Training on

HIGH RISK CONDITIONS IN PREGNANCY

STANDARD TREATMENT GUIDELINES
DIRECTORATE OF PUBLIC HEALTH AND PREVENTIVE MEDICINE,
TAMIL NADU

THYROID DISORDERS IB PREGNANCY

DEFINITION:

Hypothyroidism is a common endocrine disorder resulting from deficiency of thyroid

hormone. During Pregnancy, hypothyroidism occurs due to underactive thyroid gland.
HIGH RISK PREGNANCY WHY?
Pregnancy is a period that places great physiological stress on both the mother and the
fetus. When pregnancy is compounded by endocrine disorders such as hypothyroidism.
Physiological changes during pregnancy
• 20% increase in thyroid gland size due to hyperplasia and increased vascularity.
• Increase in estrogen, increased TBG, decreased free T4
• HCG rise, Structural similarity with TSH, increase in T4/T3, Decrease in TSH.
Increased peripheral metabolism of thyroid hormones
• Hypothyroidism in Pregnancy:
High Risk Factors
• Hypothyroidism is an endocrine disorder resulting from thyroid hormone
deficiency.
• Pregnancy places significant physiological stress on both mother and fetus.
• Hypothyroidism prevalence in India is 4.8-12%.
• Physiological changes during pregnancy include 20% increase in thyroid
gland size, increased estrogen, increased TBG, decreased free T4, HCG rise,
structural similarity with TSH, T4/T3, and increased peripheral thyroid
hormone metabolism.
 Changes in thyroid function
TSH (Initial screening
Maternal Status Free T4 Total T4 Total T3
test)
Pregnancy Decrease No change Increase Increase
Hyperthyroidism Decrease Increase Increase Increase or no change
Hypothyroidism Increase Decrease Decrease Decrease or no change

SYMPTOMS SIGNS
• Fatigue • Weight gain
• lethargy • Slowed speech and movements
• Weight gain • Dry skin
• Decreased appetite • Dull facial expression
• Cold intolerance • Coarse, brittle hair
• Dry skin • Loss of scalp hair
• Hair loss • Coarse facial features
• Sleepiness • Periorbital puffiness
• Muscle pain, joint pain, weakness in the extremities • Goiter (simple or nodular)
• Depression • Hoarseness
• Emotional lability, mental impairment • Decreased systolic blood pressure and
• Forgetfulness, impaired memory, inability to concentrate increased diastolic blood pressure
• Constipation • Bradycardia
• Menstrual disturbances, impaired fertility • Pitting edema of lower extremities
• Paraesthesia and nerve entrapment syndromes • Hyporeflexia with delayed relaxation
• Fullness in the throat, hoarseness (pseudomyotonia),
Hypothyroidism Types and Risk Factors
Subclinical Hypothyroidism:
• Incidence: 2-7%.
• Preterm birth: 2-fold higher in women with subclinical hypothyroidism.
Overt Hypothyroidism:
• Manifests as slowing in physical and mental activity.
• Risk factors:
- Residency in areas with known iodine insufficiency.
- Obesity.
- History of thyroid dysfunction or surgery.
- Symptoms or presence of goitre.
- History of thyroid dysfunction in first degree relative.
- History of diagnosed mental retardation.
- History of autoimmune diseases.
- History of recurrent miscarriages, pre-term delivery, intrauterine demise, pre-
eclampsia/eclampsia, abruption placentae.
- History of infertility.
Birth planning:

If TSH <0.1 TSH level Current dose (in Increase to

Current dose (in Decrease to mcg)
mcg) >2.5 (1st) 25 50
50 25 >2.5(1st) 50 75
25 12.05 >3 (2nd or 3rd) 25 50
>3 (2nd or 3rd) 50 75
>3 (2nd or 3rd) 75 100
Diagnosis

Thyroid problems can be hard to diagnose in pregnancy due to higher levels of thyroid
hormones and other symptoms that occur in both pregnancy and thyroid disorders. All
antenatal mothers are required to screen for thyroid function test in their first antenatal
visit.

Postnatal mother:
• In case of Sub Clinical Hypothyroidism – treatment to be discontinued after
checking TSH value
• In case of Overt Hyperthyroidism– treatment to be continued 6 weeks
postpartum then to be followed up with physician
• In case of Known hypothyroidism – pre-pregnant dose of treatment to be
given and followed up after 6 weeks with physician

Levo thyroxine should be taken 60 minutes before breakfast in the

empty stomach for optimal, consistent absorption.
Complications:
Effect of hypothyroidism in pregnancy
MATERNAL EFFECTS FETAL EFFECTS
• Miscarriages ( early pregnancy) • Preterm births
• Recurrent pregnancy loss • Intra uterine growth restriction
• Anemia • respiratory distress in new born
• Pre-eclampsia • In newborns leads cognitive,
• Gestational diabetes neurological and developmental
• Abruptio placentae impairment.
• Post partum hemorrhage
• Rarely myopathy, congestive heart failure

Fetal effects
• Preterm births
• Intra uterine growth restriction
• respiratory distress in newborn
• In newborns leads cognitive, neurological and developmental impairment.
Preventing and Counselling Thyroid Disorders

• Advises taking iodine-rich foods.

