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Presenter :Siti Azliza Binti Yaacob030.08.304
INCOMPLETE TREATMENT OF MALARIA AND SPECIAL
CONCERNS IN PREGNANCY
INTRODUCTION• A round the world, the malaria situation is serious and getting
worse.
• Malaria threatens the lives of 40% of the world’s population – over 2 200 million people.
• Each year, there are an estimated 300-500 million clinical cases.
• Malaria is a major public health problem in Indonesia with 6 million clinical cases and 700 deaths each year (Laihad, 2000).
• It has been estimated that malaria during pregnancy is responsible for 5–12% of all low birth weight and 35% of preventable low birth weight and contributes to 75 000 to 200 000 infant deaths each year. (Steketee et al., 2001)
OUTCOMES
• Incomplete of previous treatment.• Recurrency of malaria infection. • The infecting Plasmodium species• The clinical status of the patient • The drug susceptibility of the infecting parasites as
determined by the geographic area.
PATIENT IDENTITY• Name : Mrs.H• Place/born/age :Sukabumi / 5 September 1974 /38 yo• Address :Kp. Sukamarah RT 02/01 Taman Sari Bogor • Religion :Moeslim • Occupation :Housewife• Marital status :Married• Education :SMA• MR Number : 229575• Date of admission : 23 January 2013• Date of examination :1 February 2013• Consultant :Dr. Adi Wijaya Sp PD
HISTORY TAKING
• An autoanamnesis in ward on 1 February 2013 at 20.00 pm.
Chief complaint :
Increasing fatigue since 1 weeks ago before admitted to the hospital.
Additional complaint:
History of present illness:
HISTORY OF ILLNESS
Past medical history• Varicella (+)• Measles (+)• Influenza (+)• Malaria (+)• Gastritis (+)• Appendicitis (+) • *malaria : 4 times already
Family history• Father : HT• Mother : HD + DM
History of habitual:• rarely do the excersice• Smoke (-)• drink coffee and tea (-)• routine medication or herbs.(-)
History of diet:• Present diet : frequent of meal is 2x/day, with ½ portion
and variation of food.• Apetite : loss of apetite.
NUTRITIONAL STATUS
PHYSICAL EXAMINATION
GENERAL PHYSICAL EXAMINATION
LABORATORY TEST • 23 January 2013 (In Emergency Room)
Hematology
Test performed Result Unit Recommended Interpretation
Hemoglobin 9.7 g/dl 13-18
Leukocyte 6.810 /mm3 4000-10000 N
Thrombocyte 73.000 mm3 150000-400000
Hematocrit 29 % 40-54
Serologic
Widal test Negative (-)
Chemistry blood count
SGOT 36 U/l <42 N
SGPT 26 U/l <47 N
BUN 15.0 mg/dl 10-50 N
Creatinine 0.65 mg/dl 0.67-1.36 N
Blood glucose 142 mg/dl <140 N
Laboratory test : 24 January 2013• Test / 12 hours
Hematology 1st
Test performed Result Unit Recommended Interpretation
Hemoglobin 8.7 g/dl 13-18
Leukocyte 7.620 /mm3 4000-10000 N
Thrombocyte 59.000 mm3 150000-400000
Hematocrit 27 % 40-54
Hematology 2nd
Test performed Result Unit Recommended Interpretation
Hemoglobin 8.4 g/dl 13-18
Leukocyte 6.870 /mm3 4000-10000 N
Thrombocyte 52.000 mm3 150000-400000
Hematocrit 26 % 40-54
Laboratory test : 25 January 2013Hematology 1st
Test performed Result Unit Recommended Interpretation
Hemoglobin 7.9 g/dl 13-18
Leukocyte 6.620 /mm3 4000-10000 N
Thrombocyte 64.00 mm3 150000-400000
Hematocrit 24 % 40-54
Hematology 2nd
Test performed Result Unit Recommended Interpretation
Hemoglobin 7.5 g/dl 13-18
Leukocyte 5.690 /mm3 4000-10000 N
Thrombocyte 47.000 mm3 150000-400000
Hematocrit 20 % 40-54
Hematology
Test performed Result Unit Recommended Interpretation
Malaria In a sample was found the
plasmodium Vivax in a
Early trophozoite shape
(ring form)
- - -
Laboratory test: 26 January 2013
Laboratory test: 27 January 2013.
Hematology
Test performed Result Unit Recommended Interpretation
Hemoglobin 7.2 g/dl 13-18
Leukocyte 5.740 /mm3 4000-10000 N
Thrombocyte 53.000 mm3 150000-400000
Hematocrit 22 % 40-54
Hematology
Test performed Result Unit Recommended Interpretation
Hemoglobin 7.4 g/dl 13-18
Leukocyte 4.580 mm3 4000-10000 N
Thrombocyte 64.000 mm3 150000-400000
Hematocrit 22 % 40-54
Laboratory test : 28 January 2013.
