Malaria in Pregnancy - PowerPoint - PowerPoint by pengxiang

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									A Workshop for Health Care Providers
   300 million cases each year worldwide
   9 of 10 cases occur in Africa
   A person in Africa dies of malaria every 10 seconds
   Women and young children are most at risk
   Affects five times as many people as AIDS, leprosy,
    measles and tuberculosis combined




                                                          2
 25 million pregnant African women in malarious areas
  yearly
 Malaria is more frequent and complicated during
  pregnancy
 In malaria-endemic areas, malaria during pregnancy may
  account for:
      Up to 15% of maternal anemia
      8–14% of low birthweight
      30% of ―preventable‖ low birth weight
      3–8% of infant death

                                                           3
 Worldwide partnership launched by WHO, UNICEF,
  UNDP in 1998 to provide a coordinated global approach
  to fighting malaria
 Partners: governments, private groups, research
  organizations, civil society, media
 Vision: By 2015 the malaria-related Millennium Development
  Goals (MDGs) are achieved. Malaria is no longer a major
  cause of mortality and no longer a barrier to social and
  economic development and growth anywhere in the world.


                                                           4
 Priority: Prevent poor outcomes caused by malaria in
  pregnancy
 RBM Summit 2005 Yaoundé:
      Strategic plan aimed at vulnerable groups
      Target: 80% of pregnant women in areas of stable
       transmission receive IPTp by 2010
 Free advocacy resources and tools:
  http://www.rbm.who.int



                                                          5
WHO strategy:
 Use of insecticide-treated nets (ITNs)
 Intermittent preventive treatment (IPTp)
 Case management of women with symptoms and signs of
  malaria


  Platform for these services: focused antenatal care with
              health education about malaria



                                                             6
Chapter One: Focused Antenatal Care




                                      7
 Explain the differences between basic, additional and
  initial specialized care
 Describe the four main goals of focused ANC
 Describe the essential elements of a birth and
  complication readiness plan
 Discuss the frequency and timing of focused
  ANC visits
 Describe components of record keeping for focused
  ANC


                                                          8
 Emphasizes:
      Ritualistic, ―routine‖ care
        • Actions are often not evidence-based or goal-directed
      Frequent visits
 Does not emphasize individual
  clients’ needs
 Often based on risk approach




                                                                  9
An approach to ANC that emphasizes:
   Evidence-based, goal-directed actions
   Individualized, woman-centered care
   Quality vs. quantity of visits
   Care by skilled providers




                                            10
 Address most prevalent health issues affecting women
  and newborns
 Adjusted for specific populations/regions
 Appropriate to gestational age
 Based on firm rationale




                                                         11
Based on each woman’s:
   Specific needs and concerns
   Circumstances
   History, physical examination, testing
   Available resources




                                             12
 WHO multi-center study:
     Number of visits reduced without affecting outcome for
      mother or baby
 Recommendations:
   Content and quality vs. number of visits
   Goal-oriented care
   Minimum of four visits




                                                               13
 Numerous, routine visits:
      Burden to women and health care system
 Routine measurements and examinations:
    Maternal height and weight
    Ankle edema
    Fetal position before 36 weeks
 Care based on risk assessment




                                                14
Not an effective ANC strategy because:
 Complications cannot be predicted—all pregnant women
  are at risk for developing complications
 Risk factors are usually not direct cause of complications




                                                           15
 Many ―low risk‖ women develop complications:
      Have false sense of security
      Do not know how to recognize/respond to problems
 Most ―high risk‖ women give birth without
  complications:
      Inefficient use of scarce resources




                                                          16
 Has formal training and experience
 Has knowledge, skills and qualifications to deliver safe,
  effective maternal and newborn health care
 Practices in home, hospital, health center
 May be a midwife, nurse, doctor, clinical officer, etc.




                                                              17
 The scope of antenatal services includes:
      Basic care
      Care for additional needs
      Initial specialized care




                                              18
Services all women should receive to ensure,
support and maintain a normal childbearing cycle:
 Early detection of complications, chronic conditions and
  other problems/potential problems
 Health promotion to facilitate healthy practices
 Nutritional support
 Birth preparedness/complication readiness
 Testing/counseling for HIV (unless client
  ―opts out‖)
 Immunizations and other preventive measures

                                                             19
 To address concerns such as common discomforts in
  pregnancy or special needs
 Special needs: conditions or personal/social factors to
  consider when planning and implementing care
 Examples of additional care:
      Counseling on specific health topics
      Addressing the needs of pregnant adolescents
      Caring for women who are HIV-infected




                                                            20
 A few pregnant women will need initial specialized care for
  more serious problems or complications including additional
  ANC visits and/or referral
 Examples: life-threatening complications, e.g., severe malaria,
  anemia or antenatal hemorrhage
 Does not include management of the problem, but
  stabilization and preparation for referral to a higher level of
  care




