Infectious disease in pregnancy

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Pyrexia in pregnancy

41.4 can lead to convulsion

42.2 irreversible brain damage can occur
45.5 is probably incompatible with life

Sepsis

- Severe sepsis with acute organ dysfunction has a mortality rate of 20-40% which
increases to 60% with septic shock.
- Group A strep and e.coli are the most common organisms in women dying from
sepsis.
- It is advised that when GAS is detected in the peripartum, neonatologist is informed
and prophylactic abx given to baby.

Tasks to be performed within the first six hours of the identification of severe sepsis:

Obtain blood cultures prior to antibiotic administration

Administer broad-spectrum antibiotic within one hour of recognition of severe sepsis
Measure serum lactate
In the event of hypotension and/or a serum lactate >4mmol/l deliver an initial minimum
20ml/kg of crystalloid or an equivalent.
Apply vasopressors for hypotension that is not responding to initial fluid resuscitation to
maintain mean arterial pressure (MAP) >65mmHg
In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or
lactate >4mmol/l
a. Achieve a central venous pressure (CVP) of ≥8mmHg
b. Achieve a central venous oxygen saturation (ScvO2) ≥ 70% or mixed venous oxygen
saturation (ScvO2) ≥ 65%

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IVIG- recommended for severe invasive streptococcal or staphylococcal infection if other
therapies have failed.

- If preterm delivery is indicated in severe sepsis- caution should be given to the use of
antenatal corticosteroids for fetal lung maturity
- Epidural/spinal anaesthetic should be avoided in women with sepsis and a general
anaesthetic will usually be required for caesarean section

Septic shock

Criteria:
1. Hypotension requiring vasopressor therapy to maintain mean BP 65mmHg or greater
after adequate fluid resuscitation.
2. A serum lactate of 2 mmol/l or more after adequate fluid resus.

Septic shock phases table

Stage Clinical Haemodynamic

Early Warm skin, flushing Decreased peripheral resistance

Temperature instability Peripheral vasodilation
Tachypnoea Hypotension
Altered mental status Increased cardiac output

Late Cool, clammy skin

Peripheral vasoconstiction
Oliguria
Decreased cardiac output
Cyanosis Increased peripheral resistance
Adult respiratory distress syndrome

Secondar Obtundation
y Anuria Peripheral vasodilation
Hypoglycaemia Decreased cardiac output
Disseminated intravascular coagulation Decreased peripheral resistance
Myocardial failure

Chorioamnionitis

- Occurs in 1% of live births

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 - Incidence in PPROM is 30%
- 96% of cases are due to ascending infection, the remainder arise from
haematogenous dissemination due to maternal septicaemia.
- Usually polymicrobial
- The most coomon causes are mycoplasmas, E.coli, GBS and anaerobic bacteria.

Sexually transmitted infections

Sexually transmitted infections table

STI Aetiology Implications in pregnancy Diagnostic test

Miscarriage, stillbirth, FGR,

Syphilis Treponema pallidum neonatal death or disease or Serological tests
latent infection

Neonatal herpes; localised

Direct detection by
Herpes Herpes simplex virus neurological or disseminated
PCR
infection

Neonatal infection;
conjunctivitis, pneumonia,
chlamydial ophthalmia
Chlamydia C. trachomatis NAATs and POCTs
Controversial: preterm
rupture of membranes,
preterm delivery and
neonatal death

Preterm birth and premature

rupture of membranes
Gonococcu Neisseria Culture tests on
Neonatal infection;
s gonorrhoeae selective media
Gonococcal ophthalmia
neonatorum and (rarely)
neonatal sepsis

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 Sexually transmitted infections table

STI Aetiology Implications in pregnancy Diagnostic test

Serological tests for

HIV antibodies and
Human the p24 antigen
HIV immunodeficiency Vertical transmission of HIV
virus Consideration for
rapid POCTs in
certain circumstances

Syphilis

- Caused by infection with the spirochete bacterium Treponema pallidum

- The number of cases is on the rise in the UK, partly due to increased immigration
- Approx. 1/3rd of sexual contacts of infectious syphilis will develop the disease.
- Transmission is through direct contact with infectious lesion or vertical transmission
during pregnancy. (T. pallidum crosses the placenta)

- Syphilis can be transmitted at any stage of pregnancy and may result in miscarriage,
preterm birth, stillbirth and congenital syphilis
- The level of risk ranges from 70-100% in preimary syphilis, 40% in early latent
syphilis and 10% in late latent syphilis.
- Untreated syphilis in pregnancy has fetal loss rate of approx. 50%
- Most infected neonates are asymptomatic at birth
- Neonatal disease may manifest as rhinitis, a diffuse maculopapular rash,
desquamative rash with extensive sloughing of the epithelium, particularly on the
palms and soles, splenomegaly, anaemia, thrombocytopenia and jaundice.
- If clinical signs are present at birth 50% will die in the neonatal period.

