Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Tropical Medicine > Maternal and Child Health > Flashcards

Maternal and Child Health Flashcards

1
Q
  • Wiht respect to the newborn, define the following terms:
    • gestatoin
      • preterm
      • term
      • post term
    • birth weight
      • low
      • very low
      • extremely low
A
  • Gestation:
    • ​Preterm: <37 completed weeks
    • Term: 37 - <42 weeks
    • Post term: >42 weeks
  • Birthweight (BW)
    • Low (LBW): <2500 gm
    • Very low (VLBW) <1500 gm
    • Extremely low (ELBW) <1000gm
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q
  • Define:
    • Neonate, early and late period
    • Infant
    • Toddler
    • Child
    • Adolescent
A
  • Age ranges
    • Neonate: 0-28 days
      • Early neonatal period: 0-6 days
      • Late neonatal period: 7-28 days
    • Infant: 1-11 months
    • Toddler: 1-3 years
    • Child: <18 years (but varies by country)
    • Adolescent: 10-19 years
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q
  • What were the top 3 causes of child deaths in 2016?
  • Why?
  • When do most of these deaths happen?
A
  • The top 3 causes in 2016 were:
    • Neonatal causes (first 28 days of life: 46%)
    • Pneumonia (13%)
    • Diarrhoea (8%)
  • Progress in reducing deaths in older children, especially due to pneumonia and diarrhoea, has been much better than in neonates. Therefore, neonatal deaths (deaths in the first 28 days of life) now make-up a higher proportion of all under five deaths.
  • In the first week of life.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the most common threats to a healthy childhood?

A

Look at the Save the Children End of Childhood Report 2017

Stolen childhoods identifies the following 8 major risks to childhood and adolescence:

  • under-5 mortality
  • malnutrition
  • out-of-school children
  • child labor
  • early marriage
  • adolescent births
  • displacement by conflict
  • child homicide
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the SDGs directly relevant to child health?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What are the Take Home Messages in the unit on Global Childe Health?

A
  • Remarkable progress in recent years in improving under 5 survival
  • But 5.6m under 5 deaths occurred in 2016 – most in developing countries and most preventable
  • Neonatal deaths now 46% of all under 5 deaths and proportion rising (mostly in low birthweight infants)
  • Pneumonia and diarrhoea are the leading causes of death after the neonatal period
  • “First 1000 days” critical period for improving outcomes for children
  • The SDGs set ambitious targets for child survival and nutrition but many countries are unlikely to meet the targets
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is this?

A
  • Bitot’s spots are the buildup of keratin located superficially in the conjunctiva, which are oval, triangular or irregular in shape. These spots are a sign of vitamin A deficiency and are associated with drying of the cornea. In 1863, PierreBitot (1822-1888), a French physician, first described these spots.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is this?

What else should one look for in this clinical situation?

A
  • keratomalacia, one of they eye signs of vitamin deficiency
  • eye signs of vitamin A deficiency:

– dry conjunctiva or cornea, Bitot spots (below)

– corneal ulceration

– keratomalacia

Children with vitamin A deficiency are likely to be photophobic and will keep their eyes closed. It is important to examine the eyes very gently to prevent corneal rupture

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is this?

Describe this condition.

A
  • skin changes of kwashiorkor:

– hypo- or hyperpigmentation

– desquamation

– ulceration (spreading over limbs, thighs, genitalia, groin and behind the ears)

– exudative lesions (resembling severe burns) often with secondary infec- tion (including Candida).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How is shock defined in a malnourished child?

A
  • Lethargy/unconsciousness AND cold hands plus either
    • slow capillary refill or
    • rapid pulse
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How are moderate and severe malnutrition and stunting defined.

