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Cards (105)

  • Ectopic pregnancy
    Pregnancy in which the fertilized ovum is implanted and develops outside the normal endometrial cavity
  • Nearly 95% of ectopic pregnancies implant in the fallopian tube
  • Risk Factors
    • High Risk: Pelvic inflammatory disease, Tubal corrective surgery, Tubal sterilization, Previous ectopic pregnancy, In utero DES exposure, Intrauterine device, Documented tubal pathology
    • Moderate Risk: Infertility, Previous genital infection, Multiple partners
    • Slight Risk: Previous pelvic or abdominal surgery, Smoking
  • Pathophysiology of ectopic pregnancy
    • Any abnormality in tubal morphology or function may lead to ectopic pregnancy
    • Damage to the tubal mucosa, loss of cilia lining epithelium (infection or surgical, IUCD)
    • Dysfunction in the tubal smooth muscle activity leading to impairment of muscular peristalsis
    • Narrowing of the tubal lumen
    • Peritubular adhesions resulting into kinking and angulation of the tube
    • Following induced abortion
  • Symptoms and signs of ectopic pregnancy vs other conditions
    • Pain: Unilateral cramps and tenderness before rupture vs Epigastric, periumbilical, then right lower quadrant pain; tenderness localizing at McBurney's point vs Usually in both lower quadrant, with or without rebound tenderness
    • Menstruation: Sometime aberration; missed period, spotting vs Unrelated to menses vs Hypermenorrhea or metrorrhagia, or both
    • Temperature and pulse: 37.2-37.8C (99-100F), pulse variable; normal before rapid after rupture vs 37.2-37.8C (99-100F), pulse rapid; 99-100 vs 37.2-40C (99-104F), pulse elevated in proportion to fever
    • Pelvic examination: Unilateral tenderness, especially on movement of cervix, crepitant mass on one side or in cul-de-sac vs No masses, rectal tenderness high on right side vs Bilateral tenderness on movement of cervix, masses only when pyosalpinx or hydrosalpinx is present
  • Laboratory findings
    Ectopic pregnancy: White cell count 15,000/μL, red cell count strikingly low if blood loss large, sedimentation rate slightly elevated
    Threatened abortion: Negative β-hCG, white cell count 10,000-18,000/μL (rarely normal), red cell count normal, sedimentation rate slightly elevated
    Acute PID/salpingitis: Negative β-hCG, white cell count 15,000-30,000/μL, red cell count normal, sedimentation rate markedly elevated
    Ovarian cyst: Negative β-hCG, white cell count normal to 10,000/μL, red cell count normal, sedimentation rate normal
    Spontaneous abortion: White cell count 15,000/μL, red cell count normal, sedimentation rate slightly to moderately elevated. Induced abortion: White cell count to 30,000/μL, red cell count normal, sedimentation rate slightly to moderately elevated
  • Abdominal pregnancy
    Implantation and development of the fetus in the abdominal cavity
    Primary - normal tubes and ovaries, without evidence of trauma, no utero-placenta fistula, attachment of the conceptus is purely on peritoneal surface
    Secondary - more common, occurs when the conceptus is aborted from the tube to the peritoneal cavity
    More frequent in older women of low parity
  • Clinical presentation of abdominal pregnancy
    Common sites of attachment: spleen, liver, omentum, uterine surface
    Predominant presenting symptoms are those related to hemorrhage
    Bizarre pregnancy symptoms, unusual gastrointestinal symptoms, exaggerated fetal movements which are painful, easy palpation of the fetal parts and movement, pregnancy described by a multipara as "different", false labour near term, high-lying fetus in abnormal presentation, displacement of a firm, long cervix
  • Investigations for abdominal pregnancy
    1. ray findings: The fetus rides high in the abdomen over the maternal spine in the lateral view
    Ultrasonography is useful in making a diagnosis of abdominal pregnancy and also in following regression in the size of retained placenta
  • Malaria is endemic throughout most of the tropics; ongoing transmission occurs in 85 countries and territories
  • Malaria accounts for 7.8% of the global disease burden
  • Over 95% of the burden of malaria occurs in the African region
  • The greatest mortality due to malaria is associated with P. falciparum infection worldwide
  • Malaria parasites
    • P. vivax
    • P. malariae
    • P. ovale
    • P. knowlesi
    • P. simium
  • Malaria transmission
    Most frequently via the bite of a female Anopheles spp mosquito, mainly between dusk and dawn
  • Rare mechanisms for malaria transmission
    • Congenitally acquired disease
    • Blood transfusion
    • Sharing of contaminated needles
    • Organ transplantation
