hiv
DESCRIPTION
obsgynTRANSCRIPT
Infections in PregnancySterilize with steam autoclave or hot-air
oven
Preferable over disinfection for “critical” instruments
Infection
International
Boiling for 20 minutes, completely covered with water
Chemical: bleach 1:50 dilution for 20 minutes… corrosive to stainless steel
Childbirth Education Slide – encourage the use of prenatal classed as a means of reducing the need for analgesia and improving satisfaction with delivery.
Infection
International
ANTISEPTICS
iodine/iodophor
.Continuous Support Slide – Continuous support to provide direct care and comfort for a labouring woman reduces the length of labour, the need for epidural analgesia and the caesarean section rate. Just having someone in the room, observing but not interacting with the patient, has a similar although less profound effect.
Infection
International
Disinfect area with bleach 1:100 dilution
Wear gloves
Exam tables should be disinfected daily
Comfort Measures Slide – illustrates that all the discomforts of labour (such as nausea, sleeplessness, bladder distention, various aches and pains) warrant attention and that by easing them or providing “innocuous stimulation” like TENS the need for more significant analgesia may be reduced
Infection
International
Infection
Infection
International
Infection
International
Objectives
definition
treatment
prevention
Infection
International
Definition:
any patient with fever of 38.5°C 48-72 hours following a vaginal or forceps delivery with uterine tenderness
Infection
International
- less frequent with vaginal births
- complications include: shock, pelvic abscesses and pelvic thrombosis
Infection
International
Pathophysiology
- amniotic fluid and increase in white blood cells during labour
Infection
International
Predisposing factors
- trauma and tissue necrosis following deliver creates a culture medium for ascending
- cesarean section is most important predisposing
- prolonged labour and ruptured membranes
- poverty and poor hygiene/nutrition
Bacteroides fragilis
- less common:
- exogenous source:
- low grade temperature, lower abdominal pain and uterine tenderness
- also: malaise, anorexia, foul lochia
- if severe: high temperature and generalized peritonitis
Infection
International
- Group A beta-hemolytic stretpococci may be fulminant with peritonitis and septicemia
- if cultured, hospital personnel must be screened to try and identify the source
Infection
International
Diagnosis
- sites of infection to consider in post partum patient (culture if able):
endomyometritis
- correct aseptic technique
- antibiotic use in women with cesarean section or prolonged rupture of membranes (1g ampicillin IV given prophylactically in cesarean section reduces infection)
Infection
International
Management -- Treatment
mild case: single broad spectrum antibiotic (eg. ampicillin 1 g IV q6h Or orally)
if cesarean section:
OR
aminoglysocide (gentamycin or tobramycin) 60-100 mg q8h +clindamycin 900 mg q8h
Infection
International
Management - Treatment
if intravenous antibiotics used, continue for 48 hours after fever has stopped.
if fever continues and aminoglycoside-clindamycin combination was used, add penicillin (5M units q6h) to cover enterococci
oral antibiotics should be used for 5 days
Infection
International
Other issues
- the more antibiotics used, > the higher the chance of necrotizing colitis
- antibiotics do appear in breast milk but in most cases are not clinically significant (avoid tetracyclines)
Infection
International
- remove sutures if fluctuation or pus
- rarely needs debridement
necrotizing fascitis: rare, rapid progression of local inflammation followed by gangrene -patient is toxic: high dose antibiotics but MUST surgically DEBRIDE
Infection
International
- Septic pelvic thrombophlebitis--usually anaerobic sepsis
- usually patient is already on antibiotics but continues to have high spiking fevers
- diagnosis of exclusion
Infection
International
for 7-10 days
continue breast feeding!
if breast abcess--drain
Postpartum or postabortal septic shock
definition: any toxic patient who has hemodynamic or acid base changes with fever 38.5ºC (after abortion, vaginal or operative delivery)
Infection
International
- usually gram-negative bacteria (eg. E. Coli) and occasionally gram positive (staphylococci, anaerobic streptococci, clostridium)
Infection
International
- not fully understood
vascular damage and vasodilatation
Principle of management and preventive strategies
Infection
International
Causes 1 to 2.7 million deaths
90% of deaths occur in Sub -Saharan Africa
(approximately 3000 deaths each day)
Infection
International
(WHO 1999)
Population: 564
Infection
International
Related to Level of transmission and immunity of individual exposed
In areas of high transmission ,endemic or stable malaria area.
