Initial parenteral treatment for at least 48 h: choose one of following four options
Follow–up treatment, when patient can take oral medication following parenteral treatment
Quinine: 20 mg quinine salt/kg body weight on admission (IV infusion or divided IM injection) followed by maintenance dose of 10 mg/kg 8 hourly; infusion rate should not exceed 5 mg/kg per h. Loading dose of 20 mg/kg should not be given, if the patient has already received quinine
Quinine 10 mg/kg three times a day
with:
clindamycin 10 mg/kg 12 hourly to complete 7 days of treatment
Artesunate: 2.4 mg/kg IV or IM given on admission (time = 0), then at 12 h and 24 h, and then once a day
or
Artemether: 3.2 mg/kg bw IM given on admission and then 1.6 mg/kg per day
or
Arteether: 150 mg daily IM for 3 days
Full oral course of area-specific ACT:
In northeastern states: age-specific ACTAL for 3 days
In other states: treat with ACT-SP for 3 days
WHO recommends that IV artesunate is the preferred first-line drug for all severe malaria cases in adults including pregnant women [8]. As compared to quinine, artesunate is associated with 35 % reduction in mortality [9]. Although there is insufficient evidence to support the use of artemisinin in the first trimester, the drug should not be withheld if the life of the woman is endangered [10]. One of the reasons of high mortality in the past was the delay in institution of proper antimalarial drugs [11]. Artesunate is well tolerated with no attributable local or systemic adverse effects. As quinine stimulates insulin secretion, treatment with quinine in pregnancy is associated with severe and recurrent hypoglycemia [12]. Quinine does not induce abortion or labor. Mild side effects known as cinchonism are common with quinine including tinnitus, hearing loss, dizziness, nausea, uneasiness, restlessness, and blurring of vision.
Supportive care in severe malaria [8]
Manifestation or complication | Management |
|---|---|
Coma (cerebral malaria) | Monitor using Glasgow Coma Scale. Maintain airway, place patient on her side, and exclude treatable causes of coma (e.g., hypoglycemia, meningitis) |
Hyperpyrexia | Administer tepid sponging, fanning, and antipyretic drugs |
Convulsions | Maintain airway, treat promptly with intravenous diazepam |
Hypoglycemia | Check blood glucose regularly, correct hypoglycemia, and maintain with (blood glucose <40 mg/dl) glucose-containing infusion |
Severe anemia | Transfuse with packed red cells |
Acute pulmonary edema | Treat by propping patient up at an angle of 45°, give oxygen, give a diuretic, stop IV fluids, intubate, and add PEEP/CPAP if required |
Renal failure | Exclude prerenal causes; check fluid balance and urinary sodium; if in established renal failure, add hemofiltration or hemodialysis |
Spontaneous bleeding and coagulopathy | Transfuse fresh whole blood and blood products; give vitamin K injection |
Metabolic acidosis | Prevent by careful fluid balance; exclude or treat hypoglycemia, hypovolemia, and septicemia; if severe add hemofiltration or hemodialysis |
Shock | Suspect septicemia, take blood culture, give broad-spectrum antibiotics, correct hemodynamic disturbances |
Provide good nursing care. This is vital especially if the patient is unconscious. Avoid NSAIDs which increase the risk of gastrointestinal bleeding. For fluid balance urine output should be aimed at >1 ml/kg/h. Give packed cell volume (PCV) transfusion if there is severe anemia. Exchange transfusion to treat severe parasitemia is not proved by evidence.
Role of early cesarean section in severe malaria is unproven. For patients in labor, second stage should be shortened by instrumental delivery.
For prevention of malaria, personal protective measures like long protective clothing, mosquito coils and body repellants (sprays and lotion), and wire screening on windows should be practiced. Treated bed nets (ITN)/long-lasting insecticidal nets (LLIN) should be encouraged for pregnant women. Meta-analysis of intervention trials suggests that successful prevention of these infections reduces the risk of severe maternal anemia by 38 %, low birth weight by 43 %, and perinatal mortality by 27 % among primigravidae [13].
RTS,S is the most recently developed recombinant vaccine for malaria. Phase III clinical trials have shown modest protection against malaria. It might be available for clinical use soon.
Dengue
Dengue infection is a mosquito-borne viral infection causing a flu-like febrile illness and sometimes causing a potentially lethal complication called severe dengue. Dengue infection is endemic in tropical and subtropical countries including India. The incidence of dengue has increased 30-fold over the past 50 years. This increase is due to many factors like urbanization, population growth, increased international travel, and global warming. About half of the world’s population is now at risk [14]. India’s National Vector Borne Disease Control Programme reported in 2013 that the country had experienced an annual average of 20,474 dengue cases and 132 dengue-related deaths since 2007 [15]. As dengue is more common in children and young adults, pregnant patients are at increased risk. Also the infection in pregnant mothers is reported to be more severe as compared to nonpregnant females and with higher mortality rates [16].
Dengue virus is an RNA virus of the family Flaviviridae, genus Flavivirus. Originally there were four strains of the virus called serotypes DENV-1, DENV-2, DENV-3, and DENV-4. Recently, the fifth type is discovered in 2013. The Aedes aegypti mosquito is the primary vector of dengue. The virus is transmitted to humans through the bites of infected female mosquitoes. Aedes aegypti is a daytime feeder biting mainly early in the morning and in the evening before dusk. Infected humans are the main carriers and multipliers of virus serving as a source for uninfected mosquitoes.
Recovery from infection by one serotype provides lifelong immunity against that particular serotype but only partial and temporary immunity to the other serotypes. Subsequent infections by other serotypes increase the risk of developing severe dengue.
Dengue can also be transmitted via infected blood products and through organ donation. Vertical transmission during pregnancy is also reported [17]. Otherwise infection does not occur directly from human to human.
Original WHO classification (1997), still in use, divides dengue into undifferentiated fever, dengue fever, and dengue hemorrhagic fever (DHF). Dengue hemorrhagic fever was subdivided into grades I–IV. Grade I is the presence only of easy bruising or a positive tourniquet test in someone with fever, grade II is the presence of spontaneous bleeding into the skin and elsewhere, grade III is the clinical evidence of shock, and grade IV is shock so severe that BP and pulse cannot be recorded. Grades III and IV are referred to as “dengue shock syndrome” (DSS).
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