                                                                    21
Majority of pregnant
                               Core components of basic care:
women need these                to maintain normal pregnancy
services only



                                      Additional care:
Some pregnant women                 to address common
require these services also       discomforts and special
                                           needs

                                      Initial specialized
                                       care: to address
Fewer pregnant women require           life-threatening
these services                          complications




                                                                22
To promote maternal and newborn health and
survival through:
 Identification and treatment of existing
  health problems
 Early detection of complications and/or diseases arising
  during pregnancy
 Birth preparedness and complication readiness
 Health promotion and disease prevention



                                                             23
 Early detection and treatment of problems that can
  complicate the woman’s pregnancy
 Targeted assessment:
    Provider interviews, examines and tests the woman to
     detect signs/symptoms of conditions that are common in
     the population being served as well as pregnancy-related
     complications.
 Providing (or facilitating) appropriate treatment




                                                                24
 Malaria—history and physical exam:
       Does the woman live in an area of stable or unstable malaria
        transmission?
       Fever and accompanying signs/symptoms
       Uncomplicated vs. severe cases
   Severe anemia—physical exam, testing
   Hypertension—B/P measurement
   HIV testing and counseling
   Sexually transmitted infections:
       Including syphilis (RPR) and other appropriate screening




                                                                       25
 Another component of targeted assessment
 Detecting signs and symptoms of maternal complications,
  for example:
    Hemorrhage
    Pre-eclampsia/eclampsia
    Prolonged/obstructed labor
    Sepsis/infection




                                                       26
 Management of complications or initial management and
  stabilization, including life-saving measures as needed
 Facilitating management or referral to a higher level of
  care




                                                             27
 Develop birth plan—for normal birth and possible
  complications:
    Arrangements made in advance by woman and family (with
     help of skilled provider)
    Usually not a written document
    Reviewed/revised at every visit
 Minimize disorganization at time of birth or in an
  emergency
 Ensure timely and appropriate care


                                                          28
 Facility or Place of Birth: Home or health facility for birth,
  appropriate facility for emergencies
 Skilled Provider: To attend birth
 Provider/Facility: Contact information
 Transportation: Reliable, accessible, especially for odd hours
 Funds: Personal savings, emergency funds
 Decision-Making: Who will make decisions, especially in an
  emergency




                                                                   29
 Family and Community Support: Care for family in
  woman’s absence and birth companion during labor
 Blood Donor: In case of emergency
 Needed Items: For clean and safe birth and for newborn
  care
 Knowledge of: Danger signs/signs of advanced labor




                                                           30
   Vaginal bleeding
   Difficulty breathing
   Fever
   Severe abdominal pain
   Severe headache/blurred vision
   Convulsions/loss of consciousness
   Labor pains before 37 weeks




                                        31
 Inform and educate the woman with health messages
  and counseling appropriate to:
      Individual needs, concerns, circumstances
      Gestational age
      Most prevalent health issues
 Support the woman in making decisions and solving
  actual or anticipated problems
 Involve partner and family in supporting/adopting healthy
  practices



                                                          32
 Prevention of malaria:
      Intermittent preventive treatment (IPTp)
      Use of insecticide-treated nets (ITNs)
      What family can do to minimize mosquito breeding/bites
 Other important issues to be discussed include:
      Nutrition
      Care for common discomforts
      Use of potentially harmful substances
      Hygiene
      Rest and activity




                                                                33
 Sexual relations and safer sex
 Early and exclusive breastfeeding
 Testing/counseling for HIV infection:
      Unless she ―opts out‖
 Family planning/healthy timing and spacing of pregnancies




                                                          34
 Along with health messages, another important aspect
  of health promotion is the provision of safe and cost-
  effective interventions to prevent certain conditions




                                                           35
 Prevention of malaria:
      Intermittent preventive treatment (IPTp)
      Use of insecticide-treated nets (ITNs), including long- lasting
       insecticide-treated nets (LLINs)
         • Where to access them
      What the family can do to minimize mosquito breeding/bites
 Prevention of mother-to-child transmission of HIV (PMTCT) if
  applicable:
      Follow local guidelines




                                                                         36
Preventing other endemic diseases/deficiencies:
 Anemia:
    Iron/folate supplements and nutrition counseling
    Presumptive treatment for hookworm infection
 Tetanus:
    Tetanus toxoid immunization
 Vitamin A supplements (per country guidelines):
    Helps prevent night blindness and supports fetal growth
     and development


                                                               37
 Iodine supplements (per country guidelines):
      Iodine deficiency is the main cause of preventable mental
       retardation and brain damage especially in the developing
       fetus and young children. During pregnancy, it also
       increases the chance of spontaneous abortion and
       stillbirth.