• Elicits detailed history of thyroid disorder before pregnancy planning.
• Evaluates serum TSH preconception in hypothyroid women treated with
levothyroxine.
• Adjusts levothyroxine dose to achieve TSH value between lower reference
limit and 2.5 mU/L.
• Evaluates for GI disorders like Helicobacter pylori–related gastritis,
atrophic gastritis, or celiac disease.
• Re-evaluates thyroid function and levothyroxine dosage if disorders are
detected and treated.
Hyperthyroidism in pregnancy
Definition
Hyperthyroidism can be defined as 'Increased thyroid
hormone production due to an overactive thyroid gland. Value of
less than <0.1mIU/L of serum TSH and elevated free T3 and T4
levels that exceed the range for pregnancy.
High risk pregnancy why?
The most common cause of hyperthyroidism during
pregnancy is Graves' disease. In case of such auto immune
disorder, these autoantibodies cross the placenta and can cause
fetal and neonatal thyroid dysfunction even when the mother
herself is in an euthyroid condition.
Causes:
Thyrotoxicosis (a clinical condition due to increased levels of circulating thyroid hormones) in
pregnancy may be due to multiple causes:
Intrinsic disease of the thyroid:
1. Graves' disease/ 2. Thyroid nodule/ 3. Sub-acute thyroiditis
Pregnancy induced:
1. Hyperemesis/ 2. Hydatid form mole
Miscellaneous:
1. Drug induced
Clinical features:
Thyromegaly, Exophthalmia, Increased appetite, Nausea and vomiting, Sweating,
Tremor, Tachycardia, Palpitations, Heat intolerance, Nervousness, Goiter, Weight loss
Risk factors:
Those pregnant women who are at risk for developing a thyroid disease are the one who
• Are currently being treated for a thyroid condition, or if who have thyroid nodules or a
• goiter (a swollen thyroid gland)
• Had a thyroid condition in the past, or had a baby with thyroid problems
• Have an autoimmune disease, or have a family H/o autoimmune disease, such as Graves’ or
Hashimoto’s disease
• Have Type 1 diabetes

Diagnosis:
• Careful History taking
• Physical examination for clinical features
• Laboratory findings- Thyroid profile (TSH, FT3, FT4)
Management of hyperthyroidism in pregnancy
The management of hyperthyroidism in pregnancy includes Anti-thyroid drugs (ATD). The
drugs generally used are Propylthiouracil (PTU) and Methimazole. All the ATDs cross the
placental barrier and so they may cause a risk of birth defects during the initial phases of
pregnancy and may also have a potential risk of causing hypothyroidism in the fetus during the
last trimester of pregnancy.
HYPERTHYROIDISM
 The lower reference range of TSH- 0.1 mIU/L.
 DRUG OF CHOICE: Propylthiouracil
Further treatment and delivery in Tertiary care hospital under Endocrinologist guidance
Treatment
Initial dose: -
• 300 -450 mg/day to be administered orally in 3 divided doses.
Maintenance dose: -
• 100 -150 mg/day to be administered orally in 3 divided doses.
Graves' disease in Pregnancy:
• Initial dose: -50 – 150 mg to be administered orally three times a day.
Maintenance dose: -50 mg to be administered orally twice or three times a day.
Thyroid function tests and its monitoring:
The titration of the drug dosages must be done based on the FT4 levels and not the TSH as the
TSH values take multiple weeks to return to its reference range. The ATD dosages must be reduced
when the FT4 levels reach the upper limit of the normal range.
Post-partum period:
Relapse of Graves' disease is seen in many females within 3 months of their delivery.
Follow up
• Thyroid function tests should be checked once in every 4 to 6 weeks
• Women with Grave’s disease with positive TRAb antibodies are to be monitored by scans to rule
out fetal thyroid gland enlargement
Postpartum – Endocrinologist opinion
MATERNAL EFFECTS FETAL EFFECTS
• Pre eclampsia • Fetal tachycardia
Effect of hyperthyroidism in pregnancy • Congestive heart failure, • Intra uterine growth
• restriction
Thyroid storm with
labor, • Goitre formation in the
• fetus
Increased abortion rate,
• Premature labor,
• Stillbirth
• Fetal heart sounds and thyroid size should be documented on
obstetric scans for fetal tachycardia and goiter.

• Pre-pregnancy counseling is crucial for managing thyroid

disorders, and
dietary modifications, such as avoiding soy-based products, are
essential.
 Training on
HIGH RISK CONDITIONS IN PREGNANCY
STANDARD TREATMENT GUIDELINES
DIRECTORATE OF PUBLIC HEALTH AND PREVENTIVE MEDICINE,
TAMIL NADU

ENTERIC FEVER
INTRODUCTION:

 Enteric fever is a systemic

disease characterized by fever
and abdominal Pain

 Caused by dissemination of
Salmonella typhi or
salmonella paratyphi A,B,C

 Transmitted through fecal

contamination of food or water by
chronic carriers.
 Annual incidence in India is
around>100/100000 per year
CLINICAL FEATURES
Incubation period:5-21 days.
Symptoms:

 Prolonged Fever (up to 4 weeks)(>75%).

 Abdominal Pain (30-40%).
 Headache,Chills,Malaise,Sweating,Cough,Arthralgia.
 Other GI Symptoms like
 Anorexia, Nausea, Vomitting, Diarrhoea, Constipation.
Signs:

 Rose spots(30%).
 Hepato splenomegaly(3-6%).
 Relative Bradycardia with fever (>50%).
 Epistaxis
COMPLICATIONS:
 GI Bleeding (10-20%)
 Intestinal Perforation(1-3%)
 Oligohydraminos
 Preterm labor
 IUGR
 IUD
 DIC

DIAGNOSIS
 WIDAL test

 Serology for anti bodies to outer membrane protein/Vi/O:9 Ag

 Blood culture

 Stool culture

 Bone marrow culture

 Intestinal secretion culture (Duodenal string test)

 TREATMENT
AT PHC
 Adequate hydration,Antipyretics.
 Oral Antibiotic therapy 3rd
 Gen Cephalosporins(10- 14 days)

REFERRAL CRITERIA AT PHC LEVEL

 Fever not subsiding within 48hrs of initiating antibiotics
 Feeble pulse, tachypnea, basal crepitation
 Neurological complications
 Sudden fall in BP
AT CHC LEVEL :
 Ceftriaxone 1gm iv bd
 Cefotaxime 2 gm iv tds
 Cefixime 400 mg po bd
 Macrolides Relapse and Fecal carriage rate<3%
 Azithromycin 1 gm po od on day1 f/b 500 mg od for next 5days.
REFERRAL CRITERIA AT CHC LEVEL
 No signs of improvement in 5 days

 Complications (GI bleeding, intestinal perforation, typhoid encephalopathy) not

controlled by specialist at the centre
 Patient having apathy, psychosis, confusion, seizure, coma.

