Fever during pregnancy and labour

PROBLEM

• A woman has a fever (temperature 38�C or more) during pregnancy or labour.

GENERAL MANAGEMENT

• Encourage bed rest.

• Encourage increased fluid intake by mouth.

• Use a fan or tepid sponge to help decrease temperature.

DIAGNOSIS

Table S-13

Diagnosis of fever during pregnancy and labour

^a Give ampicillin 1 g by mouth four times per day OR give amoxicillin 1 g by mouth three times per day for 14 days. Alternative therapy will depend on local sensitivity patterns.

^b Provide supportive therapy and observe.

MANAGEMENT

URINARY TRACT INFECTIONS

Assume that a urinary tract infection involves all levels of the tract, from renal calyces to urethral meatus. 

TESTS

Dipstick, microscopy and urine culture tests can be used to determine if a urinary tract infection is present, but will not differentiate between cystitis and acute pyelonephritis.

• A dipstick leukocyte esterase test can be used to detect white blood cells and a nitrate reductase test can be used to detect nitrites.

• Microscopy of urine specimen may show white cells in clumps, bacteria and sometimes red cells. 

• Urine culture and sensitivity tests should be done, if available, to identify the organism and its antibiotic sensitivity.

Note: Urine examination requires a clean-catch mid-stream specimen to minimize the possibility of contamination. 

CYSTITIS

Cystitis is infection of the bladder.

• Treat with antibiotics:

- amoxicillin 500 mg by mouth three times per day for 3 days; 

- OR trimethoprim/sulfamethoxazole 1 tablet (160/800 mg) by mouth two times per day for 3 days.

• If treatment fails, check urine culture and sensitivity, if available, and treat with an antibiotic appropriate for the organism.

• If infection recurs two or more times:

- Check urine culture and sensitivity, if available, and treat with an antibiotic appropriate for the organism;

- For prophylaxis against further infections, give antibiotics by mouth once daily at bedtime for the remainder of pregnancy and 2 weeks postpartum. Give:

- trimethoprim/sulfamethoxazole 1 tablet (160/800 mg);

- OR amoxicillin 250 mg.

Note: Prophylaxis is indicated after recurrent infections, not after a single episode.

ACUTE PYELONEPHRITIS

Acute pyelonephritis is an acute infection of the upper urinary tract, mainly of the renal pelvis, which may also involve renal parenchyma. 

• If shock is present or suspected, initiate immediate treatment.

• Check urine culture and sensitivity, if possible, and treat with an antibiotic appropriate for the organism. 

• If urine culture is unavailable, treat with antibiotics until the woman is fever-free for 48 hours:

- ampicillin 2 g IV every 6 hours;

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours.

• Once the woman is fever-free for 48 hours, give amoxicillin 1 g by mouth three times per day to complete 14 days of treatment.

Note: Clinical response is expected within 48 hours. If there is no clinical response in 72 hours, re-evaluate results and antibiotic coverage.

• For prophylaxis against further infections, give antibiotics by mouth once daily at bedtime for the remainder of pregnancy and for 2 weeks postpartum. Give:

- trimethoprim/sulfamethoxazole 1 tablet (160/800 mg);

- OR amoxicillin 250 mg.

• Ensure adequate hydration by mouth or IV.

• Give paracetamol 500 mg by mouth as needed for pain and to lower temperature.

• If there are palpable contractions and blood-stained mucus discharge, suspect preterm labour.

UNCOMPLICATED MALARIA

Two species of malaria parasites, P. falciparum and P. vivax, account for the majority of cases. Symptomatic falciparum malaria in pregnant women may cause severe disease and death if not recognized and treated early. When malaria presents as an acute illness with fever, it cannot be reliably distinguished from many other causes of fever on clinical grounds. Malaria should be considered the most likely diagnosis in a pregnant woman with fever who has been exposed to malaria.

• Women without pre-existing immunity to malaria (living in non-malarial area) are susceptible to the more severe complications of malaria.

• Women with acquired immunity to malaria are at high risk for developing severe anaemia and delivering low birth weight babies.

TESTS

• If facilities for testing are not available, begin therapy with antimalarial drugs based on clinical suspicion (e.g. headache, fever, joint pain). 

• Where available, the following tests will confirm the diagnosis:

- microscopy of a thick and thin blood film:

- thick blood film is more sensitive at detecting parasites (absence of parasites does not rule out malaria);

- thin blood film helps to identify the parasite species.

- rapid antigen detection tests.

FALCIPARUM MALARIA

ACUTE, UNCOMPLICATED P. FALCIPARUM MALARIA

Chloroquine-resistant falciparum malaria is widespread. Resistance to other drugs (e.g. quinine, sulfadoxine/pyrimethamine, mefloquine) also occurs. It is, therefore, important to follow the recommended national treatment guidelines. Drugs contraindicated in pregnancy include primaquine, tetracycline, doxycycline and halofantrine. Insufficient data currently exists on the use of atovoquone/proguanil and artemether/lumefantrine in pregnancy to recommend their use at this time.

AREA OF CHLOROQUINE-SENSITIVE P. FALCIPARUM PARASITES

• Give chloroquine base 10 mg/kg body weight by mouth once daily for 2 days followed by 5 mg/kg body weight on day 3. 

