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Community Health & Tropical Medicine Revision

Community Health & Tropical Medicine UNMEB Past Papers ✨

Prepared by Nurses Revision! Let's dive in! 😊

Paper 1 - Section A: Objective Questions (MCQs)

1. Which of the following priority areas should a Primary Health Care program focus on?

  • (a) Personal hygiene and sanitation.
  • (b) Punishing all thieves.
  • (c) Having local council meetings.
  • (d) Creating a link between two parties.
Correct Answer: (a) Personal hygiene and sanitation.
Explanation:Primary Health Care (PHC) is all about keeping people healthy where they live. Things like clean water, safe toilets, and keeping yourself clean (personal hygiene) are super important for preventing diseases. This is a direct way to improve health at the community level.(Think about how many diseases spread because of poor sanitation!)
Why other options are wrong:
  • (b) Punishing thieves: This is important for law and order, but not a health priority area for a health program. That's a job for the police and courts.
  • (c) Having local council meetings: While local councils are important and can support health programs, the meetings themselves aren't a direct health priority area. They are a way to organize the community.
  • (d) Creating a link between two parties: This is too general. PHC involves working with many groups, but the core focus is on health activities, not just any kind of link.

2. Which of the following is NOT a pillar of Primary Health Care?

  • (a) Inter sectoral collaboration.
  • (b) Community participation.
  • (c) Appropriate technology.
  • (d) Accessibility of services.
Correct Answer: (d) Accessibility of services.
Explanation:Simple🤔However, when we talk about the specific *pillars* (the main supports) that make PHC work, the widely recognized ones are: Intersectoral Collaboration (different sectors working together), Community Participation (people involved), Appropriate Technology (using suitable tools and methods), and Equitable Distribution of Resources (making sure services are fair and available to everyone).
Why other options are (usually) pillars:
  • (a) Inter sectoral collaboration: Absolutely a pillar. Health needs help from education, agriculture, water, etc.
  • (b) Community participation: Essential pillar. PHC is not done *for* the community, but *with* them.
  • (c) Appropriate technology: Key pillar. Using tools and methods that the community can afford and manage.

3. The major aim of health education in Primary Health Care activities is to

  • (a) provide appropriate care to the community.
  • (b) improve health of the community.
  • (c) meet the needs of the cornmunity.
  • (d) make a health plan for the future.
Correct Answer: (b) improve health of the community.
Explanation:Health education gives people knowledge and skills so they can make healthier choices, prevent diseases, and manage their conditions better. When people do this, the overall health of the community improves!💡It's a tool used to reach the bigger goal of better health.
Why other options are wrong:
  • (a) provide appropriate care: Health education helps people seek care and manage conditions, but it's not the *provision* of care itself (like giving medicine or treatment).
  • (c) meet the needs of the community: Health education helps address health needs, but the *major aim* is the positive outcome on health status. Meeting needs is broader than just education.
  • (d) make a health plan for the future: Making plans is a separate activity, often done by health professionals and community leaders. Education helps inform the plan and get support, but isn't the planning itself.

4. Which of the following factors promote community mobilisation?

  • (a) Political interest.
  • (b) Appropriate language.
  • (c) Past bad experience.
  • (d) Poor relationship.
Correct Answer: (b) Appropriate language.
Explanation:Community mobilisation is about getting people together and motivated to work on a common goal. If you use language that people understand and connect with (appropriate language), they are more likely to get involved and feel included. Good communication is key to building trust and motivation!🗣️🤝
Why other options are wrong:
  • (a) Political interest: While political *support* can help, political *interest* alone doesn't guarantee the community will mobilize. It's an external factor that might help but isn't a direct *promoter* from within or in the interaction.
  • (c) Past bad experience: This would definitely *hinder* mobilisation, not promote it. People would be hesitant to join if previous efforts failed or were negative.
  • (d) Poor relationship: Like bad experiences, poor relationships between health workers and the community, or among community members, will make it harder to mobilize people.

5. Which of the following best explains a community based health program?

  • (a) The community is involved in planning and implementation.
  • (b) There is no outside assistance given in running community programs.
  • (c) Only members of the community are given offices.
  • (d) Offers training to the community members.
Correct Answer: (a) The community is involved in planning and implementation.
Explanation:A community-based program means the community isn't just receiving services, they are active partners in making the program happen. They help decide what's needed (planning) and help carry out the activities (implementation). This involvement makes the program more relevant and sustainable.🧑‍🤝‍🧑🗺️
Why other options are wrong:
  • (b) There is no outside assistance: Community-based doesn't mean isolated. Outside help (from government, NGOs, etc.) is often needed, but the key is the community's *central role*, not the absence of others.
  • (c) Only members of the community are given offices: While community members often take leadership roles, this isn't the *defining* feature. The involvement in planning and doing the work is the core idea.
  • (d) Offers training to the community members: Training is a common activity in community-based programs to build capacity, but it's a *part* of implementation, not the best explanation of the overall concept.

6. Which of the following is NOT a characteristic of a Primary Health Care practical approach?

  • (a) Have social development dimensions.
  • (b) Acceptable and affordable.
  • (c) Making essential health care universally accessible.
  • (d) Should not be determined by social goals.
Correct Answer: (d) Should not be determined by social goals.
Explanation:PHC is strongly driven by social goals like equity, social justice, and community empowerment. It aims to address the *social determinants* of health (like poverty, education). So, saying it "should not be determined by social goals" is completely against the spirit of PHC!🚫🌍
Why other options are characteristics:
  • (a) Have social development dimensions: Yes, PHC recognizes that health is linked to things like education, income, and equality (social development).
  • (b) Acceptable and affordable: Yes, for PHC to be practical and used by the community, it must be acceptable (culturally right) and affordable (people can pay for it).
  • (c) Making essential health care universally accessible: Yes, a core goal is that basic health services are available to everyone, no matter where they live or how much money they have.

7. Which of the following indicates the need for community participation?

  • (a) Soliciting for external support.
  • (b) Clear understanding of the project goal.
  • (c) Good leadership and administration.
  • (d) Self reliance in the set up projects.
Correct Answer: (d) Self reliance in the set up projects.
Explanation:We need community participation because we want the community to eventually be able to manage their own health projects and solutions (self-reliance). Involving them from the start builds their capacity, ownership, and ability to continue activities even without outside help.💪🏠
Why other options are wrong:
  • (a) Soliciting for external support: External support might be needed, but the *need* for participation is more about empowering the community itself, not just getting funds from outside.
  • (b) Clear understanding of the project goal: A clear understanding is important for *effective* participation, but the *need* for participation exists even if understanding is initially low; participation helps *build* that understanding.
  • (c) Good leadership and administration: Good leadership *facilitates* participation, but it's not the *reason* we need participation. The need comes from wanting the community to own and manage the initiative.

8. Which of the following is NOT a concept of equity?

  • (a) Justice.
  • (b) Fairness.
  • (c) Inequality.
  • (d) Equality.
Correct Answer: (c) Inequality.
Explanation:Equity in health means everyone has a fair chance to be as healthy as possible. It's about justice and fairness.⚖️🤝Inequality means there are unfair differences in health status or access to care, which is the *opposite* of equity. While equity doesn't always mean strict *equality* (giving everyone the exact same thing), it means giving different support as needed so everyone can reach a similar good outcome (which is a form of fairness/justice, sometimes called health equity vs. health equality). But inequality is definitely what equity tries to *remove*.
Why other options are related to equity:
  • (a) Justice: Equity is a fundamental aspect of social justice in health.
  • (b) Fairness: Equity is essentially about fairness in health opportunities and outcomes.
  • (d) Equality: While equity is not always the same as giving everyone an *equal amount* of resources, the goal of equity is to achieve greater equality in health outcomes by addressing different needs. It's related, though equity is often seen as the *means* to achieve equality in health.

9. The process of enabling people increase control over the determinants of health and thereby improve their own health is

  • (a) health education.
  • (b) health promotion.
  • (c) health prevention.
  • (d) health care.
Correct Answer: (b) health promotion.
Explanation:This is the classic definition of health promotion, according to the Ottawa Charter!🌟It's about empowering individuals and communities to understand and influence the factors that affect their health (like their environment, lifestyle, social support, etc.).
Why other options are wrong:
  • (a) health education: This is an important *tool* used in health promotion, but health promotion is broader than just giving information.
  • (c) health prevention: This is about preventing diseases (e.g., vaccination, hygiene). It's a goal that health promotion helps achieve, but health promotion is the process of empowering people.
  • (d) health care: This is about treating people who are already sick or injured. Health promotion focuses on keeping people well and addressing the root causes of ill health.

10. Which of the following factors of health does NOT affect the community?

  • (a) Life style.
  • (b) Environment.
  • (c) Health services provision.
  • (d) Empowerment.
Correct Answer: (d) Empowerment.
Explanation:Lifestyle choices (what people eat, whether they smoke), the environment (cleanliness, pollution), and the availability of health services all directly impact the health status of a community.🌍🏥🍎Empowerment is a *process* within health promotion that helps communities gain control and improve their health, but it's not typically listed as a fundamental *factor* or *determinant* of health in the same category as environment or lifestyle. It's more about the community's *capacity* to act on these factors.
Why other options ARE factors affecting community health:
  • (a) Life style: Community health is the sum of individual healths, and lifestyle choices cluster within communities.
  • (b) Environment: The physical and social environment (housing, sanitation, safety, social support) directly impacts community health.
  • (c) Health services provision: Access to quality health services is a major determinant of community health outcomes.

11. Which of the following is the best way to make a community diagnosis?

  • (a) Attend village gatherings to get information.
  • (b) Carryout home visits in the community.
  • (c) Look at existing medical records.
  • (d) Talk to village leaders and health workers.
Correct Answer: (a) Attend village gatherings to get information.
Explanation:A good community diagnosis needs information from many sources.🕵️‍♀️📊🗣️Attending village gatherings is a great way to hear directly from a wide range of community members about what *they* see as health problems, their beliefs, and their resources. It gives you a broad picture of the community's perspective, which is crucial for understanding their real needs. While the other methods are also useful, they only provide a partial view.
Why other options are useful but not the "best" single way:
  • (b) Carryout home visits: Gives detailed info about individual families, but is time-consuming and doesn't give the full community picture.
  • (c) Look at existing medical records: Provides clinical data on diseases seen at facilities, but misses many community-level issues, social determinants, and people who don't use facilities.
  • (d) Talk to village leaders and health workers: Provides important key informant perspectives, but is limited to their view and might miss the voices of ordinary community members.

12. Nurses should assess the health status of a given population at a particular time through

  • (a) community mobilisation.
  • (b) clinical diagnosis.
  • (c) community participation.
  • (d) community diagnosis.
Correct Answer: (d) community diagnosis.
Explanation:Assessing the health status of a whole group of people (a population) is exactly what community diagnosis is!👩‍⚕️📊You look at health problems, their causes, and the resources available in that specific community at a specific time.
Why other options are wrong:
  • (a) community mobilisation: This is the process of getting the community together to take action, not an assessment method.
  • (b) clinical diagnosis: This is diagnosing illness in *one* person, not a whole population.
  • (c) community participation: This is the community being involved in health activities, not a method for assessing their health status.

13. Which of the following types of prevention should be implemented when a person is in a healthy state?

  • (a) Quaternary.
  • (b) Secondary.
  • (c) Primary.
  • (d) Tertiary.
Correct Answer: (c) Primary.
Explanation:Primary prevention happens *before* any disease starts.🛡️The goal is to prevent the disease from ever occurring in a healthy person (e.g., vaccination, promoting healthy eating, using bed nets).
Why other options are wrong:
  • (a) Quaternary: This is about preventing over-medicalization (too much treatment or testing).
  • (b) Secondary: This is about detecting a disease *early* when a person might not even have symptoms yet (e.g., screening for high blood pressure).
  • (d) Tertiary: This is about managing an existing disease to prevent complications, disability, or death (e.g., rehabilitation after a stroke, managing diabetes).

14. An approach that stimulates the community to initiate and maintain the running of health activities at its own cost is called

  • (a) self reliance.
  • (b) sustainability.
  • (c) participation.
  • (d) appropriate technology.
Correct Answer: (a) self reliance.
Explanation:Self-reliance means the community can depend on itself, using its own strengths and resources (including money, represented by "at its own cost") to manage its health programs independently over time.🤝💰
Why other options are wrong:
  • (b) sustainability: This means the program continues over time, which self-reliance helps achieve, but self-reliance is the *means* (doing it themselves, perhaps at their cost) to achieve sustainability.
  • (c) participation: This is the involvement of people, which is necessary for self-reliance and sustainability, but not the term for initiating and maintaining *at their own cost*.
  • (d) appropriate technology: This is about using suitable tools, which helps self-reliance, but isn't the approach of doing it *at their own cost*.

15. An initiative by community members to look for locally available solutions for their health problems is termed as

  • (a) community mobilisation.
  • (b) community active participation.
  • (c) top-down approach.
  • (d) bottom-up approach.
Correct Answer: (d) bottom-up approach.
Explanation:A bottom-up approach means ideas, initiatives, and solutions come from the community members themselves ("the bottom"), based on their local knowledge and resources.🌱📈A top-down approach is when solutions are designed and imposed by external experts or authorities ("the top").
Why other options are wrong:
  • (a) community mobilisation: This is the *process* of getting people together, which is part of a bottom-up approach, but not the term for the *initiative* of seeking local solutions.
  • (b) community active participation: This is the *level* of involvement, which is high in a bottom-up approach, but not the term for the *approach* of seeking local solutions.
  • (c) top-down approach: This is the opposite; solutions come from outside, not locally from within the community.

16. Which of the following is defined as a collection of people identified by a set of shared values?

  • (a) Family.
  • (b) Society.
  • (c) Community.
  • (d) Communal village.
Correct Answer: (c) Community.
Explanation:In public health, a community is often defined as a group of people who share something in common – it could be location (like a village), interests, or values. Shared values are a key way to identify and understand a community.🏘️❤️
Why other options are wrong:
  • (a) Family: A family is a small unit, while a community is usually larger.
  • (b) Society: Society is a very broad term for a large group of people living in the same territory, not necessarily defined by a specific set of *shared values* in the way a community is.
  • (d) Communal village: This is a specific type of community (geographically defined), but the definition provided (shared values) also applies to communities not based purely on location (like a community of people living with diabetes, or a religious community). "Community" is the general term.

17. The step of action where members identify their health needs, prioritize and plan their health activities is community

  • (a) organisation.
  • (b) diagnosis.
  • (c) participation.
  • (d) mobilisation.
Correct Answer: (c) participation.
Explanation:This describes community participation in action!🙋‍♀️💡📝When community members are actively involved in identifying problems (part of diagnosis), deciding which are most important (prioritizing), and figuring out what to do (planning), they are participating in the health process.
Why other options are related but not the direct action step:
  • (a) organisation: Community organisation is the process of building the structure and capacity for participation, but identifying/prioritizing/planning is the *activity* the organized group does.
  • (b) diagnosis: Community diagnosis is the *outcome* or *result* of identifying needs, not the action of the members doing it.
  • (d) mobilisation: This is getting people ready and together, but identifying/prioritizing/planning are specific activities that happen *after* or *during* mobilisation and organisation.

18. A health worker's ability to create interdependent relationships with individuals, groups and organisations to accomplish mutually set objectives is

  • (a) coalition building.
  • (b) networking.
  • (c) empowerment.
  • (d) development.
Correct Answer: (a) coalition building.
Explanation:Creating *interdependent relationships* (meaning everyone relies on each other a bit) with different groups and working towards *mutually set objectives* (shared goals) is exactly what coalition building is about.🤝🎯You bring different partners together who agree to work collaboratively for a common purpose. Networking is important for coalition building, but coalition building is the specific process of forming these alliances for action.
Why other options are related but different:
  • (b) networking: This is building relationships in general, which is a necessary step before building a coalition, but coalition building is more formal and focused on achieving shared goals.
  • (c) empowerment: This is about enabling others to gain control and power, which might be an outcome or a process within coalition building, but not the definition of creating the relationships themselves.
  • (d) development: This is a broad term for progress and improvement, which coalition building can contribute to, but it's not the specific term for forming the relationships for objectives.

19. The following are both principles and pillars of primary healthcare

  • (a) sustainability.
  • (b) prioritisation and efficiency.
  • (c) equity and affordability.
  • (d) appropriate technology and equity.
Correct Answer: (d) appropriate technology and equity.
Explanation:This question is similar to Q2 and relates to the core ideas of PHC.🔄Appropriate Technology is clearly a pillar/component. Equity is a fundamental principle of PHC and also part of the "Equitable Distribution" pillar. Option (d) lists two concepts that are widely recognized as central principles *and* components/pillars of PHC.
Why other options are wrong:
  • (a) sustainability: This is a very important *goal* or *outcome* of PHC, but not usually listed as one of the foundational *pillars* or *principles* itself, though PHC principles like participation and self-reliance help achieve it.
  • (b) prioritisation and efficiency: These are good management practices, but not considered core pillars or founding principles of PHC itself.
  • (c) equity and affordability: Equity is a principle/pillar component. Affordability is part of the accessibility/equity idea. This option is close, but (d) combines Appropriate Technology (a distinct pillar) and Equity (a key principle/pillar component), covering two different core areas.

20. When a nurse determines whether resources were maximised in the implementation phase, she is evaluating

  • (a) effectiveness.
  • (b) efficiency.
  • (c) adequacy.
  • (d) appropriateness.
Correct Answer: (b) efficiency.
Explanation:Efficiency is all about getting the most out of your resources (like money, time, supplies).⏱️💰➡️ResultsIf a nurse checks if resources were "maximized" (used in the best way possible with least waste), she is looking at how efficient the program implementation was.
Why other options are wrong:
  • (a) effectiveness: This is about whether the program achieved its intended goals, regardless of the resources used.
  • (c) adequacy: This is about whether there were *enough* resources available in the first place, not how well they were used.
  • (d) appropriateness: This is about whether the interventions and methods used were suitable for the community and the problem.

Paper 1 - Fill in the Blank Spaces

21. The first step in the process of community empowerment is...?

👉Problem identification
Explanation:Before a community can take control (empowerment), they need to understand their own situation, identify the challenges they face, and recognize their potential to change things. This starts with making them aware or assessing their needs and problems together.🤔➡️💡

22. A concept of PHC that involves provision of immunisation and treatment is...?

👉Provision of essential health care/services
Explanation:Immunisation (prevention) and treatment of common illnesses (cure) are core services that PHC provides. These fall under the idea of making basic, essential health care available to everyone.💉💊🏥

23. The first step to consider when entering the community is carrying out a...?

👉Community survey
Explanation:STEP IN COMMUNITY ENTRY: 1. Preliminary study of the community: Conduct a comprehensive study to gather information about the community’s location, population size, climate conditions, education levels, ethnicity, economic status, standard of living, occupations, and religious affiliations. This information will provide a foundation for understanding the community’s needs and priorities.🗺️🔍

24. A social action process that allows people to gain mastery over their lives is known as...?

👉Empowerment
Explanation:Empowerment is when people get the power and confidence to make decisions and have control over things that affect their lives, including their health. It's about feeling able to make changes.✊✨

25. The study of populations is called...?

👉Demography
Explanation:Demography is the statistical study of human populations. Demography examines the size, structure, and movements of populations over space and time.👩‍🔬📊

26. The process of enabling people to increase control over and to improve their health is known as health...?

👉Health Promotion
Explanation:This is the definition of health promotion again! (See MCQ 9). It's empowering people to take charge of their health and make healthy choices.⬆️❤️

27. Total elimination of a disease from the population is medically termed as...?

👉Eradication
Explanation:When a disease is completely wiped out, gone forever from everywhere in the world, it's called eradication. Elimination is when it's gone from a specific area or country, but still exists elsewhere. "From the population" usually implies complete removal, fitting eradication.❌🦠🌍

28. The best action to prevent spread of measles during an outbreak is...?

👉Immunisation/Vaccination
Explanation:Measles spreads very easily. The fastest and most effective way to stop an outbreak is to give the measles vaccine to everyone who hasn't had it or been vaccinated, especially young children, to build their protection quickly.🩹🛡️

29. Health services whose cost can be met by most of the community members are said to be...?

👉Affordable
Explanation:Affordable services are those that people can pay for without it causing them financial problems. Making health care affordable is a key part of PHC so everyone can access it.💵➡️😊

30. The process that ensures maintenance of a vaccine's potency from the manufacturer to the consumer is...?

👉Cold chain
Explanation:Vaccines must be kept at the right temperature from the factory all the way to the person getting the shot. The system of keeping them cold and effective during transport and storage is called the cold chain.❄️🚚 fridge

Paper 1 - Section B: Short Essay Questions

31.(a) State the five (5) stages of home visiting.

  • Planning phase:📝Getting ready before you visit. This involves identifying the home, establishing friendly rapport and explaining the purpose of the visit. You observe the home and surroundings, survey the location, and gather information about the families and their health status. Analyzing this information helps identify health situations. You also prepare necessary documents and set objectives and goals for the visit.
  • Entry & Establishing Rapport:Knock Knock 👋This part isn't explicitly a separate step in the provided text, but it's crucial within the "Planning phase" as you establish friendly rapport and explain the purpose of the visit upon arrival. Making them feel comfortable is key!
  • Assessment & Intervention:👂觀察🩺This aligns with the "Implementation phase" where the health care provider implements the planned objectives. This includes providing health education, immunization, screening, and addressing sanitary facilities based on the assessment done during the planning phase.
  • Termination/Ending the Visit:Wrap up 👋This isn't a separate step in the provided text, but it's an important part of completing the "Implementation phase" and transitioning to "Evaluation" and "Follow up." It would involve summarizing, ensuring understanding, and agreeing on next steps.
  • Post-visit activities/Documentation & Evaluation/Follow up:✍️This combines the "Evaluation phase" and "Follow up." After the main activities, you assess the efficiency and acceptance of the services provided. Documentation of the visit would also fall under this, although not explicitly mentioned as a separate step. The "Follow up" involves monitoring activities to ensure expected proceedings.

31.(b) State five (5) advantages of home visiting.

  • Allows assessment of the home environment:🏠🔍You can see where and how the family lives, which helps you understand factors affecting their health (like sanitation, safety, living conditions) that you wouldn't see in a clinic.
  • Provides individualized and family-centred care:🧑‍👩‍👧‍👦❤️You can focus specifically on the family's unique needs and dynamics, tailoring your care and education to their specific situation in their own setting.
  • Helps build rapport and trust:🤝Visiting people in their own home can make them feel more comfortable and respected, which helps build a strong trusting relationship between the health worker and the family.
  • Facilitates reaching vulnerable populations:👵 Disabled🤱People who find it hard to come to the clinic (like the elderly, disabled, very sick, or new mothers) can be reached and cared for in their home.
  • More convenient and comfortable for the family:🛋️ Time savedFamilies don't have to travel, wait in queues, or arrange childcare. It can be less disruptive to their daily life.

32. Explain the four (4) pillars of Primary Health Care.

  • Equity:🌍➡️👩‍⚕️This pillar means that essential health services and resources should be available to everyone fairly, regardless of where they live, their social status, or how much money they have. It's about reducing inequalities in health access.
  • Community Participation:🗣️🤝This pillar emphasizes that the community should not just be recipients of health services but should be actively involved in identifying their health problems, planning programs, implementing activities, and evaluating them. Their input and ownership are crucial.
  • Intersectoral Coordination (or Collaboration):🏥🏫🌾💧Health is influenced by many things beyond just healthcare. This pillar means that the health sector must work together with other sectors like education, agriculture, water and sanitation, housing, etc., to address the root causes of ill health (social determinants).
  • Appropriate Technology:🔧💡This pillar means using health technologies (methods, equipment, drugs) that are scientifically sound, affordable, culturally acceptable to the community, and can be maintained and used with local resources and skills. It's about choosing what is best and practical for the specific setting, not necessarily the most advanced.

Paper 1 - Section C: Long Essay Questions

33.(a) Define the term 'Primary Health Care'.

Primary Health Care (PHC) is essential health care made universally accessible to individuals and families in the community.🏠🤝It is based on practical, scientifically sound, and socially acceptable methods and technology.🧪🛠️ culturally okIt involves the full participation of the community🧑‍🤝‍🧑and is provided at a cost that the community and country can afford.💰✅PHC is the first level of contact people have with the health system, bringing health care as close as possible to where people live and work.📍🏥Its goal is to improve health outcomes by addressing the main health problems in the community and focusing on prevention, health promotion, and addressing social determinants of health, not just treating sickness.

33.(b) List ten (10) elements of primary health care.

PHC includes these key elements, often remembered by acronyms like 'ELEMENTS':

  • Education:📚Health education about common health problems and how to prevent and control them.
  • Locally endemic diseases:🦠Prevention and control of diseases common in the local area (like malaria, TB).
  • Expanded Programme on Immunisation (EPI):💉Immunisation against major infectious diseases.
  • Maternal and Child Health (MCH):🤰👶Including family planning services.
  • Essential Drugs:💊Provision of essential medicines for common conditions.
  • Nutrition:🍎Promotion of food supply and proper nutrition.
  • Treatment:🩺🩹Appropriate treatment of common diseases and injuries.
  • Safe water and sanitation:💧🚽Ensuring access to clean water and basic sanitation facilities.
  • Mental Health:🧠😊Addressing mental health needs within the community.
  • Dental Health:🦷Basic dental care and prevention.

33.(c) Outline five (5) roles of the community in primary health care activities.

The community is not just a receiver; they are active partners!

  • Participation in Planning and Decision-Making:🗣️🗺️Community members help identify their own health needs and problems, prioritize them, and decide on the best ways to address them, alongside health workers.
  • Contribution of Resources:🏗️💰Communities can contribute their own resources like labour, local materials, land, or even funds to support health activities (e.g., building a health post, digging a well, community health fund).
  • Implementation of Health Activities:👷‍♀️👩‍🏫Community members can be trained as community health workers, volunteers, or health committee members to carry out various tasks like health education, basic first aid, contact tracing, or running village health teams.
  • Monitoring and Evaluation:📊🔍Community members can help monitor how programs are working, provide feedback, and participate in evaluating their effectiveness and impact on the community.
  • Promoting Healthy Behaviours and Practices:🍎🏃‍♀️🚭Community members can influence each other to adopt healthy lifestyles, practice good hygiene, use health services, and support health campaigns within their families and neighbourhoods.