AT TERTIARY LEVEL :
MANAGEMENT OF COMPLICATIONS

 For lower GI bleeding– Two large bore IV canula, Blood transfusion till
hematocrit 25% I/V Ranitidine 50 mg BD Colonoscopy.
 For CNS complications-Inj Dexamethasone.
 For peritonitis-Emergency laprotomy with surgical repair
FOLLOW UP:
 Chronic carriers should be identified and treated with oral ciprofloxacin for 4
weeks (eradication rate 80%)
 In case of anatomic abnormalities, eradication requires surgical correction
along with antibiotics.

PREVENTION:
 Adequate sewage disposal and water treatment.
 Avoidance of high risk foods and beverages.
 Personal hand hygiene
 Typhoid vaccination.
DENGUE
Introduction
 An acute febrile illness of 2-7 days duration with two or more of the following manifestations:
Headache, retro-orbital pain, myalgia, arthralgia, rash, haemorrhagic manifestations.
 Admit any pregnant women with complaints of fever and evaluate

High Risk Factor

 Obesity
 Pregnancy
 Haemoglobinopathies
 Peptic ulcer disease
 Congenital heart disease
 Patient on steroids or NSAIDs
 Hypertension, diabetes, asthma, liver failure
Hemodynamic Assessment Parameters
DAY OF FEVER HISTORY EXAMINATION
1 • Onset of fever • General Examination-
• Fever with • Mental state
• Headache, Retro orbital pain, No • Hydration state
foci • Hemodynamic state
• Myalgia, Arthralgia • Persistent tachycardia
• Rash, Haemorrhagic • Abdominal tenderness
manifestation • Hepatomegaly
• Ability to take oral fluids • Rash
• Warning symptoms • Tachypnea
• Abdominal pain • Acidotic breathing
• Persistent vomiting • Tourniquet test
• Lethargy, Giddiness • Bleeding manifestation
• Black tarry stools,
• hematemesis, haematuria,
• epistaxis, Bleeding gums
Dengue Fever

PHC GH TERTIARY CARE

1. Complete blood count 1. Complete blood count • Daily CBC
• WBC-normal/Low • WBC-normal / Low • Platelet
Leucopenia <4000 Leucopenia<4000cells/cumm <50,000-twice Daily CBC
cells/cumm • Thrombocytopenia(<1.5lakh) NS 1 antigen
• Thrombocytopenia (<1.5 • Rising hematocrit (5-10%)
lakh) 1. NS-1 Antigen
• Rising hematocrit (5-10%)

• Encourage oral fluids • Encourage oral fluids • Encourage oral fluids

• Antipyretics • Antipyretics (2.5 ltrs)
• Withhold aspirin • Withhold aspirin • Antipyretics
• Tepid sponging • Tepid sponging • Withhold aspirin
• Refer to CEmONC centre • Adequate rest • Tepid sponging
• Adequate rest
Monitor Monitor
4thhrly temperature, BP,PR,RR 4thhrly temperature, BP,PR,RR
CRT CRT
Urine output(100ml/4hrs) Urine output (100m l/ 4hrs)
IO chart IO chart
Dengue Haemorrhagic Fever
DAY OF
HISTORY EXAMINATION
FEVER
1-4days Fever with General and physical
• Headache examination-Normal
• Retro orbital pain
• Myalgia, Arthralgia, Rash
• Haemorrhagic
manifestation
DAY OF • No foci HISTORY EXAMINATION
FEVER
4-6 days Fever with General and physical
• Headache examination –
• Retro orbital pain • Petechial and mucosal
• Myalgia, Arthralgia, Rash bleeding
• Haemorrhagic manifestation • Positive Tourniquet test
• No foci • Hepatomegaly
• With plasma leakage (Persistent
vomiting, abdominal pain, Lethargy)
 PHC GH TERTIARY CARE
1. Complete blood count 1. Complete blood count 1. Complete blood count
• Thrombocytopenia • Thrombocytopenia (<1lakh) • Thrombocytopenia (<1lakh)
(<1lakh) • Hematocrit rise 20% • Hematocrit rise 20% RBS, RFT,
• Hematocrit rise 20% • RBS,RFT,LFT, LFT, coagulation profile
• Coagulation profile 1. Ns1 antigen
1. NS-1 antigen 2. IgM dengue
2. IgM dengue

• Start iv crystalloids • Start iv crystalloids solution • HDU admission

solution • Refer to tertiary care • Intense fluid resuscitation.
• Refer to tertiary care (Normal saline) Bolus
• 7-10ml/kg/hour then taper
• Monitor- BP, PR, Temp , IO
4thhrly HCT
• Avoid induction of labor/
planned surgery in this phase
Dengue Haemorrhagic Fever (III)
DAY OF
HISTORY EXAMINATION
FEVER
4-6 Fever with General and physical
• Headache, Retro orbital pain examination –
• Myalgia, Arthralgia • Weak Rapid pulse
• Rash, No foci • Pulse pressure<20 mmHg
• Haemorrhagic manifestation • Hypotension
With plasma leakage, with circulatory • Cold clammy skin
Compensated Shockfailure • Restlessness