A
  • Malnutrition
    • Severe: Wt:Ht >3 SD below National Centre for Health Statistics reference values or >70% below median or or an MUAC <110 (child 1–5 years)
    • Moderate: Wt:Ht 2-3 SD below or 70-79% below median
  • Stunting
    • Severe Ht-for-age >3 SD below reference or <85% below median
    • Moderate Ht-for-age 2-3 SD below reference or 85-89% below median
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q
  • A 23 year old woman is brought to your clinic in rural Malawi by her husband. She has a history of bipolar disorder, manic type, and has had an episode of mania after each of her three pregnancies.
    The couple have heard that medicine can prevent a recurrence of this illness and are asking for a prescription. They say they are likely to have more children.

What is the recommended drug for prophylaxis in this case?

A
  • chlorpromazine
  • lithium, carbamazepine, valproate and haldol are all teratogenic
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q
  • When should a placenta be diagnosed as retained?
A
  • Different authorities provide different cut-off points as to how long should one wait to diagnose a retained placenta. However NICE puts it at 30 min and WHO (which is perhaps the most flexible) at 1 hour. Removal of a retained placenta should be attempted at every level of facility including the basic one. One common and effective method is using pethidine and diazepum; which relieves pain, helps relax perineal muscles and can expedite delivery of the placenta and reduce blood loss. There is no evidence to suggest benefit of using prophylactic antibiotics.
  • The reason for not attempting manual removal early is because this has itself been shown to increase the risk of post-partum hemorrhage.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

How do you define tachypnea in children?

Aged 1-5 yrs?

2-12 months

neonates (0-2 mo)

Adults?

A
  • The agreed rates for tachypnoea per minute are >30/min in an adult, >40/min 1–5 years, >50/min 2–12 months, >60/min when younger than 2 months. Distinguish tachypnoea (increased rate of breathing) from dyspnoea (the distressful conscious necessity to increase the rate/depth of breathing). Tachypnoea >30/minute in an adult, associated with a pulse rate >120/min and/or blood pressure <90 mmHg, points to an acute respiratory crisis.

Simple oximetry is a most useful tool, in such cases, for indicating the use supplemental oxygen.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is diff dx of febrile child with reduced LOC?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Carpopedal spasm?

How do you respond?

A
  • Think hypocalcemia
  • If non-emergent, give oral calcium gluconate (Tim Dempsey)
  • emergent (e.g. septic, reduced loc)
    • 0.3 ml/kg 10% ca gluconate
    • repeat if needed
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q
  • What is the commonest cause of acidosis in critically ill child?
  • What clinical findings would support this dx?
  • How to manage?
A
  • hypovolemia or shock
  • Clinical findings:
    • tachypnea
    • tachycardia
    • delayed cap refill, cold peripheries
    • reduced or poor per pulse volume
    • hypotension
    • clinical signs of dehydration
  • Manage
    • whole blood & reevaluate
    • fluids & reevaluate
      • 20 ml/kg rl or ns
      • mainenance eg dex/sal at 4 ml/kg/hr
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Differential dx of Febrile child with a rash

A
  • bacterial: meningococcus, pneumococcus, scarlet fever
  • Viral: measles, rubella, parvovirus, adenovirus, HHV6, enterovirus, paraechovirus
  • Parvovirus B19: fifth disease, slapped cheek syndrome
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is the FANC?

A
  • 2001 WHO model for antenatal care
    • 4 visits
      • before 16 wks
      • 24-28 wks
      • 32 wks
      • 36 wks
  • supplanted by WHO 2016: Positive Pregnancy Experience
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What were the main recommendations for Antenatal Care made in the WHO 2016 Policy:

Positive Pregnancy Experience

A
  • FANC 8
    • first visit 12 wk gestn then
    • 20, 26, 30, 34, 36, 38, 40
  • Context-spec rec re Maternal assessment
    • Anemia: CBC or Hgb to dx
    • Assymptomatic Bacteriuria Dx with urine culture or if n/a then microscopy over dipstick
    • Int Part Violence: Inquire where able
  • Gest DM - class hyperglycemia as GDM or DM in preg
  • Tobacco - screening for past & present exp to first and 2nd hand smoke
  • Substance Use
  • HIV: PITC - Provider Initiated Test and Counselling, STD testing
  • TB: if prev > 100/100,000 screen in ANC (cs)
  • Fetal Assessments
    • ​abd palp or SFH for fetal assessment (cs)
  • Health Systems Interventions
    • woman-held case notes rec
    • midwife-led cont care where systems in place and working (cs)
      *
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is Perinatal Death Rate

A
  • deaths from 28 wks gestation to 1 wk old/# live births
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is a stillbirth?

