FEVER IN PREGNANCY BY DR SHASHWAT JANI

1. Dr. Shashwat Kamal Jani.
M. S. ( Obs – Gynec )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2. Pyrexia…
• Temperature > 38 degree C once or > 37.5 degree C
on 2 occasions 2 hours apart.
(http://www.rcog.org.uk)
• In humans, threshold temperature for
teratogenicity : 38.9 ºC (102ºF)
28-Sep-18 Dr Shashwat Jani.
99099 44160.
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3. Three periods of prenatal development in human
Pre-implantation period (∼3 weeks)
• Increased pre-implantation loss due to failure to
implantation or embryonic death.
Period of major organogenesis (3∼8 weeks)
• Especially, susceptible to the induction of
developmental defect
• CNS, skeletal, neuromuscular, and cardiac defect
Fetal periods (8∼ weeks)
• Results mainly in reduced growth & functional
defects
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99099 44160.
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4.  Pregnant women with febrile illness are
more likely to develop critical outcome and die
than the general population.
 The increased severity of infections in
pregnant women is thought to be related to
the normal physiologic changes that occur
during pregnancy.
 There is increase in heart rate and oxygen
consumption, lung capacity decreases, and
there is a shift away from cell-mediated
immunity.
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99099 44160.
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5.  Clinical manifestations of infections in
pregnant women are similar to those in the
general population.
 However, first trimester nausea and
vomiting of pregnancy may mask the warning
signs and this may delay the recognition of
severe disease.
 During and after second trimester
physiological hypervolemia, low haematocrit,
generalized vasodilatation, high pulse rate and
low BP may present difficulty in assessing
severity of the disease.
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Dr Shashwat Jani.
99099 44160.
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6. Effects Of Fever
On Pregnancy
IUGR
Oligohydramnios
Preterm
Meconium stained amniotic fluid
Fetal distress
Abortion
Postpartum sepsis
Fetal Anomalies
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Dr Shashwat Jani.
99099 44160.
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7. Causes Of Fever
ANTEPARTUM
INFECTIONS
Bacterial
Upper Respiratory Tract Infection (URTI)
Urinary Tract Infection (UTI)
Typhoid
Gastroenteritis
Chorioamnionitis
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8. Protozoal
 Malaria
 Dengue
Viral
 Varicella
 Herpes
 Rubella
 Swine flu (H1N1)
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9. INTRAPARTUM
 Can be due to infectious or non-infectious
etiology
 Prolonged labour
 Prolonged PROM (>24 hours)
 Chorioamnionitis
 Increased maternal stress
 Drugs (Oxytocin augmentation, Epidural
analgesia)
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99099 44160.
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10. POSTPARTUM
 Puerperal pyrexia
 Breast abscess
 Thromboembolic disorders
 Wound infections
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11. Most Common Causes
 URTI
 UTI
 Septic Abortion
 Chorioamnionitis
 Dengue
 Malaria
 Typhoid
 Puerperal Pyrexia
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99099 44160.
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12. URTI
Causative Organisms
Virus (Rhinovirus, coronavirus, influenza)
Bacterial (Group B Streptococcus, S.pneumoniae
H.influenza)
Hormonal (Progesterone causes swelling in
the lining of sinus)
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13. Treatment
Analgesics
(Paracetamol)
Antihistaminics
Cough Suppressants
Increased fluid intake
Antibiotics
(Azithromycin, Cefixime)
Symptoms
Sore throat
Rhinorrhea
Headache
Cough
Fever
Ear pain
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99099 44160.
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14. UTI
Asymptomatic Bacteriuria
10,000 organisms/ml in 2 consecutive urine
samples in the absence of symptoms .
Occurs in 2.5-11% of pregnant women
Symptomatic Bacteriuria
 100 organisms/ml of urine with accompanying
pyuria (>7 WBCs/ml)
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99099 44160.
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15. Acute cystitis :
 Occurs in 1% of pregnant women
Acute pyelonephritis :
 Occurs in 2% of all pregnancies
 1st trimester - 2%
 2nd trimester- 52%
 3rd trimester- 46%
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99099 44160.
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16. Increased frequency of UTI in pregnant
women is due to:
 Difficult hygiene due to distended gravid
uterus
 Immunocompromised state
 Urinary stasis (progesterone-induced ureteral
smooth muscle relaxation)
 Urinary retention (enlarged uterus)
 Loss of ureteral tone
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17. 28-Sep-18
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Causes
E.coli- most common
Klebsiella pneumonia
Proteus mirabilis
Enterobacter
Symptoms
Dysuria
Fever with chills
Suprapubic pain
Increased frequency and urgency
Burning micturition