    • Nosocomial transmission
  • High-risk groups for malaria
    • Travelers or migrants coming from areas with little or no malaria transmission
    • Children under 5 years of age
    • People Living with HIV (PLHIV)
    • Pregnant women
  • A higher prevalence of malaria has been observed among younger pregnant women, women in their first or second pregnancies, women in the first and second trimesters, and HIV-infected women
  • Reasons why pregnant women are more susceptible to malaria than non-pregnant women
    • Increased susceptibility to mosquito bites
    • Production of more exhaled air
    • Increased body temperature
    • Changes in behaviour esp. at night (increased frequency of urination)
    • Ability of infected erythrocytes to adhere to and sequester in the intervillous space
    • Immunological and hormonal changes related to pregnancy
  • Pregnant women are particularly vulnerable to P. falciparum infection because red cells infected with the parasite can sequester in the placenta, and thereby cause adverse fetal effects
  • If anti-malarial drugs do not achieve therapeutic levels in the placenta, parasites sequestered there may be released intermittently into the peripheral blood and cause recurrent maternal infection
  • Clinical manifestations of UNCOMPLICATED malaria in pregnancy
    • Headache
    • Fatigue/Malaise/Body weakness
    • Abdominal pain/discomfort
    • Muscle and joint aches
    • Fever (≥37.5°C)
    • Chills/rigors
    • Perspiration (Sweating)
    • Loss of appetite
    • Nausea
    • Vomiting
    • Diarrhea
  • Clinical manifestations of SEVERE malaria in pregnancy
    • Prostration/extreme weakness
    • Impaired consciousness
    • Change of behaviour
    • Convulsions
    • Coma
    • Respiratory distress
    • Jaundice
    • Hyperparasitemia
    • Circulatory collapse/shock
    • Vomiting everything
    • Inability to drink or breast feed
    • Bleeding tendency
    • Severe anaemia (NC/NC with absent reticulocytes)
    • Metabolic acidosis
    • Hypoglycemia
    • Acute kidney injury
  • Differential diagnosis of malaria in pregnancy
    • UTI in pregnancy
    • Meningitis
    • Gastroenteritis
    • HIV infection
    • Hepatitis
    • Typhoid fever
    • Dengue fever
    • Bacteremia/Sepsis
    • Yellow fever etc.
  • Investigations for malaria in pregnancy
    • Microscopy (Blood Slide for Malaria Parasites/BS for MPS)
    • Malaria Rapid Diagnostic Test (mRDT)
    • Full Blood Picture
    • Renal function tests (Serum creatinine and Urea)
    • Serum electrolytes
    • Random Blood Glucose
    • Arterial Blood Gases
    • Chest X-ray
    • Urinalysis (r/o UTI)
    • Lumbar Puncture (r/o meningitis)
  • Artemether/Lumefantrine (ALu)
    The recommended treatment of choice of a confirmed uncomplicated malaria to pregnant women in all trimesters
  • Treatment of Uncomplicated Malaria in Pregnancy
    1. Artemether+Lumefantrine (FDC) (PO) 20mg+120mg
    2. First dose given as DOT, second dose after 8 hours, subsequent doses 12hourly for 3 days
    3. Alternative: Dihydroartemisinin-Piperaquine
  • Treatment of Severe Malaria in Pregnancy
    1. Rapid assessment of airway, breathing, circulation, coma, convulsion, dehydration status
    2. Parenteral Artesunate is the drug of choice, given stat, then at 12 and 24 hours for minimum 3 injections
    3. Complete artesunate treatment by giving a complete course (3 days) of artemether-lumefantrine (ALu)
    4. Alternative: Injectable Artemether if Artesunate is contraindicated
  • Maternal complications of malaria in pregnancy
    • Coma (cerebral malaria)
    • Convulsions
    • Hypoglycemia
    • Severe anaemia
    • Acute pulmonary oedema
    • Acute renal failure
    • Shock
    • Preterm labour
  • Fetal complications of malaria in pregnancy
    • Abortion
    • Low birth weight
    • Prematurity
    • Intrauterine foetal growth restriction
    • Intrauterine foetal death/Stillbirth
    • Congenital malaria infection
  • Vector control measures for malaria prevention in pregnancy
    • Use of insecticide-treated bed nets (ITNs)
    • Indoor residual spraying
    • Eliminate/Reduce breeding sites of Anopheles mosquitoes
    • Cover doors and windows with wire or nylon mesh/nets
    • Wear protective clothing
    • Use chemical mosquito repellent cream
    • Use mosquito coils or spray
  • Intermittent Preventive Treatment in pregnancy with sulPHadoxine‐pyrimethamine (IPTp-SP)

    Provides a minimum of three doses to prevent the adverse consequences of malaria on maternal and fetal outcomes
  • IPTp-SP administration
    1st dose in 2nd trimester, subsequent doses 4 weeks apart, last dose after 36 weeks
  • Malaria in Pregnancy is a major public health problem in sub-Saharan Africa