PHC GH Tertiary care

Complete blood count • Complete blood count • Complete blood count
• Thrombocytopenia <1lakh) • RBS, RFT, LFT, • RBS, RFT, LFT, coagulation profile
• Hematocrit rise 20% coagulation profile • Arterial blood gas analysis
• NS-1 Antigen • Serum electrolytes
• Serum electrolytes • USG abdomen
• IgM dengue
• Start iv crystalloids • Refer to tertiary care • HDU admission
solution • IV fluids, isotonic crystalloids 10-20ml/
• Refer to tertiary care kg/hr for one hour then taper
• Monitor vitals every 5-30mins
 Day Of Diagnos
History Examination Investigation Treatment
Fever is
4-6 1. Fever with Decompensated • Complete blood Dengue • HDU admission
• Headache • Rapid count RBS, RFT, hemorrh • IV fluids, isotonic
• Retro orbital breathing LFT, agic crystalloids
pain • Cold and • coagulation fever(IV) 20ml/ kg/hr
• Myalgia cyanosed profile bolus then
• Arthralgia extremities • Arterial blood 10ml/kg/hr
• Rash • Mottled skin gas analysis • Monitor vitals
• Hemorrhagic • Feeble pulse • Serum every 5-30mins
manifestation • BP electrolytes • If refractory
• No foci unrecordable • USG abdomen shock- consider
• With plasma • Confused inotropes
leakage • Restless
• With circulatory
failure
• With shock
• BP and pulse
unrecordable
First Trimester
 Leukopenia may not be seen
 Due to physiological hemodilution – hemoconcentration with plasma leakage may be masked
 Rising Hematocrit –maternal shock, Maternal liver enzyme derangement
 Miscarriage
Second Trimester
 Cytopenia present, Platelet <80,000cells/cumm. -plasma leakage
Third Trimester and Postpartum
 No specific altered physiological status
When To Stop IV Fluids?
REDUCE IV infusion rate in step-wise manner whenever
 Haemodynamic state is stable
 Rate of plasma leakage decreases towards end of critical phase indicated by Improving haemodynamic
signs Increasing urine output, Adequate oral fluid intake, Haematocrit decreases below baseline value in a
stable patient
Definite Stop
Features of intravascular compartment overload
 Hypertension with good volume pulse
 Breathing difficulties
 Pulmonary edema
48 hours after defervescence
Effect of Dengue on Pregnancy
 Placental ischemia in first trimester
 Development of pre-eclampsia and GDM
 Pancreatitis, Hyperlipidaemia, Ischemia, Preterm delivery
 Placental abruption, Secondary autoimmune reactions
 Dengue encephalopathy
 Anticipate complications of dengue fever in any trimester of pregnancy.
 Complications are common during critical phase of dengue fever
 Fetus – neural tube defect , cleft lip, congenital heart defects in first trimester, fetal growth
restriction, low birth weight, stillbirth
Labor Management
 In the presence of warning signs –Fluid -0.9 % NS in bolus of 5-10 ml/kg/hour for 2hours followed
by 3-5ml/kg/hour for maintenance.
 Neither planned induction nor surgical procedures should be taken up during critical phase.
 Tocolytics to postpone delivery.
 Recovery phase-avoid fluid overload.
Inevitable Delivery during Critical Phase
 Anticipate bleeding.
 Blood and blood products should be cross matched.
 Ensure complete removal of placenta after delivery.
 Transfusion of platelets during or at delivery and not far too ahead.
 Do not wait for blood loss to exceed 500ml before replacement, do not wait for hematocrit to
decrease to low levels.
1. No Other NSAID (Ibuprofen/Diclofenac) for fever. Only Paracetamol to be given. Daily dose should
not exceed 4 Gram.
2. Option of fluid for resuscitation.
 Normal saline 0.9% should be used for initial resuscitation.
 NS is preferred to Ringer lactate and DNS. Plain Dextrose solution NOT to be used.
 Colloids can be given only after fluid boluses in patients of shock.
3. Transfusion -overt blood loss nearing 500ml.
4. Prophylactic platelet transfusion is NOT recommended unless delivery is inevitable (in coming
hours) platelet count > 50000/CC, and 75000/cc for operative delivery. Clinically stable Dengue with
Low or very Low platelet count in critical/recovery phase - No plat transfusion. Platelet transfusion
may be given in presence of Overt bleeding with Low platelet counts.
 NO role of steroid / IV immunoglobulin / Prophylactic antibiotics.
5. Operative delivery for obstetric indications only.
 Delivery should take place in a hospital where blood/blood components and a team of skilled
obstetricians and a neonatologist are available.
Discharge Criteria
 Afebrile for 24 hours without antipyretic
 Improved appetite
 Normal HCT at baseline value
 Rising trends of WBC and platelets
Postpartum
 New born to be closely monitored in hospital in-view of risk of vertical transmission.
Follow Up-
Clinical Examination along with CBC and haematocrit
 DO’S DONT’S

• Suspect Dengue in each acute febrile illness • No Intramuscular Injections

• Admit Probable dengue in pregnancy for close • No Hypotonic IV fluid
monitoring. • No IV fluid adequate oral
• CBC (PCV - Haematocrit) is the sole Lab intake.
parameter needed for monitoring. Serology if • No steroids /Antibiotics
necessary.
• Watchful vigilance for warning sign especially
when fever starts/ subsiding. Diagnose shock
to be detected early where intense fluid
management helps. (NS only)
• Imminent delivery: Fresh blood and platelets
to be kept ready and transfused as mentioned.
• Baby to be evaluated for congenital Dengue.
• Timely Intervention brings down fatality from
20% to 1%.
Table: 35.1 - Dengue Chart

Table: 35.2 – Dengue I/O Chart

MALARIA COMPLICATING PREGNANCY
BACKGROUND & DEFINITION

• Malaria infection is a significant public health problem with substantial risk for pregnant women and the fetus

• Fever is the cardinal symptom of malaria. It can be intermittent / associated with chills, rigor, headache, myalgia.

• In high transmission areas, non immune primi gravida are usually most affected (primi gravida have no pre existing
immunity to placental parasites and are highly susceptible). They tend to develop immunity to placental parasites
and are protected in subsequent pregnancies.
Malaria Endemic Regions In Tamilnadu

• Greater chennai corporation

• Ramanathapuram

• Tuticorin

• Dharmapuri

• Kanyakumari

Causative Organisms
• P.falciparum

• P.vivax (most wide spread species)

• P.malaria

• P.ovale
TRANSMISSION
• Bite of female anopheles mosquito

• Blood transfusion

• Contaminated needle

• Organ transplantation

• Pregnant women is at higher risk for severe disease

• Risk of infection is more in 2nd trimester

• Increased risk of contracting malaria may be due to

• Decreased immunity

• Hormonal changes

• Sequestration of parasite inside placenta

 PATHOPHYSIOLOGY

• Malaria occurs by transmission of plasmodium sporozoites via a bite from an infected female anopheline
mosquito.