18. Investigations
 Blood (CBC, electroytes, BUN, creatinine)
 Urine
Midstream urine sample clean catch in 1st antenatal
visit
Culture - Standard method for evaluation.
Positive culture - 2 consecutive voided specimens
with isolation of the same bacterial strain, at a
colony count of 1,00,000 CFU/ml or higher .
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99099 44160.
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19. Treatment
Antibiotic therapy tailored to culture results and
follow up cultures to confirm sterilization…
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99099 44160.
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20. 20
Septic Abortion
• Cause of 12.9% of maternal deaths
• Post abortion care has had tremendous
impact on reducing mortality, particularly with
use of manual vacuum aspiration.
28-Sep-18 Dr Shashwat Jani.
99099 44160.

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

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

27. Chorioamnionitis
• Chorioamnionitis also known as intra-
amniotic infection (IAI) is an inflammation of
the fetal membranes (amnion and chorion)
due to a bacterial infection.
• It typically results from bacteria
ascending into the uterus from the vagina and
is most often associated with prolonged labor.
28-Sep-18
Dr Shashwat Jani.
99099 44160.
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28. Chorioamnionitis
• Chorioamnionitis, complicates as many as
40–70% of preterm births with premature
membrane rupture or spontaneous labor, and
1–13% of term births.
• 12% of primary cesarean births at term
involve clinical chorioamnionitis, with the most
common indication for cesarean in these cases
being failure to progress usually after
membrane rupture.
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Dr Shashwat Jani.
99099 44160.
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29. Risk Factors
1. Longer duration of membrane rupture.
2. Prolonged labor.
3. Nulliparity.
4. African American ethnicity.
5. Internal monitoring of labor.
6. Multiple vaginal exams.
7. Meconium-stained amniotic fluid.
8. Smoking, alcohol or drug abuse.
9. Immune-compromised states.
10. Epidural anesthesia.
11. Colonization with group B streptococcus.
12. Bacterial vaginosis.
13. Sexually transmissible genital infections. Dr Shashwat Jani.
99099 44160. 2928-Sep-18

30. Routes of infection
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31. Organisms
Ureaplasma urealyticum
 Mycoplasma hominis
Gardnerella vaginalis
Group B Streptococcus
E.coli
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32. Clinical Features
• Fever is the most important sign.
• Uterine fundal tenderness.
• Maternal tachycardia (>100/min).
• Fetal tachycardia (>160/min).
• Purulent or foul smelling discharge
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99099 44160.
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CBC , CRP , AMNIOTIC FLUID CULTURE

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

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

36.  A protozoal disease caused by the parasite belonging to the
genus plasmodium.
- It spreads through the bite of female anopheles mosquito,
blood transfusion and transplacental transfer from mother to
fetus during pregnancy.
- The following causative organisms have been recognized ;
P. Vivax , P. Falciparum , P. Malariae and P.Ovale.
- The predominant causal organism in the South-East Asia
region is P . Vivax. Followed by Falciparum . The later accounting
for nearly half mortality.
Malaria

37. Effect on Pregnancy:
 The immuno-compromised state of the mother renders her
susceptible to Malaria. There is intense parasitisation (30%- 60%
of cases) of the placenta which gets aggravated with concurrent
HIV and Tuberculosis.
 The intervillous space becomes blocked with macrophages
and parasites. And there is diminished pacental blood flow which
is mostly seen with falciparum infection and in the second half of
pregnancy.
 Primigravidae are usually more vulnerable to infection than
multiparae.

38.  Pregnant mothers living in endemic areas have
high amount of antibody titre and due to passive
transfer to the fetus, congenital Malaria is rare in these
areas.
 Pregnant mothers living in non-endemic areas are
particularly vulnerable for developing severe
complications. Congenital malaria has been observed in
such cases.( Less than 5%)

39. Effect on Mother:
 The symptoms start after 10 to 12 days of mosquito bite and
include a typical attack which is characterized by 3 stages. The
cold, the hot and sweating stage and this episode recur at 24-48
hours interval.
 Intermittent fever with chills and rigors
 Headache, nausea and vomiting
 Malaise , muscle and joint pains

