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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
- 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.
- 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
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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:
- Asymptomatic: No symptoms of HIV-related illness.
- Persistent Generalized Lymphadenopathy: Enlargement of lymph nodes lasting more than three months.
- Performance Scale 1: Asymptomatic with normal activity level.
Clinical Stage II:
- Moderate Weight Loss: Less than 10% of presumed or measured body weight lost.
- Minor Muco-cutaneous Manifestations: Skin conditions like seborrheic dermatitis, prurigo, or fungal nail infections.
- Herpes Zoster: History of shingles within the last five years.
- Recurrent Upper Respiratory Tract Infections: Such as bacterial sinusitis, tonsillitis, or otitis media.
- Performance Scale 2: Symptomatic but normal activity level.
Clinical Stage III:
- Severe Weight Loss: More than 10% of presumed or measured body weight lost.
- Unexplained Chronic Diarrhoea: Lasting more than one month.
- Unexplained Prolonged Fever: Constant or intermittent, lasting more than one month.
- Oral Candidiasis: Oral thrush, a fungal infection.
- Oral Hairy Leukoplakia: White patches on the tongue or mouth.
- Pulmonary Tuberculosis: Active TB infection.
- Severe Bacterial Infections: Such as pneumonia, pyomyositis, or bacteremia.
- Acute Necrotizing Ulcerative Gingivitis: Severe gum disease.
- Unexplained Anaemia, Neutropenia, or Thrombocytopenia: Abnormal blood counts.
- Performance Scale 3: Bedridden for less than 50% of the day during the last month.
Clinical Stage IV:
- HIV Wasting Syndrome: Weight loss of more than 10% with chronic diarrhoea or prolonged fever.
- Pneumocystis Pneumonia (PCP): A severe fungal lung infection.
- Toxoplasmosis of the Brain: Brain infection caused by the Toxoplasma parasite.
- Cryptosporidiosis: Parasitic infection causing prolonged diarrhea.
- Cytomegalovirus Infection: A viral infection affecting various organs.
- Progressive Multifocal Leukoencephalopathy (PML): Brain infection causing neurological symptoms.
- Lymphoma: Cancer of the lymphatic system.
- Kaposi’s Sarcoma: Cancerous skin lesions caused by a herpesvirus.
- HIV Encephalopathy: Cognitive and/or motor dysfunction due to HIV infection.
- Atypical Disseminated Leishmaniasis: Parasitic infection affecting multiple organs.
- Symptomatic HIV-Associated Nephropathy or Cardiomyopathy: Kidney or heart disease associated with HIV.
- 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:
- Post-Test Counselling: Provide accurate results and information about available care.
- Next Steps Discussion: Describe the care and treatment process, emphasizing early treatment benefits.
- Address Barriers: Identify and overcome any obstacles to linkage.
- Involvement: Involve the patient and family in decision-making.
- Documentation: Complete client and referral forms.
- Escort to Clinic: A linkage facilitator escorts the client to the ART clinic.
- Enrollment: Register the patient, open an ART file, and provide preparatory counselling.
- Initiation: Start ART if ready, and continue with counselling support.
- Integrated Care: Coordinate other services if needed.
- 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
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:
- Assess for opportunistic infections, defer ART if TB or cryptococcal meningitis present.
- Offer ART on the same day through an opt-out approach.
- If not ready for same-day initiation, agree on a timely ART preparation plan.
Available ARVs in Uganda
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).
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
- 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.
- 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.
- Use the single pill of Dolutegravir 50 mg for patients on AZT-3TC-DTG based regimens.
- For eligible patients on ATV/r and LPV/r, optimize to Dolutegravir.
- 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:
- Assess Response to ART and Diagnose Treatment Failure
- Ensure Safety of Medicines: Identify Side Effects and Toxicity
- 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.
- Viral Load Monitoring: Preferred for assessing response to ART and diagnosing treatment failure.
- CD4 Monitoring: Recommended in specific scenarios.
- 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
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):
- Primary prevention of HIV among prospective parents.
- Prevention of unwanted pregnancy among HIV-infected women.
- 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:
- Health education, provision of information, and counseling on HIV prevention and care, including MTCT.
- Voluntary confidential counseling and testing services that are acceptable and accessible.
- Quality and focused antenatal care.
- Safe delivery practices.
- Support and counseling on infant feeding practices.
- Family planning services.
- Community mobilization and education to decrease stigma and discrimination against, as well as to increase support for, HIV-positive clients.
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:
- Human Tuberculosis: This is the most prevalent form of TB, primarily spread through person-to-person contact through droplet infection.
- 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:
- 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
- Ethambutol (E) 25mg/kg.
- Isoniazid (H) 300mg.
- Rifampicin (R): <50kg: 450mg; ≥50kg: 600mg.
- 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:
- Premature Labor: Increased risk of delivering before term.
- Intrauterine Fetal Death: Loss of the fetus during pregnancy.
- 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:
- Sensitize and mobilize the community to create awareness about TB.
- Health education on ensuring well-ventilated homes, avoiding overcrowding, proper disposal of sputum, covering the mouth when coughing/sneezing, and screening family members.
- Encourage good nutrition, drinking pasteurized milk products, disinfecting patients’ belongings, and immunizing children with BCG.
- Ensure adequate management of chest infections and encourage mothers to attend ANC.
In Hospital:
- Encourage mothers to attend ANC for thorough examinations, histories, and investigations for management.
- Keep the hospital environment clean and dispose of refuse properly.
- Ensure ward cleanliness by scrubbing floors, dusting windows, and cleaning equipment daily.
- 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 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:
- 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.
- 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.
- 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.
- 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:
- Malaria cycle in the mosquito (Sexual stage – union of male and female gametes to form a zygote)
- 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:
- COLD STAGE: Patient feels very cold, increased pulse, nausea, and goosebumps.
- RIGOR STAGE: Shivering attacks, fast pulse, nausea, and possible vomiting.
- HOT STAGE: Temperature rises between 38-40°C, severe headache, vomiting, restlessness, and convulsions in children.
- 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:
- Welcome the mother, offer a seat, greet, and introduce yourself.
- Take history (personal, problem, environment, pregnancy).
- Make observations (TPR, BP, weight) and interpret them.
- Conduct general and abdominal examinations to decide on treatment or referral.
- Treat symptoms like fever, headache, and anaemia.
- Administer appropriate medications (e.g., iron supplements, antimalarials).
NEW MALARIA TREATMENT POLICY
- Uncomplicated Malaria
- First-line treatment: Artemether or Artesunate + Amodiaquine
- Second line: Quinine
- Severe Malaria
- Parenteral Quinine
- Parenteral Artemisinin derivatives (ACTs)
- Uncomplicated/Severe Malaria in Special Groups
- Pregnant women in the first trimester are given Quinine. ACTs can be used after the 1st trimester.
- 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.
MALARIA IN PREGNANCY Read More »