In areas of low transmission or non endemic or unstable areas
Infection
International
Higher risk of death
Infection
International
Anaemia
Haemolysis
Malarial hyperactive splenomegaly
Nutritional & hookworm infestation
Increased risk in pregnancy to Post -partum Hemorrhage & Heart failure
Infection
International
Hypoglycemia
Use of chemo-prophylaxis or intermittent treatment presumptive treatment.
Use of insecticide treated bed nets
Regular Antenatal care and health education about malaria
Infection
International
In uncomplicated malaria: Chloroquine, SP,Mefloquine,Quinine (combination therapy)
In Severe malaria: Parenteral Quinine, Artemesinin derivatives and supportive therapy
Infection
International
A decrease in peripheral &placental parasitemia
A increase in maternal hemoglobin level
A lower proportion of Low birth weights
Infection
International
In endemic areas ,use of intermittent presumptive treatment (IPT):
Target population at Risk
1st dose: 16-24 weeks
2rd dose 28 to 36 weeks.
Alternative: Chloroquine Full dose than 2 tablets weekly dose till delivery or proguanil
Infection
International
YEAR
LOCATION
Improve implementation of existing strategies and health delivery system with emphasis on integration in existing services
Improve on Health education to community on dangers of malaria and early ,regular ANC attendance.
Infection
International
Infection
International
Objectives
Factors affecting vertical transmission
Infection
International
Introduction
UNAIDS about 25 million adults& children living with HIV/AIDS in Sub Saharan Africa.
4million new cases yearly
300,000 to 600,000 AIDS related deaths in 1999 in children (0 -14yrs)
Infection
International
Infection
International
No effect on HIV progression.
Slight decline in absolute numbers of CD4 count ( % of CD4 cells remains stable
No overall significant in deaths rate
Infection
International
Abortions
Infection
International
Accounts for > 90% of infection in children
In Africa rate of MTCT is 20 -40%
Overall risk at point estimate for transmission
During pregnancy: 5 -10%
In labour: 15 -20%
Mode of delivery
Comprehensive MCH services ( antenatal,intrapartum,postnatal)
Family planning services & counseling
Provision of quality ANC
Anti- retroviral drugs
Detailed history taking
Baseline Investigation: Hemoglobin,RPR for syphilis,Urine analysis
Voluntary confidential counseling and testing.
Infection
International
1st Visit:Detailed history, examination, investigation, folic supplements,deworming and VCCT
2rd Visit:Monitor progress of pregnancy, Counsel on pmtct and breast feeding option, 1st dose of IPT,tetanus toxoid,iron/folic supplementation.
3rd Visit:Monitor progress of pregnancy,blood pressure ,Hb and urine analysis,2rd dose IPT,tetanus toxoid, iron/folic supplementation.Counseling support
4th Visit: As above. Enrolment on the PMTCT program,Give antiretroviral drugs
Infection
International
Male involvement
Infection
International
ANC-4
identification& treatment of STI
1. Good Obstetric practice
2. Ante retroviral drugs
3. Modified Obstetric practice
AZT after 36 weeks antepartum,intrapartum amd post partum with neonatal treatment for 7 days. (%Reduction 50%) at 8weeks
Nevirapine In labour and neonatal treatment for 48 to 72 hours. (% reduction 47%) at 8 weeks
Infection
International
AZT 300mgs p.o 3hourly till delivery
AZT 300mgs p.o B.D for 7 days
4mgs/kg p.o B.D for 7 days
2. None
none
Ongoing Care
Counseling and support
Care of the Neonate,(Exclusive breast feeding for 3/12 months or Artificial infant feeding)
Infection
International
Conclusion
Effective counseling ,support,treatment of opportunistic infections and anti retroviral treatment can improve quality of life.