Herpes

- Double stranded DNA virus

- Neonatal herpes is rare but the consequences can be severe

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 - Neonatal HSV infection usually occurs when there is primary maternal HSV infection
in the third trimester, particularly within 6 weeks of delivery, so that the baby id
delivered before protective maternal antibodies.
- Signs of herpes tend to develop within 3-7 days of skin-to-skin contact with an
infected person.
- The first outbreak of herpes is usually the most painful and may last longer that later
outbreaks

Neonatal herpes
50% due to HSV 1 and 50% due to HSV 2

Classified into three subgroups:

1) Disease localised to skin, eye and/or mouth
2) Local CNS disease (encephalitis alone)
3) Disseminated infection with multiple organ involvement

Disease localised to skin, eye and/or mouth – have the best prognosis and represent
approx. 30% of neonatal herpes infections. With appropriate ARV treatment, neurological
and/or ocular morbidity is less than 2%

Local CNS disease and disseminated infection-

- 70% of infants with neonatal herpes have disseminated and/or CNS infection and
approx 60% will present wihthout eye, skin or mouth infection.
- These infants often present late (between 10 days and 4 weeks old).
- With ARV treatment, mortality is around 6% and neurological morbidity (ehich may
be lifelong) is 70%.
- Disseminated disease carried the worst prognosis; with appropriate antiretroviral
treatment, mortality is around 30% and 17% will have long term neurological
sequelae.

Neonatal infection occurs as a result of an infection at the time of birth; in contrast,

congenital herpes is extremely rare and occurs by transfer of infection in utero.

Management of pregnant women with first episode of genital herpes

First or second trimester acquisition (until 27+6)

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 - There is no evidence of increased risk of miscarriage
- Viral PCR will confirm diagnosis
- Paracetamol and topical lidocaine 2% gel can be offered as symptomatic relief
- Treatment should not be delayed.
- Aciclovir 400mg TDS for 5 days
- Following 1st or 2nd trimester acquisition, daily suppressive aciclovir 400mg TDS from
36 weeks reduces HSV lesions at term and hence need for delivery by LUSCS.
- HSV acquired in pregnancy is not associated with congenital abnormalities.

Third trimester acquisition (from 28 weeks to term)

- There is some evidence of increased perinatal morbidity (preterm labour and low
birthweight) together with stillbirth however data is conflicting.
- Treatment should not be delayed
- ACICLOVIR 4OOmg TDS for 5 days.
- In the third trimester treatment will continue with daily suppressive aciclovir
400mg TDS until delivery.
- Caesarean section should be the recommended mode of delivery for women with
the first episode of herpes in the 3rd trimester, particularly if symptoms within 6
weeks of birth when risk of neonatal transmission is 41%.

- If it is unclear if this is primary or secondary episode then do HSV antibody testing fro
IgG to HSV1 and HSV2. The presence of antibodies of the same type as the HSV
isolated from genital swab would confirm episode as being recurrent and ELUSCS
would not be recommend.

Recurrent genital herpes

- women with recurrent genital herpes should be informed that the risk of neonatal
herpes is low (0-3% for vaginal delivery)
- the majority of recurrent episodes are short lasting and resolve within 7-10 days
without antiviral treatment. Supportive treatment measures using saline bathing and
analgesia will usually suffice
- vaginal delivery should be anticipated in the absence of other obstetric indications.
- Daily suppressive aciclovir 400mg TDS should be considered from 36 weeks.

- If a women has recurrent lesions at the time of delivery risk of transmission 1-3%
must be weighed against risk of section and decision made by woman.

- If SRM at term most clinicians will expidite delivery although there is no specific
guidance for this.

- For primary infection and PPROM – MDT discussion needed. If expectant

management give 5mg/kg aciclovir every 8 hours.

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 - Recurrent genital herpes and PPROM- can be managed expectantly with 400mg
aciclovir TDS and in line with PPROM guideline.