• The sporozoites travel from the salivary glands of the mosquito through the bloodstream of the host to the
liver, where they invade the hepatocytes.
MATERNAL EFFECTS – Placental parasitemia

• P.falciparum infected erythrocyte binds placental tissue and sequestered

• Impairs movement of nutrients across placenta

• Fetal growth retardation

• Parasites not filtered through spleen maternal anemia

• Impairs splenic processing and filtration and decrease host immune response.

COMPLICATIONS:

• Early pregnancy loss

• 1st trimester – Spontaneous abortion

• 2nd trimester – IUGR, Oligohydramnios

• 3rd trimester- Fetal distress, stillbirth or low birth weight, IUFD, Oligohydramnios, Preterm labor, Prematurity.
• Congenital malaria – due to transplacental infection of fetus

Usually manifest between 2nd and 8th week of life with fever, anemia, hepatosplenomegaly

Parasites can be found in Peripheral smear of newborn from 24 hours to 7 days of life.
UNCOMPLICATED MALARIA

• < 2% parasitised red blood cells

• No signs of severity and no complicating features

COMPLICATED MALARIA

• Marked agitation

• Hyperventilation (respiratory distress)

• Low core temperature (5 mmol/L)

• Acidemia (pH < 7.3)

• Elevated total bilirubin

• Elevated liver enzymes (AST/ALT 3 times upper limit of normal)

• Renal Impairement (oliguria <0.4 ml/kg /hour)

• Hyperlactatemia( increased mortality)

• Hematology

Leukocytosis (>12,000/μL)

Severe anemia (Hemoglobin <8 g/dl)

Thrombocytopenia

>20% of parasites identified as pigment-containing trophozoites and schizonts

>5% of neutrophils contain visible malaria pigment

SCREENING/DIAGNOSIS OF MALARIA:

• Signs and symptoms mimics influenza and other infections.

• History of travel to malaria endemic area in pregnant women with pyrexia of unknown origin.
Peripheral smear
 • Thick film: Blood should be uneven in thickness

Sensitive (0.001% parasitemia) .

• Thin film – to identify plasmodium species

IN A FEBRILE PATIENT, THREE NEGATIVE MALARIA SMEARS 12–24 HOURS APART RULES OUT THE
DIAGNOSIS OF MALARIA

RAPID DIAGNOSTIC TEST:

o Monoclonal antibody capture of parasitic antigens.

o Rapid and relatively inexpensive.
o Remains positive for weeks after high density infections.
Does not quantitate parasitemia and it detect low level parasitemia with P. vivax, P. ovale, and P.
MALARIA
PREVENTION:
• INSECTICIDE TREATED NETS –

• Cheap and effective for malaria prevention in pregnancy.

• ITNs should be provided to women as early in the pregnancy as possible, at the
ANC clinic or through other sources in the public or private sectors.
• WHO recommends distribution of ITNs, more specifically LLINs, to achieve full
coverage of populations at risk of malaria.
• Distribution of LLINs through existing public health services (both routine and
campaigns).
• INDOOR RESIDUAL SPRAY

• INTERMITTENT PREVENTIVE TREATMENT (ITPP)

Areas of moderate‐to‐high malaria transmission

IPTp with Sulfadoxine‐Pyrimethamine is recommended for all pregnant women

WHO RECOMMENDS A SCHEDULE OF FOUR ANTENATAL CARE VISITS?

• The first IPTp‐SP dose should be administered as early as possible during the 2nd trimester of gestation

• Each SP dose should be given at least 1 month apart.

• The last dose of IPTp with SP can be administered up to the time of delivery, without safety concerns.

• IPTp should ideally be administered as directly observed therapy (DOT)

• SP can be given either on an empty stomach or with food

• Folic acid at a daily dose equal or above 5 mg should not be given together with SP as this counteracts its efficacy as an
antimalarial.

• SP should not be administered to women receiving cotrimoxazole prophylaxis.

TREATMENT
• Treat malaria in pregnancy as an emergency.

• Admit pregnant women with uncomplicated malaria to hospital and pregnant women with severe and complicated
malaria to an intensive care unit.

• Intravenous artesunate is the treatment of choice for severe falciparum malaria.

• Intravenous quinine can be used if artesunate is not available.

• Quinine and clindamycin to treat uncomplicated P. falciparum (or mixed, such as P. falciparum and P. vivax).

• Use chloroquine to treat P. vivax, P. ovale or P. malariae.

• Primaquine should not be used in pregnancy.

• Do not persist with oral therapy if vomiting is persistent.

• Treat fever with antipyretics.

• Screening of women with malaria for anemia.

Non falciparum malaria – Uncomplicated

• Chloroquine (sensitive):

Day 1 – 600mg (4*150 mg )

Day 2 – 600mg (4*150 mg )

Day 3 – 300mg (2*150 mg )

To prevent relapse (P. vivax/ovale) after treatment during pregnancy:

Chloroquine 300 mg weekly until delivery

To prevent relapse after delivery:

Postpone until 3 months after delivery and G6PD testing. Use Primaquine.
PRIMAQUINE CONTRAINDICATED IN PREGNANCY

Chloroquine-resistant P. vivax should be treated in the same way as chloroquine resistant P. falciparum.
COMPLICATED MALARIA

• Impaired consciousness (measure GCS and NSQ) or seizures

• Hypoglycaemia (<40 mg/dl)
• Pulmonary oedema or ARDS -- Non cardiogenic aggravated by overhydration
• Hyperparasitaemia.
• Severe anaemia (Hb < 8.0 g/dl)
• Abnormal bleeding/DIC
• Haemoglobinuria (without G6PD deficiency)
• Renal impairment/electrolyte disturbance (acidosis pH < 7.3)
• Hyperlactataemia
• Hypotension/ Shock ( BP< 90/60 mm hg)
• Jaundice
COMPLICATED MALARIA