How many globally per year.

What is the Stillbirth Rate in SSAfrica.

What stilbirth rate for every country is the WHO “Every Newborn Action Plan” target for 2030?

A
  • death after 28 wk gestation
  • 2.6 Million Stillbirths/yr
  • Africa SB rate is about 30/yr
  • ENAP Target SBR is 12/1000 by 2030
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is an early neonatal death?

What is a late neonatal death?

How Many Neonatal Deaths/Yr globally?

A
  • death before 7 days
  • death from 7-28 days
  • 2.8 million
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Perinatal Mortality Rate

A
  • deaths from 28 wk gestation to 1 wk old/# of births
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Global Burden of Maternal Mortality

How many maternal deaths per year?

Compare MMR SSA & HIC:

/100,000 live births

Life Time Risk

A
  • 303,000 Mat deaths/yr (WHO 2015)
  • /100,000LB: SSA 239 to HIC 12 (20x)
  • LTR: SSA 1/36 to HIC 1/4900 (136x)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Define:

  1. Maternal Mortality
  2. Late Maternal Death
  3. Preg-related Death
A
  1. Death of a woman:
    • while pregnant or within 42 days after termination of pregnancy
    • irrespective of the duration and the site of the pregnancy
    • from any cause related to or aggravated by the pregnancy or its management
    • but not from accidental or incidental causes
  2. Deaths cased by direct or indirect obstetric causes >42 days but <1 yr after termination of pregnancy
  3. Deaths while pregnant or within 42 days of termination of pregnancy irrespective of cause
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Define the Maternal Mortality Ratio (MMR) and give equations relating it to the Maternal Mortality Rate

What are the weaknesses of the MMR.

A
  • Maternal Mortality Ratio (MMR) - number of maternal deathe in a given time period per 100,000 live births during the same period
  • MMR = # mat deaths/#live births x 100,000
  • or
  • MMR=MMRate/General Fertility Rate (GFR)
  • or
  • MMR=1(1-LTR)1/TFR
  • MMR expresses ‘obstetric risk’ - reflects only the risk of death once pregnant
  • Weaknesses
    • ​misses cumulative mortality with # of preg
    • preg not producing live birth excluded in denominator
    • hard to measure
    • narrow focus on mortality and misses complications and disability
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Define Maternal Mortality Rate (MMRate)

What does it indicate?

Weakness?

A
  • # of mat deaths in a given period per 1000 women of reproductive age during the same time period
  • MMRate = # mat deaths/# WRA x 1000
  • MMRate = MMR x GFR
  • MMRate = 1(1-LTR)1/35

(WRA=Wom of Rep Age; GFR=General Fert Rate; LTR=Lifetime Risk; MMR=Mat Mort Ratio)

  • Indicates burden of maternal death in rep age female popn - captures both risk of death per preg or per total birth (inc live and still births)
  • Weakness: conceasl the effects of different levels of fertility
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Define Lifetime Risk (wrt death related to pregnancy)

A
  • reflects the prob of a woman dying from mat causes over course of reproductive lifespan
  • LTR = 35 x MMRate
    • = 1-(1-MMRatio)<span>TFR</span>
    • = 1-(1-MMRate)35
  • takes into account the probability of death tdue to maternal causes each time a woman becomes pregnant (MMR & TFR)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Define Proportion of Maternal Death among Death of Females of Reproductive Age (PDMF)

How does this compare in High Income and LM Income Countries?

A
  • = # maternal deaths in a period/# women aged 15-49 yrs in same period
  • Range is <1% in many HIC
  • Up to 45% in LMIC
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Why do Mothers Die?