Chlamydia infection

- Between 50-60% of babies born to mothers with chlamydia infection will become
colonised
- 20-50% will develop conjunctivitis
- 10-20% will develop a characteristic pneumonia
- its is suggested there is association between chlamydia infection in pregnancy and
PPROM, preterm delivery and neonatal death but this is unclear.
- Treatment is required to prevent vertical transmission

Treatment of chlamydia
- Azithromycin 1g PO as single dose, followed by 500mg OD for 2 days
Or
- Erythromycin 500mg QDS for 7 days
Or
- Erythromycin 500mg BD for 14 days
Or
- Amoxicillin 500mg TDS for 7 days

Doxycycline and ofloxacin are contraindicated in pregnancy

Test of cure is recommended in pregnancy, should be performed 3 weeks after abx

treatment completed.

Gonorrhea

- Can increase risk of PPROM and preterm birth.

- If untreated, infection may lead to DGI, which can result in endocarditis and
meningitis.
- Gonococcal infection may increase the risk of concomitant cervical chlamydial
infections
- Vertical transmission to the newborn may lead to conjunctivitis and rarely neonatal
sepsis.
- Unless preventative measures are taken, 28% of infants born to women with
gonorrhoea will develop gonococcal opthalmia neonatorum

Management of gonorrhoea in pregnancy

- Ceftriaxone 1g IM as a single dose
- Alternatives- azithromycin 2g PO as single dose

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HIV in pregnancy

- HIV targets lymphocytes, which express CD4 molecules on their surface.

- When the virus is active is results in the destruction of CD4 lymphocytes and
progressive immunosuppression
- Vertical transmission in areas of Africa who breastfeed is as high as 25-40%.
- In the UK, the risk of vertical transmission for women who take HAART and avoid
breastfeeding is 1%

Diagnosis
- 95% of pregnant women in UK are screened for HIV.
- Blood tests test for both HIV antitibodies and p24 antigen.
- HIV antibodies may take up to 3 months to appear following infection with HIV
(period known as seroconversion)
- The p24 antigen is detectable within 1 month of infection
- A confirmatory HIV test on a second sample is always performed.

Treatment
- Treatment with a combination of three or more antiretroviral drugs is known as
highly active anti-retroviral therapy (HAART)
- Over 95% of pregnant women with HIV in UK take some form of HAART
- HAART is initiated in those with symptomatic HIV infection and/or a CD4 count of
less than 350
- HAART should be started between 20 and 28 weeks of gestation and discontinued at
delivery.

Medications used in pregnancy:

- Tenofovir
- Abacavir and embtricitabine
- Lamivudine
- Atazanavir
- Efavirenz
- Rilpivirine
- Raltegravir
- Daunavir
- Dolutegravir

Untreated women presenting in labour should receive stat dose of nevirapine 200mg,
oral lamuvidine 150mg BD, raltegravir 400mg bd and IV zidovudine for the duration or
labour

Delivery

Elective caesarean section at 38 weeks for women:

- Taking HAART with a plasma viral load >50 copies
- Taking ZDV monotherapy

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 - With HCV co-infection

Planned vaginal delivery for women:

- Taking HAART with a plasma viral load <50 copies/ml

Intrapartum care in HIV

Women with a plasma viral load <50 HIV RNA copies at 36 weeks:
- Vaginal delivery is recommended
- There is scant evidence to support water births
- In the event of pre labour ROM, offer immediate augmentation and induction of
labour with an aim to deliver within 24 hours.
- In the event of PPROM at >34 weeks, GBS prophylaxis should be given

Women with a plasma viral load of >400 HIV RNA copies at 36 weeks:
- Planned CS is recommended
- Timing of CS should be 38-39 weeks to prevent risk of vertical transmission
- In the event of pre labour SRM, immediate CS is recommended

For women with SROM and plasma viral load 50-399 HIV RNA copies
- Immediate CS is recommended

When PPROM <34 weeks

- IM steroids according to local guideline
- If HIV viral load not controlled, this should be optimised
- MDT discussion re: timing of delivery

IV zidovudine is recommended for:

- Women with a viral load >1000 HIV RNA copies presenting with SROM or in labour or
planned CS
- Untreated women presenting with SROM/labour with unknown viral load

Postnatal care

Infant feeding:
Women are encouraged to bottle feed to minimise the risk of HIV transmission. If a women
chooses to breastfeed, then mother and infant should have a monthly review in clinic for
HIV RNA load testing during and 2 months after stopping breastfeeding.