Hematology 1st
Test performed Result Unit Recommended Interpretation
Hemoglobin 10.1 g/dl 13-18
Leukocyte 9.910 /mm3 4000-10000 N
Thrombocyte 95.000 mm3 150000-400000
Hematocrit 30 % 40-54
Hematology 2nd
Test performed Result Unit Recommended Interpretation
Hemoglobin 10.2 g/dl 13-18
Leukocyte 8.890 /mm3 4000-10000 N
Thrombocyte 91.000 mm3 150000-400000
Hematocrit 31 % 40-54
Laboratory test : 29 January 2013.
Hematology
Test performed Result Unit Recommended Interpretation
Hemoglobin 10.1 g/dl 13-18
Leukocyte 8.000 /mm3 4000-10000 N
Thrombocyte 123.000 mm3 150000-400000
Hematocrit 30 % 40-54
Chemistry blood count
SGOT 25 U/l <42 N
SGPT 30 U/l <47 N
BUN 41.1 mg/dl 10-50 N
Creatinine 0.51 mg/dl 0.67-1.36
Blood glucose 143 mg/dl <140 N
Electrolyte
Test performed Result Unit Recommended Interpretation
Natrium Na+ 139 136-146 N
Sodium K+ 4.5 3.5-5.0 N
Chloride Cl- 96 95-115 N
HEMOSTASIS
Test performed Result Unit Recommended Interpretation
APTT 26.8 Dtk 25.9-39.5 N
Protrombin time 12.2 Dtk 11.8-14.4 N
Fibrinogen 214 mg/dl 200-400 N
Laboratory test : 30 January 2013
Blood Gas Analysis
Test performed Result Unit Recommended Interpretation
Ph 7.50 7.35-7.45
PCO230 30-50 N
PO274 70-700 N
BE 0.0 -2-+3.0 N
TCO2 23.9 22-29 N
HCO323.0 18-23 N
BE act 0.7 -2.0- +3.0 N
SO297 95-98 N
O2 CT 16.6 15.0-23.0 N
Temp 35.6 N
FlO20.21
Hematology
Test performed Result Unit Interpretation
D-Dimer 6,809.36 ng/mL FEU
Laboratory test : 31 January 2013
Laboratory test : 1 February 2013.
Hematology
Test performed Result Unit Recommended Interpretation
Hemoglobin 10.1 g/dl 13-18
Leukocyte 7.580 /mm3 4000-10000 N
Thrombocyte 217.000 mm3 150000-400000 N
Hematocrit 31 % 40-54
Hematology
Test performed Result Unit Recommended Interpretation
Malaria Positive (+)
Malaria parasite was
found (Plasmodium
Vivax)
- - -
Another examination • ECG
• Normal ECG
RESUMEHISTORY TAKING :
A women, 35 years old was admitted to dr. H. Marzoeki Mahdi Hospital’s ER on 23 January that was complain increasing fatigue since a week before admitted to the hospital. She was had a history of sustained fever a long with shaking chills. The additional complaint was nausea, vomite that contain fluids, headache, loss of appetite, arthralgia and abdominal discomfort. She had instable condition with increasing fatigue, with a sudden onset of flue-like symptoms and sustained recurrent severe attacks with the highest temperature is 39.6°c with shaking chills and sometimes with sweating and arthralgia almost every day. All of this complains have become progressively worst within a last week before admitted to the
hospital.
In the past history patient often frequently travel from Papua to Java since September 2011.She was 3 times diagnosed of malaria in Papua.
• 1st diagnosed on Disember 2011• malaria tertian (P.Vivax and P.Ovale).
• she was in pregnancy, G3 P2 A0 (aborted on February 2012.)
• Admitted in the Hospital Totally recovered• 2nd diagnosed on November 2012
• Admitted in the hospital not sure recovered• 3rd diagnosed on Disember 2012
• She had a 4 weeks gestation in pregnancy. (G4 P2 A1).
• admitted discharged instable condition. • Then she was decided to going back to Java.
PHYSICAL EXAMINATION
General condition : Mrs. H appears alert, oriented and cooperative.
Consciousness: conscious
Vital signs:
Blood pressure :100/70 mmHg
Pulse rate :90x/m
Respiration rate:20x/m
Temperature :39.3°c
Eyes :conjunctival pallor (+/+)
Abdomen: palpitation : tenderness (+).