Abortions
1996 Gambia 1-10 Primegravid 17 to 3%
1998 Kenya 10 Primegravid 20 to 15
Preferable over disinfection for “critical” instruments
Infection
International
Boiling for 20 minutes, completely covered with water
Chemical: bleach 1:50 dilution for 20 minutes… corrosive to stainless steel
Childbirth Education Slide – encourage the use of prenatal classed as a means of reducing the need for analgesia and improving satisfaction with delivery.
Infection
International
ANTISEPTICS
iodine/iodophor
.Continuous Support Slide – Continuous support to provide direct care and comfort for a labouring woman reduces the length of labour, the need for epidural analgesia and the caesarean section rate. Just having someone in the room, observing but not interacting with the patient, has a similar although less profound effect.
Infection
International
Disinfect area with bleach 1:100 dilution
Wear gloves
Exam tables should be disinfected daily
Comfort Measures Slide – illustrates that all the discomforts of labour (such as nausea, sleeplessness, bladder distention, various aches and pains) warrant attention and that by easing them or providing “innocuous stimulation” like TENS the need for more significant analgesia may be reduced
Infection
International
Infection
Infection
International
Infection
International
Objectives
definition
treatment
prevention
Infection
International
Definition:
any patient with fever of 38.5°C 48-72 hours following a vaginal or forceps delivery with uterine tenderness
Infection
International
- less frequent with vaginal births
- complications include: shock, pelvic abscesses and pelvic thrombosis
Infection
International
Pathophysiology
- amniotic fluid and increase in white blood cells during labour
Infection
International
Predisposing factors
- trauma and tissue necrosis following deliver creates a culture medium for ascending
- cesarean section is most important predisposing
- prolonged labour and ruptured membranes
- poverty and poor hygiene/nutrition
Bacteroides fragilis
- less common:
- exogenous source:
- low grade temperature, lower abdominal pain and uterine tenderness
- also: malaise, anorexia, foul lochia
- if severe: high temperature and generalized peritonitis
Infection
International
- Group A beta-hemolytic stretpococci may be fulminant with peritonitis and septicemia
- if cultured, hospital personnel must be screened to try and identify the source
Infection
International
Diagnosis
- sites of infection to consider in post partum patient (culture if able):
endomyometritis
- correct aseptic technique
- antibiotic use in women with cesarean section or prolonged rupture of membranes (1g ampicillin IV given prophylactically in cesarean section reduces infection)
Infection
International
Management -- Treatment
mild case: single broad spectrum antibiotic (eg. ampicillin 1 g IV q6h Or orally)
if cesarean section:
OR
aminoglysocide (gentamycin or tobramycin) 60-100 mg q8h +clindamycin 900 mg q8h
Infection
International
Management - Treatment
if intravenous antibiotics used, continue for 48 hours after fever has stopped.
if fever continues and aminoglycoside-clindamycin combination was used, add penicillin (5M units q6h) to cover enterococci
oral antibiotics should be used for 5 days
Infection
International
Other issues
- the more antibiotics used, > the higher the chance of necrotizing colitis
- antibiotics do appear in breast milk but in most cases are not clinically significant (avoid tetracyclines)
Infection
International
- remove sutures if fluctuation or pus
- rarely needs debridement
necrotizing fascitis: rare, rapid progression of local inflammation followed by gangrene -patient is toxic: high dose antibiotics but MUST surgically DEBRIDE
Infection
International
- Septic pelvic thrombophlebitis--usually anaerobic sepsis
- usually patient is already on antibiotics but continues to have high spiking fevers
- diagnosis of exclusion
Infection
International
for 7-10 days
continue breast feeding!
if breast abcess--drain
Postpartum or postabortal septic shock
definition: any toxic patient who has hemodynamic or acid base changes with fever 38.5ºC (after abortion, vaginal or operative delivery)
Infection
International
- usually gram-negative bacteria (eg. E. Coli) and occasionally gram positive (staphylococci, anaerobic streptococci, clostridium)
Infection
International
- not fully understood
vascular damage and vasodilatation
Principle of management and preventive strategies
Infection
International
Causes 1 to 2.7 million deaths
90% of deaths occur in Sub -Saharan Africa
(approximately 3000 deaths each day)
Infection
International
(WHO 1999)
Population: 564
Infection
International
Related to Level of transmission and immunity of individual exposed
In areas of high transmission ,endemic or stable malaria area.
