acteroides fragilis

less common(

Clostridium* 2taphylococcus aurea and-seudomona

eogenous source(

roup A 'etahemolytic streptococci


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Infection

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Clinical Features usually "3 days post partum

low grade temperature* lower a'dominal

pain and uterine tenderness also( malaise* anoreia* foul lochia

if severe( high temperature andgeneralied peritonitis


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Infection

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Clinical Features

roup A 'etahemolytic stretpococci

may 'e fulminant with peritonitis andsepticemia

if cultured* hospital personnel must 'e

screened to try and identify the source


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Infection

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Diagnosis

sites of infection to consider in post partum

patient 6culture if a'le7(

endomyometritis

urinary tract

episiotomy site

a'dominal incision

'reastthrom'ophle'itis( legs* pelvis

appendicitis

other( upper respiratory infection


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Infection

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Manageent ! Prevention

correct aseptic techni&ue

anti'iotic use in women with cesarean

section or prolonged rupture of mem'ranes6g ampicillin I9 given prophylactically incesarean section reduces infection7


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Infection

International

Manageent !! "reatentmild case( single 'road spectrum anti'iotic6eg. ampicillin g I9 &:h ;r orally7

if cesarean section(flagyl 5


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Infection

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Manageent ! "reatent

• if intravenous anti'iotics used* continue for48 hours after fever has stopped.

• if fever continues and aminoglycosideclindamycin com'ination was used* addpenicillin 65# units &:h7 to cover

enterococci

• oral anti'iotics should 'e used for 5 days


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Infection

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Other issues

the more anti'iotics used* @ the higher thechance of necrotiing colitis

anti'iotics do appear in 'reast mil) 'ut inmost cases are not clinically significant6avoid tetracyclines7


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Infection

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#peci$c issues:episiotomy infection( treat with

anti'iotics* 'aths 6clean water7* heat

remove sutures if fluctuation or pus rarely needs de'ridement

necrotiing fascitis( rare* rapid

progression of local inflammation followed'y gangrene patient is toic( high doseanti'iotics 'ut #B2, surgically /1>I/


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Infection

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Other issues

2eptic pelvic throm'ophle'itisusuallyanaero'ic sepsis

usually patient is already on anti'iotics'ut continues to have high spi)ing fevers

diagnosis of eclusion

treatment is intravenous heparin condition should respond to heparin


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Infection

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Other issues

#astitispenicillin or penicillinase

resistant 6methicillin or cloacillin7

for !< days

•continue 'reast feeding

•if 'reast a'cessdrain


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Infection

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#pecial case:

-ostpartum or posta'ortal septic shoc)

efinition( any toic patient who hashemodynamic or acid 'ase changes withfever 38.5DC 6after a'ortion* vaginal or

operative delivery7


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Infection

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%tiology of postpartu&postabortal shoc'

Bsually gramnegative 'acteria

6eg./.Coli7and occasionally gram positive6staphylococci* anaero'ic streptococci*clostridium7


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Infection

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Pathophysiology of postpartupostabortal shoc'

not fully understood

endotoins from cell wall of 'acteria initiatevascular damage and vasodilatation

hypotension hypoperfusion


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Infection

International

Conclusions

ma$or pro'lem

proper diagnosis

early and aggressive treatment

prevention


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Infection

International

MALARIA IN PREGNANCY


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25/48

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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#alaria /cology and 1urden


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Infection

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#alaria /cology and 1urdenClinical #anifestations

InfectedMos(uito

Infected)uan

Chronice*ects

+neia,eurologic&cognitiveDevelopental

Ipairedgro-thanddevelopent

Malnutrition

+cutefebrileillness

#evereillness

)ypoglyce

ia+neia

Cerebralalaria

Death

.espiratorydistress

Pregnancy

Fetus

Maternal

+cute

illness+neia

Ipairedproductivity

/o- birth-eight

Infantortality


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Infection

International Factors A$ecting

%rans!ission& 'reeding sites

& Parasites

& Cli!ate

& Population


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Infection

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Insecticide(%reated Nets0ntreated ,ets

