FEVER IN PREGNANCY

Dr. GAYATHRI MD ( General medicine)

Pyrexia

 Temperature > 38 degree C once or > 37.5 degree C

on 2 occasions 2 hours apart.

 In humans, threshold temperature for teratogenicity : 38.9 ºC (102ºF)

 Pregnant women with febrile illness are
more likely to develop critical outcome and die
than the general population.
 The increased severity of infections in
pregnant women is thought to be related to
the normal physiologic changes that occur
during pregnancy.
 There is increase in heart rate and oxygen
consumption, lung capacity decreases, and
there is a shift away from cell-mediated
immunity.
 Clinical manifestations of infections in pregnant women are similar to those in the
general population.
 However, first trimester nausea and vomiting of pregnancy may mask the warning
signs and this may delay the recognition of severe disease.
 During and after second trimester physiological hypervolemia, low haematocrit,
generalized vasodilatation, high pulse rate and low BP may present difficulty in assessing
severity of the disease.
EFFECTS OF FEVER ON PREGNANCY

 IUGR
 Oligohydramnios
 Preterm
 Meconium stained amniotic fluid
 Fetal distress
 Abortion
 Postpartum sepsis
 Fetal Anomalies
Causes Of Fever

 ANTEPARTUM
INFECTIONS
Bacterial
Upper Respiratory Tract Infection (URTI)
Urinary Tract Infection (UTI)
Typhoid
Gastroenteritis
Chorioamnionitis
Protozoal
 Malaria
 Dengue
Viral
 Varicella
 Herpes
 Rubella
 Swine flu (H1N1)
Most Common Causes
 URTI
 UTI
 Septic Abortion
 Chorioamnionitis
 Dengue
 Malaria
 Typhoid
 Puerperal Pyrexia
 URTI

Causative Organisms
 Virus (Rhinovirus, coronavirus, influenza)
 Bacterial (Group B Streptococcus, S.pneumoniae H.influenza)
 Hormonal (Progesterone causes swelling in thee lining of
sinus)
URTI

SYMPTOMS TREATMENT
 Analgesics (Paracetamol)
 Sore throat  Antihistaminics
 Rhinorrhea  Cough Suppressants
 Headache  Increased fluid intake
 Cough  Antibiotics (Azithromycin, Cefixime)
 Fever
 Ear pain
 UTI

ASYMPTOMATIC BACTERIURIA SYMPTOMATIC BACTERIURIA

 10,000 organisms/ml in 2 consecutive urine  100 organisms/ml of urine with accompanying

samples in the absence of symptoms . pyuria (>7 WBCs/ml)
 Occurs in 2.5-11% of pregnant women
ACUTE CYSTITIS

Occurs in 1% of pregnant women

 ACUTE PYELONEPHRITIS :
Occurs in 2% of all pregnancies
 1 st trimester – 2%
 2 nd trimester-- 52%
 3 rd trimester-- 46%
UTI IN PREGNANCY

CAUSES SYMPTOMS

 E.coli- most common  Dysuria

 Klebsiella pneumonia  Fever with chills
 Proteus mirabilis  Suprapubic pain
 Enterobacter  Increased frequency and urgency
 Burning micturition
INVESTIGATIONS

 Blood (CBC, electroytes, BUN, creatinine)

 Urine
 Midstream urine sample clean catch in 1st antenatal visit
 Culture - Standard method for evaluation Positivee culture – 2 consecutive voided specimens with isolation
of the same bacterial strain, at a colony count of 1,00,000 CFU/ml or higher .
TREATMENT
MALARIA

 A protozoal disease caused by the parasite belonging to the genus plasmodium.

 - It spreads through the bite of female anopheles mosquito, blood transfusion and transplacental transfer
from mother to fetuss during pregnancy.
 - The following causative organisms have been recognized ;
P. Vivax , P. Falciparum , P. Malariae and P.Ovale.
 - The predominant causal organism in the South-East Asia region is P . Vivax. Followed by Falciparum .
The later accounting for nearly half mortality
 EFFECTS IN PREGNANCY

 The immuno-compromised state of the mother renders he susceptiblee to Malaria. There is intense parasitisation (30%-
60% of cases) of the placenta which gets aggravated with concurren HIVV and Tuberculosis.
 The intervillous space becomes blocked with macrophage and parasites. And there is diminished pacental blood flow
which is mostly seen with falciparum infection and in the second half of pregnancyy.
 Primigravidae are usually more vulnerable to infection tha multiparaee.
 Pregnant mothers living in endemic areas have high amount of antibody titre and due to passive transferr to
the fetus, congenital Malaria is rare in these areas.
  Pregnant mothers living in non-endemic areas are Particularlyy Vulnerable for Developing severe
complications. Congenital malaria has been observed in such cases.( Less than 5%)
EFFECT ON MOTHER

 The symptoms start after 10 to 12 days of mosquito bite and include a typical attack which is characterized
by 3 stages. The cold, the hot and sweating stage and this episode recur at 24-48 hours interval.
 Intermittent fever with chills and rigors
 Headache, nausea and vomiting
 Malaise , muscle and joint pains
COMPLICATIONS

  Anaemia due to Haemolysis

  Hypoglycemia and dehydration
  Metabolic acidosis
  Jaundice
  Acute renal failure
  Pulmonary oedema and respiratory distress.
  Cerebral Malaria- convulsion and coma
  DIC
EFFECTS ON FETUS