Contraception:
Intrauterine contraception (Mirena/Copper coil), POC, combined hormonal contraception
are safe to use in women with HIV.
Viral infections in pregnancy

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Viral infections table

Viral
Aetiology Implications in pregnancy Diagnostic test
infection

Sensorineural deafness,
diabetes mellitus, thyroid
Serological tests for IgG-
Rubella Rubella virus disease, growth hormone
specific antibodies
deficiency, vascular
effects, encephalitis

Human Serological tests for

Parvovirus Fetal anaemia
parvovirus B19 specific antibodies

Miscarriage, congenital Serological tests for

CMV Cytomegalovirus
CMV infection specific antibodies

Severe maternal morbidity

Varicella-zoster Serological tests for
Varicella and mortality, fetal
virus specific antibodies
varicella syndrome

Hepatitis B/C Serological tests for

Hepatitis Neonatal hepatitis
virus specific antibodies

Severe maternal morbidity

Influenza virus (A, Serological tests for
Influenza and mortality, preterm
B and C) specific antibodies
labour, low birthweight

Probable association with PCR testing of blood during

Zika Zika virus
congenital microcephaly the symptomatic period

COVID-19 Sarbecovirus Currently no data Detection of IgG and IgM

(SARS-COV- suggesting an increased antibodies to SARS-CoV-2
2) risk of miscarriage or early in human whole
pregnancy loss in relation

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 Viral infections table

Viral
Aetiology Implications in pregnancy Diagnostic test
infection

to COVID-19 blood, serum and plasma. 

Rubella
- Incubation period 14-21 days
- If a patient presents with a rash , investigations for acute rubella or parvovirus B!
( infection should be undertaken, irrespective of vaccination history (rubella) or prior
antibody testing (rubella or parvovirus)

Ultrasound findings of rubella

Marker Description

Fetal growth A prominent feature in cases of rubella, CMV and syphilis

restriction (see section on syphilis for more detail)

Cardiothoracic lesions Clinical features of congenital rubella syndrome include several

cardiac defects, primarily pulmonary valvular stenosis and
ventricular septal defect

Lesions of the Most congenital infections show abnormal features of the liver,
gastrointestinal tract spleen and bowel on ultrasound
The most common sonographically detected markers are
peritoneal hyperechogenicities and/or hyperechogenic fetal bowel

Lesions of the head Eye defects are observed with congenital rubella (although this is
less common now, with the use if rubella vaccine in childhood)

Risks of rubella in pregnancy

Risk of CRS

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<10 weeks: 80-90%
11-16 weeks: 10-20%
16-20 weeks: 20% (deafness)
>20 weeks: <1%

- The risk to the fetus in the first 16 weeks is substantial.

- Rubella before conception or after 20 weeks carries no documented risk.
- Primary rubella contracted between 16 and 20 weeks of gestation carries a minimal
risk of deafness only.
- Rubella poses a particular problem because the organism persists in the host and
continues to replicate and may cause tissue destruction after birth
The possible long-term outcomes of infections acquired prenatally are:
- Sensorineural deafness
- Diabetes mellitus
- Thyroid disease
- Growth hormone deficiency
- Vascular effects
- Encephalitis

Parvovirus

- Incubation period 4-20 days

- It is thought that 60% of adults in the UK have been infected with parvovirus and are
therefore immune.
- Infection in pregnancy thought to be 1 in 400
- The main effect of parvovirus is fetal anaemia.
- The most common presentation of fetal infections is by non-immune hydrops,
diagnosed on an ultrasound scan.
- Women should be referred to fetal medicine for regular scans following infection.
- Hydrops can develop up to 12 weeks, and possibly 18 weeks, after maternal infection
- Therefore a detailed USS should be undertaken for at least 12 weeks from the date
of exposure, or proven maternal infection,

Maternal serum alpha-

Congenital malformation Fetal haematology
fetoprotein

Unlike CMV and – less commonly –
syphilis, PVB19 is unlikely to be
associated with congenital
malformations, although some
parvoviruses are known to cause
characteristic congenital anomalies
Fetal blood sampling In the 1980s, some studies
by cordocentesis and observed an elevation in
B19 DNA testing by maternal serum alpha-
PCR should be carried fetoprotein (α-FP) in women
with PVB19 and it was
suggested that this could be

13
 Maternal serum alpha-
Congenital malformation Fetal haematology
fetoprotein

in animals used as a diagnostic tool

A few cases of congenital

anomalies in parvovirus-infected
human fetuses have been reported
in the literature, but the
association between these
anomalies and the viral infection out More recent reports describe
have not been proven cases where the maternal α-
FP was normal despite severe
fetal infection
Unlike most viruses, human PVB19
cannot be cultured in traditional
tissue culture cell lines and
parvovirus culture is therefore
impractical in the diagnostic setting

- More recently, viral DNA amplifications using PCR in maternal and fetal serum or
tissues and in the placenta, has proven to be the most sensitive and accurate
diagnostic.