• Artesunate IV 2.4 mg/kg at 0, 12 and 24 hours & daily thereafter (Drug of choice)

Tolerating oral medication, can be switched to oral artesunate 2 mg/kg (or IM artesunate 2.4 mg/kg) once
daily, plus clindamycin 450 mg 3 times a day 7 days

or

• Quinine IV 20 mg/kg loading dose (no loading dose if woman already taking quinine or mefloquine) in 5% dextrose
over 4 hours and then 10 mg/kg IV over 4 hours every 8 hours

Tolerating oral medication can be switched to oral quinine 600 mg 3 times/day and oral clindamycin 450 mg 3 times
day for 7 days.
RECURRENT MALARIA:

WHO Regimen of 7 days of Artesunate (2 mg/kg/day or 100 mg /day) and clindamycin (450 mg three times /day)
could be given.

• Monitor for hypoglycaemia regularly (< 40 mg/100 ml ):

Check blood glucose regularly and treatment with glucose-containing fluids .

Quinine induced hypoglycaemia can occur quite late in the course even after the patient appears to be recovering.

• COMA (cerebral malaria) :

Monitor using Glasgow Coma Score. Maintain airway, place patient on her left side, exclude treatable causes of coma
(e.g. hypoglycaemia, bacterial meningitis).

HYPERPYREXIA:

Administer tepid sponging, fanning and antipyretic drugs.

ACUTE PULMONARY OEDEMA

Clinical assessment of jugular venous or central venous pressure, aimed at keeping right arterial pressure < 10 cm
H2O. Propping patient up at an angle of 45 degrees, oxygen, diuretic, stop intravenous fluids, intubate positive end-
expiratory pressure/continuous positive airway pressure in life-threatening hypoxemia.

CONCLUSIONS:

Maintain airway; treat promptly with intravenous or rectal diazepa

• Severely anaemic(haemoglobin < 8 g/100 ml or packed cell volume < 24%)

Transfusion slowly, preferably with packed cells and intravenous frusemide 20 mg.

• Secondary bacterial infection should be suspected if the patient becomes hypotensive.

• Spontaneous bleeding and coagulopathy:

Transfuse with screened fresh whole blood (cryoprecipitate, fresh frozen plasma and platelets); Vitamin K injection
METABOLIC ACIDOSIS:

• Correction by careful fluid balance

• Monitor fetal heart rate, liquor level, growth scan for fetal well being

• Assess Hb, Blood glucose, platelet level to rule out anemia/hypoglycemia

• Treatment of fever with antipyretics

• no need to induce labor unless indicated

• In severe malaria, cardiotocograph monitoring may reveal fetal tachycardia, bradycardia or late decelerations in
relation to uterine contractions, indicating fetal distress.

• Uncomplicated malaria in pregnancy is not a reason for induction of labour.

• Stillbirth and premature delivery in malaria in pregnancy are best prevented with prompt and effective
antimalarial treatment.

• Peripartum malaria is an indication for placental histology and placenta, cord and baby blood films to detect
congenital malaria at an early stage.
MANAGEMENT OF LABOUR

• Increasing parasite load increases uterine contraction that leads to premature labour.

• Frequency and intensity of contractions is directly proportional to the height of fever  Temperature to be kept under
control with antipyretics and sponging.

• Fetal distress is common with increasing contractions.

• Monitoring of uterine contractions, Fetal heart rate, Fetal tachycardia/bradycardia is mandatory.

• Fluid management to be done to avoid dehydration/fluid overload.

• Blood glucose monitoring to be done to avoid hypoglycemia.

• If needed, induction of labour to be done.

• If there is any fetal distress/maternal distress, Do shorten 2nd stage of labour.

• Even C-Section can be done if situation demands.

PLANNING OF DISCHARGE

• Can be discharged if

• No fever for 48 hours

• Vitals- Stable

• No complications of malaria

• Reversal of good appetite

• Normal blood investigations

AN CARE AFTER RECOVERY FROM MALARIA

• Regular AN Care

• Hemoglobin monitoring, Blood glucose, Fetal growth assessment to be done regularly.

• If growth restriction is detected during scans, obstetric management as per routine treatment can be carried

out.
PN CARE AFTER RECOVERY FROM MALARIA

 Hemoglobin monitoring, Blood glucose to be done regularly

 If infant presents with fever, anemia, nausea - Screening of infant for congenital
malaria to be done.
 Women should be advised of the risk of recurrence and followed up weekly
 If fever /symptoms return, repeat blood smear is needed.
AT PRIVATE HOSPITALS

• Screening of symptomatic pregnant women and those with travel history to

endemic regions.

• In case of smear positive cases, NOTIFICATION to be given to respective primary

health centre/UPHC.

• Cases to be followed up by PHC team - MO, VHN and field staff.

TRANSMISSION TO BABY:
• Vertical transmission to Baby: Infection at the time of birth, placenta and cord with blood film positivity.

Mothers infected with malaria

Neonates screened with standard microscopy of thick and thin blood films

At birth

Weekly for 28 days

ABCD OF MALARIA PREVENTION IN PREGNANCY

• Awareness of risk
• Bite prevention
• Vector control
• Insecticide treated nets
• Residual household spraying
• Environmental management
• Chemoprophylaxis
• Diagnosis and treatment
CHIKUNGUNIYA COMPLICATING
PREGNANCY
Definition
 Chikungunya should be suspected when epidemic occurs with onset of fever, arthralgia &
myalgia, with or without rash.
 Caused by Chikungunya virus (RNA virus – family Togaviridae).
 Spread by Aedes mosquito.
 Incubation Period-3 to 7 days
 Clinical Feature – 3 Phases
 Acute Phase < 3 weeks.
 Sub-acute Phase – 3 weeks to 3 months
 Chronic Acute Phase > 3 months