What is the current Global MMR?

What is the WHO SDG ‘Saving Mothers’ Lives’ Global Goal for 2030?

A
  1. Hemorrhage 27%
  2. Indirect Causes - diabetes, hypertension, anemia, malaria, HIV, TB etc. 27%
  3. Hypertension 14%
  4. Sepsis 11%
  5. Abortion 8%
  6. Embolism 3%
  7. Other direct causes 10%
  • Current Global MMR 216/100,000 LB
  • SDG Goal <70 by 2030
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q
  • What are the steps for a Maternal Death Audity?
  • Having collected data for Maternal Death Review (registers, all available records and confidential interviews with families and HW’s), briefly outline remaining steps
A
  1. Identify cases
  2. Data Collection
  3. Analysis of Findings
    • team meeting to review
    • quantitiative analysis to identify trends looking at time of death, partographs, mode of delivery
    • qualitative to identify factors and barriers to care. 3 delays model to identify arease where quality of care substandard
    • establish cause of death
  4. Recommendations & Action
    • SMART: Smart, Measurable, Achievable, Realistic and Time Bound goals
    • what went well
    • action points for 3 priority areas
    • champions/coaches to improve
  5. Evaluation and refinement
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What are the main causes of maternal deaths and the key interventions that could prevent them?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What is EmOC?

A
  • Emergency Obstetrical Care: A package of medical/surgical interventions required to treat the seven major direct obstetric (and neonatal) complications.
    1. Hemorrhage
    2. Pre-eclampsia or eclampsia
    3. Sepsis
    4. Obstructed labour
    5. Ectopic Pregnancy
    6. Ruptured uterus
    7. Newborn Distress
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What are the Signal Functions for EmOc?

(7 Basic and 2 comprehensive)

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What are the 6 UN process indicators for EmOC?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Addressing the 3 delays in EmOC affecting pregnancy outcome and what factors may influence them?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Hypertensive Disorders in Pregnancy:

  • Differentiate between
    • chronic hypertension
    • pih
    • pre-eclampsia superimposed on ch
    • pre-eclampsia
    • eclampsia
  • define proteinuria for pre-eclampsia
A
  • proteinuria>300 mg in 24 hr urine
  • Pr:Cr ratio >0.3 when dipstick > 2+
  • in absence of proteinuria HELLP syndrome dix pre-eclampsia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Outline the management of Eclampsia?

In case of continuing seizures in spite of 1st line tx then what?

A
  • see diagram
  • for seizure MgSO4
    • ​4 g iv over min 5 min or 10 gm IM then maintenance 1 g/hr or 2.5 gm q 4 prn im use LIVKAN chart to monitor vitals, tdr’s, u/o for safety
    • Ca gluconate 1 gm IV (10ml10%10min) antidote in case of areflexia or resp depression
  • fetal brady for 3-5 min after seizure common, not emergent
  • control BP
    • hydrazine 5 mg bolus iv q 30 min
    • labetolol 10-20 mg iv psh rpt q 10-20 min with doubling dose to max 80 mg
    • oral nifedipine
  • evaluate for delivery
  • In case of continuing seizures 2 gm IV more MgSulf or increase infusion or give
    • thiopentone
    • phenytoin
    • diazepam
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Define SIRS.

A
  • •Fever of more than 38°C (100.4°F) or less than 36°C (96.8°F) •Heart rate of more than 90 beats per minute
  • •Respiratory rate of more than 20 breaths per minute or arterial carbon dioxide tension
  • (PaCO 2) of less than 32 mm Hg
  • •Abnormal white blood cell count (>12,000/μL or < 4,000/μL or >10% immature [band] forms)
  • The Society of Critical Care Medicine (SCCM), March 2015 USA
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Causes of fever during pregnancy.

Causes of fever after delivery.