Effects of parvovirus

- The main effect of parvovirus is fetal anaemia

- The risk of transmission is increased between 9-20 weeks gestation.
- Transplacental transmission risk is about 30% depending on gestation
- Infection in the first 20 weeks of pregnancy can lead to IUD and hydrops fetalis.
- Overall fetal loss rate for maternal infection is 5-10%
- Current evidence suggests that parvovirus infection in pregnancy is not associated
with long term adverse effects in the infant.
- Most infants treated with intrauterine transfusion because of parvovirus related
anaemia have been found to have normal neonatal outcomes .

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Cytomegalovirus (CMV)

- Herpes virus, incubation period 8 weeks

- CMV is the most common cause of congenital viral infection, occurring in approx. 1%
of newborns.
- Primary CMV infection occurs during pregnancy in 2% of women, with intrauterine
transmission in approx. 40% of cases.
- In almost all cases, the virus is acquired asymptomatically
- Testing for IgG can determine past infection

Diagnosis
- CMV infection is asymptomatic in 90% of individuals
- When signs are present they are rather non-specific: arthralgia, fatigue, headache,
myalgia, pharyngitis, rhinitis

The rate of fetal transmission appears to increase with advancing gestation:

1st trimester- 34.8%

2nd trimester- 42%
3rd trimester- 58.6%

Primary infection in pregnancy may lead to miscarriage

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 approx. 10% of these neonates will have clinical manifestations of CMV

75% of babies will be unaffected

10% will have severe multiple abnormalities
15% will develop sensorineural deafness which can present later in childhood

Congenital CMV
- FGR
- Hepatosplenomegaly
- Thrombocytopenic purpura
- Jaundice
- Microcephaly
- Chorioretinitis

The outlook for such children is poor:

- The vast majority suffer mental impairment and/or hearing loss
- Approx. 15% of children develop symptoms later, with the brain and inner ear being
the major target organs

Treatment
- There is currently no treatment for congenital CMV and no CMV virus
- If infection is confirmed, parents are left with difficult decision re: termination
- If CMV is confirmed, fetus should be monitored with 3-4 weekly USS.

Zika virus

- Transmitted by Aedes mosquitoes.

- Not contagious and does not spread from person to person
- South and central America, caribbean and pacific
- Most people are asymptomatic
- Some people get mild, short lived illness for 2-7 days: fever, rash, conjunctivitis,
myalgia, arthralgia/arthritis, headache, retroorbital pain and/or pruritus.
- Diagnosed by PCR

Fetal implications

- Zika virus crosses the placenta barrier

- Likely association with microcephaly
- Cannot be transmitted via breastfeeding

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Period of time to abstain/use condoms to avoid conception if travelling to ZIKA country:

Male – 3 months
Female- 2 months
Both partners- 3 months

Covid 19

- Associated with 17% risk of iatrogenic preterm birth

- Increased risk of CS 59%
- Approx. 1 in 5 require general anaesthesia- 2/3rd of these to intubate for maternal
respiratory compromise.
- There is no current evidence to implicated COVID 19 in any adverse fetal or neonatal
outcomes.

Bacterial infections

Bacterial infections table

Bacterial
Aetiology Implications in pregnancy Diagnostic test
infection

Group A Life-threatening sepsis in Bacteriological

GAS
streptococcus pregnancy or the puerperium specimens

Group B
Early-onset neonatal infection, Vaginal swab for
streptococcus
GBS which results in sepsis, bacteriological
or Streptococcus
pneumonia and meningitis screening
agalactiae

Blood culture,
Miscarriage, preterm labour
Listeria rectovaginal
Listeria and IUD. Congenital infection
monocytogenes culture and Gram
(often fatal)
staining

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 Bacterial infections table

Bacterial
Aetiology Implications in pregnancy Diagnostic test
infection

Breast abscesses (if

Mastitis Usually skin flora Usually clinical
inadequately treated)

