2B CH 4 PP Infec&Malaria Preg
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Transcript of 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
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• 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
International
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
International
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
International
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
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Manageent !! "reatentmild case( single 'road spectrum anti'iotic6eg. ampicillin g I9 &:h ;r orally7
if cesarean section(flagyl 5
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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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Pathophysiology of postpartupostabortal shoc'
not fully understood
endotoins from cell wall of 'acteria initiatevascular damage and vasodilatation
hypotension hypoperfusion
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Conclusions
ma$or pro'lem
proper diagnosis
early and aggressive treatment
prevention
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Infection
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MALARIA IN PREGNANCY
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Infection
International )ie of problem in Africa
*./O "''',• Pop!lation 512
• Ann!al birt&s #2$%
• E+posed to malaria '3(
• A coverage 13(
• 4o birt& eig&t "1(• 6alaria attrib!table fraction to 47."#-50(
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#alaria /cology and 1urden
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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$ecting
%rans!ission& 'reeding sites
& Parasites
& Cli!ate
& Population
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Infection
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Insecticide(%reated Nets0ntreated ,ets
& Pro"ide a high le"el ofprotection against !alaria
& )ill or repel !os#uitoesthat touch the net
& *educe nu!+er of!os#uitoes in,outside net
& )ill other insects such as
lice and +ed+ugs& Are safe for pregnant
o!en- young childrenand infants
Insecticide!"reated ,ets
& Pro"ide so!e protectionagainst !alaria
& Do not .ill or repel!os#uitoes that touch net
& Do not reduce nu!+er of!os#uitoes
& Do not .ill other insects
li.e lice and +ed+ugs& Are safe for pregnant
o!en- young childrenand infants
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Infection
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Insecticide(%reated Nets
ITN tucked under a bed ITN tucked under a mat
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Effect of malaria on pregnancy
Related to Level of transmission and
immunity of individual exposed
• In areas of high transmission
endemi! or sta"le malaria area#
• In areas of lo$ transmission or
non endemi! or unsta"le areas
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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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=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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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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Clinical Diagnosis
& 'ased on the patient
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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$ecti"e treat!ent for !alaria& For second and third tri!esters- AC%sshould +e the rst(line treat!ent ifa"aila+le and in line ith local protocol
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Selecting %reat!ent
& Follo local guidelines regarding hichco!+ination therapies to use 4if any5 and
ho to use the!& For unco!plicated !alaria in the st
tri!ester and for se"ere !alaria in anytri!ester- #uinine is the drug of choice
& If AC%s are the only e$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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%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$