                                                              38
 First visit: By 16 weeks or when woman first thinks she is
  pregnant
 Second visit: At 24–28 weeks or at least once in
  2nd trimester
 Third visit: At 32 weeks
 Fourth visit: At 36 weeks
 Other visits: If complication occurs, follow-up or referral is
  needed, woman wants to see provider,
  or provider changes frequency based on findings or local
  policy



                                                                   39
Necessary to:
 Adequately monitor woman’s condition
 Provide continuity of care
 Communicate effectively among health care providers or
  among health care sites (if referred)




                                                       40
 Health facility:
      Establishes and maintains a record for every woman and
       newborn who receives care
 Provider:
      Gathers information, records it, refers to it and updates it
       at the time of each visit
      Ensures that information is accurate and
       clearly written




                                                                      41
Record all information on the ANC chart and
clinic card:
 First ANC visit:
    History
    Physical examination
    Testing as appropriate (e.g., malaria, HIV)
    Care provision, including IPTp, TT, iron/folate
    Health messages discussed, including birth plan, malaria
     prevention (use of ITNs) and danger signs
    Date of next ANC visit


                                                                42
Subsequent ANC visits:
 Interim history
 Targeted physical examination, testing
 Care provision, including IPTp if appropriate
 Health messages (including review/revision of birth plan)
 Counseling/testing for HIV if not done previously or woman
  requests it
 Date of next ANC visit




                                                               43
Chapter Two: Transmission of Malaria




                                       44
 Define malaria and how it is transmitted
 Describe the extent of malaria in Africa in general and in your
  own country
 Compare the effects of malaria in areas of stable and unstable
  transmission
 List the effects of malaria on pregnant women and their
  unborn babies
 Describe the effects of malaria on pregnant women with
  HIV/AIDS



                                                                45
Caused by Plasmodium parasites:
 Plasmodium falciparum:
      The most common type in much of Africa
      Causes the most severe disease
 Plasmodium vivax
 Plasmodium ovale
 Plasmodium malaria




                                                46
 Spread by female Anopheles mosquitoes infected with
  parasites
 Anopheles mosquitoes are usually active
  at night
 Infected mosquito bites a person
 Malaria parasites reproduce in human blood
 Mosquito bites infected person, and goes on to bite and
  infect another person



                                                            47
Anopheles mosquitoes differ from other mosquitoes in the way
their 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.


                                                                  48
   Breeding sites
   Parasites
   Climate
   Population




                     49
Stagnant or slow-flowing bodies of water:
   Small ponds, ditches, pits, and canals
   Swamps, reservoirs, and rice fields
   Pools of water after rain
   Uncovered water tanks
   Streams with slow-flowing water along banks
   Water-filled animal hoof prints
   Objects that collect water: empty tins, containers



                                                         50
 Enough parasites must exist in the human population
  to infect the mosquito
 Temperature must average at least
  18–20 C and humidity stay above 60% for the mosquito
  to survive and the parasite to develop
 The warmer the weather, the faster the development of
  the parasite




                                                      51
 In Africa, Anopheles mosquitoes do not fly further than
  about 1–2 km from their breeding sites
 People must be near or within a short distance from
  these breeding sites in order to be bitten by the infected
  mosquito




                                                           52
 Children under 5 years of age:
      About 70% of malaria deaths
 Pregnant women:
      More likely to become infected compared to non-
       pregnant women
      Women in first or second pregnancies more at risk
 Unborn babies
 Immigrants from low-transmission areas
 HIV-infected persons



                                                           53
 Places where populations are continuously exposed to a fairly
  constant rate of malaria
 Immunity is developed during childhood
 Adolescents and adults are partially immune, although they may
  have a few parasites in their blood
 Immunity is reduced in pregnancy and can be lost when persons
  move out of the high transmission area for a long time
 Children and pregnant women in areas of stable transmission have
  the highest risk of becoming ill
  from malaria



                                                                     54
  Acquired Immunity – high      In absence of HIV infection, 1st
                                 and 2nd pregnancies are at
                                 higher risk
   Asymptomatic infection
                             Placental sequestration
          Anaemia            Altered placental integrity


                             Less nutrient transport



Maternal Morbidity    Low Birth Weight       Higher Infant Mortality



                                                           WHO 2004

                                                                       55
 Population is not exposed to malaria
  very often
 Malaria can sometimes be seasonal in these areas
  (e.g., rainy season)
 Population develops little or no immunity
 Children, adults, pregnant and non-pregnant women are
  equally susceptible




                                                          56
 Malaria in pregnancy can be very serious; complications
  may occur in a short time
 Pregnant women usually present with clinical
  signs/symptoms and sometimes severe malaria, which is
  life-threatening
 Common outcomes of malaria infection in unstable areas:
  Abortions, stillbirths and low birth weight




                                                       57
 Acquired Immunity – low or none


        Clinical Illness

                             All pregnancies are at risk
       Severe Disease
                             Key intervention strategies: disease
                              recognition and case management