Symptoms
 Headache
 Fever with or without Rashes
 Myalgia, Arthralgia, Fatigue

Physical Examination
 To Monitor
 Temperature
 Pulse Rate
 Blood Pressure
 Urine Output – watch for oliguria
 Rashes & Bleeding Manifestation
 Impact of Chikungunya in Pregnancy
 High risk at any stage of pregnancy.
 Fever in general can trigger uterine contractions resulting in preterm labor, miscarriage & IUD.
 Transmission from mother to child occurs during birth.
 IgM antibody doesn’t cross the placenta.
 IgG antibody crosses the placenta after 15 days of infection and confer immunity to the foetus.
 Discharge Criteria
 Afebrile for 48 hours.
 Clinically improved without complication
 When to deliver.
 Can be delivered vaginally.
 Can wait up to term with continuous monitoring & proper management
 LSCS only for obstetric indication.
 Prevention
 Insect Repellent.
 To wear fully covered clothes.
 Mosquito netting.
 Removing stagnant water from areas around your home.
 PRIMARY CARE TERTIARY CARE
SECONDARY CARE (GH)
(PHC) (MED.COLLEGE)
Investigatio CBC CBC, LFT, RFT CBC, LFT, RFT
n if possible • ELISA IgM rapid card
• ELISA IgM rapid card test
tests • RT-PCR to quantify the
• RT-PCR to quantify viral load
the viral load
Treatment • Oral Paracetamol Advised admission ICU care
• Adequate oral to get physician opinion
fluid & NSAIDS & Paracetamol
rehydration Proper hydration
Avoid NSAID in pregnancy
Referral Fever for > 48 hrs Refractory thrombocytopenia Speciality opinion and ICU
Refractory hypotension, Renal care
involvement, multi organ
failure, neurological
symptoms
SCRUB TYPHUS
INTRODUCTION

Scrub typhus, also known as bush typhus, is a disease caused by bacteria

called Orientia tsutsugamushi. Scrub typhus is spread to people through bites

of infected chiggers (larval mites). The most common symptoms of scrub

typhus include fever, headache, body aches, and rash.

Also known as CHIGGEROSIS
CAUSATIVE AGENT:

Orientia tsutsughamushi
VECTOR:

Chiggers (larval mites- leptotrombidium

MODE OF INFECTION:

Bite of chiggers
RESERVOIR:

Birds and rodents

INCUBATION PERIOD – 1 TO 2 WEEKS .
CONSIDERATIONS DURING PREGNANCY:

 Spontaneous abortions
 Still births
 Pre term delivery
 Low birth weight

WHO ARE ALL AT RISK?

Farmers those Working in Orchards and Shrub Area

People Visiting Mite Islands

WHEN TO THINK OF SCRUB TYPHUS?

Fever with chills , Enlarged lymph nodes , maculopapular rash , headache and Myalgia
 ESCHAR ------------ COMMON SITES- AXILLA, GROIN,CHEST , ABDOMEN , GENITALIA

Acute Undiffernted Febrile Illness with Fever more than 5 Days?

TREATMENT IN PREGNANCY :
AZITHROMYCIN 500 mg SINGLE DOSE x 5 DAYS

WHEN TO REFER TO HIGHER CENTRE?

If not improving/condition deteriorates within 48-72hrs

If the illness is severe with cardiac, pulmonary, renal and CNS complications In
complicated cases the following treatment is to be initiated.
 At CHC and Teritary level :

 Intravenous doxycycline(wherever available) 100mg twice daily in 100 ml normal saline to be administered as infusion

over half an hour initially followed by oral therapy to complete 7-15days of therapy.

 Intravenous Azithromycin in the dose of 500mg IV in 250 ml normal saline over 1 hour once daily for 1-2 days followed

by oral therapy to complete 5 days of therapy.

PREVENTION/CONTROL/PRECAUTIONS:

•Wear protective clothing

•Insect repellents containing benzyl benzoate can be applied to the skin and clothing to prevent chigger bites.

•Ensure Chlorinated Drinking water or hot water .

•Health Education and awareness regarding personal hand hygiene and hydration

•IEC programme should be conducted at phc level regarding symptoms of fever, headach, malaise, burning sensation,

loose stools and abdominal pain.

 For AN mother with fever symptoms tests should be done
Dengue, chikungunya,Leptospirosis,scrub typhus,widal, blood
smear for Malaria
 IEC programme should be conducted at phc level regarding
symptoms of fever,headace,
malaise, burning sensation, loose stools and abdominal pain.
Warning signs (Vomiting, giddiness, loose stools, reduced/ absent
fetal movements, vaginal bleeding) and other warning symptoms
like abdominal Pain,black tarry
stools,hemetemesis,hematuria,bleeding gums,epistaxis to be
 SCRUB TYPHUS
MANAGEMENT AT DIFFERENT LEVELS OF HEALTHCARE SYSTEM

Scrub typhus, also known as bush typhus, is a disease caused by

bacteria called Orientia tsutsugamushi

 Detailed history- travel history, h/ o exposure to mites

 Symptoms-
 onset & severity-fever,
 Headache,
 conjuctival cogestion,
 Myalgia,
 Shortness of breath,
 Loss of apettite,
 maculopapular rash over axilla,
 groin, chest, abdomen, genitalia
 Examination- Temperature, PR, BP, RR
 Refer to PHC medical officer

CLIMICAL ASSESSMENT

Clinical Danger Signs Obstetric Danger Signs Clinical & Social Risks
 Sjprtmess of breath  Labour pains  Comorbidities
 High Fever  Rupture of Membrane  Obstetric
 Maculopapular Rash  Persistent fever Complications
 Lymhadenopathy  No proper self-care
 Enlargement of spleen
 Pneumonitis