There is abnormal Utero-placental blood flow because of placental parasitaemia (15%-60%) which result in;
 - Midtrimester abortion
 - Preterm Labour
 - Pre-Maturity
 - IUGR
 - Fetal Distress
 - Stillbirth
 - IUFD
 - Poor perinatal outcome and perinatal death
INVESTIGATIONS

 Microscopic (Gold standard)

 Peripheral blood smearThick (sensitive)
 Thin (species identification)
 Antigen detection- Rapid diagnostic tests(RDT)
 MRDT-HRP-2/pLDH
 PCR
 Antibody test
CHOICE OF ANTIMALARIALS IN
PREGNANCY

 All trimesters:
 First line - Chloroquine; Quinine;
 Second line – Artesunate Artemether / Arteether
2nd / 3rd trimester: with caution
  Pyrimethamine + sulphadoxine;
  Mefloquine
Contra indicated:
 Primaquine; Tetracycline; Doxycycline; Halofantrine
DOSE OF ANTIMALARIALS

Chloroquine:
 - 600mg (base) stat, 300mg after 6 hours, 24 hours & 48 hours
Quinine:
 - IV - 20mg/kg infusion over 4 hours, repeat 8 hourly. -
 Maintenance: 10mg/kg over 4 hours, 8 hourly. Follow with oral medication after clinically stable.
 - Oral – 600mg 8hourly ( maximum 2 gm / day) for 7 days.
Artesunate:
 - Oral-100mg BD on day 1, then 50mg BD for 4-6 days (Tota dose 10mg/kg).
 - IM / IV-120mg on Day 1 followed by 60mg daily for 4 days. In severe cases an additional dose of 60mg after 6
hours on Day 1.
Artemether:
 - Six amp (480mg) IM in 5 / 3 days.
Arteether:
 - One amp (150mg) IM / day for3 consecutive days.
Pyrimethamine 25mg+sulphadoxine 500mg tablets:
 - Three tablets single dose.
Mefloquine:
 - 15mg / kg body wt., up to 1 Gm in a single dose. OR
 Tablets of 250mg, 3 tab stat, then 2 tab after 6-8 hours. With body wt >60kg, a third dose of 1 tab after 6-8 hours.
 Don't waste any time
  It is better to admit all cases of P. falciparum malaria.
Assess severity-
  General condition, pallor, jaundice, B.P., temperature, hemoglobin, Parasite count, S.G.P.T., S .bilirubin, S.creatinine,
  Malaria in pregnancy can cause sudden and dramatic
 complications. Therefore, one should always be looking for any complications by regular monitoring.
  Monitor maternal and foetal vital parameters 2 hourly.
 R.B.S. 4-6 hourly; haemoglobin and parasite count 12 hourly; S. creatinine; S. bilirubin and Intake / Output chart daily.
MANAGEMENT OF LABOR

 Anaemia, hypoglycaemia, pulmonary oedema, an secondary infections due to malaria in pregnancy lead to
problems for both the mother and the foetus.
 Severe falciparum malaria in term pregnancy carries a very high mortality.
 Maternal and foetal distress may go unrecognised in these patients. Therefore, careful monitoring of
maternal and foeta parameters is extremely important.
 Pregnant women with severe malaria are better managed in an intensive care unit
DENGUE

Dengue is an arbovirus of the Flavi viridae family and Flavi virus genus.
 • There are four serotypes of the dengue virus (DEN-1, DEN-2, DEN-3, and DEN-4).
 • DV-2 was the predominant serotype circulating in India.
 • Indian isolates of DV-2 were classified into genotype-V. However recently Genotype IV is more
predominant.
 CLINICAL PRESENTATION

Four main characteristic manifestations of dengue illness are :

 (i) Continuous high fever lasting 2-7 days;
 (ii) haemorrhagic tendency as shown by a positive
 tourniquet test, petechiae or epistaxis;
 (iii) thrombocytopoenia (platelet count <100×109/l); and
 (iv) evidence of plasma leakage manifested by hemoconcentration (an increase in haematocrit 20% above average for age, sex
and population), pleural effusion and ascites, etc .
OBSTETRIC COMPLICATIONS

 • Preterm birth
 • Low-birth weight
 • Oligohydramnios
 • Antepartum and postpartum haemorrhage
 • Foetal distress
 • Miscarriages
 • Intrauterine death
 • Neonatal death
DIAGNOSIS

 • NS1 Antigen test, Primary test done for diagnosis.

 • IgM antibody capture ELISA (MACELISA) comes as diagnostic reagent strips.
 • RT–PCR is confirmatory with 95% specificity.
MANAGEMENT

Symptomatic treatment.
 • Intravenous fluid replacement.
 • Broad spectrum antibiotics.
 • Blood transfusion and Blood component therapy.
 • Monitor maternal vital parameters.
 • Monitor serum electrolytes.
 • Monitor blood coagulation profiles.
Management Of Labour In Critical
Phase Of Dengue

 Blood and blood products should be crossmatched and saved in preparation for delivery.
 Trauma or injury should be kept to the minimum if possible.
 It is essential to check for complete removal of the placenta after delivery.
 Transfusion of platelet concentrates should be initiated during or at delivery but not too far ahead of
delivery, as the platelet count is sustained by platelet transfusion for only a few hours during the critical
phase.