Risk to Mother      Risk to Fetus



                                                          WHO 2004

                                                                     58
 Different levels of transmission can occur within a country
  or region
 Within a malarious region (such as in Southern Africa) there
  can also be malaria-free areas
 Factors affecting transmission include temperature, humidity
  and altitude:
      The lifespan of the mosquito is increased with high humidity, while cold
       weather (below 16° C) slows the development of the malaria parasite




                                                                             59
   All pregnant women in malaria-endemic areas are at risk
   Parasites attack and destroy red blood cells
   Malaria causes up to 15% of anemia in pregnancy
   Malaria can cause severe anemia
   In Africa, anemia due to malaria causes up to 10,000 maternal
    deaths per year




                                                                60
 Effects range from mild to severe, depending on the
  level of malaria transmission in a particular setting
  and the pregnant woman’s level of immunity
 The level of immunity depends on
  several factors:
      Intensity of malaria transmission
      Number of previous pregnancies
      Presence of other conditions, such as HIV, which can lower
       immune response during pregnancy




                                                                61
 Reduces a woman’s resistance to malaria
 Increases likelihood of developing clinical malaria
 Causes malaria treatment to be less effective
 Increases risk of malaria-related problems
  in pregnancy
 Increases risk of intrauterine growth restriction
 Increases the risk of preterm birth
 Increases the risk of maternal anemia




                                                        62
 Pregnant women who are co-infected
  with HIV and malaria are at a very high
  risk for anemia and malaria infection of
  the placenta
 Their newborns are therefore more
  likely to have low birth weight and die during infancy




                                                           63
 Protection by ITNs is of high priority
 HIV-infected women with malaria risk should receive either IPTp with SP
  (at least 3 doses or according to country guidelines) or daily
  cotrimoxazole prophylaxis:
       DO NOT give SP to clients on daily cotrimoxazole
 Collaboration of reproductive health programs with HIV and malaria
  control programs should occur to ensure integrated service delivery:
     Counseling and care directed at preventing/treating both malaria
      and HIV
     Appropriate diagnostic tools for both diseases, antiretrovirals, and antimalarials
      available at all levels of health care system




                                                                                      64
 Persons with sickle cell trait have some resistance to
  falciparum malaria, especially in early childhood
 Though they may have protection, it is still important that
  those with sickle cell trait receive ITPp and use ITNs and
  other preventive measures




                                                           65
 During pregnancy, malaria parasites hide in the placenta
 This interferes with transfer of oxygen and nutrients to
  the baby, increasing risk of:
    Spontaneous abortion
    Preterm birth
    Low birth weight—single greatest risk factor for
     death during first month of life
    Stillbirth




                                                             66
 Causes sick individuals to miss work (and wages)
 Causes sick children to miss school
 May cause chronic anemia in children, inhibiting growth and
  intellectual development affecting future productivity
 Uses scarce resources
 Puts strain on financial resources (treatment is more costly than
  prevention)
 Drugs (cost)
 Causes preventable deaths, especially among children and pregnant
  women




                                                                      67
 Malaria is transmitted through
  mosquito bites
 Pregnant women and children are particularly at risk for
  malaria
 Pregnant women infected with malaria may have no
  symptoms
 Women with HIV/AIDS have a higher risk of malaria
  infection



                                                             68
 Malaria can lead to severe anemia, spontaneous
  abortion and low birth weight newborns
 Malaria is preventable
 Malaria is treatable




                                                   69
Chapter Three: Prevention of Malaria




                                       70
 List the three elements of malaria prevention and control
  according to the WHO malaria in pregnancy (MIP) strategy
 List the elements of counseling women about the use of
  insecticide-treated nets (ITNs), intermittent preventive
  treatment during pregnancy (IPTp) and other means of
  malaria prevention
 Describe the use of sulfadoxine-pyrimethamine (SP) for IPTp,
  including dosage, timing and contraindications




                                                             71
 Designed to be appropriate for most African settings
  with guidance on adapting it to local situations
 Based on fact that most sub-Saharan Africans live in areas
  of stable transmission




                                                           72
 Insecticide-treated nets (ITNs)
 Intermittent preventive treatment in pregnancy (IPTp)
 Case management of malaria illness
  and anemia




                                                          73
 Very effective because mosquitoes bite at night when the
  pregnant woman is asleep
 Reduce human contact with
  mosquitoes by:
    Killing them if they land on the net, or
    Repelling them, thus driving them away from where people
     are sleeping




                                                            74
 Prevent physical contact with mosquitoes
 Kill or repel other insects:
      Lice
      Ticks
      Bedbugs




                                             75
Untreated Nets                      Insecticide-Treated Nets
 Provide a high level of            Provide some protection
  protection against malaria          against malaria
 Kill or repel mosquitoes that      Do not kill or repel
  touch the net                       mosquitoes that touch net
 Reduce number of mosquitoes        Do not reduce number of
  in/outside net                      mosquitoes
 Kill other insects such as lice    Do not kill other insects like
  and bedbugs                         lice and bedbugs
 Are safe for pregnant women,       Are safe for pregnant women,
  young children                      young children
  and infants                         and infants