Refer to medical college NO

YES
CLINICAL
ASSESSMEN
T
SEVERE DISEASE/ CRITICALLY ILL:
MODERATE DISEASE: Fever +
RR>30/ MIN (or) Severe
Respiratory symptoms Can be
respiratory distress (or) SpO2 <90%
managed at the level of GH
on RA
 Oxygen support – NRBM
 Oxygen support – NIV/ IMV
 Inj. AZITHROMYCIN 500mg IV
 Inj. AZITHROMYCIN 500mg OD for 2 days followed by oral
IV OD for 2 days followed by therapy to complete 5 days of
oral therapy to complete 5 therapy
days of therapy  Monitor vitals/ work of
breathing/ change in oxygen
 Investigations: CBC, RFT, LFT requirement
daily  Investigations: CBC, RFT, LFT every
24-48 hours
LEPTOSPIROSIS
LEPTOSPIROSIS
• Caused by serotypes of leptospira(spirochetes)

 Recent travel to endemic area

 History of Eating raw vegetables

 Visiting public baths

 Exposure to farm animals

 Working in paddy fields ,milk parlour

 Lack of protective footwear

 Transmission of infection depends on climate, population

density ,degree of contact with host

EFFECT OF LEPTOSPIROSIS ON PREGNANCY

 Oligohydramnios

 Preterm labour

 Intrauterine fetal demise

FEATURES OF MILD DISEASE

• Stable vital signs

• Anicteric sclera

• Good urine output

• No evidence of meningeal irritation

• No evidence of sepsis/septic shock

• No difficulty breathing

• No jaundice
FEATURES OF SEVERE DISEASE

• Unstable vital signs

• Jaundice / icteric sclera

• Abdominal pain, nausea, vomiting and diarrhea

• Oliguria / Anuria

• Sepsis/septic shock

• Altered mental states

• Difficulty breathing and hemoptysis.

MARKERS OF SEVERE LEPTOSPIROSIS

Complete blood count (CBC) with plateiet count:

Leucocytosis with neutrophilia and thrombocytopenia
Serumcreatinine>3mg/dl and BUN>23 mg/dL

Liver function tests: AST/ALT ratio>4, bilirubin>190 pmol/ L

Bleeding parameters: prolonged prothrombin time (PT)<85%

Serum potassium>4 mmol/l

Arterial blood gas (ABG): severe metabolic acidosis

Chest radiograph -extensive alveolar infiltrates.

Electrocardiogram -signs of heart blockage myocarditis.

 PHC GH Tertiary care
History • Fever with chills • Fever with chills • Fever with chills
• Conjunctival suffusion • Conjunctival suffusion • Conjunctival suffusion
• Headache • Headache • Headache
• Cough • Cough • Cough
• Chest pain • Chest pain • Chest pain
• Hemoptysis • Hemoptysis • Hemoptysis
• Hemorrhagic tendencies • Hemorrhagic tendencies • Hemorrhagic tendencies
• Myalgia • Myalgia • Myalgia
• Diarrhoea Abdominal pain • Diarrhoea Abdominal pain • Diarrhoea Abdominal pain

Examination • Mental state • Mental state • Mental state

• Hydration • Hydration Hemodynamic status • Hydration Hemodynamic
• Hemodynamic status • Physical examination status
• Physical examination • Physical examination
 PHC GH Tertiary care
• Diagnosis • History taking • WBC count –elevated • All investigations done at GH
neutrophils • Isolation
• Increased ESR • ELISA
• Urine analysis – • MAT
proteinuria,hematuria
• LFT
• IgM leptospira
• Manageme • History • Clinically suspected • Inj.Ceftriaxon
nt • taking • leptospirosis • e 1gm Iv 6thhrly for 7 days
• T.Azithromycin • T.Azithromycin 500mg od • Inj.cefotaxim 1g Iv 6thhrly x 7
500mg od • Refer to higher centre – days
• Refer to CEmONC • Hypotension • T.Azithromyci n 500mg od x 7days
centre • Decreased urine output • Organ specific care at tertiary
• Jaundice level
• Hemoptysis • Severe disease –
• Bleeding tendency • Inj.Penicillin G
 MODIFIED FAINE’S CRITERIA
1. CLINICAL DATA

Headache 2
Fever 2
Fever > 39 °c 2
Conjunctival suffusion 4
Meningism 4
Myalgia 4
Jaundice 1
Albuminuria 2
Hemoptysis/dysnea 2
1) Epidemiological :

Rainfall 5

Contact with contaminated environment 4

Animal contact 1

Score 26 or more suggests possible leptospirosis

Discharge criteria

• Afebrile for 48hrs

• Improving CBC, LFT
 LEPTOSPIROSIS
Caused by serotypes of leptospira

Fever symptoms in heavy rainfall and flooded area Exposure to

At PHC
farm animals like rodent ,Goat (Contaminated water bodies )
AT VHN
LEVEL
LEVEAT VHN Refer to PHC
LEVEL L
CLINICAL ASSESSMENT

MILD SYMPTOMS(ACUTE PHASE) SEVERE SYMPTOMS/ IMMUNE PHASE

• Fever with Chills • J aundice (Hepatic failure)

• Headache and retroorbital pain • Oliguria (Renal failure)

• Conjunctival suffusion • Difficulty breathing (Pulmonary

hemorrhage)
• Myalgia (calf and low back ache) • Altered mental status (aseptic meningitis)

• Hemodynamic instability
AT PHC
LEVEL
Clinical symptoms – mild symptoms

T.Azithromycin 500mg OD X 7 Days If Symptoms persistent for more than 48 hours.

Refer to GH

AT GH LEVEL

Clinical Assesment Plus positive lab investigations

T.AZITHROMYCIN 500mg OD X 7 days OR

PROGRESS TO SEVERE SYMPTOMS
Inj CEFTRIAXONE 1gm IV Q6H X 7 Days. OR REFER TO TERTIARY CARE CENTER
Inj CEFOTAXIM1gm IV Q6H X 7 Days

AT TERTIARY LEVEL

Clinical assessment plus positive lab

findings and Severe symptoms

Inj. Penicillin G 1.5 MU IV Q6H + IV Organ specific care Hemodialysis and

Hydration and supportive measures Mechanical Ventillation