A
  • Causes of fever during pregnancy.
    • UTI/Pyelonephritis
    • Septic abortion
    • Chorioamnionitis
    • Chest infection
    • Malaria
    • Typhoid or non typhoid salmonellosis
    • Hepatitis
    • Meningitis
    • Phlebitis
    • Other: TB, HIV, appendicitis etc
  • Causes of fever after delivery
    • Puerperal sepsis
    • Endometritis, pelvic cellulitis, pelvic abscess, peritonitis
    • Wound infection after CS
    • UTI/Pyelonephritis
    • Malaria, enteric fever
    • Pneumonia
    • Mastitis, breast abscess
    • Phlebitis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

How many maternal deaths in 2015?

What was MMR (Maternal Mortality Ratio?)

What proportion of global births attended by skilled health personel?

A
  • 303,000
  • 210 deaths/100,000 live births (2013)
  • 71%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

What are the 5 Goal 3: Good Health & Well Being targets for SDG wrt Maternal and Child Health.

MMR?

neonatal mortality?

under 5 mortality?

A
  1. By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births
  2. By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births
  3. By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes
  4. Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

What percentage of pregnancies in Sub-Saharan Africa occur in girls 15-19 yr old?

A
  • 35%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q
  • What is Quality in Health Care?
  • What are the 7 Pillars to operationalize this concept for pregnant women and newborn according to WHO.
  • Tools for quality?
A
  • “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional practice”

Institute of Medicine 2001

  • Health care should be:
    1. Safe
    2. Effective
    3. Timely
    4. Efficient
    5. Equitable
    6. People-centred
  • Tools
    • Maternal death audit/review
    • Maternal death Surveillance & Response
    • Perinatal death audit/review
    • Standards based audits
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q
  • Diff Dx for genital bleeding in early pregnancy?
  • (Organize by
    • Upper - Uterus & amniotic sac
    • Middle - Cervix or vagina
    • Lower - Bladder, anus or vulva
A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Algorithm for management of suspected Ectopic preg in resource poor setting?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

What is the risk of recurrence of ectopic pregnancy in the next pregnancy?

A
  • 10-17%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q
  • Incidence, presentation, US appearance of Molar Pregnancy.
  • What is risk of malignant change?
  • Post evacuation management?
  • Management of malignancy?
  • Cure Rate?
A
  • risk of malig change 1/10
  • f/u serial preg tests
  • avoid preg for 12 mo (at least 6 months of normal HcG levels)
  • if preg test pos and not pregnant suspect recurrence and do full involvement inc cxr & rpt evacuation
  • Malignancy (Gest Trophoblastic Dis) tx with methotrexate, very good cure rate.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Outline Management of miscarriage

Include dosage of med.

A
  • wait and watch ok if pt can remain under observation or lives nearby with no transport difficulties
  • Manual Vaccuum Aspiration is preferred surgical method, no need for anesthetic, safe and effective
  • Misoprostol if available, under observation. Watch pt swallow or insert it yourself PV
  • Dosage 6-800 mcg
  • Evacuation of retained prod of conception (ERPC) risk perforation and need anesthesia, but good if all else fails or not available
  • Beware risks of septic abortion, heavy bleeding
  • should wait at least 2 weeks before conception
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

List the complications of unsafe abortion

A
  • sepsis
  • peritonitis
  • hemorrhage
  • poisoning
  • uterine, cervical or vag injury
  • visceral injury
  • psych. damage
  • infertility
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Medical options for treatment of abnormal uterine bleeding.

A
  • (GnRH analogues eg Lupron, Zoladex are Gonadotropin Releasing Hormone)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

What are risk factors for Cervical Cancer?

How many women die each year from Cervical Cancer (2015)?

A
  • 270,000, nearly as many as maternal deaths (303,000)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

How does HIV influence the incidence and progression of Cervical Cancer?

A
  • occurs in younger age group
  • more aggressive, progresses and metastasizes more rapidly
  • twice as frequent as HIV -ve
  • happens at highter CD4 than Kaposi’s sarcome and other HIV-related cancers
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

What strains of HPV are targeted by HPV vaccines?