                                                                       76
 Prevent mosquito bites
 Protect against malaria, resulting in less:
      Anemia
      Prematurity and low birth weight
      Risk of maternal and newborn death
 Help people sleep better
 Promote growth and development of fetus and newborn




                                                    77
 Cost less than treating malaria
 Reduce number of sick children and adults (helping
  children grow to be healthy and helping working adults
  remain productive)
 Reduce number of deaths




                                                           78
   General merchandise shops
   Drug shops/pharmacies
   Markets
   Public and private health facilities
   Community health workers
   NGOs, community-based organizations




                                           79
   Hang above bed or sleeping mat
   Tuck under mattress or mat
   Use every night, all year long
   Use for everyone, if possible, but
    give priority to pregnant women, infants and children




                                                            80
ITN tucked under a bed   ITN tucked under a mat



                                                  81
   Handle gently to avoid tears
   Tie net up during day to avoid damage
   Regularly inspect for holes, repair if found
   Re-treat regularly so they stay effective
   Keep away from smoke, fire, direct sunlight




                                                   82
 A pre-treated, ready-to-use net that lasts between
  3 and 5 years (depending on type) and does not require
  re-treatment during that time
 Compared to ITNs, long-lasting nets:
    Usually have a one-time cost
    Do not require additional treatments
    Save money as there are no additional costs associated
     with
     re-treatment, re-treatment campaigns or additional
     insecticides

                                                              83
Based on the assumption that every pregnant woman
living in an area of high malaria transmission has malaria
parasites in her blood or placenta, whether or not she has
symptoms of malaria
  Although a pregnant woman with malaria may have no
symptoms, malaria can still affect her and her unborn child.




                                                             84
WHO 2004:
 All pregnant women should be given at least two doses of
  sulfadoxine-pyrimethamine (SP) during ANC visits
 Give the first dose after quickening and no earlier than 16
  weeks of pregnancy
 Give the 2nd dose at least 1 month (4 weeks) later

       Preventing parasites from attacking the
    placenta helps the fetus develop normally and
                avoid low birth weight


                                                                85
 A single dose is three tablets of sulfadoxine 500 mg +
  pyrimethamine 25 mg
 Health care provider should dispense dose and directly
  observe client taking dose




                                                           86
 Ensure woman is at least 16 weeks pregnant and that
  quickening has occurred
 Inquire about use of SP in last 4 weeks
 Inquire about allergies to SP or other sulfa drugs
  (especially severe rashes)
 Explain what you will do; address the woman’s questions
 Provide cup and clean water




                                                        87
 Directly observe woman swallow three tablets of SP
 Record SP dose on ANC and clinic card
 Advise the woman when to return:
      For her next scheduled visit
      If she has signs of malaria
      If she has other danger signs
 Reinforce the importance of using ITNs




                                                       88
 Do NOT give during first trimester: Be sure quickening
  has occurred and woman is at least 16 weeks pregnant
 Do NOT give to women with reported allergy to SP or
  other sulfa drugs: Ask about sulfa drug allergies before
  giving SP
 Do NOT give to women taking cotrimoxazole or other
  sulfa-containing drugs: Ask about use of these medicines
  before giving SP
 Do not give SP more frequently than monthly: Be sure at
  least 1 month has passed since the last dose of SP

                                                         89
 Main purpose: to lower malaria transmission by reducing
  survival of mosquitoes entering houses or sleeping areas
 An effective intervention when these conditions
  are met:
      A large number of the structures in an area have adequate
       sprayable surfaces
      A majority of the vector population rests indoors
        • Most malaria vectors in Africa are indoor-resting
      The vector is susceptible to the insecticide in use
 Providers should keep updated about any local IRS
  programs in their areas and educate clients accordingly

                                                               90
 Cover doors and windows with wire or nylon mesh/ nets to
  prevent mosquitoes from entering the house
 Avoid going outside after dark; when out in evenings:
    Wear protective clothing covering arms and legs
    Apply chemical mosquito repellent cream on exposed
     skin surfaces
    Use mosquito coils that release smoke; the smoke keeps
     mosquitoes away or kills them when they fly through it
 Spray rooms with insecticide before going to bed:
      Only effective for a few hours, so spray in combination with
       other measures, such as screening doors and windows
 Physically kill mosquitoes indoors by swatting them

                                                                      91
 There are many ways of preventing bites and reducing
  mosquito breeding sites
 Sleep under ITNs; where available, LLINs are preferred as they
  last longer and do not require re-treatment
 Use of IPTp prevents parasites from attacking the placenta
 IPTp helps prevent malaria and reduces the incidence of
  maternal anemia, spontaneous abortions, preterm birth,
  stillbirth and low birth weight
 IRS programs can be effective in reducing number of
  mosquitoes that transmit malaria; they are not a replacement
  for ITNs and IPTp, but support and enhance these efforts