34.(a) Define the term 'school health'.

School health refers to a set of planned activities and programs implemented within the school setting to protect and promote the health and well-being of students, school staff (teachers, administrators), and sometimes the wider community.🏫👩‍🏫🧑‍🎓It includes providing health services, teaching health education, and creating a safe and healthy school environment.🩺📚🌳The goal is to help students learn and grow into healthy adults by addressing their health needs while they are in school.

34.(b) State nine (9) reasons why school health programs are important.

School health programs are crucial for many reasons:

  • Reach a large, accessible population:🏟️Schools gather large numbers of children and staff regularly, making it an efficient place to deliver health services and education.
  • Address health issues affecting learning:🧠📖Health problems like poor vision, hearing loss, malnutrition, or infections can make it hard for children to learn. School health helps identify and address these barriers.
  • Instill healthy habits early:🌱🍎Children form habits early. School health education can teach them about hygiene, healthy eating, physical activity, and preventing risky behaviours that will benefit them for life.
  • Provide early detection of health problems:👀👂School health services can offer screenings for common issues (eyes, ears, growth) allowing for early detection and intervention before problems become severe.
  • Offer a safe and supportive environment:🛡️😊A healthy school environment includes safe buildings, sanitation, clean water, and a supportive atmosphere free from violence or bullying, all of which affect physical and mental health.
  • Promote mental and emotional well-being:😊🧘‍♀️Counselling and support services in schools help students deal with stress, emotional problems, and social challenges.
  • Link school with family and community health:🏘️🤝🏫Schools can be a focal point for health information and activities that involve parents and the wider community, extending health promotion beyond the school gates.
  • Prevent infectious disease outbreaks:🧼🚫🦠Programs can implement hygiene measures, vaccinations, and rapid response plans to control outbreaks within the school and prevent spread to the community.
  • Prepare students for a healthy future:🎓➡️🌟By providing health knowledge and skills, school health programs equip students to make informed health decisions as they grow into adults.

34.(c) Outline seven (7) components of school health.

School health programs typically include several key components working together:

  • School Health Education:📚🧠Teaching students knowledge and skills about health topics like hygiene, nutrition, preventing diseases (HIV/AIDS, malaria), safety, and healthy relationships.
  • School Health Services:🩺🩹Providing basic health checks, first aid, managing minor illnesses, giving immunizations, health counselling, and referrals to other health facilities.
  • Healthy School Environment:🌳💧🚽Ensuring safe buildings, clean water, proper sanitation (toilets), ventilation, lighting, space for physical activity, and a social climate that is supportive and free from harm.
  • School Nutrition Services:🍎🥪Promoting healthy eating, providing school meals or snacks, and educating students about good nutrition.
  • School Physical Education and Activity:🏃‍♀️⚽Providing opportunities for regular physical activity and teaching skills for various sports and exercises.
  • School Counseling, Psychological, and Social Services:😊🗣️🤝Offering support for students' mental and emotional health, addressing social issues, and providing counselling services.
  • School-Community Health Promotion:🏫🤝🏘️Activities that involve parents, families, and the wider community in supporting school health initiatives and extending health messages beyond the school.

Paper 2 - Section A: Objective Questions (MCQs)

1. The approach of diagnosing and treating a disease in its earliest stage is called ______ prevention.

  • (a) Primary.
  • (b) Secondary.
  • (c) Tertiary.
  • (d) Health.
Correct Answer: (b) Secondary.
Explanation:Secondary prevention is about finding a disease early (diagnosis) and starting treatment quickly to stop it from getting worse or causing complications.🔍💊This happens when the disease has *started*, but ideally before severe symptoms appear.
Why other options are wrong:
  • (a) Primary: Prevents the disease from starting at all (e.g., vaccination).
  • (c) Tertiary: Manages an existing disease to prevent disability or complications (e.g., rehabilitation).
  • (d) Health: This is the state of well-being, not a type of prevention.

2. Which of the following is the most appropriate approach to community entry?

  • (a) Radio announcement.
  • (b) Community survey.
  • (c) Community leaders.
  • (d) Church leaders.
Correct Answer: (c) Community leaders.
Explanation:When you first enter a community to work, it's best to start by meeting with the recognized community leaders (local council, elders, health committee chair, etc.).🤝🔑They can give you permission, introduce you, explain community structure, and help you gain trust. Starting with radio announcements or surveys before meeting leaders can be seen as disrespectful or lead to misunderstanding. Meeting only church leaders might not cover everyone.
Why other options are less appropriate as the *first* step:
  • (a) Radio announcement: Good for informing later, but not the initial way to build relationships and get approval.
  • (b) Community survey: This is a method for assessment *after* you've gained entry and permission.
  • (d) Church leaders: Important in many communities, but focusing only on one type of leader might exclude others or sections of the community. Meeting broader community leaders is usually better initially.

3. Which of the following is NOT related to the importance of school health programme?

  • (a) Promote provision of medical and dental care.
  • (b) Promote better nutrition and feeding practices.
  • (c) Provide counselling services to adolescents.
  • (d) Tap talents of both male and female students.
Correct Answer: (d) Tap talents of both male and female students.
Explanation:School health programs focus on improving health outcomes, behaviors, and the health environment. Providing care, promoting nutrition, and offering counselling are direct health-related activities.🩺🍎🗣️Tapping student talents is an important educational or social goal of the school, but it's not a reason *why* a *health* program is important. Healthy students might be better able to use their talents, but developing talents isn't the core purpose of the health program itself.
Why other options ARE related to school health importance:
  • (a) Promote provision of medical and dental care: Access to basic care in school is a clear health benefit.
  • (b) Promote better nutrition and feeding practices: Good nutrition is fundamental to child health and development, a key area for school health.
  • (c) Provide counselling services to adolescents: Adolescence is a time of unique health challenges, and counselling is a vital support service.

4. Environmental disease control measures include the following EXCEPT;

  • (a) better housing and living conditions.
  • (b) provision of safe water supply.
  • (c) good life styles and healthy habits.
  • (d) proper disposal of refuse.
Correct Answer: (c) good life styles and healthy habits.
Explanation:Environmental control measures are about changing the physical surroundings to prevent disease spread.🏠💧🗑️Housing, water, and waste disposal are all parts of the environment. Lifestyles and habits are about individual behaviors, not the environment itself, although they are related to health.
Why other options ARE environmental control measures:
  • (a) better housing and living conditions: Reduces overcrowding and exposure to poor sanitation.
  • (b) provision of safe water supply: Prevents waterborne diseases.
  • (d) proper disposal of refuse: Reduces breeding grounds for pests and prevents spread of pathogens.

5. The disease that is present the whole time in the community and occurs all year round is referred to as

  • (a) holoepidermic.
  • (b) holo endemic.
  • (c) hyper epidemic.
  • (d) hypo endemic.
Correct Answer: (b) holo endemic.
Explanation:When a disease is always present in a population or region at a stable level, it's called endemic.📍🔄"Holoendemic" is a specific term for a highly endemic disease that affects most people in the population early in life, often leading to some immunity later on (like malaria in some areas). While the question's description ("present the whole time... all year round") could fit basic "endemic", among the options using "endemic," "holo endemic" best describes a significant, constant presence that affects the community widely.
Why other options are wrong:
  • (a) holoepidermic: Not a standard epidemiological term.
  • (c) hyper epidemic: Hyperendemic describes a persistent *high* level, but "epidemic" itself means an *increase* beyond the usual level.
  • (d) hypo endemic: Describes a disease that is endemic but at a *low* level.

6. The type of survey that involves questioning and examining a sample of the population at one point at a period of time is termed as

  • (a) longitudinal survey.
  • (b) cross sectional survey.
  • (c) horizontal survey.
  • (d) screening.
Correct Answer: (b) cross sectional survey.
Explanation:A cross-sectional survey is like taking a snapshot of the population at a specific moment.📸📊You collect data (by asking questions or examining) from a sample of people at one point in time to understand the prevalence of something (like a disease or a behavior).
Why other options are wrong:
  • (a) longitudinal survey: Follows the same group of people over a period of time, taking measurements at different points.
  • (c) horizontal survey: Not a standard epidemiological term.
  • (d) screening: This is a quick test to *identify* potential cases of a disease, not a full survey method.

7. Which of the following is a method of community mobilization?

  • (a) Political commitment.
  • (b) Good leadership.
  • (c) Home visiting.
  • (d) Guidance and counseling.
Correct Answer: (c) Home visiting.
Explanation:Community mobilization involves engaging with individuals and groups to address shared concerns. Home visiting is a direct method of outreach that can build rapport, disseminate information, and encourage participation in community activities. It allows for personalized engagement and can be a crucial first step in connecting with community members who may not attend larger meetings.
Why other options are less direct methods of mobilization:
  • (a) Political commitment: This is an enabling factor that can support community mobilization efforts, but it's not a method of engaging the community directly.
  • (b) Good leadership: While essential for guiding and facilitating mobilization, leadership itself is a quality or role, not a specific *method* of reaching and engaging the community.
  • (d) Guidance and counseling: These are individual-level support services and are not typically used as primary methods for mobilizing a whole community.

8. The best course of action to take when there is an outbreak of measles in the community is to

  • (a) instruct mothers to feed their community adequately.
  • (b) instruct mothers to keep their babies home.
  • (c) give to babies aged 6-11 months vitamin A.
  • (d) immunize babies aged 6-9 month with measles vaccine.
Correct Answer: (d) immunize babies aged 6-9 month with measles vaccine.
Explanation:During a measles outbreak, the most urgent action is to protect those who are most vulnerable and stop the spread.💉🛡️Rapidly vaccinating susceptible young children (often the target group in outbreaks) is the most effective way to build immunity and contain the outbreak. The standard first dose is often around 9 months, but in outbreaks, it can be given as early as 6 months, with a repeat dose later.
Why other options are less effective for outbreak control:
  • (a) instruct mothers to feed adequately: Good nutrition is important for recovery but doesn't stop transmission.
  • (b) instruct mothers to keep their babies home: Isolation helps, but vaccination is more proactive and provides lasting protection.
  • (c) give to babies aged 6-11 months vitamin A: Vitamin A helps reduce the severity of measles, but it doesn't prevent infection or transmission. Vaccination is the primary preventive measure.

9. Which of the following is true with regards to guinea worm infection?

  • (a) Cyclops are the intermediate hosts.
  • (b) Larvae enter the body through intact skin.
  • (c) Female worm may be seen in subcutaneous tissues.
  • (d) To prevent infestation, step well should be used in bathing.
Correct Answer: (a) Cyclops are the intermediate hosts.
Explanation:Guinea worm (Dracunculus medinensis) infection is caused by drinking water containing tiny water fleas called Cyclops, which are infected with guinea worm larvae.💧🔬🐛The Cyclops are the intermediate hosts.
Why other options are false:
  • (b) Larvae enter the body through intact skin: Infection happens by *drinking* contaminated water, not through the skin.
  • (c) Female worm may be seen in subcutaneous tissues: The adult female worm migrates through the body and eventually emerges *from* the skin, usually on the leg, often causing a painful blister. You see her emerging, not just passively "seen" under the skin before she comes out.
  • (d) To prevent infestation, step well should be used in bathing: This is wrong. Step wells are easily contaminated. Using *protected* water sources or filtering water is how you prevent infection. Bathing in infected water sources (like step wells) can spread the disease if an infected person enters the water while their worm is emerging.

10. Hyper pigmentation in onchocererciasis results in

  • (a) module formation.
  • (b) blindness.
  • (c) lizard skin.
  • (d) calabar swelling.
Correct Answer: (c) lizard skin.
Explanation:Onchocerciasis (River Blindness) causes various skin changes.🦎Chronic infection can lead to thickened, dry, scaly skin that resembles lizard skin, often accompanied by changes in pigmentation (both hyperpigmentation - darkening, and depigmentation - lightening, sometimes called "leopard skin"). So, hyperpigmentation is part of the changes that result in the appearance known as "lizard skin".
Why other options are wrong:
  • (a) module formation: Onchocerciasis causes subcutaneous nodules (lumps) where adult worms live, but hyperpigmentation is a skin symptom, not the nodules themselves.
  • (b) blindness: Blindness is a severe complication affecting the eyes, not a skin pigmentation issue.
  • (d) calabar swelling: These are large, temporary swellings associated with Loiasis ("African eye worm"), a different parasitic infection.

11. The single and most important measure in the control of Tuberculosis in the community is

  • (a) health education.
  • (b) BCG immunization.
  • (c) contact tracing.
  • (d) treatment compliance.
Correct Answer: (d) treatment compliance.
Explanation:TB spreads from person to person when someone with active, infectious TB coughs or sneezes. The *most* important thing to stop this is to make sure people who have TB complete their full course of treatment.💊✅This cures them, stops them from spreading the bacteria, and prevents the development of drug-resistant TB. If people stop treatment early, they remain infectious.
Why other options are important but not the *single most* important:
  • (a) health education: Helps people understand TB and seek care, but doesn't stop spread from already infected, untreated individuals.
  • (b) BCG immunization: Protects young children from severe forms but is less effective against pulmonary (lung) TB in adults, which is the main source of spread.
  • (c) contact tracing: Helps find people who might be infected, but they also need treatment/prevention (which relies on *treatment compliance* of the original case).

12. Which of the following gastro-intestinal complication may occur in a child with severe paroxysms of whooping cough?

  • (a) Gastric ulcer.
  • (b) Umblical hernia.
  • (c) Ulcerative colitis.
  • (d) Pylorospasm.
Correct Answer: (b) Umblical hernia.
Explanation:Whooping cough (Pertussis) causes severe, violent coughing fits (paroxysms).Cough! Cough! ➡️ Hernia?This intense coughing significantly increases pressure inside the abdomen. In children, this increased pressure can cause or worsen an umbilical hernia, where part of the intestine pushes through a weak spot near the belly button.
Why other options are unrelated:
  • (a) Gastric ulcer: Sores in the stomach lining, not caused by coughing pressure.
  • (c) Ulcerative colitis: Inflammation and ulcers in the large intestine, an inflammatory bowel disease.
  • (d) Pylorospasm: Spasm of the muscle controlling the exit from the stomach, typically seen in infants causing vomiting, not directly related to whooping cough pressure.

13. Resistance of susceptible individual to certain bacterial or viral infections can be artificially enhanced by

  • (a) medical treatment.
  • (b) health education.
  • (c) immunization.
  • (d) good nutrition.
Correct Answer: (c) immunization.
Explanation:Immunization (vaccination) is specifically designed to artificially train your immune system to recognize and fight off specific bacteria or viruses, making you resistant to them if you are exposed.💉🛡️🦠
Why other options are wrong:
  • (a) medical treatment: Treats an infection *after* it happens, doesn't prevent it by enhancing resistance beforehand.
  • (b) health education: Provides information about preventing infection through behavior, but doesn't directly enhance the body's internal resistance.
  • (d) good nutrition: Supports overall immune function, contributing to general resistance, but immunization provides specific, targeted artificial resistance.

14. An acute bacterial infection characterized by step ladder fever spread through contamination of food and water is

  • (a) Typhoid.
  • (b) Malaria.
  • (c) Measles.
  • (d) Dysentery.
Correct Answer: (a) Typhoid.
Explanation:This describes Typhoid fever perfectly!📈💧🍽️It's caused by Salmonella Typhi bacteria, spreads through contaminated food and water, and a characteristic symptom is the fever rising higher each day in a "step-ladder" pattern.
Why other options are wrong:
  • (b) Malaria: Caused by a parasite, spread by mosquitoes, and has cyclical fever, not step-ladder.
  • (c) Measles: Caused by a virus, spread by air, causes rash, and has a different fever pattern.
  • (d) Dysentery: Bacterial or amoebic, spreads via food/water (fecal-oral), causes severe diarrhea with blood, but step-ladder fever is not a key characteristic.

15. Organisms that usually benefit the person infested are called

  • (a) pathogens.
  • (b) commensals.
  • (c) symbiotics.
  • (d) parasites.
Correct Answer: (c) symbiotics.
Explanation:The question asks about organisms that benefit the *infested person* (the host).😊🐛This describes a mutualistic relationship where both the host and the organism benefit. Mutualism is a type of symbiosis. So, "symbiotics" (referring to organisms in a symbiotic, specifically mutualistic, relationship) is the best fit here, meaning they live together and the host benefits.
Why other options are wrong:
  • (a) pathogens: Cause harm to the host.
  • (b) commensals: Benefit themselves without significantly helping *or* harming the host.
  • (d) parasites: Benefit themselves *at the expense of* the host (cause harm).

16. The primary health care pillar which helps in policy formation, resource allocation, community mobilization and support is called

  • (a) community participation.
  • (b) appropriate technology.
  • (c) political commitment/will.
  • (d) intersectoral collaboration.
Correct Answer: (c) political commitment/will.
Explanation:Political commitment and will from the government and leaders are essential for PHC.Govern 🤝 HealthThey decide on policies, allocate budgets (resources), and provide the necessary support and framework that enables community mobilization and intersectoral work. Without political will, PHC cannot be implemented effectively on a large scale.
Why other options are related but not the driving force for these activities:
  • (a) community participation: The community's role in the program, enabled by support and policy.
  • (b) appropriate technology: The suitable tools used in PHC.
  • (d) intersectoral collaboration: Different sectors working together, which is facilitated by policy and political support.

17. The sustainable development goal builds on a principle called

  • (a) health for all.
  • (b) gender inequality.
  • (c) holistic approach.
  • (d) leaving no one behind.
Correct Answer: (d) leaving no one behind.
Explanation:A core guiding principle of the Sustainable Development Goals (SDGs) is "Leaving No One Behind".🚶‍♀️🚶‍♂️➡️🌟This means making sure that development benefits everyone, especially the poorest and most vulnerable, and that disparities (differences) are reduced across all goals.
Why other options are wrong:
  • (a) health for all: A key principle of PHC and a goal addressed by SDG 3, but "leaving no one behind" is a broader principle guiding *all* SDGs.
  • (b) gender inequality: This is a problem the SDGs aim to *solve* (SDG 5), not a principle they are built upon.
  • (c) holistic approach: The SDGs do take a holistic view (seeing how everything is connected), but "leaving no one behind" is a more specific, named principle guiding their implementation.

18. The following are sustainable development goals EXCEPT;

  • (a) affordable and clean energy.
  • (b) climatic action.
  • (c) to stop accidents.
  • (d) industry innovation and infrastructure.
Correct Answer: (c) to stop accidents.
Explanation:The SDGs are a specific list of 17 global goals.✅✅❌✅Affordable and Clean Energy is SDG 7. Climate Action is SDG 13. Industry, Innovation, and Infrastructure is SDG 9. While reducing accidents is important for safety and health (linked to SDG 3), "to stop accidents" is not one of the 17 named SDGs.
Why other options ARE SDGs:
  • (a) affordable and clean energy (SDG 7).
  • (b) climatic action (SDG 13).
  • (d) industry innovation and infrastructure (SDG 9).

19. Which of the following explains the meaning of appropriate technology?

  • (a) Drawing up of joint plans.
  • (b) improving local capacity.
  • (c) Improving development projects.
  • (d) Improving community mobilization.
Correct Answer: (b) improving local capacity.
Explanation:Appropriate technology means using methods and tools that are suitable for the local setting – they should be affordable, easy to use, and maintainable by people in the community using local resources and skills.🔧➡️💪🏠This directly relates to building and improving the community's capacity to manage health activities themselves.
Why other options are outcomes or other activities:
  • (a) Drawing up of joint plans: This is part of planning, not the meaning of appropriate technology itself.
  • (c) Improving development projects: Appropriate technology helps make projects better, but it's a means to an end, not the definition of the technology concept.
  • (d) Improving community mobilization: Appropriate technology can support mobilization (e.g., simple communication tools), but that's not what the concept of appropriate technology primarily means.

20. Which of the following is NOT a condition for effectiveness of the community health Services?

  • (a) Availability.
  • (b) Accessibility.
  • (c) Equity.
  • (d) Utilization.
Correct Answer: (d) Utilization.
Explanation:Effectiveness means whether the services achieve their intended health outcomes.🩺➡️ healthier?Availability (services exist), Accessibility (people can reach them), and Equity (services are fair) are *conditions* or factors that influence whether services *can be* effective and *will be used*. However, Utilization (whether people *actually use* the services) is an *indicator* of whether services are being accessed, which is important for effectiveness, but it's more of a measure of usage than a *condition* that *ensures* effectiveness itself.🩺➡️Availability: Services need to exist to be effective.🩺➡️Accessibility: People need to be able to reach and use the services (considering factors like location, cost, and transportation).🩺➡️Equity: Services should be fair and available to everyone, regardless of their background. While utilization is a result of effective services (people use services that are available, accessible, and equitable), it's not typically considered a condition for the effectiveness of the services themselves. The effectiveness of the service is determined by its quality and ability to achieve desired health outcomes, assuming people can access and use it.

Paper 2 - Fill in the Blank Spaces

21. Contact tracing of a person who has been exposed to a communicable epidemic disease helps the health worker to carry out...?

👉Disease control
Explanation:When you do contact tracing, you find people who might have caught the disease from an infected person. By finding them quickly, you can test them, treat them if needed, or ask them to isolate. This stops the disease from spreading further, helping to control the outbreak.🔗🕵️‍♀️🚫🦠

22. The component of community health that promotes the well being of the child and her education is called...?

👉School health
Explanation:School health programs focus on the health of children while they are in school.🏫❤️📖They help make sure children are healthy so they can learn well and get a good education.

23. The causative micro organism of jiggers infection is...?

👉Tunga penetrans (Sand flea / Jigger flea)
Explanation:Jiggers are caused by a tiny flea called *Tunga penetrans*.🐜🦶The female flea burrows into the skin (usually feet or toes) and lays eggs, causing itching, pain, and swelling. While the term "microorganism" is not scientifically correct for a flea (which is a visible insect), this is the agent that causes the infection. It is a type of parasite.

24. Severe form of malaria caused by plasmodium falciparum is called...?

👉Malignant malaria / Complicated malaria / Severe malaria
Explanation:Plasmodium falciparum is the most dangerous type of malaria parasite.🦟➡️🤒The illness it causes can be very severe, affecting the brain, kidneys, and other organs. This severe form is often called malignant or complicated malaria.

25. The characteristic sign that appears during the prodromal stage of measles is called...?

👉Koplik's spots
Explanation:Before the famous measles rash appears, tiny white spots with reddish centers can show up inside the mouth, usually on the inside of the cheeks opposite the molars.👄 نقطThese are called Koplik's spots and are a specific sign of measles in the early stage.

26. The period of isolation of an infectious or suspect case to prevent the spread of the disease is called...?

👉Isolation
Explanation:Isolation means separating someone who is sick with an infectious disease (or suspected of being sick) from healthy people.🚪🚫🤧This is done to prevent the germs from spreading to others. Quarantine is for people who were *exposed* but are not yet sick.

27. The recommended dose of BCG given to a child below 12 months is...?

👉0.05ml (intradermal)
Explanation:The BCG vaccine protects against Tuberculosis and is given as a shot into the skin (intradermal). For babies under one year old, the standard dose is 0.05 milliliters.👶💉

28. Evaluation of immunization campaign is by carrying out...?

👉Vaccination coverage rate.
Explanation:To see how well an immunization campaign worked, health workers do things like conduct surveys to find out how many children actually received the vaccine (coverage) and look at disease rates to see if the campaign reduced illness (impact). This is part of an evaluation study or specifically a coverage survey.📊👶📈

29. Health services whose cost can be met by most of the community members are said to be...?

👉Affordable
Explanation:(Same as Paper 1, Q29). If people can pay for health services without struggling financially, those services are affordable.Accessible to wallet 👛

30. The process that ensures maintenance of a vaccine's potency from the manufacturer to the consumer is...?

👉Cold chain
Explanation:(Same as Paper 1, Q30). Keeping vaccines within the correct temperature range from where they are made to where they are given is vital so they work properly. This system is the cold chain.Keep it cool 😎

Paper 2 - Section B: Short Essay Questions

31. Outline five (5) strategies of primary prevention of diseases.

Primary prevention aims to stop diseases from starting in the first place, for healthy people.

  • Health Education and Promotion:📚🍎🏃‍♀️Teaching people about healthy lifestyles, good hygiene, balanced diet, and the importance of physical activity to prevent various diseases.
  • Immunization/Vaccination:💉🛡️Giving vaccines to protect individuals from specific infectious diseases (like measles, polio, tetanus) before they are exposed.
  • Improving Environmental Sanitation:💧🚽🌳Ensuring access to clean and safe drinking water, proper disposal of waste (faeces, refuse), and vector control (like mosquito nets) to prevent infectious diseases.
  • Specific Protection Measures:🧤🧢Using methods that directly protect against harm, such as using condoms to prevent STIs, wearing helmets when cycling, or using seatbelts in cars.
  • Nutritional Programs:🥕🍚Promoting adequate and balanced nutrition, providing supplements (like Vitamin A or iron) to prevent deficiency diseases, especially in vulnerable groups like children and pregnant women.

32. Outline five (5) factors that promote community mobilization.

These factors help get a community motivated and organized for action:

  • Strong Local Leadership:🗣️👍Having respected and dynamic leaders within the community who can inspire, guide, and organize people.
  • Clear Identification of a Felt Need/Problem:💡🔥When community members clearly see and agree on a problem that affects them, they are more likely to be motivated to act to solve it.
  • Trust and Good Relationship:🤝😊Building trust between the community members themselves and between the community and external health workers encourages open communication and willingness to work together.
  • Perceived Benefit/Incentive:🎁🌟When community members believe that participating will bring clear benefits to them or their families, or if there's some form of motivation, they are more likely to get involved.
  • Effective Communication:📣👂Using clear, simple, and culturally appropriate language and methods to share information, discuss issues, and plan activities ensures everyone understands and feels included.

Paper 2 - Section C: Long Essay Questions

33.(a) Outline five (5) clinical manifestation of scabies.