LABORATORY TEST (23 Jan 2013)• Hemoglobin 9.7g/dl • Thrombocyte 73.000mm3
• Hematocrit 29%
• Anemia • Thrombocytopenia
24 Jan 25 Jan 26 Jan
27 Jan
28 Jan
29 Jan 30 Jan
31 Jan 1 Feb
Hemoglobin (g/dl)
-8.7-8.4
-7.9-7.5
-7.2 -7.4 -10.1-10.2
10.1 - 10.1 -
Hematocrit %
-29-26
-24-20
-22 -22 -30-31
39 - 31 -
Thrombocyte (mm3)
-59.000-52.000
-64.000-47
53.000
64.000
91.000
123.000
- 217.000
-
Microscopic of malaria
P.vivax in a Early trophozoite Shape (ring form)
- - - - - - (+) P.vivax
Chemistry blood count
- - - - N - - -
Electrolyte - - - - N - - -
Hemostasis - - - - N - - -
Blood gas analysis
- - - - - N - -
D-Dimer (ng/ml FEU)
- - - - - 6,809.36
- -
PROBLEMS• Sustained recurrent high fever• Fatigue • Dyspepsia (Nausea,vomit,abdominal
discomfort), Loss of apetite• Arthralgia• Anemia , Thrombositopenia• Recurrent malaria infection. • Pregnancy• Most probably she was infected from the
high transmission area that is Papua New Guinea.
Differential diagnosis :• Relapse of malaria.• Thyphoid fever• Dengue hemorrhagic fever.
THERAPY
Medicamentosa• IVFD RL /8hrs• Oxygen canul 2L/m• Antipyretic : Paracetamol 3x1g
• H2 Blocker : Ranitidine 2x1
• Planning for transfusion of PRC 200cc.• Planning for giving of anti-malaria drugs.
DISCUSSION
RESOLUTION AND THERAPY
In 9th hospitalization On 1 February 2013 patient was ask to discharge by her on dicision and there is no provided any anti-malarial drugs during she was discharged.
Condition :
• Conscious, mild illness.
• Mild headache
• Nausea (+),vomit(-), Apetite is good
• Arthralgia(+).
• BP: 110/60mmHg Pulse: 80x/m
• RR: 20x/m Temp: 36 °c
• Hb : 10.1 g/dl
• Ht : 31%
Throm : 217,000 mm3
DEFINITION AND EPIDEMIOLOGY
• Malaria is caused by infection of red blood cells with protozoan parasites of the genus Plasmodium .
• The four Plasmodium species that infect humans are P. falciparum, P. vivax, P. ovale and P. malariae.
• Increasingly, human infections with the monkey malaria parasite, P. knowlesi, have also been reported from the forested regions of South-East Asia.(1)
• The World Health Organization estimates that malaria caused approximately 655,000 deaths in 2010.
• Most are in young children in sub-Saharan Africa.• Malaria can also cause dangerously low birth weights and
permanent disability
LIFE CYCLE OF MALARIA PARASITES
The incubation period : • Malaria bite until
clinical symptoms appear 7 days (1-2 weeks).
• Symptom due to the cycling parasitemia in the bloodstreams.
• symptoms every 2 to 3 days depending on the type of Plasmodium with which they are infected.
PHATOFISIOLOGY
Blood stage
BODY’S INFLAMMATORY RESPONSE
• Repeated malarial infections lead to some immunity. “learned immunity”
• In fact, in areas where malaria incidence is episodic rather than endemic, patients will present with more severe forms of the disease, as their previously “learned immunity” appears to fade over time.
• It is not surprising, therefore, that malaria-naive and immunocompromised patients are prone to more severe infection.
• This puts pregnant women, children, travelers to endemic regions, and persons with coexisting HIV infection at highest risk for morbidity and mortality secondary to malarial infection.(9)
CLINICAL DISEASE• Caused by the asexual erythrocytic or blood stage parasites. • When the parasite develops in the erythrocyte, substances such as :• hemozoin pigment and other toxic factors accumulate in the infected red
blood cell. • These are dumped into the bloodstream when the infected cells lyse
and release invasive merozoites. • The hemozoin and other toxic factors such as glucose phosphate
isomerase (GPI) stimulate macrophages and other cells to produce cytokines and other soluble factors which act to produce fever and rigors and probably influence other severe pathophysiology associated with malaria.
Pregnancy-malaria and intensity of transmission:
Complication High Transmission Low transmission
Hypoglycemia - ++
Severe Anemia +++ +++
Pulmonary oedema - ++
ARF - ++
Hyperpyrexia + +++
Placental malaria +++ +++
LBW babies +++ +++
Abortions - +++
Congenital malaria - +++
PATENT PARASITEMIA FOR MALARIA CAUSED BY P.VIVAX
When a parasitemia reappears after blood schizonticidal therapy, it may be a relapse from the liver, a reinfection by a mosquito, or a recrudescence originating from asexual blood-stage parasites that survived therapy. The emergence of CQ-resistant P. vivax favors the last possibility.
DIAGNOSIS
• The diagnosis of malaria is based on :
• - clinical suspicion • -the detection of
parasites in the blood ( parasitological or confirmatory diagnosis).