                                                              92
Chapter Four: Diagnosis and Treatment of Malaria




                                                   93
 Explain why self-diagnosis/treatment may lead to treatment
  failure or recurring infection
 Describe the types of diagnostic tests available for malaria and
  their advantages and disadvantages
 Identify other causes of fever during pregnancy
 List the signs and symptoms of uncomplicated and severe
  malaria during pregnancy
 Describe the treatment for uncomplicated malaria
  in pregnancy
 Explain the steps to appropriately refer a pregnant woman
  who has severe malaria


                                                                94
 Usually based on signs and symptoms of the patient,
  clinical history and physical examination and/or
  laboratory confirmation of the malaria parasite, if
  available.
 Prompt and accurate diagnosis leads to:
      Improved differential diagnosis of febrile illness
      Improved management of non-malarial illness
      Effective case management of malaria




                                                            95
 Clients who experience symptoms often rely on self-diagnosis
  and treatment
 Because symptoms are similar to those of several other
  common ailments, mis-diagnosis is possible
 Prevalence of asymptomatic infections makes self-diagnosis
  even more complex
 Client may take the wrong medicines, or the right medicines
  but not in the proper dosage or for the recommended
  duration



                                                             96
 When a client has self-treated and presents with
  malaria symptoms or reports that symptoms have
  worsened/recurred, it is possible that she:
      Has self-treated with the wrong drug or dosage
      Has not completed the treatment
      May have been given incorrect treatment instructions (or did not
       understand instructions)
      Has received a poor-quality or counterfeit drug (this can happen
       even at health facilities)
  Often clients can purchase drugs without a prescription or
 verification of diagnosis at pharmacies, local shops, roadside
           kiosks and other easily accessible locations.

                                                                          97
 Parasitological diagnosis has several major advantages
  including:
      Prevents wastage of drugs through unnecessary treatment,
       resulting in cost savings
      Improves care in parasite-positive patients due to greater
       certainty of malaria diagnosis
      Prevents unnecessary exposure to malaria drugs
      Confirms treatment failure




                                                                98
 The two methods of diagnostic testing for malaria are
  light microscopy and rapid diagnostic testing (RDT).
 Once the woman presents with malaria symptoms and is
  tested, results should be available within a short time
  (< 2 hours). When this is not possible, she must be
  treated on the basis of clinical diagnosis (WHO 2006).




                                                        99
 ―Gold standard‖ for laboratory confirmation of malaria
 Examination of the client’s blood, spread out as a thick or
  thin ―blood smear‖ on a microscopic slide
 Confirms the presence of malaria parasite and therefore
  the diagnosis of malaria
 Also useful when a client has vague symptoms




                                                           100
 Often preferred for routine estimation of parasites
  because organisms are easier to see and count
 Inadequate for detecting low parasite density




                                                        101
 Concentrates the layers of red blood cells on the slide,
  using about 2 to 3 times more blood than the thin film
 Better than the thin film in detecting low levels of
  parasites and reappearance of circulating parasites during
  relapses
 Requires experienced technician because scanning for
  parasites among white blood cells and platelets can be
  difficult




                                                          102
If facilities for blood testing are not available or negative
lab results are received, malaria is considered the most
likely diagnosis in a pregnant woman who has recently been
exposed to mosquito bites and has symptoms of malaria.




                                                           103
 Developed to provide quick, accurate and accessible
  malaria diagnosis without the need for laboratory
  facilities
 Successful RDT programs require:
    A ―cool chain‖ for transport and storage
    Training for providers
    A clear policy on actions to take based on test results




                                                               104
 Diagnosis by health care workers without access to
  microscopy services
 Remote diagnosis for organized workforces in malaria-
  endemic areas:
       e.g., military or mining companies
   Outbreak investigation and malaria prevalence surveys
   Self-diagnosis by trained individuals or groups
   ―After-hours‖ diagnosis in hospital labs or clinics
   Diagnosis in suspected drug-resistant or
    unresponsive malaria


                                                            105
 When using RDTs, remember that a negative result
  does not always exclude malaria because:
    There may be insufficient parasites to register a positive
     result
    The RDT may have been damaged, reducing its sensitivity
    Illness may be caused by another species of malaria
     parasite that the RDT is not designed
     to detect




                                                                  106
 A positive result does not always signify malaria
  illness because:
      The antigen may sometimes be detected after the parasites
       have died (i.e., after treatment) or due to the persistence of
       malaria gametocytes that do not cause illness
      Presence of other substances in the blood may sometimes
       produce a false-positive result
      Presence of parasites does not always signify malaria in
       persons with high immunity as there may be other causes of
       fever



                                                                    107
 Storage between 2° C and 30° C is recommended by
  RDT manufacturers.
 Expiry dates are generally set according to these
  conditions.
 If storage temperatures exceed these recommended
  limits, it is likely that the shelf life of the RDTs will be
  reduced and sensitivity lost before the expiration date.