A
  • Cervarix - HPV 16&18 prevents 70% cervical ca
  • Gardasil ( + 6, 11)
  • Gardasil 9 (+5 more: 31, 33, 45, 52, 58) Prevents 90%
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

What is the commonest site for ischemic injury and Vaginovescular Fistula due to obstructed labour?

A
  • junction of bladder and urethra
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Female Genital Mutilation

Classification

A
  • Type 1: part or all of clitoris removed
  • Type 2: clitoris and part or all of labia
  • Type 3: infundibulation - above + bringing together labia majora to cover urethra and most of vag opening
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q
  • Female Genital Mutilation
  1. How many girls alive today have been mutilated?
  2. Which countries have highest rates (>80%)
  3. In which countries are >1/2 of procedures performed by medical professionals?
A
  1. 200 million
  2. Somalia, Egypt, Sudan, Mali
  3. Sudan, Egypt
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Legal status of FGM

  • 1993 Vienna World Conference on Human Rights did what?
  • legal status in countries where practiced?
A
  • VWC
    • classified FGM as form of violence against women
    • acknowledged that it fell under the purview of international human rights law
  • 24/29 enacted decrees or legislation concerning FGM
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Surgical Repair of FGM?

A
  • defibulation and clitoral repair
  • positive effect on pain and sexual arousal
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q
  • WHO position on FGM
    • Guiding principles?
    • Recommendations
A
  • Guiding Principles
    1. harmful practice, victims should have quality health care
    2. all stakeholders should work towards prevention
    3. medicalization (perf by hc providers) never acceptable
  • Recommendations
    • deinfibulation for prevention and tx of obstetric complications due to type 3
    • antepartum or intrapartum deinfibulation
    • for prevention and tx of recurrent uti and retention
    • CBT for psych probs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

Placenta Previa

  • how common?
  • role of cervical cerclage?
  • general principles?
A
  • common, about 0.5% of deliveries, usually undiagnosed
  • reduced risk of delivery before 34 wks GA
  • admit or refer, generally conservative approach
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

Placental Abruption

  • how presents?
  • how common?
  • how serious?
  • Management:
A
  • usually painful bleeding
  • less common than previa, about 6.5/1000 preg
  • >10 x perinatal mortality
  • Management
    1. Deliver to avoid DIC
    2. Blood (fresh)
    3. Analgesia
    4. Mother
    5. Fetus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q
  • Post Partum Hemorrhage
  • Definition?
A
  • Def
    • blood loss >500 ml for SVD and >1000 mls for CS delivery
    • may be less if anemia or small stature: any amount leading to CV compromise
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

PPH Prevention

  • How? (rec of FIGO, ICM, WHO)
  • Active Management of third stage of labour (AMTSL)
    • durg alternatives?
  • Role and effects of controlled cord traction
    • what does it do and not do?
A
  • how?
    • give utertonic drug within 1st minute of birth
    • clamp and cut cord
    • controlled cord traction
    • =/- rubbing uterus q 15 min for first 2 hr
  • AMTSL
    • decreases incidence of PPH by 68%
    • oxytocin by 40% (NNT=12)
    • Misoprostol sl less effective (NNT=18) but cheap, heat and light stable, no syringe
    • recommended dose 6-800 mg
    • advance community distribution of misoprostol not recommended as more risks than benefits
  • Controlled Cord Traction
    • reduces
      • ​duration of 3rd stage
      • incidence of PPH
      • risk of retained placenta
    • no effect on
      • incidence of severe PPH
      • need for blood transfusion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

Post partum hemorrhage

  • how common is it?
  • how many deaths?
  • Common causes?
A
  • about 10% of all deliveries
  • 130,000 deaths per year
  • Common causes 4 T’s
    • Tone 70%: uterine atony
    • Trauma 20%: lacerations, hematomas, inversion, rupture
    • Tissue 10%: retained tissue, invasive placenta
    • Thrombin 1%: coagulopathies
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