Scabies is a skin condition caused by tiny mites burrowing into the skin. Here are common signs you would see or hear about:

  • Intense Itching (Pruritus):😩 itchy!This is the most common symptom, often severe and typically worse at night, which can disturb sleep.
  • Rash:🔴bumpsSmall red bumps (papules) or tiny blisters can appear on the skin, often in a widespread pattern or clustered in certain areas.
  • Burrows:〰️Tiny, slightly raised lines that look like tracks or tunnels on the skin surface. These are where the mites burrow. They are often found in the thin skin between fingers, on wrists, elbows, or feet.
  • Sores or Crusting (especially in severe cases):🩹Scratching the itchy rash can lead to open sores, which can then get infected with bacteria. Crusted scabies is a very severe form with thick crusts containing many mites.
  • Distribution Pattern:✋ Wrist🦶The rash and burrows often appear in specific body areas where the mites like to live, such as the webs of fingers and toes, wrists, elbows, armpits, waistline, buttocks, and genitals. In infants, the head, neck, palms, and soles can also be affected.

33.(b) Describe the management of an adult patient with scabies.

Managing scabies requires treating not only the patient but also their close contacts and cleaning the environment to prevent reinfection.

Aims of Management of Scabies
  • Eliminate the mites:🚫🕷️The primary aim is to kill the scabies mites. This is usually done with prescription medicated creams or lotions that are applied to the skin.
  • Relieve symptoms:🧴 soothing reliefManagement aims to stop the intense itching and irritation caused by the mites. This can involve using anti-itch creams or oral medications.
  • Prevent spread:🧼🧺 Stop the spreadIt's crucial to prevent the scabies mites from spreading to other people. This involves treating all close contacts of the infected person, even if they don't have symptoms, and thoroughly cleaning or isolating contaminated items like clothing and bedding.
  • Prevent complications:⚕️ Healing skinScratching can lead to skin infections. Management includes addressing any existing infections and preventing new ones by keeping the skin clean and using treatments that promote healing.
  • Educate and follow-up:📚🗣️ Stay informedPatients and their contacts need to understand how to use the treatments correctly, how to prevent re-infestation, and what to expect during and after treatment. Follow-up is important to ensure the treatment was successful and to address any ongoing issues.
    • Management include;

    • Diagnosis Confirmation:🔍🩺A doctor or nurse examines the skin for the characteristic rash and burrows. Sometimes, a skin scraping is done to look for mites, eggs, or faeces under a microscope.
    • Application of Scabicide:🧴The most common treatment is a lotion or cream (like Permethrin 5%). The patient is instructed to apply it to their *entire body* from the neck downwards, making sure to cover all skin folds, between fingers and toes, and under nails.
    • Treatment Duration:⏱️⏰The scabicide is usually left on the skin for a specific time (e.g., 8-14 hours, often overnight) before being washed off. A second application might be recommended a week later to kill mites that hatch from eggs missed in the first treatment.
    • Treatment of Contacts:🧑‍🤝‍🧑 SimultaenousIt is VITAL that all people who had close, prolonged skin-to-skin contact with the infected person (like family members, sexual partners, or housemates) are treated at the *same time*, even if they don't show symptoms yet. This breaks the cycle of transmission.
    • Hygiene Measures (Clothing and Bedding):🧺🔥All clothing, bedding, and towels used by the infected person and contacts in the 72 hours before treatment should be washed in hot water (at least 50°C or 122°F) and machine dried on a hot cycle, or dry-cleaned. Items that cannot be washed should be sealed in a plastic bag for at least 72 hours to a week to kill the mites.
    • Management of Symptoms:soothe 🌬️Itching can continue for a few weeks even after the mites are dead. Antihistamines can be prescribed to help with the itching, and sometimes topical steroid creams for the rash (but not used if scabicide is on).
    • Follow-up:🔄✅A follow-up appointment might be needed to check if the treatment worked and to manage any persistent symptoms or secondary infections.

    33.(c) Outline five (5) prevention and control measures of the above condition (Scabies).

    To prevent and control scabies:

    • Early Diagnosis and Prompt Treatment:⏰💡Quickly identifying people with scabies and treating them as soon as possible stops them from spreading the mites.
    • Simultaneous Treatment of Contacts:🏠👨‍👩‍👧‍👦Making sure everyone who lived with or had close contact with the infected person gets treated at the same time is essential to prevent reinfection and continued spread.
    • Proper Hygiene and Environmental Cleaning:🧼🧺Washing clothes, bedding, and towels in hot water and drying them thoroughly helps kill mites that have fallen off the skin.
    • Avoid Close Skin-to-Skin Contact:🙅‍♀️🤝Avoiding prolonged direct physical contact with someone known to have scabies can prevent transmission.
    • Health Education:📚🗣️Educating individuals and communities about how scabies spreads, its symptoms, and the importance of treating everyone in the household at once, and hygiene measures.

    34.(a) Outline ten (10) sustainable development goals, excluding good health and well being.

    The Sustainable Development Goals (SDGs) are a set of 17 global goals adopted by the United Nations. Here are all seventeen, with ten outlined as requested (excluding SDG 3 Good Health and Well-being):

    1. SDG 1: No Poverty➡️💵🚫Ending poverty in all its forms everywhere.
    2. SDG 2: Zero Hunger🍎🥖Ending hunger, achieving food security and improved nutrition, and promoting sustainable agriculture.
    3. **SDG 3: Good Health and Well-being**❤️‍🩹💪Ensuring healthy lives and promoting well-being for all at all ages.
    4. SDG 4: Quality Education📚👩‍🎓Ensuring inclusive and equitable quality education and promoting lifelong learning opportunities for all.
    5. SDG 5: Gender Equality👩=👨Achieving gender equality and empowering all women and girls.
    6. SDG 6: Clean Water and Sanitation💧🚽Ensuring availability and sustainable management of water and sanitation for all.
    7. SDG 7: Affordable and Clean Energy💡☀️Ensuring access to affordable, reliable, sustainable, and modern energy for all.
    8. SDG 8: Decent Work and Economic Growth💼📈Promoting sustained, inclusive, and sustainable economic growth, full and productive employment, and decent work for all.
    9. SDG 9: Industry, Innovation, and Infrastructure🏗️🏭💡Building resilient infrastructure, promoting inclusive and sustainable industrialization, and fostering innovation.
    10. SDG 10: Reduced Inequalities📉⚖️Reducing inequality within and among countries.
    11. SDG 11: Sustainable Cities and Communities🏙️🏘️Making cities and human settlements inclusive, safe, resilient, and sustainable.
    12. SDG 12: Responsible Consumption and Production♻️🛍️Ensuring sustainable consumption and production patterns.
    13. SDG 13: Climate Action🌍🔥❄️Taking urgent action to combat climate change and its impacts.
    14. SDG 14: Life Below Water🐠🌊Conserving and sustainably using the oceans, seas, and marine resources for sustainable development.
    15. SDG 15: Life on Land🌳🦁Protecting, restoring, and promoting sustainable use of terrestrial ecosystems, sustainably managing forests, combating desertification, and halting and reversing land degradation and halting biodiversity loss.
    16. SDG 16: Peace, Justice, and Strong Institutions🕊️⚖️🏛️Promoting peaceful and inclusive societies for sustainable development, providing access to justice for all, and building effective, accountable, and inclusive institutions at all levels.
    17. SDG 17: Partnerships for the Goals🤝🌍Strengthening the means of implementation and revitalizing the global partnership for sustainable development.

    34.(b) Explain five (5) targets of the third sustainable development goal. (ensure good health and well being)

    SDG 3 is "Ensure healthy lives and promote well-being for all at all ages". It has many targets to achieve this goal. Here are five examples:

    • Reduce Maternal Mortality:🤰📉A target is to reduce the global maternal mortality ratio (deaths of mothers during pregnancy or childbirth) to less than 70 per 100,000 live births. This means making pregnancy and delivery safer.
    • End Preventable Child Deaths:👶➡️grow upA target is to end preventable deaths of newborns and children under 5 years old, aiming to reduce neonatal mortality (deaths in the first month) to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births.
    • Fight Communicable Diseases:🚫🦠 ाA target is to end the epidemics of diseases like AIDS, Tuberculosis, Malaria, and neglected tropical diseases, and combat Hepatitis, water-borne diseases, and other major infectious diseases.
    • Reduce Non-Communicable Diseases (NCDs):❤️🧠📉A target is to reduce premature deaths from NCDs (like heart disease, cancer, diabetes, lung diseases) by one-third through prevention and treatment, and promote mental health and well-being.
    • Achieve Universal Health Coverage (UHC):🏥ForAllA target is to achieve UHC, meaning everyone has access to the health services they need, when and where they need them, without facing financial hardship. This includes access to essential medicines and vaccines.

    35.(a) Outline five (5) measures that are used to protect a susceptible host from an infectious disease in the community.

    These measures focus on strengthening or protecting the person (the susceptible host) so they don't get sick, even if they are exposed to the disease agent:

    • Immunization:💉🛡️Giving vaccines to a healthy person to make their immune system strong against a specific infection, so they don't get the disease or get a milder form if exposed.
    • Chemoprophylaxis:💊🛡️Giving medication to a healthy person to prevent them from getting infected, even if exposed (e.g., taking antimalarial drugs when traveling to a malaria area, or medication to prevent TB in contacts).
    • Health Education and Behaviour Change:📚🧼🚶‍♀️Teaching people about how diseases spread and promoting healthy behaviours like handwashing, safe food handling, safe sex, avoiding crowded places during outbreaks, or using bed nets. This empowers the host to reduce their own risk.
    • Improved Nutritional Status:🍎💪Ensuring people have good nutrition strengthens their overall immune system, making them less susceptible to infections and better able to fight them off if they do get infected.
    • Use of Personal Protective Measures:😷🚫🐜Advising individuals to use personal protective equipment like wearing masks (for airborne diseases), using treated bed nets (for malaria), or filtering/treating drinking water at home (for waterborne diseases).

    35.(b) Explain five (5) techniques applied in home visiting.

    When a health worker visits a home, they use different techniques to interact effectively with the family:

    • Establishing Rapport and Trust:🤝😊From the moment you arrive, focus on making the family feel comfortable and respected. Be polite, listen actively, show empathy, and build a trusting relationship. This opens the door for effective communication and assessment.
    • Active Listening:👂🤔Pay full attention to what family members are saying, both verbally and non-verbally. Ask clarifying questions, summarize what you've heard to show you understand, and don't interrupt. This helps uncover their real concerns and needs.
    • Using Open-ended Questions:❓🗣️Ask questions that require more than just a 'yes' or 'no' answer (e.g., "Tell me about..." or "How have you been managing...?"). This encourages family members to share more information and express their feelings.
    • Observation:👀🔍While interacting, observe the home environment (cleanliness, safety, resources), the family dynamics (how members interact), the health status of individuals, and their interactions with each other. Observation provides valuable non-verbal information.
    • Demonstration and Return Demonstration:👩‍🏫➡️🧑‍💻When teaching skills (e.g., how to prepare ORS, how to care for a wound, how to breastfeed), first show the family how to do it (demonstration). Then, ask them to do it themselves while you watch and guide (return demonstration) to make sure they learned correctly.
    • Collaborative Problem-Solving:🗺️👥💡Work *with* the family to identify solutions to their health problems, rather than just telling them what to do. Discuss options, consider their resources and preferences, and help them choose solutions that work best for them.

    ✨ Keep revising and believe in yourself! You can do this! ✨

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    Community Health & Tropical Medicine UNMEB Past Papers Read More »

    HIV AND PREGNANCY

    HIV AND PREGNANCY

    HIV (Human Immunodeficiency Virus) is a virus that attacks the body’s immune system, specifically the CD4 cells (T cells), which are important for immune defence. 

    If untreated, HIV can lead to AIDS (Acquired Immunodeficiency Syndrome), a condition where the immune system is severely weakened

    HIV is a lenti-virus (slow and long acting) and belongs to the Retroviruses group. HIV invades the helper T cells to replicate itself thereby limiting the body’s ability to fight infection . HIV is the virus that causes AIDS, and it has no cure

    Types of HIV 

    1. HIV-1: This is the most common and widespread type of HIV, accounting for the vast majority of HIV infections globally. It is highly infectious and has several subtypes (or clades), labelled A through K. HIV-1 is the primary cause of the global HIV pandemic and is more aggressive in its progression to AIDS compared to HIV-2.
    2. HIV-2: This type is less common and primarily found in West Africa. It is less transmissible and generally progresses more slowly to AIDS than HIV-1. There are fewer subtypes of HIV-2, labelled A through H. 

    Modes of HIV Transmission

    1. Sexual Contact:

    • Unprotected Vaginal Sex: HIV can be transmitted through vaginal fluids and semen during unprotected vaginal intercourse..

    2. Blood-to-Blood Contact:

    • Sharing Needles: Using contaminated needles or syringes, common among intravenous drug users, can transmit HIV.
    • Blood Transfusions: Although rare in countries with stringent blood screening, HIV can be transmitted through infected blood transfusions.
    • Exposure to Contaminated Blood: Health care workers can be at risk through needle stick injuries or contact with open wounds.

    3. Mother-to-Child Transmission:

    • During Pregnancy: HIV can cross the placenta from mother to baby.
    • During Childbirth: The baby can be exposed to HIV in the mother’s blood and vaginal fluids during delivery.
    • Breastfeeding: HIV can be transmitted through breast milk from an infected mother to her child.

    4. Other Modes:

    • Contaminated Medical Equipment: Use of non-sterile instruments during medical or dental procedures can transmit HIV.
    • Organ and Tissue Transplants: Transplantation of infected organs or tissues, though rare due to screening practices, can transmit HIV.

    5. Less Common Modes:

    • Tattooing and Piercing: If non-sterile needles are used, there is a risk of HIV transmission.
    • Contact Sports: Although extremely rare, transmission can occur if both participants have open wounds.
     

    Factors That Facilitate Mother-to-Child Transmission of HIV

    Maternal Factors:

    1. Viral Load and Immune Status:

    • High Viral Load: Higher levels of HIV in the mother’s blood increase the risk of transmission to the baby.
    • Low CD4 Count: A weakened immune system due to low CD4 counts enhances transmission risk.
    • Maternal Acquisition of HIV: New HIV infections during pregnancy or lactation significantly increase transmission risk.

    2. Infections and Inflammation:

    • Vaginal Infections: Infections such as bacterial vaginosis can elevate the risk of HIV transmission.
    • Chorioamnionitis: Inflammation of the foetal membranes due to infection can facilitate HIV transmission.

    3. Access to Antiretroviral Therapy (ART):

    • Lack of ART: Mothers who do not receive ART are more likely to transmit HIV.
    • Poor Adherence to ART: Inconsistent use of ART reduces its effectiveness in preventing transmission.
    • Timing of ART Initiation: Starting ART late in pregnancy or not at all reduces its preventive benefits.

    4. Socioeconomic Factors:

    • Lack of Healthcare Access: Limited access to prenatal care and HIV testing can lead to missed opportunities for prevention.
    • Education and Awareness: Lack of knowledge about HIV transmission and prevention strategies among pregnant women.

    5. Nutritional Status:

    • Poor Maternal Nutrition: Malnutrition can weaken the mother’s immune system, increasing the risk of transmission.

    Labour and Delivery Factors:

    6. Delivery Method:

    • Vaginal Delivery: Higher risk of transmission compared to elective caesarean section, especially if the mother has a high viral load.
    • Prolonged/Difficult Labour: Increased exposure to maternal fluids during extended or complicated labour can raise the risk.

    7. Prematurity:

    • Premature Birth: Prematurity can increase the risk of transmission due to underdeveloped immune systems in infants.

    8. Membrane Rupture:

    • Prolonged Rupture of Membranes (PROM): Rupture lasting more than 4 hours before delivery increases the risk of HIV transmission.

    9. Invasive Monitoring and Procedures:

    • Use of invasive monitoring or procedures during labour can increase the risk of HIV transmission.

    Postnatal Feeding Factors:

    10. Breastfeeding Practices:

    • Prolonged Breastfeeding: Longer duration of breastfeeding increases the risk of HIV transmission.
    • Breast Health: Conditions like sore nipples, abscesses, or mastitis can increase the risk.
    • Mixed Feeding: Combining breastfeeding with other foods or fluids increases transmission risk. Exclusive breastfeeding for the first 3-6 months does not show excess transmission compared to formula feeding alone.

    11. Exclusive Breastfeeding:

    •  Exclusive breastfeeding means providing breast milk only, without additional fluids, water, food, teats, or pacifiers, and involves on-demand feeding.

    12. Oral Health in Infants:

    • Oral Thrush: Presence of oral thrush in breastfed infants can increase the risk of HIV transmission.
    Phases of HIV Entry into Host Cells

    Phases of HIV Entry into Host Cells

    1. Binding: The HIV virus first attaches to the CD4 receptors on the surface of the host cell, typically a type of immune cell called a CD4+ T lymphocyte. HIV’s envelope protein, gp120, specifically binds to the CD4 receptor. This interaction triggers a conformational change in gp120 that allows it to also interact with a co-receptor, usually CCR5 or CXCR4, on the host cell surface. This dual receptor binding is essential for the virus to proceed to the next step.
    2. Fusion: After binding, the HIV viral envelope fuses with the host cell membrane, allowing the viral contents to enter the host cell. The conformational change in gp120 caused by CD4 and co-receptor binding exposes another viral protein, gp41. gp41 facilitates the merging of the viral envelope with the host cell membrane, creating a fusion pore through which the viral capsid containing the viral RNA and enzymes can enter the host cell cytoplasm.
    3. Reverse Transcription: Once inside the host cell, the viral RNA genome is reverse transcribed into DNA. The enzyme reverse transcriptase, carried within the viral capsid, converts the single-stranded viral RNA into double-stranded DNA. This process is error-prone, leading to a high mutation rate which contributes to the virus’s ability to evade the immune system and develop drug resistance.
    4. Integration: The newly synthesized viral DNA is integrated into the host cell’s genome. The viral DNA is transported into the host cell nucleus, where the enzyme integrase integrates it into the host cell’s DNA. This integrated viral DNA is known as a provirus and can remain dormant for a period before becoming active.
    5. Replication: Once integrated, the viral DNA can be transcribed and translated to produce new viral RNA and proteins. The host cell’s machinery reads the integrated viral DNA and begins to produce viral RNA. Some of this RNA will serve as genomes for new viral particles, while others will be used to produce viral proteins through the process of translation.
    6. Assembly: New viral particles are assembled within the host cell. The newly made viral RNA and proteins are transported to the host cell’s surface, where they assemble into new immature viral particles. This assembly process involves the gathering of viral components into a budding virion.
    7. Budding: The new viral particles bud off from the host cell, acquiring an envelope from the host cell membrane in the process. The immature viral particles bud off from the host cell, during which they incorporate a portion of the host cell’s membrane as their envelope. The viral enzyme protease then cleaves certain viral precursor proteins into their mature forms, resulting in a fully mature and infectious virus ready to infect other cells.

    Clinical Manifestations of HIV/AIDS

    The World Health Organization (WHO) has established a staging system to classify HIV infection and disease progression:

    Clinical Stage I:

    1. Asymptomatic: No symptoms of HIV-related illness.
    2. Persistent Generalized Lymphadenopathy: Enlargement of lymph nodes lasting more than three months.
    3. Performance Scale 1: Asymptomatic with normal activity level.

    Clinical Stage II:

    1. Moderate Weight Loss: Less than 10% of presumed or measured body weight lost.
    2. Minor Muco-cutaneous Manifestations: Skin conditions like seborrheic dermatitis, prurigo, or fungal nail infections.
    3. Herpes Zoster: History of shingles within the last five years.
    4. Recurrent Upper Respiratory Tract Infections: Such as bacterial sinusitis, tonsillitis, or otitis media.
    5. Performance Scale 2: Symptomatic but normal activity level.

    Clinical Stage III:

    1. Severe Weight Loss: More than 10% of presumed or measured body weight lost.
    2. Unexplained Chronic Diarrhoea: Lasting more than one month.
    3. Unexplained Prolonged Fever: Constant or intermittent, lasting more than one month.
    4. Oral Candidiasis: Oral thrush, a fungal infection.
    5. Oral Hairy Leukoplakia: White patches on the tongue or mouth.
    6. Pulmonary Tuberculosis: Active TB infection.
    7. Severe Bacterial Infections: Such as pneumonia, pyomyositis, or bacteremia.
    8. Acute Necrotizing Ulcerative Gingivitis: Severe gum disease.
    9. Unexplained Anaemia, Neutropenia, or Thrombocytopenia: Abnormal blood counts.
    10. Performance Scale 3: Bedridden for less than 50% of the day during the last month.

    Clinical Stage IV:

    1. HIV Wasting Syndrome: Weight loss of more than 10% with chronic diarrhoea or prolonged fever.
    2. Pneumocystis Pneumonia (PCP): A severe fungal lung infection.
    3. Toxoplasmosis of the Brain: Brain infection caused by the Toxoplasma parasite.
    4. Cryptosporidiosis: Parasitic infection causing prolonged diarrhea.
    5. Cytomegalovirus Infection: A viral infection affecting various organs.
    6. Progressive Multifocal Leukoencephalopathy (PML): Brain infection causing neurological symptoms.
    7. Lymphoma: Cancer of the lymphatic system.
    8. Kaposi’s Sarcoma: Cancerous skin lesions caused by a herpesvirus.
    9. HIV Encephalopathy: Cognitive and/or motor dysfunction due to HIV infection.
    10. Atypical Disseminated Leishmaniasis: Parasitic infection affecting multiple organs.
    11. Symptomatic HIV-Associated Nephropathy or Cardiomyopathy: Kidney or heart disease associated with HIV.
    12. Performance Scale 4: Bedridden for more than 50% of the day during the last month.

    Diagnostic Measures for HIV/AIDS

    Pre and Post-Counselling and Consent: Essential for all diagnostic procedures unless in specific circumstances:

    • Testing of very sick, unconscious, symptomatic, or mentally ill individuals by healthcare teams for better patient management.
    • Routine testing for individuals likely to pose a risk of HIV infection to others, such as pregnant and breastfeeding mothers, sexual offenders and survivors, and blood or organ donors. These individuals must still be given the opportunity to know their status.

    Criteria for Diagnosis: Diagnosis based on:

    • Clinical Staging Criteria.
    • Positive HIV Blood Test: Confirmation of HIV infection through serological (antibody) testing.

    Testing Protocol: Testing for Adults and Children >18 Months:

    • Serological (Antibody) Testing: Most common method. Due to the window period between infection and antibody production, negative individuals should be re-tested after three months if exposed.
    • Reactive Rapid Test: Requires confirmation before diagnosis.

    Diagnostic Tests

    Screening Tests:

    • ELISA (Enzyme-Linked Immunosorbent Assay) AglAb Tests: Commonly used to screen blood donations to exclude those in the window period.

    Molecular Tests:

    • PCR (Polymerase Chain Reaction) Tests: Nucleic-Acid Amplification Testing (NAT) detects genetic material of HIV itself, not antibodies or antigens.

    Considerations: Testing should consider:

    • Clinical status, medical history, and risk factors of the individual being tested.
    • Use of tests in conjunction with patient assessment for accurate diagnosis and appropriate care.

    Immediate Connection to HIV Care

    • If positive, immediate referral to HIV care services for management and treatment initiation.

    HIV Testing Provision Protocol

    Step 1: Pre-Test Information and Counseling

    • Provide information on HIV transmission, prevention measures, and testing benefits.
    • Discuss potential test results, available services, and ensure consent and confidentiality.
    • Conduct individual risk assessment and complete necessary documentation.

    Step 2: HIV Testing

    Perform blood-based testing.

    • For infants below 18 months: Use DNA PCR testing.
    • For individuals above 18 months: Conduct antibody testing as per testing algorithms.

    Step 3: Post-Test Counseling (Individual/Couple)

    • Assess readiness to receive results and deliver them simply.
    • Address concerns, provide guidance on disclosure, partner testing, and risk reduction.
    • Offer information on basic HIV care, ART, and complete documentation.

    Step 4: Linkage to Other Services

    • Provide information on available services and assist in completing referral forms.
    • Upon enrollment in services, record pre-ART enrollment numbers and transfer relevant information to ART registers.

    Principles of HIV Testing Services (HTS)

    • Confidentiality: Ensure privacy and confidentiality of test results.
    • Consent: Obtain informed consent from individuals before testing.
    • Counselling: Offer supportive counselling before and after testing.
    • Correct Test Result: Ensure accuracy of test results through proper testing procedures.
    • Connection to Other Services: Facilitate access to appropriate services for individuals testing positive.

    Linkage from HIV Testing to Prevention, Care, and Treatment

    Linkage is the process of connecting individuals who test positive for HIV to the necessary services. 

    Successful linkage to care ensures that patients receive the services they need. For HIV-positive clients, linkage should occur promptly, within seven days if within the same facility, and within 30 days for referrals between facilities or from the community. Lay providers are recommended as linkage facilitators. 

    Types of Linkages:

    • Internal Facility Linkage: Connecting patients within the same facility.
    • Inter-Facility Linkage: Connecting patients to another facility.
    • Community-Facility Linkage: Connecting clients from the community to a health facility.

    Internal Facility Linkage Steps:

    1. Post-Test Counselling: Provide accurate results and information about available care.
    2. Next Steps Discussion: Describe the care and treatment process, emphasizing early treatment benefits.
    3. Address Barriers: Identify and overcome any obstacles to linkage.
    4. Involvement: Involve the patient and family in decision-making.
    5. Documentation: Complete client and referral forms.
    6. Escort to Clinic: A linkage facilitator escorts the client to the ART clinic.
    7. Enrollment: Register the patient, open an ART file, and provide preparatory counselling.
    8. Initiation: Start ART if ready, and continue with counselling support.
    9. Integrated Care: Coordinate other services if needed.
    10. Follow-Up: Ensure the patient attends appointments.

    Inter-Facility and Community-Facility Linkages:

    • Inter-Facility Linkage: Refers to connecting patients to another facility. The referring facility should track referred patients and ensure enrollment within 30 days.
    • Community-Facility Linkage: Connects clients from the community to a health facility. Utilize community health systems and mobilize peer leaders for outreach and follow-up. Linkage should occur within 30 days after diagnosis.

