FEVER IN PREGNANCY BY DR SHASHWAT JANI

FEVER IN PREGNANCY BY DR SHASHWAT JANI

1. Dr. Shashwat Kamal Jani.
M. S. ( Obs – Gynec )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : [phone].
E-mail : [email protected]

2. Pyrexia…
•Temperature > 38 degree C once or > 37.5 degree C
on 2 occasions 2 hours apart.
(http://www.rcog.org.uk)
•In humans, threshold temperature for
teratogenicity : 38.9 ºC (102ºF)

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Dr Shashwat Jani.
99099 44160.
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3. Three periods of prenatal development in human
Pre-implantation period (∼3 weeks)
• Increased pre-implantation loss due to failure to
implantation or embryonic death.
Period of major organogenesis (3∼8 weeks)
• Especially, susceptible to the induction of
developmental defect
• CNS, skeletal, neuromuscular, and cardiac defect
Fetal periods (8∼ weeks)
• Results mainly in reduced growth & functional
defects

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4.  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.

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5.  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.

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6. Effects Of Fever
On Pregnancy
IUGR
Oligohydramnios
Preterm
Meconium stained amniotic fluid
Fetal distress
Abortion
Postpartum sepsis
Fetal Anomalies
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7. Causes Of Fever
ANTEPARTUM
INFECTIONS
Bacterial
Upper Respiratory Tract Infection (URTI)
Urinary Tract Infection (UTI)
Typhoid
Gastroenteritis
Chorioamnionitis


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8. Protozoal
Malaria
Dengue
Viral
Varicella
Herpes
Rubella
Swine flu (H1N1)

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9. INTRAPARTUM
 Can be due to infectious or non-infectious
etiology
 Prolonged labour
 Prolonged PROM (>24 hours)
 Chorioamnionitis
 Increased maternal stress
 Drugs (Oxytocin augmentation, Epidural
analgesia)

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10. POSTPARTUM
 Puerperal pyrexia
 Breast abscess
 Thromboembolic disorders
 Wound infections
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11. Most Common Causes
 URTI
 UTI
 Septic Abortion
 Chorioamnionitis
 Dengue
 Malaria
 Typhoid
 Puerperal Pyrexia

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12. URTI
Causative Organisms
Virus (Rhinovirus, coronavirus, influenza)
Bacterial (Group B Streptococcus, S.pneumoniae
H.influenza)

Hormonal (Progesterone causes swelling in
the lining of sinus)

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13. Treatment
Analgesics
(Paracetamol)
Antihistaminics
Cough Suppressants
Increased fluid intake
Antibiotics
(Azithromycin, Cefixime)
Symptoms
Sore throat
Rhinorrhea
Headache
Cough
Fever
Ear pain
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14. UTI
Asymptomatic Bacteriuria
10,000 organisms/ml in 2 consecutive urine
samples in the absence of symptoms .
Occurs in 2.5-11% of pregnant women

Symptomatic Bacteriuria
 100 organisms/ml of urine with accompanying
pyuria (>7 WBCs/ml)

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15. 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%
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16. Increased frequency of UTI in pregnant
women is due to:
 Difficult hygiene due to distended gravid
uterus
 Immunocompromised state
 Urinary stasis (progesterone-induced ureteral
smooth muscle relaxation)
 Urinary retention (enlarged uterus)
 Loss of ureteral tone
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Causes
E.coli- most common
Klebsiella pneumonia
Proteus mirabilis
Enterobacter
Symptoms
Dysuria
Fever with chills
Suprapubic pain
Increased frequency and urgency
Burning micturition

18. Investigations
 Blood (CBC, electroytes, BUN, creatinine)
 Urine
Midstream urine sample clean catch in 1
st
antenatal
visit
Culture - Standard method for evaluation.
Positive culture - 2 consecutive voided specimens
with isolation of the same bacterial strain, at a
colony count of 1,00,000 CFU/ml or higher .

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19. Treatment
Antibiotic therapy tailored to culture results and
follow up cultures to confirm sterilization…
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20. 20
Septic Abortion
•Cause of 12.9% of maternal deaths
•Post abortion care has had tremendous
impact on reducing mortality, particularly with
use of manual vacuum aspiration.
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99099 44160.