40.  Complications:
 Anaemia due to Haemolysis
 Hypoglycemia and dehydration
 Metabolic acidosis
 Jaundice
 Acute renal failure
 Pulmonary oedema and respiratory distress.
 Cerebral Malaria- convulsion and coma
 DIC

41. Effect on Fetus:
 There is abnormal Utero-placental blood flow because of
placental parasitaemia (15%-60%) which result in;
- Midtrimester abortion
- Preterm Labour
- Pre-Maturity
- IUGR
- Fetal Distress
- Stillbirth
- IUFD
- Poor perinatal outcome and perinatal death

42. Investigations
 Microscopic (Gold standard)
Peripheral blood smear-
Thick (sensitive)
Thin (species identification)
 Antigen detection- Rapid diagnostic tests(RDT)
MRDT-HRP-2/pLDH
 PCR
 Antibody test
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99099 44160.
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43. Choice of Anti malarials in pregnancy
 All trimesters:
First line - Chloroquine; Quinine;
Second line – Artesunate Artemether / Arteether
 2nd / 3rd trimester: with caution
 Pyrimethamine + sulphadoxine;
 Mefloquine
 Contra indicated:
Primaquine; Tetracycline; Doxycycline; Halofantrine

44. Dose of Anti malarials:
 Chloroquine:
- 600mg (base) stat, 300mg after 6 hours, 24 hours & 48 hours
 Quinine:
- IV - 20mg/kg infusion over 4 hours, repeat 8 hourly. -
Maintenance: 10mg/kg over 4 hours, 8 hourly. Follow with oral
medication after clinically stable.
- Oral – 600mg 8hourly ( maximum 2 gm / day) for 7 days.
 Artesunate:
- Oral-100mg BD on day 1, then 50mg BD for 4-6 days (Total
dose 10mg/kg).
- IM / IV-120mg on Day 1 followed by 60mg daily for 4 days. In
severe cases an additional dose of 60mg after 6 hours on Day 1.

45.  Artemether:
- Six amp (480mg) IM in 5 / 3 days.
 Arteether:
- One amp (150mg) IM / day for3 consecutive days.
 Pyrimethamine 25mg+sulphadoxine 500mg tablets:
- Three tablets single dose.
 Mefloquine:
- 15mg / kg body wt., up to 1 Gm in a single dose. OR
Tablets of 250mg, 3 tab stat, then 2 tab after 6-8 hours. With
body wt >60kg, a third dose of 1 tab after 6-8 hours.

46.  Don't waste any time
 It is better to admit all cases of P. falciparum malaria.
 Assess severity-
 General condition, pallor, jaundice, B.P., temperature,
haemoglobin, Parasite count, S.G.P.T., S .bilirubin, S.creatinine,
Blood sugar.
 Malaria in pregnancy can cause sudden and dramatic
complications. Therefore, one should always be looking for any
complications by regular monitoring.
 Monitor maternal and foetal vital parameters 2 hourly.
R.B.S. 4-6 hourly; haemoglobin and parasite count 12 hourly; S.
creatinine; S. bilirubin and Intake / Output chart daily.

47.  The physiologic changes of pregnancy pose special
problems in management of malaria.
 In addition, certain drugs are contra indicated in pregnancy or
may cause more severe adverse effects.
 All these factors should be taken into consideration while
treating these patients.
 Choose drugs according to severity of the disease/ sensitivity
pattern in the locality.
 Avoid drugs that are contra indicated
 Avoid over / under dosing of drugs
 Avoid fluid overload / dehydration
 Maintain adequate intake of calories