    Treatment Modalities of HIV/AIDS

    Treatment Modality

    Description

    Antiretroviral Therapy (ART)

    Suppresses viral load to undetectable levels, reducing morbidity, mortality, and transmission of HIV.

    Treatment of Acute Bacterial Infections

    Addresses immediate bacterial infections.

    Prophylaxis and Treatment of Opportunistic Infections

    Prevents and manages opportunistic infections.

    Maintenance of Good Nutrition

    Ensures adequate nutrition to support overall health.

    Immunization

    Administers vaccines to prevent opportunistic infections.

    Management of AIDS-Defining Illnesses

    Addresses specific illnesses associated with advanced HIV infection.

    Psychological Support for the Family

    Provides emotional support and guidance for affected families.

    Palliative Care for the Terminally Ill

    Offers comfort and support for patients nearing the end of life.

    Antiretroviral Drug Treatment

    Goal of ART: Suppress viral load to undetectable levels, reducing morbidity, mortality, and transmission of HIV.

    When to Initiate ARV:

    • All HIV-infected children below 12 months.
    • Clinical AIDS
    • Mild to moderate symptoms and immunosuppression.

    Process of Starting ART:

    1. Assess for opportunistic infections, defer ART if TB or cryptococcal meningitis present.
    2. Offer ART on the same day through an opt-out approach.
    3. If not ready for same-day initiation, agree on a timely ART preparation plan.

    Available ARVs in Uganda

    Drug Class

    Examples

    Nucleoside Reverse Transcriptase Inhibitors (NRTIs): Incorporate into the DNA of the  virus, thereby stopping the building process. 

    Tenofovir (TDF), Zidovudine (AZT), Lamivudine (3TC), Abacavir (ABC)

    Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): stop HIV production by binding directly onto the reverse transcriptase enzyme, and prevent the conversion of RNA to DNA.

    Efavirenz (EFV), Nevirapine (NVP), Etravirine (ETV)

    Integrase Inhibitors: interfere with the HIV DNA’s ability to insert itself into the host DNA and copy  itself.

    Dolutegravir (DTG), Raltegravir (RAL)

    Protease Inhibitors (PIs): prevent HIV from being successfully assembled and released from the infected CD4 cell.

    Atazanavir (ATV), Lopinavir (LPV), Darunavir (DRV)

    Entry Inhibitors:  prevent the HIV virus particle from infecting the CD4 cell.

    Enfuvirtide (T-20), Maraviroc

    Recommended First Line Regimens in Adults, Adolescents, Pregnant Women and Children

    HIV management guidelines are constantly being updated according to evidence and public policy decisions. Always refer to the latest official guidelines.

    The 2022 guidelines recommend DOLUTEGRAVIR (DTG) an integrase inhibitor as the anchor ARV in the preferred first and second-line treatment regimens for all HIV infected clients; children, adolescents, men, women (including pregnant women, breastfeeding women, adolescent girls and women of child bearing potential).

    Patient Category

    Preferred Regimens

    Alternative Regimens

    Adults and Adolescents

      

    Adults (including pregnant women, breastfeeding mothers, and adolescents ≥30Kg)

    TDF + 3TC + DTG

    – If DTG is contraindicated: TDF + 3TC + EFV400

    – If TDF is contraindicated: TAF + FTC + DTG 

    – If TDF or TAF is contraindicated: ABC + 3TC + DTG 

    – If TDF or TAF and DTG are contraindicated: ABC + 3TC + EFV400 

     – If EFV and DTG are contraindicated: TDF + 3TC + ATV/r or ABC + 3TC + ATV/r

    Children

      

    Children ≥20Kg – <30Kg

    ABC + 3TC + DTG

    – If DTG is contraindicated: ABC + 3TC + LPV/r (tablets) 

     – If ABC is contraindicated: TAF + FTC + DTG (for children >6 years and >25Kg) 

     – If ABC and TAF are contraindicated: AZT + 3TC + DTG

    Children <20Kg

    ABC + 3TC + DTG

    – If intolerant or appropriate DTG formulations are not available: ABC + 3TC + LPV/r granules 

    – If intolerant to LPV/r: ABC + 3TC + EFV (in children >3 years and >10Kg) 

     – If ABC is contraindicated: AZT + 3TC + DTG or LPV/r

    Notes:

    • Contraindications for DTG include known diabetics, patients on anticonvulsants (carbamazepine, phenytoin, phenobarbital) – use the DTG screening tool prior to DTG initiation.
    • Contraindications for TDF and TAF include renal disease and/or GFR <60ml/min, weight <30Kg.
    • TAF can be used in subpopulations with bone density anomalies.
    • Children will be assessed individually for their ability to correctly take the different formulations of LPV.

    Notes from Ministry of Health

    1. For clients on an ABC-3TC-DTG based regimen weighing >25 kg, use the fixed-dose combination of Abacavir/Lamivudine/Dolutegravir 600/300/50 mg instead of the separate pills of Abacavir/Lamivudine 600/300 mg plus Dolutegravir 50 mg.
    2. Use Abacavir/Lamivudine 600/300 mg for patients on the following regimens: ABC-3TC-ATV/r, ABC-3TC-LPV/r, and ABC-3TC-DRV/r.
    3. Use the single pill of Dolutegravir 50 mg for patients on AZT-3TC-DTG based regimens.
    4. For eligible patients on ATV/r and LPV/r, optimize to Dolutegravir.
    5. For PrEP, while the guidelines provide options for the use of either TDF/3TC 300/300 mg or TDF/FTC 300/200 mg, use TDF/FTC 300/200 mg for PrEP in terms of programmatic implementation.

    Monitoring of ARV Treatment

    The monitoring of patients on antiretroviral therapy (ART) serves several purposes:

    1. Assess Response to ART and Diagnose Treatment Failure
    2. Ensure Safety of Medicines: Identify Side Effects and Toxicity
    3. Evaluate Adherence to ART

    Methods of Monitoring ARV Treatment

    1. Clinical Monitoring: Involves medical history and physical examination.

    2. Laboratory Monitoring: Includes various laboratory tests.

    1. Viral Load Monitoring: Preferred for assessing response to ART and diagnosing treatment failure.
    2. CD4 Monitoring: Recommended in specific scenarios.
    3. Other Minor Laboratory Tests: Includes tests for specific indications.

    Viral Load Monitoring

    • Preferred method for monitoring ART response. A patient who has been on ART for more than 6 months and is responding to ART should have viral suppression (VL <1000 copies/ml) irrespective of the sample type (either DBS or plasma). 
    • Provides an early and more accurate indication of treatment failure and the need to switch from first line to second-line drugs, hence reducing the accumulation of drug resistance mutations and improving  clinical outcomes. 
    • Early and accurate indication of treatment failure.
    • Differentiates between treatment failure and non-adherence.
    • Recommended frequency: Every six months for children and adolescents under 19 years.

    CD4 Monitoring

    • Baseline CD4 count is essential for assessing opportunistic infection risk.
    • Recommended for patients with high viral load or advanced clinical disease.

    Other Laboratory Tests

    Tests

    Indication

    CrAg

    Screen for cryptococcal infection

    Complete Blood Count (CBC)

    Assess anaemia risk

    TB Tests

    Suspected tuberculosis

    Serum Creatinine

    Assess kidney function

    ALT, AST

    Evaluate liver function

    Lipid Profile, Blood Glucose

    Assess metabolic health

    HIV AND PREGNANCY

    In 2004, the WHO reported that 40 million people were infected with HIV/AIDS, including 17.6 million women, 2.7 million children, and 13 million orphans worldwide. In 2005, 700,000 children became infected with HIV, with approximately 95% arising from mother-to-child transmission of HIV (MTCT). Ninety percent of new infections in children occur in Africa due to the near non-existence of PMTCT interventions.

    Mother-to-child transmission (MTCT) is the vertical transmission of HIV from mother to child that occurs during pregnancy, childbirth, and breastfeeding. The most probable point of transmission occurs in the late third trimester and even more so during the intrapartum period. In some areas of the world, MTCT has been virtually eliminated thanks to the availability of specific interventions to reduce the risk of transmission. These interventions include:

    • Effective voluntary and confidential testing and counselling.
    • Access to Antiretroviral Therapy (ART).
    • Safe delivery practices.
    • Availability and safe use of breast milk substitutes.

    Factors Affecting Perinatal Transmission

    HIV-related Factors:

    • Viral load: The higher the viral load, the greater the risk of transmission.
    • Strain variation (genotype): HIV1 or 2.
    • Biological growth characteristics.
    • CD4 cell count: Lower CD4 count or decreased CD4
      ratio is associated with increased risk of transmission.

    Maternal and Obstetric Factors:

    • Clinical stage: Primary infection with greater viremia is associated with increased risk.
    • STDs: Increased HIV shedding in genital tract epithelial disruption is associated with an increased risk of transmission.
    • Sexual behavior: Unprotected sex with multiple partners is associated with increased risk.
    • Placental abruption: Disruption of fetal-placental barriers increases exposure to the fetus.
    • Duration of membrane rupture: The transmission rate is directly proportional to the increased duration of rupture of membranes, with a 2% increase for each hour increment.
    • Gestational age at delivery: Prematurity is associated with increased risk.
    • Invasive procedures in labor such as episiotomy, vacuum delivery, artificial rupture of membranes.
    • Modes of delivery: A study in developed countries shows that elective cesarean section done prior to rupture of membranes and labor significantly reduces the risk of perinatal transmission. Planned cesarean section surgery must be considered in the context of the woman’s life and availability of local resources.
    • Knowledge of HIV status combined with accessibility to and acceptance of ART decreases transmission.
    • Substance abuse: Substance use during pregnancy is associated with increased risk.

    Maternal and Neonatal Factors:

    • Immature immune system (especially in preterm babies).
    • Genetic susceptibility.

    Breastfeeding:

    • Without ART, the risk of transmission through breastfeeding by an infected mother may increase the risk to a total of 20-45%.
    • Where breastfeeding is common and prolonged, transmission through breastfeeding may account for up to half of HIV infections in infants and young children.
    • Early findings show a low rate of transmission through breastfeeding in the first 3 months in infants receiving prophylaxis with either Lamivudine or Nevirapine.
    • The risk can be reduced to under 2% by a combination of antiretroviral prophylaxis during pregnancy and delivery, and to the neonate, with elective cesarean section and avoidance of breastfeeding.
    • Availability of safe breast milk substitutes must be considered, including a safe water supply, when educating and counseling women to avoid breastfeeding.

    Strategies for Prevention of Mother-to-Child Transmission (PMTCT):

    1. Primary prevention of HIV among prospective parents.
    2. Prevention of unwanted pregnancy among HIV-infected women.
    3. Prevention of MTCT among HIV-infected mothers through:
    • Provision of voluntary confidential counseling and testing.
    • Antiretroviral agents.
    • Safe delivery practices.
    • Safe infant feeding practices.
    • Support for the affected family and the community at large. Education and counseling services may help the woman’s family understand the issues and thus support the woman in her choice to prevent transmission of HIV to her baby.

    Components of a Comprehensive HIV Prevention Program:

    1. Health education, provision of information, and counseling on HIV prevention and care, including MTCT.
    2. Voluntary confidential counseling and testing services that are acceptable and accessible.
    3. Quality and focused antenatal care.
    4. Safe delivery practices.
    5. Support and counseling on infant feeding practices.
    6. Family planning services.
    7. Community mobilization and education to decrease stigma and discrimination against, as well as to increase support for, HIV-positive clients.

    HIV AND PREGNANCY Read More »

    Tuberculosis in Pregnancy

    PULMONARY TUBERCULOSIS

    Pulmonary Tuberculosis is an infectious disease of the lungs caused by acid-fast bacilli known as Mycobacterium.

    INCIDENCE: 

    The incidence ranges between 1% and 2% amongst the hospital deliveries in the tropics, being confined predominantly to the underprivileged sectors of society. Incidence of tuberculosis is rising worldwide with the rising prevalence of HIV infected patients. In 2000, WHO showed the emergence of multidrug resistant tuberculosis (MDR-TB) all over the world. It is a “global health emergency”.

    Causes of Tuberculosis in Pregnancy:

    TB is caused by the bacterium Mycobacterium tuberculosis. This bacteria spreads through the air when an infected person coughs, sneezes, talks, or sings, releasing tiny droplets containing the bacteria. When a healthy person inhales these droplets, the bacteria can enter the lungs and cause infection.

    Incubation Period:

    • The time between exposure to M. tuberculosis and the onset of symptoms is usually 4-6 weeks, but it can vary widely depending on individual factors.

    Mode of Spread:

    • Droplet Infection: The primary mode of transmission is through airborne droplets released when an infected person coughs, sneezes, talks, or sings. These droplets contain the bacteria, which can be inhaled by a healthy person.
    • Sputum in Open Air Spaces: The presence of infected sputum in shared spaces can also facilitate transmission.
    • Drinking Unpasteurized Milk: While less common, bovine tuberculosis can be transmitted through unpasteurized milk.
    • Inhalation: Inhalation of contaminated dust containing M. tuberculosis can also lead to infection.

    Types of Tubercle Bacterium:

    1. Human Tuberculosis: This is the most prevalent form of TB, primarily spread through person-to-person contact through droplet infection.
    2. Bovine Tuberculosis: This form is spread through infected animals, primarily cattle, and can be transmitted to humans through consumption of unpasteurized milk or contact with infected animals.

    Types of Tuberculosis:

    Pulmonary TB: This is the most common form of TB, affecting the lungs.

    Signs & Symptoms:

    • Persistent Cough: A cough that lasts for more than 3 weeks, often with the production of sputum.
    • Sputum: Sputum may be purulent (containing pus), blood-stained (hemoptysis), or both.
    • Evening Fevers: Fluctuations in body temperature, with fever typically occurring in the evening.
    • Low-grade Fever and Malaise: Feeling unwell with a persistent low-grade fever and fatigue.
    • Night Sweats: Excessive sweating during the night.
    • Weight Loss: Significant and unexplained weight loss.
    • General Lymphadenopathy: Swelling of lymph nodes throughout the body.
    • Loss of Appetite: Decreased appetite and difficulty eating.
    • Pleural Effusion: Fluid accumulation in the space between the lungs and the chest wall.
    • Anemia and Massive Hemoptysis: Severe blood loss from the lungs, along with a decrease in red blood cells.
    • Enlargement of Cervical Glands: Swelling of lymph nodes in the neck.
    • Family History of Tuberculosis: Having a close family member with a history of TB increases the risk of infection.
    • Amenorrhea: Absence of menstruation, particularly in women who are of reproductive age.

    Extra Pulmonary TB: This form of TB affects organs other than the lungs. While less common than pulmonary TB, it can be serious and life-threatening.

    Affected Areas:

    • Meninges (Meningitis): Inflammation of the membranes surrounding the brain and spinal cord.
    • Abdominal Pelvic Organs: Can affect the intestines, stomach, liver, and reproductive organs.
    • Peritoneum: Inflammation of the membrane lining the abdominal cavity.
    • Spine (Tuberculous Spondylitis): Infection of the vertebrae, often resulting in pain, stiffness, and deformity.
    • Lymph Nodes: Swelling and inflammation of lymph nodes, particularly in the neck, armpits, and groin.
    • Bones: Can affect bones throughout the body, leading to pain, swelling, and joint dysfunction.
    Risk Factors for Tuberculosis in Pregnancy:

    Risk Factors for Tuberculosis in Pregnancy:

    • Pre-existing TB infection: A previous history of TB infection, even if treated, increases the risk of reactivation during pregnancy.
    • Exposure to infected individuals: Living with or working closely with someone who has TB increases the risk of infection.
    • Weakened Immune System: Pregnancy can temporarily suppress the immune system, making it easier for the TB bacteria to take hold and multiply.
    • Malnutrition and Anaemia: Pregnant women who are malnourished or anaemic have a weaker immune system, making them more susceptible to TB infection.
    • HIV Infection: HIV infection weakens the immune system significantly, increasing the risk of TB infection and making the disease more difficult to treat.
    • Other Underlying Health Conditions: Conditions like diabetes, chronic kidney failure, and alcoholism can weaken the immune system and increase the risk of TB infection.
    • Socioeconomic Factors: Poverty, overcrowding, poor sanitation, and inadequate access to healthcare can all contribute to the spread and development of TB.
    • Environmental Factors: Exposure to dust, smoke, and other airborne irritants can irritate the lungs, making them more susceptible to TB infection.

    Diagnosis of Tuberculosis in Pregnancy:

    • Tuberculin Skin Test (TST): The TST involves injecting a small amount of purified protein derivative (PPD) under the skin. A positive reaction (induration ≥ 5 mm) indicates exposure to TB, especially in high-risk individuals (e.g., those with HIV).
    • Chest X-ray: A chest X-ray can reveal abnormalities in the lungs consistent with TB infection. However, it is usually performed after 12 weeks of pregnancy to minimize potential risks to the fetus.
    • Sputum Culture: Early morning sputum samples are collected for three consecutive days and examined for the presence of acid-fast bacilli (AFB), the hallmark of TB.
    • Gastric Washings: For individuals who cannot produce sputum, gastric washings can be analyzed for AFB.
    • Diagnostic Bronchoscopy: In some cases, a bronchoscopy, a procedure that allows for visualization of the airways, may be necessary to obtain tissue samples for diagnosis.
    • Extrapulmonary TB Diagnosis: TB can affect other organs like lymph nodes and bones (although rare in pregnancy).
    • Direct Amplification Tests: These tests, like PCR (polymerase chain reaction), amplify DNA specific to M. tuberculosis, allowing for sensitive and specific detection.

    Investigations:

    • Sputum examination will reveal the bacilli.
    • Examination of aspirates for pleural effusion.
    • Tuberculosis skin test (to show whether the patient has been in contact with tuberculosis bacilli).
    • Biopsy, e.g., of lymph nodes.
    • Serology for HIV.
    • Blood smear for malaria parasites.
    • Chest X-ray examination.
    • Erythrocyte sedimentation rate (ESR).
    • Haemoglobin (HB).
    • Urinalysis.
    • Stool examination.

    Management in Maternal/Child (M/C) Care:

    Aims:

    • Health education about the disease.
    • Promote healing.

    Procedure when a Mother Comes:

    • Create a nurse-patient relationship and take history (family, social, medical, and obstetrical).
    • Observations: Take TPR (temperature, pulse, respiration) and BP (blood pressure).
    • Conduct general and abdominal examinations.
    • Reassure the mother, document all findings, and refer her to a hospital.

    In Hospital: During Pregnancy:

    • If sputum is negative, she can be treated as an outpatient before delivery, under the care of a physician and obstetrician.
    • She should visit ANC (Antenatal Care) regularly.
    • If she is infectious, she should be admitted to an isolation room.
    • Histories and observations (BP, TPR) are taken.
    • General and abdominal examinations are done, and the doctor is informed.
    • Prepare an examination tray for taking specimens for observations.
    • When the doctor comes, he examines the patient.

    Medical Treatment: New Cases:

    • 2EHRZ 6EH 
    1. Ethambutol (E) 25mg/kg. 
    2. Isoniazid (H) 300mg.
    3. Rifampicin (R): <50kg: 450mg; ≥50kg: 600mg.
    4. Pyrazinamide (Z): <50kg: 1.5g; ≥50kg: 2.0g.

    Other Treatment for TB: 

    • Relapse: Patients treated before, who had initial care but the disease reoccurred later. 
    • Defaulters: Patients who stop treatment regardless of the reason.
    • Treatment: 2SE (HR) Z/IE (HR) Z/5EHR. Streptomycin 60 injections dose 0.75g (not given in pregnancy due to side effects).

    Failures: Patients with positive sputum 2 months after starting treatment.

    • Treatment: 2 months SE (HR) Z/E (HR) 5 months SE (HR).

    Side Effects of Drugs:

    • Some other drugs: pyridoxine, prednisone for TB meningitis, codeine phosphate to reduce the rate of spread of infectious bacteria.
    • All patients must be counseled before starting treatment to ensure understanding of the number of drugs, duration of treatment, and expected side effects.

    Nursing Care:

    • Isolation room should be ventilated.
    • Diet: Plenty of protein and fluids; intake and output should be well recorded.
    • Rest and sleep: Important during day and night, with occupational therapy.
    • Hygiene: Daily bath, oral hygiene, spitting in a sputum mug (emptied and disinfected regularly), using disposable handkerchiefs that should be burned, changing and disinfecting bed sheets.
    • Exercise: Teach deep breathing to expand the lungs.
    • Position: Sitting up if dyspneic.
    • Observations: Take T, R, P, and BP; assess general condition and fetal well-being twice a week.
    • Bowel and bladder: Encourage regular bowel and bladder function.
    • Reassurance: Provide support and encouragement to the mother.

    During Labour: Problems May Include:

    • Fatigue
    • Reduced lung function

    Doctor’s Case:

    • Inform the doctor, physician, obstetrician, and paediatrician once labour starts.
    • Manage the first stage as usual, with Oxygyen if ordered by the doctor. Use sitting up position if dyspneic.
    • In the second stage, use episiotomy, forceps, or vacuum extraction to reduce over-straining from pushing.
    • Perform C-section only for specific obstetrical indications, e.g., fetal distress.
    • Actively manage the third stage to prevent unnecessary blood loss.

    During Puerperium:

    • Manage as other mothers.
    • If the mother has an active infection, she should breastfeed with a mask, and the baby should be taken back to the nursery.
    • No Contraindication: Breastfeeding is not contraindicated when a woman is taking anti-tuberculous drugs.
    • Avoidance: Breastfeeding should be avoided if the infant is also receiving anti-tuberculosis medications to prevent drug accumulation.
    • Active Lesions: Breastfeeding is contraindicated in cases of active TB. The infant should be isolated from the mother after delivery and given prophylactic isoniazid (10-20 mg/kg/day) for 3 months.
    • Chemotherapy: If the mother has been on effective chemotherapy for at least two weeks, there is no need to isolate the baby.
    • If the mother’s sputum is positive, give the baby BCG at birth and protect with isoniazid syrup (2.5mg/kg/day). The vaccine becomes effective in 3-6 weeks; if any family member is infected, separation is advised.
    • Mantoux test is carried out after 6 weeks.
    • If the mother is negative or inactive, she can stay with her baby.
    • Advise rest and sleep, and a well-balanced diet to avoid recurrence of active disease.
    • Avoid pregnancies until the disease has been controlled for 2 years.
    • Long-term medical and social follow-up is necessary to monitor the disease and its treatment.

    Effects of TB on Pregnancy:

    Maternal Effects on Pregnancy:

    • General Debilitation: TB weakens the mother’s overall health, making it challenging to cope with the demands of pregnancy.
    • Placental Insufficiency: TB can impair placental function, leading to:
    1. Premature Labor: Increased risk of delivering before term.
    2. Intrauterine Fetal Death: Loss of the fetus during pregnancy.
    3. Intrauterine Growth Retardation (IUGR): The fetus fails to grow at an appropriate rate due to inadequate nutrient and oxygen supply.
    • Fetal Hypoxia: Reduced oxygen levels in the fetus due to placental insufficiency.
    • Asphyxia: Severe oxygen deprivation in the fetus, potentially leading to brain damage or death.

    During Labour:

    • Increased Risk of Assisted Deliveries: TB-related complications can increase the need for interventions like forceps or vacuum extraction.
    • Maternal and Fetal Distress: Both the mother and the fetus may experience complications during labor, such as heart rate abnormalities, due to TB-related physiological changes.
    • High Prenatal Mortality Rate: The risk of stillbirth is significantly elevated in mothers with TB.

    Note: Pregnant or breastfeeding women with TB should be treated with short-course chemotherapy (e.g., Rifampicin, Isoniazid, Pyrazinamide, Ethambutol).

    Effects on Puerperium:

    • Anaemia: TB can worsen existing anaemia or lead to new iron deficiency in the postpartum period.
    • Poor Lactation: TB can impair breast milk production, impacting infant nutrition.
    • Lowered Resistance to Infection: The mother’s immune system is compromised, increasing her susceptibility to infections during the postpartum period.

    Prevention:

    In the Community:

    1. Sensitize and mobilize the community to create awareness about TB.
    2. Health education on ensuring well-ventilated homes, avoiding overcrowding, proper disposal of sputum, covering the mouth when coughing/sneezing, and screening family members.
    3. Encourage good nutrition, drinking pasteurized milk products, disinfecting patients’ belongings, and immunizing children with BCG.
    4. Ensure adequate management of chest infections and encourage mothers to attend ANC.

    In Hospital:

    1. Encourage mothers to attend ANC for thorough examinations, histories, and investigations for management.
    2. Keep the hospital environment clean and dispose of refuse properly.
    3. Ensure ward cleanliness by scrubbing floors, dusting windows, and cleaning equipment daily.
    4. Health workers should avoid droplet infections, wash hands after every procedure, and isolate TB patients.

    Complications:

    • Spontaneous Pneumothorax: A collapsed lung due to air leaking into the space between the lung and chest wall.

    • Pleural Effusion: Fluid buildup in the space between the lung and chest wall.
    • Gastrointestinal TB: TB infection affecting the digestive system.
    • Massive Hemolysis: Breakdown of red blood cells, leading to anemia and potentially fatal complications.
    • TB Meningitis: Infection of the membranes surrounding the brain and spinal cord.
    • TB Pericarditis: Inflammation of the sac surrounding the heart.
    • Anaemia: Iron deficiency, which can be exacerbated by TB infection.
    • Death: In severe cases, TB can be fatal, especially in pregnant women who are immunocompromised.
    • Hemoptysis: Coughing up blood due to lung damage.
    • High Maternal Mortality Rate: The risk of death from TB is significantly elevated in pregnant women.

    Tuberculosis in Pregnancy Read More »

    MALARIA IN PREGNANCY

    MALARIA IN PREGNANCY

    Malaria is a febrile condition/disease caused by a Plasmodium parasite and is the most common cause of pyrexia in tropical regions, usually associated with rigors.