Meningitis, but it is also a rare

commensal of the vaginal flora
and can cause
Haemophilus Haemophili Culture or ELISA
chorioamnionitis,
endometritis and neonatal
infection

Group B strep

- Streptococcus agalactiae
- Found in the genital tract of 10-20% of pregnant women
- Normal commensal of the female genital tract and can be found in bowel flora in 20-
40% of adults
- Early onset GBS is infection appearing within 7 days of a baby being born, although
90% of cases occur within 24 hrs.
- Infection predominantly occurs after a baby is exposed to maternal GBS during
childbirth
- 1 in 170000 babies die each year from GBS

The risk of the infant contracting the disease is increased if the mother has one of more of
the following risk factors:

- Previous infant with early-onset GBS disease

- BGS bacteriurea in current pregnancy or GBS colonisation at term
- PROM (>18hrs)
- Preterm labour at <37 weeks
- Maternal temp >38

- Women with a baby with previous GBS have a 50% chance of having in fection in this
pregnancy

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 - The baby has a 1in 700- 1-800 chance of being affected

GBS and pre labour ROM- should be offer IAP and immediate induction

PPROM and GBS +ve- before 34 weeks, the risk of preterm delivery are likely to outweigh
the risk of perinatal infection. For those >34- it is beneficial to expidite delivery if GBS +ve

If allergy to penicillin, a cephalosporin should be used (e.g cefuroxime 1.5g loading dose
followed by 750mg 8 hrly).
If severe allergy then IV Vancomycin (1g every 12hrs) is recommended.

In women who refuse IAP- babies should be monitored for at least 12 hours
For women who have received abx in 4 hrs prior to delivery babies need no extra
monitoring past initial 4 hr obs and are suitable for early discharge

Listeria

- Soft cheese
- Milk
- Shrimps
- Rice salad
- Uncooked chicken

- The classic pathology is of abscess formation, although maternal infection may be

asymptomatic.
- Can present with malaise, chills, fever, pharyngitis, lymphadenopathy, headache,
msk pain, nausea, vomiting
- Most likely to present as GI illness that lasts a few days

Fetus

Early onset listeriosis- sithin 2 days of birth, presents with signs of septicaemia and
meningitis. Infected neonates are often delivered preterm, and would usually have
acquired the infection from the placenta

Late onset listeriosis- presents after 5 days with meningitis, is usually the result of
infection during delivery

- Listeriosis does not normally make the mother seriously ill.

- It may however lead to maternal septicaemia or meningitis.

- The impact on the fetus is seen in the days/weeks following infection

- Potential complications include fetal death in utero
- Congenital infection is often fatal, but the long term morbidity is currently unknown

Management

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 Typical treatment include IV ampicillin +gentamycin
In women allergic to penicillin it is typical to use trimethroprim or erythromycin

Toxoplasma

- Affects around 2 per 1000 pregnancies in UK

Mother to fetus transmission:

1st trimester- 10%
2nd trimester- 25%
3rd trimester >85%

Toxoplasmosis triad of intracerebral calcification, hydrocephaly and chorioretinitis are

uncommon in utero or at birth

Pregnancy implications:
Miscarriage
Ascites and hepatosplenomegaly (visible on ultrasound)
Chorioretinitis
Hydrocephaly
Brain tissue calcification

Management

- When toxoplasmosis is diagnosed, termination may be an option

- Otherwise treat with spiramycin to try to prevent congenital infection
- If congenital infection confirmed, treat with sulphadiazine and pyrimethamine.

Malaria

- 79% of infections from plasmodium falciparum.

- P. vivax is more prevalent in asia (especially indian subcontinent)

Prophylaxis

- Mefloquine is the recommended drug of choice for prophylaxis in the second and
third trimesters for chloroquine resistant areas. With very few areas in world free
from chloroquine resistance, mefloquine is essentially the only drug considered safe
for prophylaxis in pregnant travellers.

- Atovaquone and proguanil (malarone) are potentially good alternatives for

prophylaxis in the second and third trimester but are not first choice.

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Treatment of malaria

- Admit pregnant women with uncomplicated malaria to hospital and pregnant

women with severe and complicated malaria to ITU
- IV Artesunate is the treatment of choice for severe falciparum malaria. Use IV
quinine if artesunate not available.

Uncomplicated P. Falciparum – quinine

P. Vivax, P. ovale or P.malariae- chloroquine

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