& Pro"ide a high le"el ofprotection against !alaria

& )ill or repel !os#uitoesthat touch the net

& *educe nu!+er of!os#uitoes in,outside net

& )ill other insects such as

lice and +ed+ugs& Are safe for pregnant

o!en- young childrenand infants

Insecticide!"reated ,ets

& Pro"ide so!e protectionagainst !alaria

& Do not .ill or repel!os#uitoes that touch net

& Do not reduce nu!+er of!os#uitoes

& Do not .ill other insects

li.e lice and +ed+ugs& Are safe for pregnant

o!en- young childrenand infants


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Infection

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Insecticide(%reated Nets

ITN tucked under a bed ITN tucked under a mat


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Infection

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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

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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

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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

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=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

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Malaria Diagnosis

& /sually +ased on signs and sy!pto!s ofthe patient- clinical history and physicale0a!ination and,or la+oratory conr!ationof the !alaria parasite- if a"aila+le1

& Pro!pt and accurate diagnosis leads to:

2 I!pro"ed di$erential diagnosis of fe+rile illness

2I!pro"ed !anage!ent of non(!alarial illness2 3$ecti"e case !anage!ent of !alaria

3!


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Infection

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Methods of Diagnostic %esting

& %he to !ethods of diagnostic testing for!alaria are light !icroscopy and rapid

diagnostic testing 4*D%51& Once the o!an presents ith !alaria

sy!pto!s and is tested- results should +ea"aila+le ithin a short ti!e 46 7 hours51

8hen this is not possi+le- she !ust +etreated on the +asis of clinical diagnosis489O 7;51


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Infection

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Clinical Diagnosis

& 'ased on the patient


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Infection

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%ypes of Malaria

& /nco!plicated:

2 Most co!!on

& Se"ere:2 =ife(threatening- can a$ect +rain

2 Pregnant o!en !ore li.ely to get

se"ere !alaria than non(pregnanto!en


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Infection

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Co!+ination %herapy

& Plasmodium falciparum has +eco!e resistantto single(drug therapy- resulting in ine$ecti"etreat!ent and increased !or+idity and!ortality

& 89O no reco!!ends that countries use aco!+ination of drugs to ght !alaria

&Drug resistance is far less li.ely ithco!+ination therapy than ith single(drugtreat!ents


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%ypes of Co!+ination %herapy

Artemisinin-based Combination Therapy(ACT):

& %he si!ultaneous use of drugs thatincludes a deri"ati"e of arte!isinin alongith another anti(!alarial drug

& %his co!+ination is currently the !ost

e$ecti"e treat!ent for !alaria& For second and third tri!esters- AC%sshould +e the rst(line treat!ent ifa"aila+le and in line ith local protocol


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Infection

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Selecting %reat!ent

& Follo local guidelines regarding hichco!+ination therapies to use 4if any5 and

ho to use the!& For unco!plicated !alaria in the st

tri!ester and for se"ere !alaria in anytri!ester- #uinine is the drug of choice

& If AC%s are the only e$ecti"e treat!enta"aila+le- they can +e used in the rsttri!ester


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Infection

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%reating /nco!plicated Malaria

First triester:

& Buinine !g salt,.g +ody eight three ti!es daily clinda!ycin !g,.g +ody eight tice daily for days

2 If clinda!ycin is not a"aila+le- use #uinine only& AC% can +e used if it is the only e$ecti"e treat!ent

a"aila+le

#econd and third triesters:

& /se the AC% .non to +e e$ecti"e in the country,region-O*

& Artesunate clinda!ycin 4 !g,.g +ody eight ticedaily5 for days- O*

& Buinine clinda!ycin for days


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Infection

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%reating /nco!plicated Malaria

& O+ser"e client ta.ing anti(!alarialdrugs

& Ad"ise client to:2 Co!plete course of drugs

2 *eturn if no i!pro"e!ent in E hours

2 Consu!e iron(rich foods2 /se I%Ns and other pre"enti"e

!easures

4!


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oncl!sions

• 8mprove implementation of e+isting

strategies and &ealt& delivery system it&

emp&asis on integration in e+isting services• 8mprove on /ealt& ed!cation to comm!nity

on dangers of malaria and early >reg!lar

A attendance$

2b ch 4 pp infec&malaria preg

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