    CAUSES 

    Malaria is caused by Plasmodium parasites (protozoa), which are of four types: 

    1. Plasmodium falciparum: This is the most dangerous species, responsible for the majority of malaria deaths worldwide. It can cause severe complications, including cerebral malaria, which can lead to coma and death. During pregnancy, P. falciparum infections are particularly dangerous, increasing the risk of low birth weight, preterm birth, and stillbirth.
    2. Plasmodium vivax: This species is less deadly than P. falciparum but can still cause serious illness. It is characterized by relapses, where symptoms can reappear months after the initial infection. During pregnancy, P. vivax can cause anemia and increase the risk of miscarriage.
    3. Plasmodium ovale: This species is similar to P. vivax in its symptoms and ability to cause relapses. It is less common than P. vivax and P. falciparum.
    4. Plasmodium malariae: This species is the least common and usually causes a milder form of malaria. However, it can cause severe complications in some cases, particularly in pregnant women.

    MODE OF ENTRY 

    Malaria parasites are transmitted by a female Anopheles mosquito. The mosquito spits saliva onto human skin to soften it. Since malaria parasites are stored in the saliva, they are introduced through the proboscis while the mosquito sucks blood, which is used by the female mosquito for egg maturation.

    MALARIA CYCLE 

    There are two cycles: 

    1. Malaria cycle in the mosquito (Sexual stage – union of male and female gametes to form a zygote)
    2. Malaria cycle in humans (Asexual stage)
    MALARIA CYCLE IN THE MOSQUITO (SEXUAL STAGE) 

    When a mosquito bites an infected person, it acquires gametocytes (sexual cells of a malaria parasite). After ingestion, these gametocytes travel through the blood to the mosquito’s stomach, where they unite and form a zygote on the stomach walls.

    Zygote Ookinete Oocyst Sporozoite (mature malaria parasite still within the mosquito). 

    The sporozoites move to the mosquito’s salivary glands, ready to be injected into a healthy person.

    MALARIA CYCLE IN HUMANS (ASEXUAL STAGE) 

    An infected mosquito bites a healthy person, introducing sporozoites that spread within the body in approximately 30 minutes. These sporozoites enter the bloodstream and are transported to the liver for further development, known as PRIMARY TISSUE SCHIZONTS. The parasites develop and mature within liver cells, eventually destroying them. After about 7-14 days (incubation period), the parasites rupture from the liver cells as merozoites, entering the bloodstream to infect red blood cells.

    Chronic malaria: Merozoites are the mature malaria parasites. They attack and feed on red blood cells until they destroy them completely, releasing waste products and causing the body to react.

    CAUSES OF FEVER IN MALARIA

    • Presence of malaria parasites in the body is recognized as foreign by the immune system.
    • The rupture of red blood cells as the parasite destroys them triggers a response.
    • The release of toxins from the parasites causes fever due to waste products and destroyed haemoglobin.

    SIGNS & SYMPTOMS OF MALARIA

     They range from mild to severe.

    MILD TO MODERATE SIGNS & SYMPTOMS

    • Fever: Low-grade fever, often intermittent or fluctuating
    • Headache: Often severe and persistent
    • Joint pain: Muscles and joints may ache
    • Nausea and vomiting: Feeling sick to the stomach with or without throwing up
    • Anorexia: Loss of appetite
    • Abdominal issues: Constipation or diarrhea
    • Malaise: Feeling generally unwell and weak
    • Dizziness: Feeling lightheaded or unsteady
    • Nightmares: Disturbing dreams while sleeping

    SEVERE MALARIA SYMPTOMS:

    • High fever: Persistent high temperature
    • Severe headache: Intense and unrelenting headache
    • Confusion and disorientation: Difficulty thinking clearly
    • Seizures: Uncontrolled muscle spasms
    • Coma: Loss of consciousness
    • Jaundice: Yellowing of the skin and eyes
    • Rapid breathing: Increased breathing rate
    • Kidney failure: Inability of the kidneys to filter waste
    • Blood in urine: Blood appearing in the urine
    • Severe anemia: Low red blood cell count

    SEVERE SIGNS AND SYMPTOMS 

    Can also be characterized in four stages:

    1. COLD STAGE: Patient feels very cold, increased pulse, nausea, and goosebumps.
    2. RIGOR STAGE: Shivering attacks, fast pulse, nausea, and possible vomiting.
    3. HOT STAGE: Temperature rises between 38-40°C, severe headache, vomiting, restlessness, and convulsions in children.
    4. SWEATING STAGE: Temperature lowers, sometimes to normal or subnormal levels, lasting 3-4 hours, with or without treatment.

    TREATMENT OF MALARIA 

    Classified into: 

    A. Uncomplicated malaria

    B. Severe and complicated malaria

    C. Intermittent preventive treatment

    D. Severe malaria in pregnant women and children under 4 months

    Uncomplicated Malaria

    • Artemether/Lumefantrine (50mg per tablet): Start with 200mg, then 100 mg daily.
    • Artesunate + Amodiaquine (similar to Artemether).

    Second Line

    • Quinine (300mg per tablet): 600 mg dose every 8 hours for 7 days.

    Severe and Complicated Malaria

    • Artemisinin combination therapies (ACTs)
    • Parenteral Artemether (IM or IV)
    • Quinine (600mg, adjusted by body weight)

    Intermittent Preventive Treatment

    • Fansidar (1500mg, 3 tablets taken at once from 4 months or 16 weeks).

    Severe Malaria in Pregnancy

    • Parenteral Quinine (600 mg every 8 hours): Given in the 1st trimester. After the 1st trimester, ACTs can be administered.
    • For children under 4 months or weighing below 5kg, Quinine is given.

    SIGNS OF UNCOMPLICATED MALARIA

    • Fever: Intermittent or fluctuating fever, may be low-grade or high.
    • Headache: Often severe and persistent.
    • Chills: Episodes of shivering and cold sensations.
    • Sweats: Episodes of profuse sweating.
    • Muscle aches: Muscle soreness and pain.
    • Fatigue: Feeling tired and weak.
    • Nausea and vomiting: Feeling sick to the stomach with or without throwing up.
    • Diarrhea: Loose stools.
    • Loss of appetite: Decreased hunger.
    • Dehydration: Loss of body fluids, leading to dry mouth and skin.
    • Abdominal pain: Pain in the stomach area.

    SIGNS OF COMPLICATED MALARIA

    • Severe anemia: Low red blood cell count, leading to fatigue, weakness, and pale skin.
    • Jaundice: Yellowing of the skin and eyes due to bilirubin buildup.
    • Renal failure: Kidney failure, leading to decreased urine output and waste buildup.
    • Cerebral malaria: Parasites infect brain cells, causing confusion, seizures, coma, and death.
    • Pulmonary edema: Fluid buildup in the lungs, leading to difficulty breathing.
    • Shock: Life-threatening condition where the body is unable to circulate blood effectively.
    • Metabolic acidosis: Build-up of acid in the blood, leading to various complications.
    • Hypoglycemia: Low blood sugar, potentially leading to seizures and coma.
    • Respiratory distress: Difficulty breathing, including rapid breathing and wheezing.
    • Bleeding: Increased risk of bleeding, including gastrointestinal bleeding.
    • Behavioural changes: Confusion, disorientation, delirium, and hallucinations.
    • Prostration: (trying to touch something that isn’t there)

    MANAGEMENT

    The midwife manages mild cases of malaria and treats it as an outpatient. She treats malaria between 16-36 weeks of pregnancy due to the new drug policy.

    First Line Drug

    • Refer mothers below 16 weeks and above 36 weeks of pregnancy for hospital management.

    Steps for Management: 

    1. Welcome the mother, offer a seat, greet, and introduce yourself. 
    2. Take history (personal, problem, environment, pregnancy). 
    3. Make observations (TPR, BP, weight) and interpret them. 
    4. Conduct general and abdominal examinations to decide on treatment or referral. 
    5. Treat symptoms like fever, headache, and anaemia. 
    6. Administer appropriate medications (e.g., iron supplements, antimalarials).

    NEW MALARIA TREATMENT POLICY

    • Uncomplicated Malaria
    1. First-line treatment: Artemether or Artesunate + Amodiaquine
    2. Second line: Quinine
    • Severe Malaria
    1. Parenteral Quinine
    2. Parenteral Artemisinin derivatives (ACTs)
    • Uncomplicated/Severe Malaria in Special Groups
    1. Pregnant women in the first trimester are given Quinine. ACTs can be used after the 1st trimester.
    2. For children under four months, Quinine is given while ACTs are contraindicated.

    FOR SEVERE COMPLICATED MALARIA,

    • Admit the patient
    • Take history (personal, pregnancy, complications)
    • Inform the doctor
    • Prepare for examination and treatment
    • Administer emergency treatment and anti-malarial medications
    • Manage complications and provide supportive care

    Emergency Treatment

    • Resuscitation with attention to the airway
    • IV infusion introduction
    • Effective anti-malarial medication administration based on body weight
    • Correct hypoglycemia with Dextrose
    • Correct/prevent dehydration
    • Reduce high body temperature with antipyretics
    • Control convulsions with Diazepam
    • Determine the need for blood transfusion

    Supportive Care

    • Comfortable bed with a treated mosquito net
    • Clean environment and proper hygiene
    • Complete bed rest, daily baths, and tepid sponging
    • Oral hygiene every 4 hours
    • Adequate diet with small servings, sweetened foods, fruits, and vitamin supplements
    • Monitor bowel and bladder functions
    • Provide passive and active exercises
    • Regular observations (TPR, BP, fetal heart, weight, jaundice, blood smears)
    • Discharge with advice on diet, rest, medication, and mosquito net usage

    COMPLICATIONS OF MALARIA

    Effects on Pregnancy: 

    To the mother:

    • Increased Risk of Severe Malaria: Pregnancy significantly increases the susceptibility to severe malaria, putting mothers at higher risk of complications like cerebral malaria, pulmonary edema, and renal failure.
    • High Temperatures: Fever associated with malaria can cause intense discomfort and dehydration, particularly for pregnant women who are already experiencing hormonal changes and increased body temperature.
    • Anaemia: Malaria parasites destroy red blood cells, leading to anaemia, which can be exacerbated during pregnancy when blood volume increases. Severe anaemia can lead to fatigue, weakness, and shortness of breath, further jeopardizing the mother’s health.
    • Puerperal and Cerebral Malaria: These life-threatening conditions pose a high risk to pregnant women. Puerperal malaria occurs during or after childbirth, while cerebral malaria involves the brain and can lead to coma and death.
    • Antepartum and Postpartum Haemorrhage: Malaria increases the risk of bleeding before or after childbirth, leading to severe blood loss and potential complications for both mother and baby.
    • Ill Health and Compromised Immunity: Malaria symptoms, including nausea, vomiting, diarrhoea, and loss of appetite, can affect a pregnant woman’s health and worsen nutritional deficiencies. The weakened immune system makes her more susceptible to infections.
    • Jaundice and Dehydration: The buildup of bilirubin, a breakdown product of red blood cells, can cause jaundice, which further compromises the mother’s health and can impact the baby’s development. Dehydration, a common symptom of malaria, can lead to complications for both the mother and fetus.

    To the baby:

    • Abortions: Malaria increases the risk of miscarriage, especially during the first trimester.
    • Prematurity: Malaria can trigger premature labor, leading to babies born before 37 weeks of pregnancy, increasing their risk of health problems.
    • Intrauterine Fetal Death (IUFD): Malaria can lead to the death of the baby in the womb, especially in the third trimester.
    • Low Birth Weight: Babies born to mothers with malaria are more likely to have low birth weight, increasing their risk of health problems and long-term developmental issues.
    • Congenital Malaria: The baby can be infected with malaria parasites in the womb, leading to complications at birth or later in life.
    • Intrauterine Growth Restriction (IUGR): Malaria can hinder the baby’s growth in the womb, leading to smaller size at birth, impacting their long-term health and development.

    Effects on the Ward:

    • Extended Hospital Stays: Malaria complications can lead to prolonged hospital stays, burdening healthcare resources and increasing the risk of infections.
    • Blockage of Space for Urgent Obstetric Cases: Long stays by malaria patients can limit space and resources for urgent obstetric cases, delaying critical care for other mothers.
    • Ward Congestion and Cross-Infection: Overcrowding due to malaria cases can increase the risk of cross-infection, affecting the health of other patients and healthcare workers.
    • Financial Strain on Families: Treatment and hospitalization for malaria can strain the finances of families, especially in developing countries where access to healthcare is limited.
    • Deprivation of Maternal Care for Children at Home: Mothers hospitalized for malaria are unable to care for their other children, potentially leading to neglect and health issues.
    • Economic Inefficiency: Malaria during pregnancy not only affects individual families but also impacts economic productivity due to lost work days, reduced income, and increased healthcare costs.

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    EPILEPSY IN PREGNANCY

    EPILEPSY IN PREGNANCY

    Epilepsy is a chronic disorder characterized by recurrent, unpredictable seizures due to temporary dysfunction of the brain’s neurons producing excessive electrical discharge. 

    Although it typically presents in childhood, it has a second peak in older adults, with women of childbearing age accounting for 23% of those affected. The prevalence of epilepsy in pregnancy is 0.35%.

    Types of Epilepsy

    Types of Epilepsy

    A. Partial Epilepsy

    1. Simple Partial Seizures:

    • Consciousness remains intact.
    • Experiences an aura (premonition).
    • Sensations like pins and needles in the arms or legs.
    • Pallor or a flushed face with sweating.
    • Muscle twisting in limbs with some stiffness.

    2. Complex Partial Seizures:

    • Loss of memory of the event.
    • Hand rubbing.
    • Chewing and smacking of lips.
    • Random noises.
    • Unusual posture.

    B. Generalized Epilepsy

    1. Absence Seizures:

    • Staring and blinking.
    • Daydreaming with loss of awareness for 5-20 seconds (mainly affects children).

    2. Myoclonic Seizures:

    • Brief muscle jerking in an arm or leg, lasting a fraction of a second while remaining conscious.
    • All body muscles contract for less than 20 seconds without convulsions, causing the individual to fall.

    3. Tonic-Clonic Seizures:

    • Whole body contracts, arms and legs convulse.
    • Incontinence is possible.
    • Lasts 1-2 minutes, leaving the individual tired and wanting to sleep.
    • The most common type of seizure (60% of cases).

    4. Atonic Seizures:

    • Sudden loss of muscle tone, causing the individual to fall limply.
    • Head injury is probable, but the individual gets up immediately with no confusion.

    Causes of Epilepsy in Pregnancy

    1. Idiopathic: Most cases have no underlying cause.
    2. Genetic Predisposition: 30% of cases have a family history of epilepsy.
    3. Secondary Epilepsy: Can be encountered in pregnancy in patients with:
    • Previous brain surgery.
    • Intracranial mass lesions (e.g., meningiomas and arteriovenous malformations).
    • Antiphospholipid syndrome.

    Other Causes of Seizures in Pregnancy

    • Eclampsia.
    • Cerebral vein thrombosis (CVT).
    • Thrombotic thrombocytopenic purpura (TTP).
    • Stroke.
    • Subarachnoid hemorrhage.
    • Drug and alcohol withdrawal.
    • Hypoglycemia.
    • Infections (e.g., tuberculoma, toxoplasmosis).
    • Gestational epilepsy (seizures confined to pregnancy).

    Diagnosis

    Most women are already diagnosed with epilepsy. However, if a first seizure occurs during pregnancy, the following investigations are appropriate:

    • Blood pressure, urinalysis, platelet count, clotting screen, blood film.
    • Blood glucose, serum calcium, serum sodium, liver function tests.
    • CT or MRI of the brain.
    • EEG (electroencephalogram).

    Effects of Epilepsy on Pregnancy

    On the Fetus:

    • No increased risk of miscarriage or obstetric complications unless a seizure results in abdominal trauma. This is a positive aspect, indicating that epilepsy itself doesn’t inherently increase the risk of these complications.
    • Fetal malformations: These can include a range of abnormalities affecting various organs and systems.
    • Intrauterine growth restriction (IUGR): This refers to the fetus not growing at the expected rate, potentially leading to low birth weight.
    • Oligohydramnios: This is a condition where there is too little amniotic fluid surrounding the fetus, which can be associated with developmental issues.
    • Preeclampsia: This is a serious condition characterized by high blood pressure and protein in the urine, which can affect both mother and fetus.
    • Stillbirths: This refers to the death of a fetus before birth.

    On the Newborn:

    • Birth defects are increased two-fold. This could be related to the severity of the disease and also due to the anticonvulsants used. Pattern of abnormalities is related to the type of anticonvulsant drugs (valproate 5.9%, Carbamazepine, 2.3% and Lamotrigine 2.1%).
    • The malformations include—Cleft lip and/or palate, mental retardation, cardiac abnormalities, limb defects and hypoplasia of the terminal phalanges. Sodium valproate is associated with neural tube defects. 
    • There is chance of neonatal hemorrhage and is related to anticonvulsant induced reduction of coagulation factors (vitamin K dependent). The risk of developing epilepsy to the offspring of an epileptic mother is 10%.

    On the Mother:

    • Increased risk of seizures during pregnancy and postpartum. Hormonal changes and physiological stress associated with pregnancy can trigger seizures.
    • Potential for worsening of epilepsy. Some women may experience an increase in seizure frequency or severity during pregnancy.
    • Difficulty in managing epilepsy medication during pregnancy. Many anticonvulsants are teratogenic (can cause birth defects), requiring careful consideration and monitoring.
    • Increased risk of postpartum depression. This can be exacerbated by the challenges of managing epilepsy and raising a child.
    • Stress and anxiety associated with pregnancy and childbirth. The fear of seizures and their potential impact on the baby can contribute to maternal stress.

    Management of Epilepsy in Pregnancy

    Pre-Pregnancy Counseling

    1. Control of Epilepsy:

    • Maximize seizure control with the lowest dose of the most effective treatment.
    • Review antiepileptic drugs (AEDs) considering the risk of teratogenesis and adverse neurodevelopmental effects.

    2. Stopping Treatment:

    • AEDs should be withdrawn slowly to reduce the risk of withdrawal-associated seizures, particularly important for benzodiazepines and phenobarbitone.
    • Current recommendations suggest stopping driving from the start of the drug withdrawal period and for six months after cessation of treatment if there are no seizures.

    Newer Drugs with Safety Profiles:

    • Topiramate: 100–400 mg/day.
    • Levetiracetam: 1–3 gm/day, not an enzyme inducer.

    Folic Acid: All women on AEDs should take pre-conception folic acid 4 mg daily starting before pregnancy and continuing throughout pregnancy.

    Antenatal Management

    1. Medication:

    • Keep the dose of chosen drugs as low as possible and monitor serum levels regularly.
    • Commonly used drugs include:
    1. Phenobarbitone (60-100mg daily in divided doses).
    2. Phenytoin (150-300mg daily in divided doses).
    3. Carbamazepine (0.8-1.2g daily in divided doses).
    • Continue folic acid daily before conception and throughout pregnancy to prevent folate-deficiency anemia.

    2. Seizure Control:

    • IV Phenytoin: Administer a slow loading dose of 15–20 mg/kg for effective, long-duration control with fewer side effects.
    • Benzodiazepines: 10–20 mg slow IV if phenytoin is not effective.

    3. Support:

    • Educate relatives, friends, and partners on placing the woman in the recovery position to prevent aspiration during a seizure.
    • Administer Vitamin K (10 mg daily) orally in the last two weeks of pregnancy.
    • Intrapartum Management

    4. Seizure Risk:

    • The risk of seizures increases around delivery. Women with major convulsive seizures should deliver in a hospital.
    • Continue anticonvulsant medication throughout labor with regular review by the obstetric team.
    • Administer short-acting benzodiazepines if seizures recur.

    5. Labor and Delivery:

    • Women should not be left alone during labor, and dehydration, hyperventilation, and exhaustion should be avoided as they can trigger seizures.

    6. Vitamin K

    • 10 mg daily orally to the mother in the last two weeks of pregnancy.
    • Infant: 1 mg IM at birth to prevent neonatal hemorrhage
    • Birth can be spontaneous, facilitated by the midwife. Administer vitamin K to the baby promptly after birth to protect against AED-induced hemorrhagic disease.
    • Caesarean section is only necessary for recurrent generalized seizures in late pregnancy or labor.

    Postpartum Management

    7. Seizure Risk:

    • The risk of seizures increases in the first 24 hours after birth, so the woman should remain in the hospital.
    • Encourage breastfeeding.
    • Monitor the baby closely and report any concerns to the pediatrician immediately.
    • Provide safety advice for caring for the baby in case of maternal seizures.

    8. Breastfeeding:

    • There is no contraindication for breastfeeding.
    • Infant: May be drowsy due to medication.

    9. Postpartum Management:

    • Readjustment of Anticonvulsant Dosage: Reduce to pre-pregnancy levels by 4–6 weeks postpartum.

    10. Contraception:

    • Avoid steroidal contraceptives due to hepatic microsomal enzyme induction.

    11. Risk to Infant:

    • The risk of having epilepsy in an infant born to a mother with a seizure disorder is four times higher compared to infants born to mothers without a seizure disorder.

    Complications Associated with Epilepsy

    1. Trauma: During seizures, injuries such as tongue biting and head or limb injuries can occur.
    2. Status Epilepticus: A seizure lasting more than 30 minutes or a series of seizures without regaining consciousness between them.
    3. Sudden Unexpected Death in Epilepsy (SUDEP): An unexplained sudden death in a person with epilepsy.

    EPILEPSY IN PREGNANCY Read More »

    ASTHMA IN PREGNANCY

    ASTHMA IN PREGNANCY

    Asthma is a chronic respiratory disorder characterized by recurrent attacks of wheezing and difficulty in breathing due to reversible narrowing of the airways. Asthma flare-ups during pregnancy can cause decreased oxygen in blood, which means less oxygen reaches the baby. This put the baby at higher risk for premature birth, low birth weight and poor growth.

    Causes

    The exact cause of asthma is unknown, but several predisposing factors contribute to its onset. These factors include:

    Predisposing Factors

    1. Heredity: Asthma often runs in families, suggesting a genetic predisposition.
    2. Infections: Respiratory infections, such as the common cold, can trigger asthma attacks.
    3. Psychological Factors: Emotions like fear, anger, and nervousness can lead to the release of histamines, precipitating an asthma attack.
    4. Allergies: Common allergens include:
    • Foods
    • Pollen
    • Dust
    • Weather changes
    • Fungi
    • Spores
    • Feathers
    • Drugs (e.g., aspirin)

    Respiratory Changes During Pregnancy

    Anatomical Changes

    • Upper Respiratory Tract: Increased mucosal hyperemia, edema, and glandular hyperactivity.
    • Thorax and Diaphragm:
      • Subcostal Angle: Increases from 68 to 103 degrees in the first trimester.

      • Diaphragm: Rises by up to 4 cm.

    Hormonal Effects on the Respiratory System

    • Oestrogen: Likely responsible for tissue edema, capillary congestion, and hyperplasia of mucous glands.
    • Progesterone: Contributes to improved asthma control through increased minute ventilation, smooth muscle relaxation, or cAMP-induced bronchodilation. However, it may also worsen asthma by altering beta2-adrenoceptor responsiveness and airway inflammation. Progesterone acts as a partial glucocorticoid agonist, suppressing histamine release from basophils.
    • Cortisol: Maternal plasma cortisol levels increase, which may improve asthma control and reduce steroid requirements, though the effects are variable.
    • Prostaglandins: Amniotic fluid contains various prostaglandins (PGE2, PGD2, PGF2-alpha). PGE2 is a bronchodilator, while others are bronchoconstrictors. The relationship between increased PGF2-alpha levels and asthma exacerbations is not well established.

    Signs & Symptoms

    History Taking

    • Family History: A family history of asthma, allergies, or frequent upper respiratory infections, particularly in the mother, increases the risk.
    • Personal History: A prior history of asthma, eczema, or hay fever can indicate a predisposition to asthma during pregnancy.
    • Onset: Sudden onset of wheezing, shortness of breath, and chest tightness, especially if it’s a new experience for the mother.
    • Triggers: Identifying known triggers such as dust, pollen, smoke, exercise, or certain medications can help manage the condition.
    • Severity: Determining the severity of past asthma episodes, including hospitalizations or emergency room visits, can inform treatment decisions.
    • Medications: Knowing current asthma medications, including inhalers and oral medications, and adherence to the treatment plan.

    Examination

    • Cough: May be productive (with phlegm) or dry, often worse at night or during exercise.
    • Dyspnea: Difficulty breathing, shortness of breath, and feeling like you can’t get enough air.
    • Chest Tightness: A constricting or squeezing sensation in the chest.
    • Wheezing: High-pitched whistling sound during exhalation, sometimes heard during inhalation.
    • Rhonchi: Rattling or rumbling sounds in the chest, often indicating airway inflammation or mucus buildup.
    • Cyanosis: Bluish discoloration of the skin, lips, or fingernails, signifying low blood oxygen levels.
    • Accessory Muscle Use: Overuse of respiratory muscles in the neck, abdomen, or chest, to aid breathing, indicating significant respiratory effort.
    • Prolonged Expiration: Exhalation takes longer than inhalation due to narrowed airways.
    • Tachypnea: Rapid breathing rate.
    • Retractions: Pulling in of the chest wall or neck muscles during inhalation, a sign of respiratory distress.
    • Agitation: Restlessness, anxiety, or confusion, often associated with low blood oxygen levels.
    • Pulsus Paradoxus: A significant drop in blood pressure during inhalation, indicating severe airway narrowing.
    Warning signs of Asthma Attack

    History Findings:

    • Cough: A persistent cough, especially if it’s dry and hacking, can be an early sign.
    • Shortness of breath: Difficulty catching your breath, feeling like you can’t get enough air.
    • Chest tightness: A constricting feeling in the chest, making it difficult to breathe deeply.
    • Noisy breathing: Wheezing (high-pitched whistling sound), or rhonchi (rattling or rumbling sounds) during breathing.
    • Nocturnal awakenings: Waking up at night due to difficulty breathing.
    • Exacerbations possibly provoked by nonspecific stimuli: Triggers like dust, pollen, smoke, or exercise causing worsening symptoms.
    • Personal or family history of other atopic diseases: Having a history of allergies, eczema, or hay fever can increase the risk of asthma.