21. Clinical evidences of infection are-
1. History of pregnancy or Abortion.
2. Fever 38 C or more for at least 24 hrs
3. Offensive or purulent vaginal discharge
4. Lower abdominal pain, tenderness or mass.
5. Tachycardia of more than 100 per min.
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22. Clinical Grading
• Grade–I: The infection is localized in the uterus.
• Grade–II: The infection spreads beyond the
uterus to the parametrium , tubes and ovaries or
pelvic peritoneum.
• Grade–III: Generalized peritonitis and/or
endotoxic shock or jaundice or acute renal failure.
 Grade-I is the commonest and is usually
associated with spontaneous abortion.
 Grade- III is almost always associated with
illegal induced abortion.
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23. •Routine Investigations
Haematology:
• Hb : may be low
• Platelets: may be low
• TLC: raised
• DLC: Neutrophil raised
• Blood C/S.
• Blood grouping and cross matching
Urine analysis:
• UPT
• RME and C/S
High vaginal swab is taken prior to internal examination for-
1. culture in aerobic and anaerobic media to find out the dominant micro
organisms
2. sensitivity of the micro organisms to antibiotics
3. smear for Gram stain
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Dr Shashwat Jani.
99099 44160.
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24. Special Investigations
• Ultrasonography pelvis and abdomen to detect
intrauterine retained products of conception ,
foreign body- intrauterine or intraabdominal, free
fluid in the peritoneal cavity or in the pouch of
Douglas
• Fibrinogen level, fibrin degradation product and d-
dimer to rule out
DIC
RFT
•Plain chest X-ray to rule out atelectasis and
abdomen to rule out bowel injury or foreign body.
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25. Treatment
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Medical
• Antibiotic
Surgical
• Dilation and curretage
• Posterior colpotomy
• Laparotomy
• Hysterectomy

26. 26
Treatment
•Begin antibiotics as soon as possible before
evacuation:
–Ampicillin every 6 hours
–PLUS gentamicin daily
–PLUS metronidazole every 8 hours
•Continue until fever-free for 48 hours
•Manual vacuum aspiration
28-Sep-18
Dr Shashwat Jani.
99099 44160.

27. Chorioamnionitis
•Chorioamnionitis also known as intra-
amniotic infection (IAI) is an inflammation of
the fetal membranes (amnion and chorion)
due to a bacterial infection.
• It typically results from bacteria
ascending into the uterus from the vagina and
is most often associated with prolonged labor.
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99099 44160.
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28. Chorioamnionitis
• Chorioamnionitis, complicates as many as
40–70% of preterm births with premature
membrane rupture or spontaneous labor, and
1–13% of term births.
• 12% of primary cesarean births at term
involve clinical chorioamnionitis, with the most
common indication for cesarean in these cases
being failure to progress usually after
membrane rupture.
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99099 44160.
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29. Risk Factors
1. Longer duration of membrane rupture.
2. Prolonged labor.
3. Nulliparity.
4. African American ethnicity.
5. Internal monitoring of labor.
6. Multiple vaginal exams.
7. Meconium-stained amniotic fluid.
8. Smoking, alcohol or drug abuse.
9. Immune-compromised states.
10. Epidural anesthesia.
11. Colonization with group B streptococcus.
12. Bacterial vaginosis.
13. Sexually transmissible genital infections.
Dr Shashwat Jani.
99099 44160.
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30. Routes of infection
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31. Organisms
Ureaplasma urealyticum
 Mycoplasma hominis
Gardnerella vaginalis
Group B Streptococcus
E.coli
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32. Clinical Features
• Fever is the most important sign.
• Uterine fundal tenderness.
• Maternal tachycardia (>100/min).
• Fetal tachycardia (>160/min).
• Purulent or foul smelling discharge
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CBC , CRP , AMNIOTIC FLUID CULTURE

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Dr Shashwat Jani.
99099 44160.
Management of Amnionitis
•Give combination of antibiotics until delivery:
–Ampicillin every 6 hours
–PLUS gentamicin daily
•If woman delivers vaginally, discontinue
antibiotics postpartum
•If woman has cesarean section:
–Continue above antibiotics
–Add metronidazole every 8 hours
–Continue until fever-free for 48 hours
ACOG 1998.
28-Sep-18

34. 34
Dr Shashwat Jani.
99099 44160.
Management of Amnionitis
(continued)
•If cervix is favorable, induce labor with
oxytocin
•If cervix is unfavorable, ripen with
prostaglandins and infuse oxytocin or deliver
by cesarean section
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35. Maternal
complications
• Cesarean delivery
• Endomyometritis
• Wound infection
• Pelvic abscess
• Bacteremia
• Postpartum hemorrhage
• Septic shock
• Disseminated intravascular
coagululation
• Adult respiratory distress
syndrome
• Maternal death
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Fetal complications
• Fetal death
• Neonatal sepsis
• Perinatal death,
• Asphyxia,
• Early onset neonatal sepsis,
• Septic shock,
• Pneumonia,
• Intraventricular hemorrhage
(IVH),
• Cerebral white matter
damage, and
• Cerebral palsy.

36.  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
fetus 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.
Malaria

37. Effect on Pregnancy:

 The immuno-compromised state of the mother renders her
susceptible to Malaria. There is intense parasitisation (30%- 60%
of cases) of the placenta which gets aggravated with concurrent
HIV and Tuberculosis.

 The intervillous space becomes blocked with macrophages
and parasites. And there is diminished pacental blood flow which
is mostly seen with falciparum infection and in the second half of
pregnancy.

 Primigravidae are usually more vulnerable to infection than
multiparae.

38.  Pregnant mothers living in endemic areas have
high amount of antibody titre and due to passive
transfer to the fetus, congenital Malaria is rare in these
areas.