                                                                 108
 The ―cool chain‖ starts before shipping from the
  manufacturer:
      The shipper or air carrier is notified of temperature storage
       requirements and in clear markings on cartons, documents
 Ground transportation:
      Attention to outside temperatures while the vehicle is moving
       and parked during all stages of delivery
 Storage:
      Storage at any stage before reaching final destination
       should conform to manufacturers’ specifications, which is usually
       ≤30° C


                                                                       109
 For pregnant women, a parasitological diagnosis is
  recommended prior to starting treatment:
      Those who live in or have come from areas of unstable transmission
       are the most likely candidates for severe malaria, which can be life-
       threatening
 As a test of cure in clients who have been treated for malaria
  but still have symptoms:
      If treatment was adequate, clients may have been reinfected or have
       another problem causing similar symptoms
      Counterfeit or poor quality drugs may also be a the cause of
       treatment failure



                                                                               110
 Based on the patient's symptoms and on physical
  findings at examination
 The first symptoms of malaria and physical findings are
  often not specific and are common to other diseases




                                                            111
The most common symptoms of malaria are:
   Fever
   Chills
   Headaches
   Muscle or joint pains




                                           112
 In severe malaria (caused by Plasmodium falciparum),
  clinical findings are more striking and may increase the
  suspicion of malaria.
 Thus, in most cases the early clinical findings in malaria
  are not typical and may need to be confirmed by a
  laboratory test.




                                                               113
   Confusion
   Coma
   Neurologic focal signs
   Severe anemia
   Respiratory difficulties




                               114
 Where the risk of malaria is low, clinical diagnosis of
  uncomplicated malaria should be based on the degree of
  exposure to malaria and a history of fever in the previous
  3 days with no features of other severe diseases.




                                                          115
 In areas where the risk of malaria is high, clinical
  diagnosis should be based on a history of fever in the
  previous 24 hours and/or the presence of anemia.




                                                           116
 Patients who suffer from a fever that does not have any
  obvious cause are presumed to have malaria and are
  treated for that disease, based only on clinical suspicion,
  and without the benefit of laboratory confirmation.




                                                            117
 Dictated by practical considerations
  and allows the treatment of a potentially fatal disease
 Can often lead to incorrect diagnoses and unnecessary
  use of antimalarial drugs:
      Results in additional expenses and increases the risk of
       selecting for drug-resistant parasites
      For children and pregnant women, may be the best option
       when diagnostic testing is not available




                                                              118
 Temperature of 38° C or higher
 May be caused by malaria, but also by:
    Bladder or kidney infection
    Pneumonia
    Typhoid, dengue fever, yellow fever
    Uterine infection
 Careful history and physical exam are required to rule
  out other causes



                                                           119
 Ask about or examine for:
 Type, duration, degree of fever
 Whether she has or has had:
      Chills/rigors
      Episodes of a spiking fever
      Fits/convulsions
 Take the client’s temperature




                                     120
 Signs of severe malaria
 Signs of other infections:
       Chest pain/difficulty breathing
       Foul-smelling watery vaginal discharge
       Tender/painful uterus or abdomen
       Frequency/urgency/pain in urinating/flank pain
   Any fluid leaking from vagina/rupture of membranes
   Headache
   Muscle/joint pain
   Dry or productive cough
   Chest pain and/or difficulty breathing
   Other danger signs

                                                         121
 Uncomplicated:
      Most common
 Severe:
      Life-threatening, can affect brain
      Pregnant women more likely to get severe malaria than
       non-pregnant women




                                                               122
Uncomplicated Malaria         Severe Malaria
                              Signs of uncomplicated malaria PLUS
   Fever                     one or more of the following:
   Shivering/chills/rigors    Confusion/drowsiness/coma
   Headaches                  Fast breathing, breathlessness,
   Muscle/joint pains          dyspnea
   Nausea/vomiting            Vomiting every meal/unable
   False labor pains           to eat
                               Pale inner eyelids, inside of mouth,
                                tongue, and palms
                               Jaundice



                                                                 123
  Refer the woman
     immediately
if you suspect anything
      other than
uncomplicated malaria




                          124
 Despite preventive measures, some pregnant women
  will still become infected with malaria
 The goal of malaria treatment during pregnancy:
  To completely eliminate the infection because any
  amount of parasites in the blood can affect the mother
  or fetus




                                                           125
 Determine whether malaria is uncomplicated or
  severe
 Uncomplicated: Manage according to local protocol
 Severe: Refer immediately to higher level of care;
  consider giving pre-referral treatment or first dose
  of antimalarial if available and provider is familiar with
  its use