    General Physical Examination:

    • Tachypnea: Rapid breathing.
    • Retraction (sternomastoid, abdominal, pectoralis muscles): Muscles in the neck, abdomen, or chest pulling inwards during inhalation as the body tries to get more air.
    • Agitation: Restlessness, anxiety, or confusion, often a sign of hypoxia (low oxygen levels).
    • Pulsus paradoxus ( > 20 mm Hg): A significant drop in blood pressure during inhalation.

    Pulmonary Findings:

    • Diffuse wheezes: Long, high-pitched whistling sounds on exhalation and sometimes inhalation.
    • Diffuse rhonchi: Short, high- or low-pitched rattling sounds during inhalation and/or exhalation.
    • Bronchovesicular sounds: Abnormal lung sounds indicating airway narrowing.

    Signs of Fatigue and Near-Respiratory Arrest:

    • Alteration in the level of consciousness: Lethargy, drowsiness, or confusion, indicating respiratory acidosis and fatigue.
    • Abdominal breathing: Using the abdominal muscles to help with breathing, a sign of respiratory distress.
    • Inability to speak in complete sentences: Speaking in short, choppy phrases due to shortness of breath.

    Signs of Complicated Asthma:

    • Equality of breath sounds: Checking for equal air movement on both sides of the chest (signs of pneumonia, mucous plugs, or barotrauma).
    • A silent chest: The absence of wheezing in someone experiencing respiratory distress can be more worrisome than the presence of wheezing.
    • Jugular venous distension: Swelling of the neck veins, suggesting increased pressure in the chest cavity (possible pneumothorax).
    • Hypotension and tachycardia: Low blood pressure and fast heart rate, suggesting possible tension pneumothorax.
    • Fever: May indicate an upper or lower respiratory infection, which can worsen asthma symptoms.

    Management of Asthma in Pregnancy

    Aims of Management

    • Control symptoms, including nocturnal symptoms.
    • Prevent acute exacerbations.
    • Ensure no limitations on activities.
    • Maintain (near) normal pulmonary function.
    • Protect the mother and fetus from adverse effects.

    Preventive Measures

    When the patient is not experiencing an attack, prevention is very important. The following advice is given:

    1. Education: Inform the patient about asthma and identify potential triggers.
    2. Avoidance of Triggers: Avoid substances that trigger attacks (varies by individual).
    3. Warm Clothing: Use warm clothes, such as scarves, in cold weather.
    4. Emotional Control: Learn to manage emotions to prevent attacks.
    5. Deep Breathing Exercises: Practice exercises to ensure full lung expansion.
    6. Medication: Always have a supply of prescribed drugs (e.g., inhalers) according to the prescriptions.

    Emergency Management

    If the patient is experiencing an attack, treat it as an emergency:

    1. Admission: Quickly admit the patient in an upright position and administer oxygen if available.
    2. Reassurance: Reassure the patient and relatives to reduce anxiety, which can exacerbate the condition.
    3. Ventilation: Ensure proper ventilation and inform the doctor.
    4. Medical Treatment:
    5. Bronchodilators: Administer intravenous Aminophylline (250-500mg every 8 hours, given slowly over 20 minutes). Nebulized salbutamol (4mg every 8 hours), which may later be replaced with ordinary inhalers.
    • Corticosteroids: Hydrocortisone (100mg intravenously every 8 hours), later changed to oral prednisolone.
    • Antihistamines: Piriton or Phenergan to reduce allergic reactions and congestion.
    • Antibiotics: Crystalline penicillin (2ml every 6 hours) or Ampicillin (500mg every 6 hours) to prevent or treat respiratory infections.
    • Intravenous Fluids: Administer dextrose 5% to prevent dehydration and provide energy.

    Quick Relief for All Patients

    • Short-acting bronchodilator: 2-4 puffs of short-acting inhaled beta-agonist(Such as Salbutamol) as needed for symptoms. Intensity of treatment depends on the severity of exacerbation; up to 3 times at 20-minute intervals or a single nebulizer treatment as needed. A course of systemic corticosteroids may be needed. Use of short-acting inhaled beta-agonist more than 2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate or increase long-term control therapy.

    Step Ladder Management

    1. Step 1: Occasional use of inhaled short-acting beta2-adrenoceptor agonist bronchodilators.
    2. Step 2: Introduction of regular preventer therapy, preferably inhaled corticosteroids (ICS).
    3. Step 3: Add-on therapy with long-acting beta2-agonists (LABAs), such as salmeterol and formoterol.
    4. Step 4: Poor control with Step 3: Addition of a fourth drug, such as leukotriene receptor antagonists or theophyllines.
    5. Step 5: Continuous or frequent use of oral steroids.

    Non-Pharmacological Management

    Patient Education

    • Explain that it is safer for pregnant women with asthma to take asthma medications than to have ongoing symptoms or exacerbations.
    • Reassure that safe and adequate asthma treatment is possible during pregnancy and that good asthma control minimizes the risk of complications.

    Smoking Cessation

    • Smoking increases the risk of asthma exacerbations, bronchitis, or sinusitis, and necessitates an increased need for medication.
    • Associated with adverse pregnancy outcomes, including spontaneous pregnancy loss, placental abruption, preterm premature rupture of membranes (PPROM), placenta previa, preterm labor and delivery, low birth weight, and ectopic pregnancy.

    Control of Environmental Triggers

    • Reduce the need for pharmacologic intervention by avoiding exposure to allergens and nonspecific airway irritants like tobacco smoke, dust, and environmental pollutants.
    • Particular allergens of concern include dander from pets and antigens from household dust mites.

    Nursing Care

    Bed Rest: Complete bed rest is essential, with assistance provided for all activities due to dyspnea.

    • Maternal Positioning: Pregnant patients with acute asthma should rest in a seated or lateral position to avoid aortocaval compression by the gravid uterus, particularly in the third trimester.
    • Hydration: Intravenous fluids are not necessary unless the patient cannot maintain oral hydration.
    • Supplemental Oxygen: Initially 3 to 4 L/min by nasal cannula, adjusting to maintain a PaO2 of at least 70 mmHg and/or oxygen saturation of 95% or greater.
    • Observation: Monitor fetal condition and mother’s response to treatment closely.

    Management Of Acute Attacks Of Asthma (Asthma Exacerbation) In Pregnancy

    • Avoidance of asthma triggers (allergens, irritant) to minimize airway inflammation and hyper-responsiveness.
    • Oxygen inhalation with mask to maintain Oxygen saturation > 95% (pulse oximeter).
    • High dose albuterol by nebulization every 20 minutes and inhaled ipratropium bromide and systemic corticosteroid. 
    • Repeat assessment of symptom, physical examination and Oxygen  saturation to be done.
    • Corticosteroids: Intravenous hydrocortisone 200 mg stat and to be repeated after 4 hours. Because of long onset of action, corticosteroids should be given along with β2-agonists. 
    • Mechanical ventilation is needed for status asthmaticus to avoid hypoxemia and carbon dioxide retention.

    Pharmacotherapy in Exacerbations

    • Agents: The recommended agents include inhaled short-acting beta-agonists e.g Albuterol (ProAir, Ventolin), levalbuterol (Xopenex), terbutaline (Brethine). These are often given via nebulizer or metered-dose inhaler (MDI), inhaled anticholinergic agents e.g Ipratropium bromide (Atrovent), oral or intravenous glucocorticoids Oral prednisone or methylprednisolone (Solu-Medrol).
    • Systemic Glucocorticoids: Benefits outweigh risks in preventing life-threatening asthma exacerbations e.g Dexamethasone.
    • Ipratropium: Used to treat severe acute asthma exacerbations.
    • Intravenous Magnesium Sulfate: Magnesium sulfate can be used in severe, life-threatening asthma exacerbations, especially in those who haven’t responded well to other treatments. It has bronchodilating and anti-inflammatory effects.

    Asthma Management During Labor and Delivery

    • Only 10-20% of women develop an exacerbation during labor and delivery.
    • Opiate analgesics should be avoided as they are bronchoconstrictor and respiratory depressant. Maternal oxygenation should be adequately maintained. Labetalol should be avoided as it may precipitate asthma.
    • Hydrocortisone 100 mg IV 8 hourly during labor and 24 hours postpartum is to be given if the patient had steroids within the previous 4 weeks. Inhaled corticosteroid (fluticasone, budesonide) prevents bronchial hyper-responsiveness to allergens.
    • Syntocinon is better than ergometrine because of bronchoconstrictor effect of the latter. PGF2 α should not be used, as it precipitates bronchospasm. PGE1 and PGE2 compounds can be used locally for induction of labour or abortion.
    • Epidural anesthesia is preferable to general anesthesia because of risk of atelectasis and subsequent chest infection following the latter. Halothane is better in general anesthesia. However, it produces uterine atony.
    • Ketamine is used for induction of general anesthesia as it prevents bronchospasm.
    • Oxygen saturation is assessed with pulse oximeter or arterial blood gases.
    • Postnatal physiotherapy is maintained and drugs are continued.
    • Breastfeeding should be encouraged, as it delays the onset of allergic problems in the child. Drugs used in asthma: Prednisolone, corticosteroids, LABA, LTRA do not contraindicate breast feeding.
    • Contraception: Barrier method is the best. For terminal contraception, husband is to be motivated for vasectomy.

    Peripartum Care

    • Oxytocin: The drug of choice for labor induction and postpartum hemorrhage control.
    • Pain Control: Avoid morphine and meperidine; use fentanyl or butorphanol. Epidural anesthesia is preferred; if general anesthesia is needed, use ketamine due to its bronchodilatory effect. Avoid ergot derivatives.
    • Monitoring: Monitor blood glucose levels in the baby if high doses of short-acting beta-agonists were used during labor and delivery.

    Effects of Asthma on Pregnancy

    1. Infections: Increased susceptibility due to lowered resistance.
    2. Physiological Changes: Nervous system changes can lead to frequent attacks.
    3. Complications:
    • Exhaustion, stress, cyanosis, and dyspnea can cause intrauterine hypoxia.
    • Rapid pulse, tachypnea, and lowered blood pressure.
    • Mental confusion due to reduced oxygen to the brain.
    • Placental insufficiency leading to intrauterine growth retardation.

    Maternal Risks:

    • Hyperemesis (severe nausea and vomiting): Asthma medications, particularly inhaled corticosteroids, can contribute to nausea and vomiting.
    • Accidental haemorrhage: Increased risk of bleeding during pregnancy since some asthma features can predispose mother to trauma.
    • Respiratory failure: Severe asthma attacks can lead to respiratory failure, requiring mechanical ventilation.
    • Pregnancy-induced hypertension (PIH): Asthma may increase the risk of developing PIH, a serious condition characterized by high blood pressure during pregnancy.
    • Preterm labour and premature birth: Asthma exacerbations can trigger contractions and lead to early delivery.
    • Increased risk of maternal death: Severe asthma complications, particularly respiratory failure, can be life-threatening.

    Effects on Labor

    • Status Asthmaticus: An attack that does not respond to usual treatment.
    • Fetal Asphyxia: Due to constriction of blood vessels in the lungs.
    • Maternal Distress: Significant distress and potential obstetric shock.
    • Assisted Delivery: Necessary due to the mother’s inability to push effectively.

    Effects on the Baby

    1. Oligohydramnios (low amniotic fluid levels): Asthma medications can affect the baby’s fluid balance, potentially leading to low amniotic fluid.
    2. Low birth weight (LBW): Premature birth, which is more common in women with asthma, is a major factor contributing to LBW.
    3. Premature delivery: Asthma can increase the chances of delivering before the full term of pregnancy.
    4. Fetal demise (death): Severe asthma complications, particularly during the third trimester, can lead to fetal distress and death.
    5. Meconium staining (indicating fetal distress): Fetal distress can cause the baby to release meconium (first stool) into the amniotic fluid.

    Neonatal Risks:

    1. Neonatal hypoxemia (low oxygen levels): Premature babies born to mothers with asthma are more likely to experience low oxygen levels at birth.
    2. Low newborn assessment scores: Prematurity and low oxygen levels can negatively impact the baby’s apgar score.
    3. Increased perinatal mortality: Premature birth and complications associated with asthma can increase the risk of infant death.

    Complications

    1. Cardiac Failure: Due to the increased strain on the heart.
    2. Respiratory Failure: Severe and untreated attacks can lead to respiratory failure.
    3. Poor Lactation: Due to the physical stress and medication.
    4. Chronic Bronchitis: Frequent attacks may lead to chronic bronchitis.
    5. Atonic Uterus: Resulting in prolonged labor or postpartum hemorrhage.
    6. Abortions and Premature Labor: Due to the stress and physical demands of asthma.
    7. Neonatal Complications: Various complications can arise due to the mother’s condition.

    ASTHMA IN PREGNANCY Read More »

    ESSENTIAL HYPERTENSION IN PREGNANCY

    ESSENTIAL HYPERTENSION IN PREGNANCY 

    Apart from Pregnancy Induced Hypertension (PIH), Essential Hypertension is the most common hypertensive state in pregnancy. This is primary hypertension where the blood pressure is raised over 140/90mmHg during the first 20 weeks of pregnancy. It’s usually present before pregnancy. It doesn’t present with any proteinuria as in severe preeclampsia.

    Essential hypertension in pregnancy refers to high blood pressure that develops before pregnancy or within the first 20 weeks of gestation and persists throughout pregnancy.

    Classifications of Essential Hypertension

    Hypertension, or high blood pressure, can be categorized into three levels based on the diastolic blood pressure reading:

    1. Mild Hypertension: Diastolic blood pressure between 95 and 105 mmHg.
    2. Moderate Hypertension: Diastolic blood pressure between 105 and 115 mmHg.
    3. Severe Hypertension: Diastolic blood pressure above 115 mmHg.

    Causes of Essential Hypertension

    The exact causes of essential hypertension are not fully understood

    Factors that may contribute to the development of essential hypertension include;

    1. Genetics: Family history of hypertension significantly increases the risk. Studies have identified specific genes associated with the condition.

    2. Lifestyle Factors:

    • High Sodium Intake: Excessive salt consumption can contribute to fluid retention and increased blood pressure.
    • Low Potassium Intake: Adequate potassium is essential for regulating blood pressure, and low levels can contribute to hypertension.
    • Obesity: Excess body weight increases the workload on the heart and blood vessels, leading to higher blood pressure.
    • Physical Inactivity: Lack of regular exercise can contribute to weight gain and cardiovascular problems, including hypertension.
    • Smoking: Nicotine constricts blood vessels, raising blood pressure.
    • Excessive Alcohol Consumption: Heavy drinking can damage blood vessels and increase blood pressure.
    • Stress: Chronic stress can trigger the release of hormones that increase blood pressure.

    3. Underlying Medical Conditions:

    • Kidney Disease: Kidney problems can impair the body’s ability to regulate blood pressure.
    • Thyroid Disorders: Hyperthyroidism can lead to increased heart rate and blood pressure.
    • Sleep Apnea: Disrupted sleep patterns can raise blood pressure.
    • Diabetes: Diabetes can damage blood vessels and increase the risk of hypertension.

    SIGNS AND SYMPTOMS

    Essential hypertension is often referred to as the “silent killer” because it most of the time doesn’t cause noticeable symptoms in its early stages. This makes it even more dangerous because damage to the heart, blood vessels, and other organs can occur without any warning signs.

    • Raised blood pressure of 140/90mmHg or more in early pregnancy: This indicates elevated blood pressure readings, specifically a systolic pressure (top number) of 140 mmHg or higher and/or a diastolic pressure (bottom number) of 90 mmHg or higher. 
    • Headaches: High blood pressure can cause persistent, throbbing headaches, often at the back of the head or temples.
    • Shortness of breath: Hypertension can lead to fluid buildup in the lungs, making it difficult to breathe.
    • Chest discomfort: The strain on the heart from high blood pressure can cause chest pain or tightness.
    • Sleep disturbances: Hypertension may contribute to sleep apnea and other sleep problems.
    • Palpitations and tachycardias: High blood pressure can cause an irregular or rapid heartbeat.
    • Fluid retention: Hypertension can lead to fluid buildup in the body, causing swelling in the legs, ankles, and feet.
    • Blurred vision: Damage to the blood vessels in the eyes is a potential complication of hypertension. 
    • Nausea or vomiting: Nausea and vomiting in hypertensive pregnancies can occur due to generalized malaise or as a response to the stress placed on the body by elevated blood pressure.
    • Fatigue and loss of energy: The strain on the cardiovascular system from high blood pressure can lead to feelings of tiredness and low energy.

    Management of Essential hypertension

    Elevated blood pressure is usually caused by a combination of several abnormalities such as psychological stress, genetic inheritance, environmental and dietary factors and others. Patients in whom no specific cause of hypertension can be found are said to have essential hypertension or primary hypertension (accounts for 80-90 % of cases). 

    The choice of therapy of a patient with hypertension depends on a variety of factors: age, sex, race, body build, life-style of the patient, cause of the disease, other coexisting disease, rapidity of onset and severity of hypertension, and the presence or absence of other risk factors for cardiovascular disease (e.g. smoking, alcohol consumption, obesity, and personality type).

    The aims/principles of management are: 

    • To stabilize the blood pressure to below 130/90 mm Hg.
    • To prevent superimposition of preeclampsia.
    • To monitor maternal and fetal well-being.
    • To terminate the pregnancy at the optimal time.

    History Taking:

    • A thorough history should be taken for all mothers in the ANC Clinic to rule out essential hypertension (HT) in families.
    • This helps in early identification and management of at-risk mothers.

    Blood Pressure and Urine Testing:

    • Regular and careful monitoring of blood pressure (BP) and urine testing is essential.
    • This helps in the early detection of any deviations from normal parameters.

    Condition Management:

    • This condition is managed in the maternity centre (m/c) by midwives.
    • All mothers with signs of hypertension should be referred to a hospital for further management.

    Non pharmacological therapy of hypertension

    • Low sodium chloride diet  Weight reduction.
    • Exercise.
    • Cessation of smoking.
    • Psychological methods (relaxation, meditation …etc).
    • Dietary decrease in saturated fats.
    • Decrease in excessive consumption of alcohol.
    Management in Hospital

    Mild Cases

    Blood Pressure Range:

    • Mild cases are defined by blood pressure between 140/90 mmHg and 150/100 mmHg.

    Antenatal Clinic Visits:

    • Patients should attend the Antenatal Clinic regularly every two weeks and be seen by a doctor.
    • Close monitoring of blood pressure and urine for albumin is necessary.
    • Weight checks and observation for edema should be conducted at every visit.

    Fetal Monitoring:

    • Fetal growth and well-being should be carefully monitored to ensure normal development.
    • Excessive weight gain in the mother increases the risk of pre-eclampsia.

    Medication:

    • Hypertensive drugs are usually not necessary for mild cases.
    • A sedative like Phenobarbital 30-60 mg nocte may be prescribed to reduce anxiety and ensure adequate rest.

    Admission and Rest:

    • Mother is admitted at 36 weeks for rest in preparation for labor.
    • If blood pressure rises above 150/100 mmHg or there is albumin in the urine, immediate admission is required.

    Advice on Diet and Rest:

    • Reduce intake of fats and carbohydrates, and avoid additional salt.
    • Ensure 10 hours of rest at night and 2 hours in the afternoon.
    • Avoid alcohol, smoking, and constipation.

    Severe Cases

    Admission:

    • Mother is admitted to the hospital and the doctor is informed.
    • Routine history taking, observation, and examination are conducted.

    Urine and Blood Tests:

    • A mid-stream urine test is conducted to rule out albumin and check for pus cells and white blood cells.
    • Blood tests for blood urea are also performed.

    Observation for Edema:

    • Examination for the presence of edema is necessary.
    • The mother is put on complete bed rest.

    Nursing Care

    Bed Rest:

    • Mother remains in bed for most of the day, with occasional sitting for relaxation.
    • The midwife provides a bedpan and brings necessities to the mother.

    Hygiene:

    • Bed baths and vulva toilets are carried out every 4 hours.
    • Position changes and treatment of pressure areas are done 4-hourly.
    • Oral hygiene is maintained every 4 hours.
    • Bed linen is changed daily.

    Diet:

    • A salt-free, light, and nourishing diet with plenty of proteins is provided.
    • Strict control of fluid intake to reduce and prevent edema.

    Observations:

    • Temperature, pulse, respiration, and BP are checked every 4 hours.
    • Daily urine checks to rule out edema.
    • Fetal heart rate and growth are checked twice daily to rule out anoxia and intrauterine fetal death.
    • Placenta functional tests for efficiency.

    Medical Treatment

    Hypertensive Drugs:

    • Methyldopa, is the drug of choice during pregnancy, effective and safe for the mother and fetus. (Dosages below)
    • Indomethacin or methyldopa 250-750 mg orally as per the doctor’s prescription.
    • Hydralazine 1-4 mg twice a day.
    • Sedatives like Valium 5-10 mg 8-hourly.
    • Diuretics like furosemide.
    • Nifedipine 5 mg sublingually.

    Obstetrical Management

    Labor Induction:

    • Hypertensive mothers are not allowed to carry pregnancy to term.
    • In mild to moderate cases, labor is induced at about 38 weeks of gestation.
    • In severe cases, labor is induced at about 36 weeks of gestation.

    First Stage of Labor:

    • Careful observations at 30-minute intervals.
    • BP checked every 2 hours or more frequently as ordered by the doctor.
    • Fetal heart rate checked every 30 minutes.

    Second Stage of Labor:

    • Preparation may include additional equipment like vacuum extraction.
    • A large episiotomy is given to prevent maternal exhaustion.
    • Caesarean section may be done if progress is slow to avoid eclampsia.

    Third Stage of Labor:

    • Injection of morphine 15 mg upon completion of labor.
    • Pitocin 10 IU in a drip.

    Effects of Hypertension During Pregnancy

    • Abortion
    • Pre-eclampsia: Frequent complication with development of edema and proteinuria.
    • Eclampsia
    • Abruptio Placenta
    • Maternal Mortality
    • Renal Complications: Acute renal failure.

    Effects of Hypertension During Labor

    • Premature Labor
    • Eclampsia
    • Poor Progress: Assisted delivery by vacuum extraction.
    • Cerebral Damage
    • Heart Failure

    Effects of Hypertension During Puerperium

    • Low Resistance to Infection
    • Anemia
    • Postpartum Hemorrhage
    • Fits

    Effects of Hypertension on Baby

    • Intrauterine Fetal Growth Retardation: Due to placental insufficiency.
    • Prematurity
    • Hypoxia and Anoxia
    • Abruptio Placenta
    • Asphyxia at Birth: Due to maternal cyanosis.
    • Mental Retardation
    • Deformity

    Nursing Care Plan for a Patient with Essential Hypertension

    Assessment

    Diagnosis

    Planning (Goals/Expected Outcomes)

    Implementation

    Rationale

    Evaluation

    1. Elevated blood pressure reading of 150/95 mmHg.  

    2. Complains of headache and dizziness. 

    3. Family history of hypertension. 

    4. Patient’s diet includes high sodium intake. 

    5. Sedentary lifestyle.

    Hypertension related to lifestyle factors and genetic predisposition evidenced by blood pressure reading of 150/95 mmHg.

    Short Term: 

     – Reduce blood pressure to below 140/90 mmHg within one week. 

    – Patient will verbalize understanding of the importance of dietary and lifestyle modifications within three days.  Intermediate Term:  

    – Blood pressure maintained between 120/80 mmHg and 130/85 mmHg within one month. 

     Long Term:  – Patient will adopt a healthier lifestyle, including a balanced diet and regular exercise, to maintain blood pressure within normal limits (<120/80 mmHg) within six months.

    – Monitor blood pressure twice daily and record readings. 

     – Educate patient on the DASH diet (Dietary Approaches to Stop Hypertension). 

     – Encourage reduction of sodium intake to less than 2,300 mg per day. 

     – Advise patient to engage in at least 30 minutes of moderate-intensity exercise, such as brisk walking, five days a week. 

     – Administer antihypertensive medications as prescribed by the doctor. 

     – Discuss stress management techniques, such as deep breathing exercises and meditation.

    – Regular monitoring helps track progress and adjust interventions as needed. 

    – The DASH diet is proven to reduce blood pressure. 

    – Reducing sodium intake helps lower blood pressure. 

    – Regular exercise strengthens the heart and improves blood circulation, which can lower blood pressure. 

    – Medications help control blood pressure levels. 

    – Stress management can reduce blood pressure by calming the nervous system.

    – Blood pressure reduced to 138/88 mmHg within one week. 

    – Patient accurately explains the importance of dietary and lifestyle changes after three days. 

    – Blood pressure maintained at 125/82 mmHg after one month. 

    – Patient reports regular adherence to a healthier lifestyle and maintains blood pressure at 118/78 mmHg after six months.

    1. Complaints of headache and dizziness. 

    2. Elevated blood pressure reading of 150/95 mmHg.

    Acute pain related to increased blood pressure evidenced by patient complaints of headache.

    Short Term: 

    – Patient will report a decrease in headache severity within one hour of intervention. 

    Intermediate Term: 

    – Patient will report fewer headaches within one month.

    – Assess pain level using a 0-10 pain scale. 

    – Administer prescribed analgesics for headache relief. 

    – Encourage rest in a quiet, dark room. 

    – Teach relaxation techniques, such as deep breathing or guided imagery.

    – Pain assessment helps in determining the effectiveness of interventions. 

    – Analgesics can provide immediate relief from headache. 

    – A quiet environment reduces stimuli that may exacerbate headache. 

    – Relaxation techniques can help reduce pain perception.

    – Patient reports headache severity reduced from 8/10 to 2/10 within one hour. 

    – Patient reports fewer and less severe headaches after one month.

    1. Family history of hypertension. 

    2. Elevated blood pressure reading of 150/95 mmHg.

    Knowledge deficit related to lack of information about hypertension management evidenced by patient questions about diet and exercise.

    Short Term: 

    – Patient will demonstrate understanding of hypertension management by correctly answering questions about diet and exercise within one week. 

    Long Term: 

    – Patient will implement lifestyle changes to manage hypertension within three months.

    – Provide educational materials on hypertension and its management. 

    – Review the importance of medication adherence. 

    – Demonstrate how to monitor blood pressure at home. 