In areas of low transmission or non endemic or unstable areas
Infection
International
Higher risk of death
Infection
International
Anaemia
Haemolysis
Malarial hyperactive splenomegaly
Nutritional & hookworm infestation
Increased risk in pregnancy to Post -partum Hemorrhage & Heart failure
Infection
International
Hypoglycemia
Use of chemo-prophylaxis or intermittent treatment presumptive treatment.
Use of insecticide treated bed nets
Regular Antenatal care and health education about malaria
Infection
International
In uncomplicated malaria: Chloroquine, SP,Mefloquine,Quinine (combination therapy)
In Severe malaria: Parenteral Quinine, Artemesinin derivatives and supportive therapy
Infection
International
A decrease in peripheral &placental parasitemia
A increase in maternal hemoglobin level
A lower proportion of Low birth weights
Infection
International
In endemic areas ,use of intermittent presumptive treatment (IPT):
Target population at Risk
1st dose: 16-24 weeks
2rd dose 28 to 36 weeks.
Alternative: Chloroquine Full dose than 2 tablets weekly dose till delivery or proguanil
Infection
International
YEAR
LOCATION
Improve implementation of existing strategies and health delivery system with emphasis on integration in existing services
Improve on Health education to community on dangers of malaria and early ,regular ANC attendance.
Infection
International
Infection
International
Objectives
Factors affecting vertical transmission
Infection
International
Introduction
UNAIDS about 25 million adults& children living with HIV/AIDS in Sub Saharan Africa.
4million new cases yearly
300,000 to 600,000 AIDS related deaths in 1999 in children (0 -14yrs)
Infection
International
Infection
International
No effect on HIV progression.
Slight decline in absolute numbers of CD4 count ( % of CD4 cells remains stable
No overall significant in deaths rate
Infection
International
Abortions
Infection
International
Accounts for > 90% of infection in children
In Africa rate of MTCT is 20 -40%
Overall risk at point estimate for transmission
During pregnancy: 5 -10%
In labour: 15 -20%
Mode of delivery
Comprehensive MCH services ( antenatal,intrapartum,postnatal)
Family planning services & counseling
Provision of quality ANC
Anti- retroviral drugs
Detailed history taking
Baseline Investigation: Hemoglobin,RPR for syphilis,Urine analysis
Voluntary confidential counseling and testing.
Infection
International
1st Visit:Detailed history, examination, investigation, folic supplements,deworming and VCCT
2rd Visit:Monitor progress of pregnancy, Counsel on pmtct and breast feeding option, 1st dose of IPT,tetanus toxoid,iron/folic supplementation.
3rd Visit:Monitor progress of pregnancy,blood pressure ,Hb and urine analysis,2rd dose IPT,tetanus toxoid, iron/folic supplementation.Counseling support
4th Visit: As above. Enrolment on the PMTCT program,Give antiretroviral drugs
Infection
International
Male involvement
Infection
International
ANC-4
identification& treatment of STI
1. Good Obstetric practice
2. Ante retroviral drugs
3. Modified Obstetric practice
AZT after 36 weeks antepartum,intrapartum amd post partum with neonatal treatment for 7 days. (%Reduction 50%) at 8weeks
Nevirapine In labour and neonatal treatment for 48 to 72 hours. (% reduction 47%) at 8 weeks
Infection
International
AZT 300mgs p.o 3hourly till delivery
AZT 300mgs p.o B.D for 7 days
4mgs/kg p.o B.D for 7 days
2. None
none
Ongoing Care
Counseling and support
Care of the Neonate,(Exclusive breast feeding for 3/12 months or Artificial infant feeding)
Infection
International
Conclusion
Effective counseling ,support,treatment of opportunistic infections and anti retroviral treatment can improve quality of life.
Abortions
1996 Gambia 1-10 Primegravid 17 to 3%
1998 Kenya 10 Primegravid 20 to 15