Department of Reproductive Health and Research (RHR), World Health Organization
Managing Complications in Pregnancy and Childbirth
A guide for midwives and doctors
Section 2 - Symptoms
Fever during pregnancy and labour
Diagnosis of fever during pregnancy and labour
URINARY TRACT INFECTIONS
Assume that a urinary tract infection involves all levels of the tract, from renal calyces to urethral meatus.
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.
Note: Urine examination requires a clean-catch mid-stream specimen to minimize the possibility of contamination.
Cystitis is infection of the bladder.
Acute pyelonephritis is an acute infection of the upper urinary tract, mainly of the renal pelvis, which may also involve renal parenchyma.
Note: Clinical response is expected within 48 hours. If there is no clinical response in 72 hours, re-evaluate results and antibiotic coverage.
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.
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
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:
Note: Sulfadoxine/pyrimethamine should not be used if the woman is allergic to sulfonamides.
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:
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:
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.
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:
Note: The dose of quinine is less than that used for falciparum malaria; diagnosis of species is essential.
Note: Sulfadoxine/pyrimethamine is not generally recommended because it acts slowly to clear vivax parasites.
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.
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:
Rapid initial assessment