Note: Chloroquine is considered safe in all three trimesters of pregnancy.

AREA OF CHLOROQUINE-RESISTANT P. FALCIPARUM PARASITES

Oral sulfadoxine/pyrimethamine or quinine salt (dihydrochloride or sulfate) can be used for treating chloroquine-resistant malaria throughout pregnancy. Treatment options include:

• Sulfadoxine/pyrimethamine 3 tablets by mouth as a single dose;

Note: Sulfadoxine/pyrimethamine should not be used if the woman is allergic to sulfonamides.

• OR Quinine salt 10 mg/kg body weight by mouth three times per day for 7 days.

Note: If compliance with 7 days of quinine is not possible or side effects are severe, give a minimum of 3 days of quinine PLUS sulfadoxine/pyrimethamine 3 tablets by mouth as a single dose on the first day of treatment (providing sulfadoxine/pyrimethamine is effective; consult the national guidelines).

Mefloquine may also be used for treating symptomatic P. falciparum in pregnancy if treatment with quinine or sulfadoxine/pyrimethamine is unsuitable because of drug resistance or individual contraindications.

Note: Clinicians should carefully consider the use of mefloquine in early pregnancy due to limited safety data in the first trimester of pregnancy:

• In areas of mefloquine-sensitive parasites, give mefloquine 15 mg/kg body weight by mouth as a single dose;

• In areas of emerging mefloquine resistance, give mefloquine 15 mg/kg body weight by mouth followed by 10 mg/kg body weight 24 hours later.

AREA OF MULTIDRUG-RESISTANT P. FALCIPARUM MALARIA

Multidrug resistant P. falciparum malaria (resistant to chloroquine and sulfadoxine/pyrimethamine and quinine or mefloquine) is present in certain areas limiting treatment options.  Consult the national treatment guidelines. Treatment options include:

• quinine salt (dihydrochloride or sulfate) 10 mg/kg body weight by mouth three times daily for 7 days; 

• OR quinine salt 10 mg/kg body weight by mouth 3 times daily for 7 days PLUS clindamycin 300 mg 4 times daily for 5 days;

Note: The quinine/clindamycin combination can be used in areas of quinine resistance.

• OR artesunate 4 mg/kg bodyweight by mouth in a divided loading dose on day 1, followed by 2 mg/kg bodyweight by mouth once daily for 6 days.

Note: Artesunate can be used in the second and third trimester for treating uncomplicated malaria but there are insufficient data to recommend its use in the first trimester. Artesunate may be used, however, if no suitable alternative exists.

VIVAX MALARIA

AREA OF CHLOROQUINE-SENSITIVE P. VIVAX PARASITES

Chloroquine alone is the treatment of choice in areas with chloroquine-sensitive vivax malaria and areas with chloroquine-sensitive vivax and falciparum malaria. Where there is chloroquine-resistant P. falciparum, manage as a mixed infection.

• Give chloroquine base 10 mg/kg body weight by mouth once daily for 2 days followed by 5 mg/kg body weight by mouth on day 3.

AREA OF CHLOROQUINE-RESISTANT P. VIVAX PARASITES

Chloroquine-resistant P. vivax has been reported in several countries and there are limited data available to determine the optimal treatment. Before considering second line drugs for treatment failure with chloroquine, clinicians should exclude poor patient compliance and a new infection with P. falciparum. If diagnostic testing is not available, manage as a mixed infection (see below). Treatment options for confirmed chloroquine-resistant vivax malaria include: 

• quinine salt (dihydrochloride or sulfate) 10 mg/kg body weight by mouth twice daily for 7 days;

Note: The dose of quinine is less than that used for falciparum malaria; diagnosis of species is essential.

• OR mefloquine 15 mg/kg body weight by mouth as a single dose;

• OR sulfadoxine/pyrimethamine 3 tablets by mouth as a single dose;

Note: Sulfadoxine/pyrimethamine is not generally recommended because it acts slowly to clear vivax parasites.

• OR artesunate 4 mg/kg body weight by mouth in a divided loading dose on day 1 followed by 2 mg/kg body weight daily for 6 days.

TREATMENT OF LIVER STAGES OF VIVAX MALARIA

Vivax malaria may remain dormant in the liver. From time to time, these dormant stages are released into the blood to cause a new, symptomatic vivax infection. Primaquine can be used to clear the liver stages but its use is not acceptable during pregnancy. Primaquine should be used after delivery. Dose regimes vary by geographic region; use the dose recommended in the national guidelines.

AREAS OF MIXED FALCIPARUM-VIVAX MALARIA

In areas of mixed transmission, the proportions of malaria species and their drug sensitivity patterns vary. Referral to the national treatment guidelines is essential. If microscopic diagnosis is available, specific treatment can be prescribed. Where unavailable, options include:

• assume the infection is due to P. falciparum and treat accordingly (follow national guidelines);

• in areas of chloroquine-resistant but sulfadoxine/pyrimethamine sensitive P. falciparum and chloroquine sensitive P. vivax, treat with standard dose chloroquine and standard
  dose sulfadoxine/ pyrimethamine.

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