 Pregnant mothers living in non-endemic areas are
particularly vulnerable for developing severe
complications. Congenital malaria has been observed in
such cases.( Less than 5%)

39. 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

40.  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

41. Effect 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

42. Investigations
 Microscopic (Gold standard)
Peripheral blood smear-
Thick (sensitive)
Thin (species identification)
 Antigen detection- Rapid diagnostic tests(RDT)
MRDT-HRP-2/pLDH
 PCR
 Antibody test
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43. Choice of Anti malarials in pregnancy
All trimesters:

First line - Chloroquine; Quinine;

Second line – Artesunate Artemether / Arteether

2
nd
/ 3
rd
trimester: with caution

 Pyrimethamine + sulphadoxine;

 Mefloquine

Contra indicated:

Primaquine; Tetracycline; Doxycycline; Halofantrine

44. Dose of Anti malarials:
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 (Total
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.

45. 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.

46. 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,
haemoglobin, Parasite count, S.G.P.T., S .bilirubin, S.creatinine,
Blood sugar.
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.

47. The physiologic changes of pregnancy pose special
problems in management of malaria.

In addition, certain drugs are contra indicated in pregnancy or
may cause more severe adverse effects.

All these factors should be taken into consideration while
treating these patients.

Choose drugs according to severity of the disease/ sensitivity
pattern in the locality.

Avoid drugs that are contra indicated

 Avoid over / under dosing of drugs

 Avoid fluid overload / dehydration

 Maintain adequate intake of calories

48. Management of Labour
 Anaemia, hypoglycaemia, pulmonary oedema, and
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 foetal
parameters is extremely important.

 Pregnant women with severe malaria are better managed in
an intensive care unit
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49. • Falciparum malaria induces uterine contractions, resulting in
premature labour. The frequency and intensity of contractions
appear to be related to the height of the fever.

•Fetal distress is common and often unrecognised. Therefore only
monitoring of uterine contractions and fetal heart rate may
reveal asymptomatic labour and foetal distress.

•All efforts should be made to rapidly bring the temperature
under control,

–By tepid sponging (cold sponging causes cutaneous
vasoconstriction and can result in core hyperpyrexia).
–Anti pyretics like paracetamol etc.

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50. •Careful fluid management is also very important. Dehydration as
well as fluid overload should be avoided, because both could be
detrimental to the mother and/or the foetus.

•In cases of very high parasitemia, exchange transfusion may
have to be carried out.

•If the situation demands, induction of labour may have to be
considered.

•Once the patient is in labour, foetal or maternal distress may
indicate the need to shorten the 2nd stage by forceps or vacuum
extraction.

•If needed, even caesarean section must be considered
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51. 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.
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52. 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
haemoconcentration (an increase in haematocrit 20%
above average for age, sex and population), pleural
effusion and ascites, etc .
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53. Dengue is fever is classified into three different
phases based
on the symptoms and the severity of the
disease presentation.
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54. Obstetric Complications
•Preterm birth
•Low-birth weight
•Oligohydramnios
•Antepartum and postpartum haemorrhage
•Foetal distress
•Miscarriages
•Intrauterine death
•Neonatal death
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55. 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.
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99099 44160.
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56. 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.
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99099 44160.
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57. Management Of Labour In Critical
Phase Of Dengue
 Blood and blood products should be cross-
matched 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.
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58. • Fresh whole blood/fresh packed red cells
transfusion should be administered as soon as
possible.
• Do not wait for blood loss to exceed 500 ml
before replacement, as in postpartum
haemorrhage.
• Do not wait for the haematocrit to
decrease to low levels.
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99099 44160.
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59. Enteric Fever

•Widal test should be done on Day 5 of fever.
•Multidrug therapy
•Inj Ceftriaxone 1.5 gm 12 hourly till 24 hours after
last fever followed by oral Cefixime 400 mg BD for
14 days
•+ Tab Azithromycin 500 mg BID for 5 days ( from
day 1)
•Fleuroquinolones for resistant Enteric fevers.
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60. Puerperal Pyrexia
A rise in temperature reaching
100.4 degree F (38 degree C) or more on
separate occasions at 24 hours apart,
excluding the first 24 hours and within the
first 10 days following delivery
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61. Common Causes
 UTI (multiple P/V examinations, multiple
catheterization, untreated bacteriuria)
 Wound infection (C-section, trauma during
delivery)
 Mastitis (nipple trauma from breast feeding)
 Atelectasis (General anaesthesia, smoking, COPD)
 Septic Pelvic Thrombophlebitis(Prolonged labour,
prolonged PROM)
 Endometritis (Prolonged labour, prolonged PROM)


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62. Investigations
Blood (CBC, CRP)
Blood culture
Urine (If UTI is indicated)
Chest X-ray
Wound culture
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63. Treatment
 IV infusion of broad spectrum antibiotics
 Continued for 48 hours after fever is resolved
 Supportive care and symptomatic treatment
 Heparin therapy in thrombophlebitis
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