CLINICAL DIAGNOSIS
• Ring-form trophozoites of P. vivax in thin blood smears
• Trophozoite of P. vivax in a thick blood smear
TREATMENT OF MALARIA INFECTION
Treatment should be guided by three main factors :
TREATMENT OF MALARIA CAUSED BY P.VIVAX
Classes and representative antimalarial drugs
Type of drug TargetClinical
application Prophylaxis Licensed drug(s)Experimental
drug(s)
Blood schizontocide
Trophozoite in blood
Treatment of acute malaria
Suppressive Chloroquine, quinine, mefloquine, doxycycline, AV-PG, DH-PP
Tafenoquine, ACTs
Primary tissue schizontocide
Active schizont in liver
None Causal Primaquine Tafenoquine
Hypnozoitocide Dormant hypnozoite in liver
Prevention of relapse
None Primaquine Tafenoquine, elubaquine
Gametocytocide Gametocyte in blood
Prevention of transmission
None Primaquine Tafenoquine, artesunate, artemether
Sporontocide Forms in mosquito including sporozoite
Prevention of transmission
Causal prophylaxis
Primaquine Tafenoquine
• Deterioration of chloroquine (CQ) efficacy between 1945 (green line) and 1995 (red line) among tropical Asian strains of P. vivax relative to natural relapse of the same strains following quinine (QN) therapy (blue line). The suppression of relapse by chloroquine in 1945 is due to lingering levels of drug in blood up to day 35, and the 1995 data suggest not only failure to suppress relapse but also failure to clear primary asexual parasitemia. Data were derived from various sources
• Plot of the cumulative incidence of recurrent parasitemia after chloroquine therapy of vivax malaria in western Indonesian Borneo and eastern Indonesian New Guinea
A regimen recommended for chloroquine-resistant P. vivax infections.
Artemisinin-based combination therapy (ACTs)
• Recent studies have also demonstrated the efficacy of the recommended ACTs in the treatment of vivax malaria.
• ACTs based on either amodiaquine, mefloquine or piperaquine, rather than monotherapy, are the recommended treatment of choice.
• The exception to this is artesunate plus sulfadoxine-pyrimethamine.
• P. vivax has developed resistance to sulfadoxine-pyrimethamine. (study from Afghanistan reported)
TREATMENT DURING PREGNANCY
• Parenteral artesunate is preferred over quinine in the second and third trimesters, because quinine is associated with recurrent hypoglycaemia.
• In the first trimester, the risk of hypoglycaemia is lower and the uncertainties over the safety of the artemisinin derivatives are greater.
• However, weighing these risks against the evidence that artesunate reduces the risk of death from severe malaria, both artesunate and quinine may be considered as options until more evidence becomes available. Treatment must not be delayed; so if only one of the drugs artesunate, artemether or quinine is available, then it should be started immediately
• ????????????
PRIMAQUINE IN PREGNANCY
• For P. vivax or P. ovale infections, primaquine phosphate for radical treatment of hypnozoites should not be given during pregnancy.
• Pregnant patients with P. vivax or P. ovale infections should be maintained on chloroquine prophylaxis for the duration of their pregnancy.
• The chemoprophylactic dose of chloroquine phosphate is 300mg base (=500 mg salt) orally once per week.
• After delivery, pregnant patients with P. vivax or P. ovale infections should be treated with primaquine.
• Pregnant women di agnosed with severe malaria should be treated aggressively with parenteral anti malarial therapy .(10)
Prevention and Control of Malaria during Pregnancy
78
Facts about Malaria and Pregnancy
• 30 million African women are pregnant 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 • 5–14% of low birthweight• 30% of “preventable” low birthweight
Chemoprophylaxis
• Remind women that there is no malaria prophylaxis regimen that is 100% protective.
Chemoprophylaxis for long-term travellers
• Long-term travellers are defined as those travelling through or visiting malaria-endemic countries for over six months.
• Chloroquine and proguanil are the only drugs licensed for long-term use but there effectiveness is reduced in some areas, due to resistance.
• Mefloquine is licensed for up to one year (although it has been used for up to three years without problems).
• Doxycycline can be used for up to two years.
• Malarone® is licensed for up to 28 days but can be safely used for up to three months (and possibly six months or longer).
CLONCLUSIONMalaria in a pregnant woman increases the risk of maternal death, miscarriage, stillbirth and low birth weight with associated risk of neonatal death. Pregnant women should be advised to avoid travelling to areas where malaria transmission occurs. When travel cannot be avoided, it is very important to take effective preventive measures against malaria, even when travelling to areas with transmission only of vivax malaria. Pregnant women should seek medical help immediately if malaria is suspected. There is very limited information on the safety and efficacy of most antimalarials in pregnancy, particularly during the first trimester. However, inadvertent exposure to antima -larials is not an indication for termination of the pregnancy.
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