    – Discuss the role of diet, exercise, and stress management in controlling blood pressure.

    – Education empowers the patient to take an active role in managing their condition. 

    – Understanding medication importance improves adherence. 

    – Home monitoring provides immediate feedback on lifestyle changes. 

    – Knowledge of lifestyle factors helps in making informed decisions.

    – Patient correctly answers questions about diet and exercise within one week. 

    – Patient implements and adheres to recommended lifestyle changes, as evidenced by improved blood pressure readings within three months.

    1. Patient’s diet includes high sodium intake. 

    2. Elevated blood pressure reading of 150/95 mmHg.

    Imbalanced nutrition: more than body requirements related to excessive sodium intake evidenced by elevated blood pressure.

    Short Term: 

    – Patient will identify high-sodium foods to avoid within one week. 

    Intermediate Term: 

    – Patient will reduce daily sodium intake to less than 2,300 mg within one month.

    – Provide a list of high-sodium foods to avoid. 

    – Teach label reading to identify sodium content in packaged foods. 

    – Suggest healthier food alternatives. 

    – Encourage cooking at home using fresh ingredients.

    – Identifying high-sodium foods helps in making healthier choices. 

    – Label reading educates on hidden sodium sources. 

    – Healthier alternatives can reduce overall sodium intake. 

    – Home-cooked meals allow better control of ingredients.

    – Patient identifies high-sodium foods correctly within one week. 

    – Patient reports reduced sodium intake and improved dietary habits within one month.

    1. Sedentary lifestyle. 

    2. Elevated blood pressure reading of 150/95 mmHg.

    Activity intolerance related to sedentary lifestyle evidenced by complaints of fatigue and shortness of breath on exertion.

    Short Term: 

    – Patient will verbalize the importance of physical activity in managing hypertension within one week. 

    Intermediate Term: 

    – Patient will engage in 30 minutes of moderate-intensity exercise five days a week within one month.

    – Assess current activity level and limitations. 

    – Develop an individualized exercise plan starting with low-impact activities. 

    – Encourage gradual increase in physical activity duration and intensity. 

    – Monitor patient’s response to activity and adjust plan as needed.

    – Understanding current activity level helps in setting realistic goals. 

    – An individualized plan ensures activities are appropriate and safe. 

    – Gradual increase in activity prevents injury and encourages adherence. 

    – Monitoring response ensures safety and effectiveness of the plan.

    – Patient verbalizes understanding of the importance of physical activity within one week. 

    – Patient consistently engages in regular exercise, as evidenced by improved stamina and blood pressure readings within one month.

     

    Pharmacological Therapy of Hypertension

    Most patients with hypertension require drug treatment to achieve a sustained reduction in blood pressure. Currently available drugs lower blood pressure by decreasing either cardiac output or total peripheral vascular resistance, or both.

    Anti-hypertensive drugs are classified according to the principal regulatory site or mechanism on which they act. They include:

    A) Diuretics

    Diuretics lower blood pressure by depleting the body’s sodium and reducing blood volume. They are effective in lowering blood pressure by 10-15 mmHg in most patients. Diuretics include:

    1. Thiazides and Related Drugs

    • Examples: hydrochlorothiazide, bendrofluazide, chlorthalidone
    • Mechanism: Initially, thiazide diuretics reduce blood pressure by reducing blood volume and cardiac output due to increased urinary water and electrolyte (particularly sodium) excretion. With chronic administration (6-8 weeks), they decrease blood pressure by decreasing peripheral vascular resistance as the cardiac output and blood volume return to normal values.

    2. Loop Diuretics

    • Examples: furosemide, ethacrynic acid
    • Mechanism: Loop diuretics are more potent than thiazides. The antihypertensive effect is mainly due to the reduction of blood volume. They are indicated in cases of severe hypertension associated with renal failure, heart failure, or liver cirrhosis.

    3. Potassium-Sparing Diuretics

    • Examples: spironolactone
    • Mechanism: Used as adjuncts with thiazides or loop diuretics to avoid excessive potassium depletion and enhance the effect of other diuretics. The diuretic action of these drugs is weak when administered alone.

    B) Direct Vasodilators

    These include arterial vasodilators and arteriovenous vasodilators.

    1. Arterial Vasodilators

    • Example: hydralazine
    • Mechanism: Dilates arterioles but not veins. It is used particularly in severe hypertension.
    • Side Effects: Common adverse effects include headache, nausea, anorexia, palpitations, sweating, and flushing.

    2. Arteriovenous Vasodilators

    • Example: sodium nitroprusside

    METHYLDOPA

    • Mechanism of Action: Central/peripheral antiadrenergic action resulting in decreased arterial pressure.
    • Dose: 250 mg – 500 mg orally.
    • Indications: Hypertension, pre-eclampsia.
    • Contraindications: Hepatic disorders, psychiatric patients, congestive heart failure, postpartum depression.
    • Side Effects: Hemolytic anemia, sodium retention, nausea, vomiting, diarrhea, constipation, weight gain, depression, dizziness, headache, fetal intestinal ileus.
    • Nursing Considerations:
    1. Monitor blood values of neutrophils and platelets.
    2. Monitor blood pressure before beginning treatment, periodically, and after.
    • Patient Instructions:
    1. Store tablets in tight containers.
    2. Avoid hazardous activities.
    3. Take the tablet one hour before meals.
    4. Do not stop the drug unless directed by a physician.
    5. Rise slowly to minimize orthostatic hypotension.

    HYDRALAZINE

    • Mechanism of Action: Peripheral vasodilation as it relaxes the arterial smooth muscles. It increases cardiac output and renal blood flow.
    • Indications: Essential hypertension.
    • Dose:
    1. Orally: 100 mg/day in 4 divided doses.
    2. Intravenously: 5-10 mg every 20 minutes with a maximum of 20 mg.
    • Side Effects: Hypotension, tachycardia, fluid retention, muscle cramps, headache, depression, anorexia, diarrhea, neonatal thrombocytopenia.
    • Contraindications: Rheumatic heart disease.
    • Nursing Considerations:
    1. Monitor BP every 15 minutes for 2 hours, then hourly for 2 hours, then 4-hourly.
    2. Monitor fluid intake and output.
    3. Take weight daily.
    4. Administer in a recumbent position and keep the patient in that position for 1 hour after administration.
    5. Evaluate for edema, assess skin turgor, and monitor for dyspnea, orthopnea, joint pains, headaches, and palpitations.
    • Patient Instructions:
    1. Take with food to increase bioavailability.
    2. Notify the doctor if there is chest pain, severe fatigue, muscle or joint pains.

    LABETALOL

    • Mechanism of Action: Decreases systemic arterial blood pressure and systemic vascular resistance due to its combined alpha and beta-adrenergic blocking activity.
    • Indications: Hypertension, hypertensive emergencies.
    • Dose:
    1. Orally: 100 mg three times daily.
    2. IV infusion: 20-40 mg every 10-15 minutes until the desired effect is achieved in a hypertensive crisis.
    • Contraindications: Hepatic disorders, asthma, congestive heart failure.
    • Side Effects: Tremors, headache, asthma, congestive cardiac failure, sodium retention, postural hypotension.
    • Nursing Considerations:
    1. Assess urine input and output.
    2. Take weight daily.
    3. If given intravenously, keep the patient in a recumbent position for 3 hours.
    4. Check for edema of legs and feet.
    5. Assess skin turgor and mucous membrane dryness for hydration status.
    • Patient Instructions:
    1. Take the tablet orally before food.
    2. Do not discontinue the drug abruptly.
    3. Report bradycardia, dizziness, confusion, or depression.
    4. Avoid alcohol, smoking, and excess sodium intake.
    5. Take medication at bedtime to prevent the effect of orthostatic hypotension.

    NIFEDIPINE

    • Mechanism of Action: Dihydropyridine calcium channel blocker. Direct arterial vasodilator by inhibiting the slow inward calcium channel in vascular smooth muscles. Reduces muscle contractility.
    • Dose:
    1. Orally: 5-10 mg three times daily.
    2. Tocolytic dose: Initial dose of 20 mg orally, followed by 20 mg orally after 30 minutes. If contractions persist, continue with 20 mg orally every 3-8 hours for 48-72 hours with a maximum dose of 160 mg/day. Long-acting nifedipine (30-60 mg daily) can be used after 72 hours if maintenance is still required.
    • Indications: Hypertension, angina pectoris, preterm labor.
    • Contraindications: Simultaneous use with magnesium sulfate due to synergistic effects.
    • Side Effects: Flushing, hypotension, headache, tachycardia, inhibition of labor, fatigue, nausea and vomiting, drowsiness.
    • Nursing Considerations: Administer before meals.
    • Patient Instructions: Limit caffeine consumption.

    PROPRANOLOL

    • Mechanism of Action: Sympatholytic non-selective beta-blocker that decreases preload and afterload, reducing left ventricular end-diastolic pressure and systemic vascular resistance.
    • Indications: Hypertension.
    • Contraindications: Bronchial asthma, diabetes mellitus, cardiac failure.
    • Side Effects: Severe hypotension, sodium retention, bradycardia, bronchospasms, intrauterine growth restriction (IUGR) with prolonged therapy, headache.
    • Dose: 80-240 mg once daily orally.
    • Nursing Considerations:
    1. Assess BP, pulse, and respirations during treatment therapy.
    2. Take weight often and report excess weight gain.
    3. Evaluate tolerance if taken for long periods.
    4. Evaluate for headaches.
    • Patient Instructions:
    1. Take with plenty of water on an empty stomach.
    2. Make position changes slowly to prevent fainting.

    Common Diuretics Used

    FRUSEMIDE

    • Type: Loop diuretic.
    • Mechanism of Action: Acts on the loop of Henle to prevent the reabsorption of sodium and potassium.
    • Dose:
    1. Oral: 10 mg/mL, 40 mg/5 mL.
    2. Injection: 10 mg/mL.
    3. Tablet: 20 mg, 40 mg, 80 mg.
    • Indications: Pregnancy-induced hypertension, eclampsia with pulmonary edema.
    • Contraindications: Anuria, hypersensitivity to the drug.
    • Side Effects: Fatigue, muscle cramps, hypokalemia, fetal compromise.

    Anticonvulsants

    Magnesium Sulphate

    • Mechanism of Action: Competitive inhibition to calcium ions either at the motor end plate or at the cell membrane, reducing calcium influx and directly acting on uterine muscles and motor plate sensitivity.
    • Indications: Premature rupture of membranes, active labor, planned delivery within 24 hours, prevention or control of seizures in pre-eclampsia, hypomagnesemia.
    • Dose Regimen:
    1. Loading Dose: 
    2. Maintenance Dose: 5 g IM 4 hourly on alternate buttocks, or 1-2 g/hr IV infusion.
    • Route of Administration

      Loading Dose

      Maintenance Dose

      Intramuscular

      4 g IV over 3-5 minutes, followed by 10 g deep IM.

      5g 4 hourly on alternate buttocks

      Intravenous

      4-6g i.v over 15-20 minutes

      1-2 g/hr i.v infusion

     

    • Side Effects: Flushing, nausea, vomiting, headache, blurred vision, respiratory depression.
    • Contraindications: Impaired renal function.

    Diazepam

    • Mechanism of Action: Depresses subcortical levels of the CNS.
    • Dose:
    1. Orally: 2-10 mg three to four times daily.
    2. IV: 5-20 mg bolus, may repeat in 30 minutes if seizures reappear.
    • Side Effects: Hypotension, dizziness, drowsiness, headache, respiratory depression, birth hypotonia, thermoregulatory problems in the newborn.

    Phenytoin

    • Mechanism of Action: Prolongs the inactivation state of sodium channels, reducing the likelihood of repetitive discharge.
    • Indications: Prevention and control of seizures in pre-eclampsia and eclampsia, status epilepticus.
    • Side Effects: Sedation, cleft palate (in fetuses).

    Anticoagulants

    Heparin Sodium

    • Mechanism of Action: Prevents the conversion of fibrinogen to fibrin.
    • Indications: Deep vein thrombosis, thromboembolism, disseminated intravascular coagulation, patients with prosthetic valves in the heart.
    • Action: Interferes with blood clotting by direct means, depressing hepatic synthesis of vitamin K-dependent coagulation factors.

    Treatment of Shock

    Shock is a clinical syndrome characterized by decreased blood supply to tissues. Signs and symptoms include oliguria, heart failure, disorientation, mental confusion, seizures, cold extremities, and coma. Most, but not all, people in shock are hypotensive. The treatment varies with the type of shock. The choice of drug depends primarily on the pathophysiology involved.

    • Anaphylactic Shock or Neurogenic Shock: Characterized by severe vasodilation and decreased PVR, a vasoconstrictor drug (e.g., levarterenol) is the first drug of choice.
    • Hypovolemic Shock: Intravenous fluids that replace the type of fluid lost should be given.
    • Septic Shock: Appropriate antibiotic therapy in addition to other treatment measures

    ESSENTIAL HYPERTENSION IN PREGNANCY  Read More »

    Renal Diseases in Pregnancy

    Renal Diseases in Pregnancy

    COMMON TERMS IN URINARY SYSTEM 

    •  Proteinuria: Daily excretion of proteins in the urine is more than 150mg. It signifies that the kidney is damaged/ perforated.
    • Haematuria: Means passing urine containing blood and is due to bleeding into the urinary tract.
    • Crystalluria : Presence of crystals like oxalates, phosphates in the urine detected by microscopic examination of urine
    • Glycosuria : Means presence of sugar (glucose) in urine either due to diabetes mellitus or due to renal glycosuria
    • Azotemia: Increase in the serum concentration of urea and creatinine above their normal values. This occurs when glomerular filtration pressure (GFR) of the kidneys falls due to renal failure. “uremia”.
    •  Oliguria : Diminished urine volume output of urine i.e. 100 mL to 400 mL  per day.
    •  Anuria – Complete absence of urine formation i.e zero to 100 mL per day
    •  Dysuria – Difficulty or pain in passing urine 
    •  Polyuria – Urine volume above 3 litres per day 
    •  Retention of urine – occurs due to obstruction of urine outflow from the bladder, this is relieved by catheterization

    Anatomy of the Renal System 

    The urinary system is the main excretory system eliminating waste products from blood through urine. Its anatomy consists of two kidneys, each joined to the bladder by the tube called ureter, which conveys urine from the kidneys to the bladder for storage. Following bladder contraction, urine is expelled through the urethra

    The Kidneys

    There are two kidneys which lie behind the peritoneum on either side of the vertebral column. In adults, they measure approximately 12 to 14 cm.

    The urine is formed in the kidney by the nephrons. 

    Each kidney has approximately one million nephrons. 

     

    Role of the Kidneys 

    • Influence blood pressure control 

    • Release renin to activate the renin-angiotensin system 

    • Can lead to water retention or excretion 

    Waste excretion(Urea, Creatinine, Uric Acid)

    • Blood filtration

    • Blood glucose regulation(glucose absorption)

    • Acid Base Balance/pH regulation

    Electrolyte balance (Sodium, Potassium, Chloride)

    •Erythropoiesis regulation(also produces Erythropoietin)

    URINARY BLADDER

    It is made up of four layers i.e. 

    •  Mucosa; this is the innermost layer with rugae that allows its distention. 

    •  Sub mucosa which provides rich vascular supply 

    •  Smooth muscle layer/ detrusor muscle; which contracts during urination  for urine expulsion.

    •  Serosa: a continuation of peritoneum 

     

    The bladder has a triangular area called trigone with three openings at its angles i.e two for ureters laterally and one for the urethra at the apex

    URETHRA

    This conveys urine from the urinary bladder to outside of the body. 

    The internal sphincter of smooth muscle and external urethral sphincter of skeletal muscles constricts the lumen of the urethra causing bladder to fill. 

    Female urethra is 4cm long and male urethra is 20 cm

    NEPHRON

    This is a functional (urine) forming units of the kidneys

    Components of the Nephron 

    • Bowman’s Capsule a cup-like structure made of squamous epithelium and inner layer has modified cell (podocytes) closely associated with glomerular capillaries 
    • Glomerulus made of highly permeable capillary network 
    • Proximal convoluted tubule, made of cuboidal epithelium with microvilli. It is a primary site of tubular reabsorption and secretion mechanisms. 
    • Loop of Henle, both ascending and descending loops are involved in urine concentration 
    • Distal Convoluted tubule; this is shorter than the proximal and contains macula densa specialized sensory cells which monitor NaCl concentrations. it’s a site of tubular reabsorption and secretion 
    • Collecting Ducts; these empty urine into the renal pyramids
     
    Physiology of the urinary system  (1)

    Physiology of the urinary system 

    The volume of the urine excreted per day is about 1500m/s or roughly 1 ml /min. The processes responsible for urine formation are ultra filtration at the glomeruli and reabsorption in the tubules of the nephrons. 

    The kidneys are largely responsible for maintaining this constancy and the excretion of waste products of metabolism. 

    For example, urea which is a waste product of protein metabolism is excreted in a large quantity. Various renal functions are illustrated below 

     

    FUNCTIONS OF THE RENAL SYSTEM 
    1.  Regulation of the water content of the body: About 2/3 of water filtered by the glomeruli is reabsorbed in the proximal tubules iso-osmotically.  The remaining water is reabsorbed in distal tubules and collecting duct; under the influence of antidiuretic hormone (ADH).
    2. Regulation of normal acid-base balance of the blood. The kidneys help to maintain a normal internal environment by preventing body fluids from becoming too acidic or too alkaline. 
    3.  Regulation of electrolyte content of the body. A large part of sodium ions (Na+), chloride ions (Cl- ) are actively reabsorbed in the PCT, DCT and collecting ducts. The kidney regulates the fluid balance by excreting more urine when a large amount of urine is taken and retains fluid when much has been lost. 
    4.  Hormonal and metabolic functions. The kidney produces many hormones which take part in various metabolic functions >Renin is produced in the “Juxta glomerular apparatus” and stimulates aldosterone secretion. 
    • > Erythropoietin – stimulates red blood cells production 
    • > Prostaglandins produced in the kidneys help in vasodilation of blood vessels.
    Processes Involved in urine formation 
    • Filtration
    • Selective Reabsorption
    • Tubular Secretion
    FILTRATION
    This takes place through the semipermeable walls of the glomerulus and glomerular capsule/Bowman’s Capsule. Water and other small molecules pass through, although some are reabsorbed later. Blood cells, plasma proteins and other large molecules are too large to filter through and therefore remain in the capillaries.

    Filtration takes place because there is a difference between the blood pressure in the glomerulus and the pressure of the filtrate in the glomerular capsule

    Because the afferent arteriole is narrower than the afferent arteriole, a capillary hydrostatic pressure builds up in the glomerulus. This pressure is opposed by the osmotic pressure of the blood, provided mainly by plasma proteins, and by filtrate hydrostatic pressure in the glomerular capsule, 

    The volume of filtrate formed by both kidneys each minute is called the glomerular filtration rate (GFR). In a healthy adult the GFR is about 125 ml/min, i.e. 180 liters of filtrate are formed each day by the two kidneys. Nearly all of the filtrate is later reabsorbed from the kidney tubules with less than 1%, i.e. 1 to 1.5 liters, excreted as urine. The differences in volume and concentration are due to selective reabsorption of some filtrate constituents and tubular secretion of others 

    SELECTIVE REABSORPTION

    Most reabsorption from the filtrate back into the blood takes place in the proximal convoluted tubule, whose walls are lined with microvilli to increase surface area for absorption.


     Materials essential to the body are reabsorbed here, including some water, electrolytes and organic nutrients such as glucose. Some reabsorption is passive, but some substances are transported actively. Only 60–70% of filtrate reaches the loop of the nephron.

     

    Much of this, especially water, sodium and chloride, is reabsorbed in the loop, so only 15–20% of the original filtrate reaches the distal convoluted tubule, and the composition of the filtrate is now very different from its starting values. More electrolytes are reabsorbed here, especially sodium, so the filtrate entering the collecting ducts is actually quite dilute. The main function of the collecting ducts therefore is to reabsorb as much water as the body needs.

    TUBULAR SECRETION

    Filtration occurs as the blood flows through the glomerulus

    Substances not required and foreign materials, e.g. drugs including penicillin and aspirin, may not be cleared from the blood by filtration because of the short time it remains in the glomerulus.

    Such substances are cleared by secretion from the peritubular capillaries into the convoluted tubules and excreted from the body in the urine. 


    Tubular secretion of hydrogen ions (H+) is important in maintaining normal blood pH.

    Pyelonephritis in Pregnancy

    Pyelonephritis in Pregnancy

    Pyelonephritis is an infection of the kidneys, specifically affecting the renal pelvis and tubules.

     It occurs in approximately 2% of pregnant women, particularly during the second trimester (16-26th week), with a higher incidence in first-time mothers (primigravidas).

    It is more common in;

    • Primigravidae than multiparae.
    • Previous history of urinary tract infection increases the chance by 50%.
    • Presence of asymptomatic bacteriuria increases the chance by 25%.
    • Abnormality in the renal tract is found in about 25%.

    There is an increased chance of urinary tract infections (UTIs) in females compared to males due to:

    • Short urethra (4 cm): The female urethra is significantly shorter than the male urethra, making it easier for bacteria to ascend from the external opening to the bladder.
    • Close proximity of the external urethral meatus to areas (vulva and lower third of vagina) contaminated heavily with bacteria: The proximity of the urethra to areas harbouring a high concentration of bacteria increases the risk of contamination.
    • Catheterization: The use of urinary catheters, often for medical reasons, can introduce bacteria into the bladder and increase the risk of infection.
    • Sexual intercourse: Sexual intercourse can introduce bacteria into the urethra, particularly in women who are not properly lubricated.

    Types of Infection:

    • Ascending Infection: Bacteria ascend from the bladder or urethra, often originating from neighbouring organs like the rectum.
    • Bloodborne Infection: Bacteria enter the bloodstream, often stemming from conditions like septicemia.

    Causative Organisms for Pyelonephritis

    • E. coli (70%): The most common causative organism, usually originating from the gut.
    • Klebsiella pneumoniae (10%).
    • Enterobacter.
    • Proteus.
    • Pseudomonas.
    • Staphylococcus aureus group.

    Predisposing Causes

    • Urinary Stasis: The growing uterus puts pressure on the ureters (tubes that carry urine from the kidneys to the bladder), causing them to dilate and kink. This creates areas where urine can pool, leading to stagnation and a favourable environment for bacterial growth.
    • Loss of Urethral Tone: Pregnancy hormones relax smooth muscles throughout the body, including the muscles surrounding the urethra. This loss of tone can contribute to urine stagnation and increased risk of infection.
    • Increased Vaginal Secretions: The increased production of vaginal discharge (leukorrhea) during pregnancy can introduce bacteria into the urethra, increasing the chances of infection.
    • Prior History of Nephritis: Women who had acute nephritis (kidney inflammation) in childhood are more susceptible to developing pyelonephritis during pregnancy. This suggests a predisposition to kidney infections.

    Signs and Symptoms

    • Fever and Chills: A high fever (38-40°C) accompanied by chills is a common sign.
    • Painful and Frequent Urination: The inflammation of the urethra causes pain and increased frequency of urination, often with a burning sensation.
    • Tachycardia: An elevated heart rate (110-130 beats per minute or higher) is another typical sign.
    • Vomiting: Nausea and vomiting are frequent symptoms.
    • General Malaise: The patient may feel unwell with a coated tongue and overall weakness.
    • Offensive Urine: The urine may have a strong, unpleasant odor due to the presence of bacteria.
    • Epigastric Pain: Pain in the upper abdomen due to vomiting can also occur.
    • Tenderness on Examination: The doctor may find tenderness when examining the renal angles (the areas where the kidneys are located) and the area above the pubic bone.
    • Acute Aching Pain: A sharp, aching pain in the loins (lower back) is often felt, radiating to the groin and the costovertebral angle (the area where the ribs meet the spine).
    • Tenderness on Palpation: The costovertebral angle is often tender when pressed upon.
    • Urinary Symptoms: These include urgency (feeling like you need to urinate urgently), frequency (urinating more often than usual), dysuria (painful urination), and hematuria (blood in the urine).
    • Fever and Flu-like Symptoms: The fever can be high and spiky (reaching 40°C), with chills and rigors (muscle spasms). This may be followed by hypothermia (low body temperature, around 34°C). Other flu-like symptoms include anorexia (loss of appetite), nausea, vomiting, and myalgias (muscle aches).
    • Respiratory Distress: In severe cases, pyelonephritis can lead to respiratory distress and pulmonary edema (fluid in the lungs). This is due to endotoxin (a toxin released by bacteria) damaging the alveoli (tiny air sacs in the lungs). This is also known as Acute Respiratory Distress Syndrome (ARDS).

    Diagnosis

    A combination of factors aids in the diagnosis of pyelonephritis:

    • History: The patient’s history of painful urination, fever, and other symptoms is crucial.
    • Urinalysis: Examining the urine under a microscope reveals protein (from dead epithelial cells), sugar, and pus cells, all indicative of infection.
    • Urine Culture and Sensitivity: A culture of the urine helps identify the specific bacteria causing the infection. This information is crucial for selecting the appropriate antibiotic treatment.

    Effects on Pregnancy

    • Increased Pregnancy Wastage: There is a higher risk of miscarriage or premature birth.
    • Abortions: The infection can trigger premature labor and lead to a miscarriage.
    • Premature Labor: Pyelonephritis can induce premature contractions and lead to early delivery.
    • Intrauterine Fetal Death: In severe cases, the infection can cause the fetus to die in the womb.
    • Small for Dates: The fetus may grow more slowly than expected due to the infection.
    • Accidental Haemorrhage: The infection can weaken the cervix and make it more prone to bleeding.
    • Anaemia: Pyelonephritis can contribute to anaemia due to the body’s response to infection.
    • Hypertension: The infection can elevate blood pressure, posing a risk to both the mother and fetus.
    • Septicemia and Septic Shock: The infection can spread to the bloodstream (septicemia), potentially leading to a life-threatening condition called septic shock.
    • Renal Dysfunction: Pyelonephritis can damage the kidneys, leading to impaired kidney function.

    ACUTE PYELONEPHRITIS 

    This is characterized by acute inflammation of the parenchyma(core substance of the kidney/kidney tissue) and the pelvis of the kidneys. 