48. Management of Labour
 Anaemia, hypoglycaemia, pulmonary oedema, and
secondary infections due to malaria in pregnancy lead to
problems for both the mother and the foetus.
 Severe falciparum malaria in term pregnancy carries
a very high mortality.
 Maternal and foetal distress may go unrecognised in these
patients. Therefore, careful monitoring of maternal and foetal
parameters is extremely important.
 Pregnant women with severe malaria are better managed in
an intensive care unit
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Dr Shashwat Jani.
99099 44160.
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49. • Falciparum malaria induces uterine contractions, resulting in
premature labour. The frequency and intensity of contractions
appear to be related to the height of the fever.
• Fetal distress is common and often unrecognised. Therefore only
monitoring of uterine contractions and fetal heart rate may
reveal asymptomatic labour and foetal distress.
• All efforts should be made to rapidly bring the temperature
under control,
– By tepid sponging (cold sponging causes cutaneous
vasoconstriction and can result in core hyperpyrexia).
– Anti pyretics like paracetamol etc.
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99099 44160.
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50. • Careful fluid management is also very important. Dehydration as
well as fluid overload should be avoided, because both could be
detrimental to the mother and/or the foetus.
• In cases of very high parasitemia, exchange transfusion may
have to be carried out.
• If the situation demands, induction of labour may have to be
considered.
• Once the patient is in labour, foetal or maternal distress may
indicate the need to shorten the 2nd stage by forceps or vacuum
extraction.
• If needed, even caesarean section must be considered
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99099 44160.
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51. Dengue
• Dengue is an arbovirus of the Flavi viridae family
and Flavi virus genus.
• There are four serotypes of the dengue virus
(DEN-1, DEN-2, DEN-3, and DEN-4).
• DV-2 was the predominant serotype circulating
in India.
• Indian isolates of DV-2 were classified into
genotype-V. However recently Genotype IV is
more predominant.
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99099 44160.
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52. Clinical Presentation
Four main characteristic manifestations of
dengue illness are :
(i) Continuous high fever lasting 2-7 days;
(ii) haemorrhagic tendency as shown by a positive
tourniquet test, petechiae or epistaxis;
(iii) thrombocytopoenia (platelet count <100×109/l); and
(iv) evidence of plasma leakage manifested by
haemoconcentration (an increase in haematocrit 20%
above average for age, sex and population), pleural
effusion and ascites, etc .
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53. Dengue is fever is classified into three different
phases based
on the symptoms and the severity of the
disease presentation.
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54. Obstetric Complications
• Preterm birth
• Low-birth weight
• Oligohydramnios
• Antepartum and postpartum haemorrhage
• Foetal distress
• Miscarriages
• Intrauterine death
• Neonatal death
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99099 44160.
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55. Diagnosis
• NS1 Antigen test,
Primary test done for
diagnosis.
• IgM antibody capture
ELISA (MACELISA)
comes as diagnostic
reagent strips.
• RT–PCR is confirmatory
with 95% specificity.
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99099 44160.
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56. Management
Symptomatic treatment.
• Intravenous fluid replacement.
• Broad spectrum antibiotics.
• Blood transfusion and Blood component therapy.
• Monitor maternal vital parameters.
• Monitor serum electrolytes.
• Monitor blood coagulation profiles.
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99099 44160.
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57. Management Of Labour In Critical
Phase Of Dengue
 Blood and blood products should be cross-
matched and saved in preparation for delivery.
 Trauma or injury should be kept to the minimum
if possible.
 It is essential to check for complete removal of
the placenta after delivery.
 Transfusion of platelet concentrates should be
initiated during or at delivery but not too far ahead
of delivery, as the platelet count is sustained by
platelet transfusion for only a few hours during
the critical phase.
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58. • Fresh whole blood/fresh packed red cells
transfusion should be administered as soon as
possible.
• Do not wait for blood loss to exceed 500 ml
before replacement, as in postpartum
haemorrhage.
• Do not wait for the haematocrit to
decrease to low levels.
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99099 44160.
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59. Enteric Fever
• Widal test should be done on Day 5 of fever.
• Multidrug therapy
• Inj Ceftriaxone 1.5 gm 12 hourly till 24 hours after
last fever followed by oral Cefixime 400 mg BD for
14 days
• + Tab Azithromycin 500 mg BID for 5 days ( from
day 1)
• Fleuroquinolones for resistant Enteric fevers.
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99099 44160.
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60. Puerperal Pyrexia
A rise in temperature reaching
100.4 degree F (38 degree C) or more on
separate occasions at 24 hours apart,
excluding the first 24 hours and within the
first 10 days following delivery
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61. Common Causes
 UTI (multiple P/V examinations, multiple
catheterization, untreated bacteriuria)
 Wound infection (C-section, trauma during
delivery)
 Mastitis (nipple trauma from breast feeding)
 Atelectasis (General anaesthesia, smoking, COPD)
 Septic Pelvic Thrombophlebitis(Prolonged labour,
prolonged PROM)
 Endometritis (Prolonged labour, prolonged PROM)
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99099 44160.
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62. Investigations
Blood (CBC, CRP)
Blood culture
Urine (If UTI is indicated)
Chest X-ray
Wound culture
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63. Treatment
 IV infusion of broad spectrum antibiotics
 Continued for 48 hours after fever is resolved
 Supportive care and symptomatic treatment
 Heparin therapy in thrombophlebitis
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Dr Shashwat Jani.
99099 44160.