                                                               126
 Selection of treatment is based on:
 The gestational age of the pregnancy
 Available drugs:
      Drugs that are approved for malaria treatment in
       accordance with national guidelines




                                                          127
 Plasmodium falciparum has become resistant to single-
  drug therapy, resulting in ineffective treatment and
  increased morbidity and mortality
 WHO now recommends that countries use a
  combination of drugs to fight malaria
 Drug resistance is far less likely with combination therapy
  than with single-drug treatments




                                                           128
Artemisinin-based Combination Therapy (ACT):
 The simultaneous use of drugs that includes a derivative
   of artemisinin along with another anti-malarial drug
 This combination is currently the most effective
   treatment for malaria
 For second and third trimesters, ACTs should be the
   first-line treatment if available and in line with local
   protocol



                                                          129
Non-Artemisinin-based Combination Therapy:
 Sulfadoxine-pyrimethamine with chloroquine (SP + CQ) OR
  Amodiaquine (SP + AQ)
 Due to the high levels of CQ resistance, the SP + CQ
  combination is not recommended
 If more effective ACTs are not available, and both SP and AQ
  are effective (efficacy is greater than 80%), then SP + AQ can
  be used as an interim measure (WHO 2006)
 Clients receiving non-ACTs containing SP for treatment
  of malaria:
      May continue to take IPTp but should wait at least 1 month
       after completing treatment to take next dose of IPTp; refer to
       local guidelines for details


                                                                        130
 Follow local guidelines regarding which combination
  therapies to use (if any) and how to use them
 For uncomplicated malaria in the 1st trimester and for
  severe malaria in any trimester, quinine is the drug of
  choice
 If ACTs are the only effective treatment available, they
  can be used in the first trimester




                                                             131
First trimester:
 Quinine 10 mg salt/kg body weight three times daily +
   clindamycin 10 mg/kg body weight twice daily for 7 days
      If clindamycin is not available, use quinine only
 ACT can be used if it is the only effective treatment available
Second and third trimesters:
 Use the ACT known to be effective in the country/region, OR
 Artesunate + clindamycin (10 mg/kg body weight twice daily)
  for 7 days, OR
 Quinine + clindamycin for 7 days

                                                               132
 Observe client taking anti-malarial drugs
 Advise client to:
    Complete course of drugs
    Return if no improvement in 48 hours
    Consume iron-rich foods
    Use ITNs and other preventive measures
 Follow country guidelines with regard to use of IPTp and
  iron/folate during and after treatment of malaria



                                                        133
 Provide first-line anti-malarial drugs:
      Follow country guidelines
 Manage fever:
      Analgesics, tepid sponging
 Diagnose and treat anemia
 Provide fluids




                                            134
Stabilize and refer the woman immediately
    if she has any symptoms that suggest
                severe malaria.




                                            135
 If a pregnant woman presents with convulsions, it is
  necessary to
  determine whether they are due to
  malaria or eclampsia
 Gather the following information to determine the cause
  of convulsions/fits




                                                       136
 Signs/Symptoms     Severe Malaria   Eclampsia
Recent history of
                         Yes            No
fever, chills
Temperature            > 38° C        < 38° C
                      Diastolic <    Diastolic >
Blood pressure
                      90 mm Hg       90 mm Hg
Enlarged spleen          Yes            No

Jaundice                 Yes            No


                                                   137
 If eclampsia is suspected, stabilize and treat with
  magnesium sulfate per national guidelines and refer
 If severe malaria is suspected, stabilize and treat with
  quinine and diazepam or per country guidelines and refer




                                                        138
 The risk of death from severe malaria is greatest in the
  first 24 hours
 Delaying the start of appropriate antimalarial treatment can
  result in worsening of the woman’s condition or even death
 If possible, start treatment immediately and give pregnant
  women the full dose of parenteral antimalarials before referral
 First trimester:
      Quinine is the drug of choice, but artesunate is also an option
 Second and third trimesters:
    IM or IV artesunate is the first and artemether the second
     option
    Rectal administration of artesunate or artemether may be given
     if injections are not possible
                                                          WHO 2006

                                                                         139
 Explain situation to the client and her family
 Give pre-referral treatment if possible
 Help arrange transport to other facility, if possible
 Accompany the woman during transport, if possible, and be
  sure to have sufficient medication available
 Record information on ANC card and clinic record




                                                              140
 Include the following information in your
  referral note:
      Brief history of client’s condition
      Details of any treatment provided
      Reason for referral
      Any significant findings from history, physical exam or
       lab tests
      Highlights of any important details of current pregnancy
      Copy of client’s ANC record, if possible
      Contact information in case the referral facility or provider has any
       questions



                                                                               141
 Uncomplicated malaria can be easily treated if
  recognized early, but it is very important to finish the
  course of treatment to be effective
 Because severe malaria requires specialized management,
  women with severe malaria should be referred
  immediately to avoid complications and death




                                                        142

								
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