    The disease may be bilateral or unilateral. This usually results from untreated bacterial cystitis and may be associated with pregnancy, trauma of the urinary bladder, and urinary obstruction Also Ascending and Descending infections.

    Presentation; flunk tenderness,

    • fever, chills 
    • Dysuria
    • Urgency
    • frequency

    Chronic pyelonephritis 

    This occurs due vesicoureteral reflux ( back flow of urine from the bladder to the ureters allowing spread of infection upwards to the kidneys. The condition is also called reflux nephropathy(This can lead to kidney distention called Hydronephrosis

    It clinical presents with 

    • bacteriuria, 
    • hypertension, 
    • flunk tenderness,
    • septic shock, 
    • dizziness fainting and signs of renal insufficiency 

    Management/Treatment of Pyelonephritis in Pregnancy

    Aims of management

    The management of pyelonephritis in pregnancy focuses on treating the infection and preventing further complications:

     

    A midwife is permitted to treat mild pyelonephritis. If the temperature is 38oC or more, this won’t be mild, the patient must be transferred to hospital

    Mild Pyelonephritis (Temperature Below 38°C):

    Maternity Centre Management:

    • Fluid Intake: Encourage the mother to drink plenty of fluids.
    • Sulphadimidine: Administer sulphadimidine 2g stat, followed by 1g six-hourly for 5 days.
    • Nitrofurantoin: Prescribe nitrofurantoin 100mg six-hourly for 1 week.
    • Monitoring: Closely observe the patient’s progress. If no improvement is seen within 3 days, transfer to a hospital for further evaluation and management.

    In hospital

    • Admission: Immediate hospitalization is required for patients with a temperature of 38°C or higher.
    • Bed Rest: Provide complete bed rest in a well-ventilated room.
    • Positioning: Encourage the mother to lie on the unaffected side.
    • Fluid Management: Ensure adequate fluid intake and monitor fluid balance closely.
    • Intravenous Fluids: Intravenous fluids (crystalloid solutions) are administered to ensure adequate hydration.
    • Monitoring: Urine output (greater than 60 ml/hour), temperature, and blood pressure are closely monitored
    • Vital Signs: Monitor vital signs (temperature, pulse rate, respiration, blood pressure) every four hours.
    • Blood Tests: Blood tests including a complete blood count (hemogram), serum electrolytes, and creatinine levels are performed to assess the patient’s health and kidney function.
    • Urine Testing: Test urine for albumin daily.
    • Dietary Management: As the patient improves, gradually introduce a light diet.
    • Fever Control: Administer tepid sponging as needed to reduce fever.
    • Constipation Management: Prescribe mild laxatives if constipation occurs.
    • Keep strict fluid balance chart.

    Medical Treatment:

    • Antibiotic Therapy: Intravenous antibiotics are administered for 48 hours. Common choices include cephalosporins, aminoglycosides (gentamicin), Cefazolin, or Ceftriaxone. Once the culture results are available, the antibiotic may be switched to an oral therapy for another 10-14 days.
    • Repeat Cultures: Urine cultures are repeated after 2 weeks of antibiotic therapy and at each trimester of pregnancy.
    • Retreatment: If symptoms recur or the urine dipstick test for nitrate and leukocyte esterase is positive, a urine culture is repeated, and treatment is given if the culture is positive.
    • Imaging Studies: If the patient does not respond to treatment, imaging studies like ultrasound, CT scan, or radiography may be required to rule out urinary tract obstruction.
    • Antimicrobial Suppression Therapy: To prevent recurrence (which occurs in 30-40% of cases), antimicrobial suppression therapy may be continued until the end of pregnancy. Nitrofurantoin 100 mg daily at bedtime is an effective option.  Cephalexin 250–500 mg orally every day for the remainder of pregnancy and continuing until 4–6 weeks postpartum is also recommended if nitrofurantoin is not available.
    • Potassium Citrate: Prescribe potassium citrate 15 ml four-hourly to alkalinize the urine and potentially relieve pain.
    • Fever Management: Acetaminophen (paracetamol) is given to reduce fever.
    • Fluid Intake: There is a danger of crystallisation of these sulphur drugs to the kidneys if enough fluids are not given especially if the patient is vomiting so much, also watch for haematuria and oliguria. 

    Complications:

    for the Mother:

    • Sepsis: A severe and life-threatening condition where the infection spreads throughout the body.
    • Kidney Damage: Repeated or untreated pyelonephritis can lead to long-term damage to the kidneys, potentially causing chronic kidney disease.
    • Preterm Labor: The infection can trigger premature contractions and lead to premature birth, especially in the second and third trimesters.
    • Low Birth Weight: Pyelonephritis can restrict fetal growth, leading to babies being born with low birth weight.
    • Urinary Tract Obstruction: Infection can contribute to or worsen urinary tract blockages, making it harder to treat the infection.
    • Acute Renal Failure: In rare cases, severe pyelonephritis can lead to kidney failure, requiring dialysis.

    for the Fetus:

    • Premature Birth: As mentioned above, premature delivery is a significant risk.
    • Fetal Growth Restriction: The infection can hinder fetal growth and development.
    • Stillbirth: In severe cases, pyelonephritis can increase the risk of stillbirth.
    • Congenital Anomalies: While not fully established, some studies suggest a possible link between pyelonephritis in pregnancy and certain congenital anomalies in the baby.

    CYSTITIS 

    Cystitis is a lower urinary infection involving inflammation of the urinary bladder. 

    Acute bacterial cystitis is common in women as the short urethra predisposes them to infection of the bladder. 

    It is defined as significant bacteriuria with associated bladder mucosal invasion presenting as urgency, frequency, dysuria, pyuria and haematuria without evidence of systemic illness.

    Urine may be cloudy and malodorous and should be cultured. Has similar causative agents as asymptomatic bacteriuria- E.coli implicated in almost 80% of cases.

    Causes of Cystitis 

    • Hormonal Changes: Pregnancy hormones, particularly oestrogen, can relax the bladder muscles and urethral sphincter, making it easier for bacteria to enter the bladder.
    • Urinary Tract Obstruction: The growing uterus can compress the ureters, the tubes that carry urine from the kidneys to the bladder, causing urine to back up and increasing the risk of infection.
    • Increased Urinary Frequency: Pregnancy often leads to increased urine frequency, which can flush out bacteria less effectively, increasing the risk of infection.
    • Immune System Suppression: The body’s immune system is naturally suppressed during pregnancy to protect the fetus. This suppression can make it easier for bacteria to grow and cause infection.
    • Changes in Urinary Flow: The growing uterus can compress the bladder, making it difficult to empty completely. This can leave residual urine in the bladder, providing a breeding ground for bacteria.
    • Sexual Activity: While not always the case, sexual activity can introduce bacteria into the urethra, increasing the risk of infection.
    • Previous UTIs: Having a history of UTIs increases the risk of developing cystitis during pregnancy.
    • Bladder Incompetence: This can happen during pregnancy due to hormonal changes, and is a major contributor to cystitis.
    • Ascending infections: This is a primary cause of cystitis, both in pregnancy and generally, due to bacteria traveling up the urinary tract.

    Signs and symptoms

    1. Frequent Urination: Feel the urge to urinate more often than usual, even if you haven’t consumed much fluid. It’s common in pregnancy anyway, but the urge may be particularly strong and urgent with cystitis.
    2. Painful Urination (Dysuria): A burning or stinging sensation during urination is a hallmark symptom. This can be especially uncomfortable during pregnancy, as the bladder may be more sensitive.
    3. Urgency: A strong, sudden urge to urinate that’s difficult to ignore. This can be exacerbated by the pressure of the growing uterus on the bladder.
    4. Pelvic Pain: A dull ache or pressure in the lower abdomen or pelvis, often located above the pubic bone.
    5. Blood in Urine (Hematuria): Presence of blood in your urine, ranging from a faint pink to bright red. While rare, it can happen with cystitis and is a sign that the infection is more severe.
    6. Fever: A low-grade fever, usually below 101°F (38.3°C), may occur with cystitis.
    7. Cloudy Urine: Urine may appear cloudy or have a strong odour/smell.
    8. Nausea and Vomiting: While less common, these symptoms can occur with severe cystitis.
    9. Back Pain: If the infection has spread to the kidneys (pyelonephritis), you may experience back pain, often on one side.
    10. Chills: If you have a fever, you may also experience chills.

    Management of Cystitis in Pregnancy

    Assessment:

    History and Physical Exam:

    • Thoroughly assess the patient’s symptoms (frequency, urgency, pain, fever, etc.).
    • Obtain a detailed medical history, including any existing conditions, previous urinary tract infections (UTIs), and current medications.
    • Perform a physical exam focusing on signs of dehydration, fever, tenderness in the abdomen or back, and a general assessment of her overall health.

    Urinalysis and Urine Culture:

    • Obtain a urine sample for urinalysis and culture to confirm the presence of bacteria and identify the specific strain. This is crucial for guiding antibiotic choice.

    Treatment

    Hydration:

    • Encourage the patient to drink plenty of fluids, especially water, to flush out the bacteria and prevent dehydration.

    Antibiotics:

    Choice: The choice of antibiotic will depend on the specific organism identified in the urine culture. The following options are commonly used for UTIs during pregnancy:

    • Nitrofurantoin: A first-line option, generally safe in pregnancy, especially during the first trimester.
    • Amoxicillin/Amoxicillin-Clavulanate: Effective against many common UTI bacteria.
    • Cephalexin: Another safe and effective option.
    • Fosfomycin: A single-dose antibiotic that can be an option for uncomplicated cystitis.

    Duration: The antibiotic course should be for 7 days, even if symptoms resolve sooner. This is to prevent persistent bacteriuria and recurrent UTIs.

    Admission vs. Outpatient Management

    Outpatient Management:

    • Most cases of uncomplicated cystitis in pregnancy can be managed as outpatients.
    • The patient can be discharged home with instructions to take the prescribed antibiotics, stay well-hydrated, and monitor for any worsening symptoms.

    Admission to Hospital:

    Admission may be considered in cases of:

    • Severe Symptoms: High fever, chills, nausea, vomiting, severe pain, or blood in the urine.
    • Pregnancy Complications: Premature labor, preeclampsia, or other complications.
    • Failed Outpatient Treatment: If symptoms worsen or persist despite antibiotics.
    • Underlying Conditions: If the patient has other health issues like diabetes or kidney disease.

    Follow-up and Discharge:

    Follow-up:

    • Schedule a follow-up visit with the patient 1-2 weeks after completing the antibiotic course. This should be negative to confirm effective treatment.
    • Repeat urinalysis and urine culture to confirm eradication of the infection.

    Discharge Instructions:

    • Advise the patient to continue adequate hydration.
    • Educate her on the importance of wiping from front to back after using the toilet to reduce the risk of recurrent UTIs.
    • Explain the signs and symptoms of complications (fever, chills, severe pain) and when to seek immediate medical attention.

    Nursing care plan for a patient with renal diseases in pregnancy

    Assessment

    Nursing Diagnosis

    Goals/Expected Outcomes

    Intervention

    Rationale

    Evaluation

    Patient reports fatigue and weakness

    Fatigue related to decreased erythropoietin production and anaemia secondary to renal disease as evidenced by patient reports of feeling tired and weak.

    – Reduce fatigue within 48 hours.

    – Patient reports improved energy levels.

    – Encourage frequent rest periods.

    – Administer iron supplements as prescribed.

    – Educate patient on energy conservation techniques.

    – Rest periods help prevent overexertion.

    – Iron supplements help correct anemia.

    – Energy conservation techniques help manage fatigue.

    – Patient reports improved energy levels.

    – Fatigue is reduced.

    Blood pressure 150/100 mmHg, proteinuria, peripheral edema

    Ineffective Renal Perfusion related to altered blood flow to the kidneys as evidenced by hypertension, proteinuria, and peripheral edema.

    – Maintain effective renal perfusion within 24 hours.

    – Blood pressure stabilized within normal range.

    – Decrease in proteinuria and edema.

    – Monitor blood pressure and urine output regularly.

    – Administer antihypertensive medications as prescribed.

    – Educate patient on the importance of medication adherence and lifestyle modifications.

    – Regular monitoring detects early changes in renal perfusion.

    – Antihypertensive medications help control blood pressure.

    – Patient education promotes adherence to treatment.

    – Blood pressure stabilized within normal range.

    – Proteinuria and edema decreased.

    Patient reports difficulty breathing, SpO2 88%, crackles on lung auscultation

    Impaired Gas Exchange related to fluid overload secondary to renal disease as evidenced by difficulty breathing, decreased SpO2, and crackles on lung auscultation.

    – Improve gas exchange within 4 hours.

    – SpO2 improved to 92% or higher.

    – Patient reports easier breathing.

    – Administer oxygen therapy as prescribed.

    – Monitor respiratory status and SpO2 regularly.

    – Administer diuretics as prescribed and monitor fluid balance.

    – Oxygen therapy improves oxygen saturation.

    – Regular monitoring ensures timely adjustments in care.

    – Diuretics help reduce fluid overload and improve breathing.

    – SpO2 improved to 92% or higher.

    – Patient reports easier breathing.

    – Crackles on lung auscultation decreased.

    Patient reports difficulty concentrating, confusion, serum creatinine elevated

    Acute Confusion related to uremia secondary to renal disease as evidenced by difficulty concentrating, confusion, and elevated serum creatinine.

    – Prevent acute confusion within 24 hours.

    – Patient demonstrates improved cognitive function.

    – Monitor neurological status regularly.

    – Educate patient and family on signs of worsening renal function.

    – Administer medications to manage uremia as prescribed.

    – Regular monitoring detects early signs of confusion.

    – Patient education promotes early intervention.

    – Medications help manage uremia and prevent confusion.

    – Patient demonstrates improved cognitive function.

    – No signs of acute confusion.

    Patient reports swelling, weight gain, decreased urine output

    Fluid Volume Excess related to impaired renal function as evidenced by swelling, weight gain, and decreased urine output.

    – Maintain fluid balance within 24 hours.

    – Decrease in swelling and weight gain.

    – Urine output normalized.

    – Monitor daily weight and intake/output.

    – Administer diuretics as prescribed.

    – Educate patient on low-sodium diet.

    – Regular monitoring helps assess fluid status.

    – Diuretics help reduce fluid retention.

    – Low-sodium diet prevents fluid overload.

    – Swelling and weight gain decreased.

    – Urine output normalized.

    – Fluid balance maintained.

    Renal Diseases in Pregnancy Read More »

    Dracunculosis (Guinea worm)

    Dracunculiasis (Guinea Worm Disease)

    Dracunculiasis is a parasitic disease caused by the nematode worm Dracunculus medinensis. 

    It is characterized by the emergence of a long, thread-like worm from a painful blister on the skin, usually on the legs or feet.

    Dracunculiasis is a neglected tropical disease (NTD) that primarily affects poor communities in rural areas with limited access to safe water. It is a debilitating disease that can cause significant pain and disability.

    The disease is transmitted through contaminated drinking water.

    Transmission:

    Vector: The disease is transmitted by copepods, tiny crustaceans found in stagnant water.

    Lifecycle:

    • In the Copepod (Vector):
    1. Copepods ingest the infective larvae of Dracunculus medinensis from contaminated water.
    2. The larvae develop into infective stage within the copepod.
    • In Humans (Host):
    1. Humans become infected when they drink contaminated water containing the infected copepods.
    2. In the human stomach, the copepod is digested, releasing the larvae.
    3. The larvae penetrate the intestinal wall and migrate through the body, typically reaching subcutaneous tissue (beneath the skin).
    4. Larvae mature into adult worms within one year.
    5. The female worm migrates to the surface of the skin and emerges from a blister, usually on the legs or feet.
    6. The worm releases larvae into the water, continuing the cycle.

    Routes of Transmission:

    • Drinking Contaminated Water: This is the primary route of transmission.

    Causes/Aetiology:

    • Dracunculus medinensis Worm: The disease is caused by the Dracunculus medinensis nematode.

    Clinical Features:

    Initial Stage:

    • A small, itchy blister appears on the skin, typically on the legs or feet.
    • Fever, nausea, and vomiting may occur.

    Blister Stage:

    • Blister becomes painful, swollen, and filled with fluid.
    • The worm may be visible within the blister.

    Worm Emergence Stage:

    • The female worm emerges from the blister, forming a long, thread-like structure.
    • The worm can be several feet long and can cause intense pain as it emerges.

    Secondary Complications:

    • Infection of the wound: The emergence site can become infected with bacteria.
    • Joint pain and stiffness.
    • Lymphedema: Fluid buildup in the affected limb.
    • Abscess formation: Pus collection around the worm.

    Other Symptoms:

    • Swelling and tenderness of the lymph nodes.
    • Generalized weakness.
    • Loss of appetite.

    Diagnosis and Investigations:

    • Clinical Examination: A typical blister with a visible worm emerging is usually diagnostic.
    • Microscopic Examination: Examining the blister fluid or the emerging worm under a microscope can confirm the presence of Dracunculus medinensis.
    • Serological Tests: Blood tests to detect antibodies against Dracunculus medinensis.

    Prevention:

    • Safe Water: Provide access to safe drinking water sources and promote safe water handling practices.
    • Water Filtration: Use filters to remove copepods from drinking water.
    • Boiling Water: Boiling water for at least 1 minute kills copepods.
    • Education: Educate communities about the disease, its transmission, and prevention strategies.
    • Environmental Management: Control mosquito breeding sites and improve sanitation in rural areas.

    Management:

    • There is no known drug treatment for guinea worm 

    Aims of Management:

    • To relieve pain and discomfort.
    • To prevent secondary infections.
    • To prevent transmission of the disease.

    Early Management:

    • Wound Care: Clean the affected area with antiseptic solutions and dress the wound.
    • Pain Relief: Administer pain relievers as needed.
    • Preventing Secondary Infections: Administer antibiotics if secondary bacterial infection is suspected.
    • Extraction of the Worm: A healthcare provider can carefully extract the worm from the blister. This process can be slow and painful and may take several days.

    Medical Management:

    All patients: 

    • To facilitate removal of the worm, slowly and carefully roll it onto a small stick over a period of days.
    • Dress the wound occlusively to prevent the worm passing ova into the water.
    • Give analgesics for as long as necessary If there is ulceration and secondary infection give: 
    • Amoxicillin 500 mg every 8 hours for 5 days 
    • Child: 250 mg every 8 hours for 5 days 
    • Or cloxacillin 500 mg every 6 hours for 5 days
    • Pain Relief: Over-the-counter pain relievers can help manage pain.
    • Antibiotics: Prescribed for any bacterial infections.
    • Anti-inflammatory Medications: Can help reduce swelling and inflammation.

    Nursing Care:

    • Pain Management: Assist patients in managing pain and discomfort.
    • Wound Care: Provide wound care and dressing changes as needed.
    • Infection Prevention: Monitor for signs of infection and ensure appropriate wound care.
    • Education: Teach patients about the disease, treatment, and prevention strategies.

    Complications:

    • Secondary Infections: The emergence site can become infected with bacteria, leading to cellulitis, abscesses, or sepsis.
    • Arthritis: The worm can migrate into joints, causing inflammation and pain.
    • Lymphedema: Fluid buildup in the affected limb due to lymphatic obstruction.
    • Disability: Chronic pain, joint stiffness, and lymphedema can lead to significant disability.
    • Social Stigma: The disease can lead to social isolation and discrimination.

    Dracunculosis (Guinea worm) Read More »

    Elephantiasis (Bancroftian Filariasis)

    Elephantiasis (Lymphatic Filariasis)

    Elephantiasis, also known as lymphatic filariasis, is a chronic parasitic disease caused by filarial worms. 

    It results in severe swelling, primarily of the legs, arms, breasts, and genitals, due to blockage of the lymphatic system. The condition gets its name from the enlargement of affected limbs, resembling that of an elephant.

    Elephantiasis is a debilitating disease that can significantly impact a person’s physical, social, and economic well-being. The swelling can cause pain, disfigurement, disability, and social stigma. It is a neglected tropical disease (NTD) primarily affecting impoverished communities in tropical and subtropical regions.

    Transmission:

    Vector: The disease is transmitted by mosquitoes, specifically species of the genera Culex, Anopheles, and Aedes.

    Lifecycle:

    In the Mosquito (Vector):

    • Infected mosquitoes ingest filarial larvae (microfilariae) from an infected person’s blood.
    • The microfilariae develop into mature larvae (L3 larvae) in the mosquito.
    • L3 larvae migrate to the mosquito’s mouthparts, ready for transmission.

    In Humans (Host):

    • Infected mosquitoes bite humans, transmitting the L3 larvae into the bloodstream.
    • L3 larvae mature into adult worms in the lymphatic system, typically residing in lymph nodes.
    • Adult worms reproduce, releasing microfilariae into the bloodstream, which can then be ingested by mosquitoes, completing the cycle.

    Routes of Transmission:

    • Mosquito Bite: The primary route of transmission is through the bite of an infected mosquito.
    • Blood Transfusion: Transmission is possible through contaminated blood transfusions, although less common.

    Causes/Aetiology:

    Filarial Worms: The disease is caused by three main species of filarial worms:

    • Wuchereria bancrofti (most common)
    • Brugia malayi
    • Brugia timori

    Clinical Features:

    1. Early Stage (Lymphangitis):

    • Fever
    • Chills
    • Pain and redness along lymphatic vessels
    • Lymphadenitis (swollen lymph nodes)

    2. Subcutaneous Stage (Lymphedema):

    • Swelling in the extremities, particularly legs and arms.
    • Pitting edema (fluid retention that leaves indentations when pressed)
    • Skin thickening and roughness

    3. Late Stage (Elephantiasis):

    • Massive swelling of the limbs, breasts, or genitals.
    • Thickened and deformed skin.
    • Lymphatic obstruction leading to fluid buildup.
    • Increased susceptibility to secondary infections.

    4. Genital Manifestations:

    • Hydrocele (fluid accumulation in the scrotum).
    • Lymphoedema of the scrotum (scrotal elephantiasis).
    • Lymphoedema of the vulva (vulvar elephantiasis).

    5. Other Complications:

    • Chylous ascites (fluid buildup in the abdomen).
    • Chylothorax (fluid buildup in the chest).
    • Chronic kidney disease.

    Diagnosis and Investigations:

    Clinical Examination: Characteristic swelling and history of mosquito bites in endemic areas.

    Microscopic Examination:

    • Blood smear: To detect microfilariae in blood samples.
    • Lymph node aspirate: To detect microfilariae in lymph node fluid.

    Serological Tests: Blood tests to detect antibodies against filarial worms.

    Imaging Studies:

    • Ultrasound: To visualize the lymphatic system and detect adult worms.
    • CT scan: To evaluate the extent of lymphatic obstruction.
    • MRI: To assess the lymphatic system and surrounding tissues.

    Prevention:

    Vector Control:

    • Mosquito control measures, such as insecticide spraying, insecticide-treated bed nets, and source reduction (eliminating mosquito breeding sites).
    • Use of repellents.

    Mass Drug Administration (MDA):

    • Regular administration of anti-filarial medications (DEC and albendazole) to prevent transmission and reduce disease burden.
    • Large scale treatment/preventive chemotherapy Give annually
    • to all population at risk, for 4-6 years
    • Ivermectin 150-200 mcg/kg plus albendazole 400 mg single dose

    Health Education: Educate communities about the disease, transmission, and preventive measures.

    Improved Sanitation and Hygiene: Maintain clean surroundings and reduce mosquito breeding sites.

    Management:

    Aims of Management:

    • To kill adult worms and prevent the spread of infection.
    • To reduce lymphatic obstruction and swelling.
    • To improve quality of life and reduce disability.

    Medical Management:

    • Anti-filarial Medications: Diethylcarbamazine (DEC) and Albendazole are the primary drugs for treatment.
    1. Diethylcarbamazine (DEC)
    2. Albendazole
    3. Ivermectin (alternative medication)
    4. Combinations of these drugs may be used.
    • Antibiotics: For treating secondary bacterial infections.

    • Doxycycline 100 mg twice a day for 4-6 weeks (do not administer antiparasitic treatment during an acute attack)

    • Pain Relievers: To manage pain and inflammation.

    • Diuretics: To reduce fluid buildup.

    • Supportive Care:
    1. Elevate affected limbs.
    2. Use compression bandages.
    3. Manage pain and inflammation.
    4. Supportive treatment during an attack (bed rest, limb elevation, analgesics, cooling, hydration)

    Continuous Management:

    • Long-term Anti-filarial Therapy: May be required to prevent disease progression.
    • Lymphedema Management:
    1. Regular massage.
    2. Compression therapy.
    3. Skin care and hygiene.
    • Monitoring for Complications: Regular follow-up appointments to monitor for complications, such as secondary infections and kidney damage.

    Surgical Management:

    • Chronic case:  Supportive treatment: bandage during the day, elevation of affected limb at rest, analgesics and surgery (hydrocelectomy)
    • Surgery for Complications:
    1. Surgery may be required to treat complications such as hydrocele, lymphoedema, and chylous ascites.
    2. Lymphatic bypass surgery may be considered in some cases.

    Nursing Care:

    • Symptom Management: Provide comfort measures for pain, swelling, and discomfort.
    • Skin Care: Promote good skin hygiene to prevent infections.
    • Compression Therapy: Apply compression bandages to reduce swelling and improve lymphatic flow.
    • Lymphedema Management: Teach patients techniques for self-management of lymphoedema.
    • Education: Educate patients about the disease, treatment, and prevention.

    Complications:

    • Secondary Infections: Frequent skin infections due to impaired lymphatic drainage.
    • Lymphedema: Progressive swelling of the affected limbs, leading to disfigurement and disability.
    • Elephantiasis: Severe and permanent disfigurement and disability.
    • Hydrocele and Lymphoedema of the Genitals: Can cause pain, discomfort, and reproductive problems.
    • Chronic Kidney Disease: Fluid overload and lymphatic obstruction can strain the kidneys.
    • Social Stigma: Elephantiasis can lead to social isolation and discrimination.
    • Psychological Distress: The disease can have a significant impact on self-esteem and mental health.

    Elephantiasis (Bancroftian Filariasis) Read More »

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