Post-Partum Hemorrhage: Management

  • Physical Management: how?
  • Uterotonics?
  • Antifibrinolytic?
  • Surgery?
A
  • ensure bladder empty
  • Compression minimum 5 minutes
    • bimanual compression of uterus or
    • aortic compression
  • Uterine Balloon Tamponade (UBT)
    • if no response to uterotonics or uterotonics not available
    • temporary measure while transfer or referral
    • success up to 84%
    • can be used with topical Tranexamic Acid
  • Non-pneumatic Antishock Garment
    • decreased mat mortality from 6.3 to 3.5%
    • reduced severe morbidity and halved emergency cs from 8.9% to 4.0%
  • Uterotonics
    • Oxytocin 10 IU IM, if not response then 20 IU in 500 ml NS to run slowly over 2-4 hrs
    • IM Ergometrine 0.5 mg, no more than 4 mg - risk of CVA
    • combi available Syntometrine
    • Ergo better than Oxy or Misoprostol but causes marked increase in BP
  • Antifibrinolytic: Tranexamic Acid
    • only within 3 hrs of childbirth, beyond that more harm than good
  • Surgery:
    • B-Lynch (Brace) Sutre or Hysterectomy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q
  • Management of Retained Placenta
  • How long before removal? (NICE vs WHO)
  • Prophylactic Antibiotics?
A
  • NICE 30 min
  • WHO 60 min
  • No evidence of benefit.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

Obstructed Labour

  • outline causes
  • if prolonged obstructive labour remember to catheterize min 10 days to prevent obstetric fistula
A
  • Powers: inadequate contractions/dysfx labour
  • Passage: CPD proportion
  • Passenger: abn presentation or fetal abnormality
  • Psyche: lack of companion during labour
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
70
Q
  • Assisted Vaginal Delivery
  • What are the Indications
  • What are the necessary conditions to proceed?
  • When should you Stop?
A
  • Ind
    • expedite second stage
    • Maternal condition: severe anemia, prosthetic valves, renal disease
    • Fetal condition: distress, cord prolapse
  • Need
    • Live, term baby (>34 completed weeks)
    • adequate dilatation
    • adequate descent
    • adequate contractions
  • Stop!!!
    • take no more than 30 min
    • no advance with each pull
    • cup slips off twice
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
71
Q

What are the main risks for placenta accreta/increta/percreta?

(based on UK study)

A
  • main risks are previous LSCS (OR 15), diagnosed previa (OR 65)
  • overall risk if previous LSCS or diagnosed previa about 1/20
  • Conclusions: women with both prior caesarean delivery and placenta praevia have a high incidence of placental accreta/increta/percreta. There is a need to maintain a high index of suspicion of abnormal invasion in such women and preparations for delivery should be made accordingly.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
72
Q

What are WHO recommendations for intrapartum care for a +ve childbirth experience (2018 - not yet implemented anywhere).

A
  • Changes include:
    • Latent phase definition: up to 5cm cervical dilatation with some cervical effacement
    • Active labour: from 5cm cervical dilatation
    • Length of first stage (primips: normally not beyond 12
    • hours and multips: 10 hours)
    • Slower than 1cm/hour cervical dilatation not a routine indicator for obstetric intervention
    • FH auscultation during and for at least 30 seconds after contraction. If abnormal, prolong auscultation for at least three contractions.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
73
Q

Skilled Birth Attendant

  • What is the WHO definition? (2004)
  • What proportion of births in Africa were attended by one?
  • Globally?
A
  • An accredited health professional – such as a midwife, doctor or nurse
  • Educated and trained to proficiency in the skills needed to manage
  • normal pregnancy, childbirth and the immediate postnatal period
  • identify, manage and refer women and newborns with complications
    • WHO. Making pregnancy safer: the critical role of the skilled attendant. WHO 2004.
  • just over 50% in Africa
  • Globally 22%: i.e. nearly 31 million unattended births
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
74
Q

Companion in Labour

  • What is the evidence? (Cochrane review, Hodnett et al 2013)
A
  • Women who received continuous labour support were more likely to:
    1. give birth ‘spontaneously’, i.e. no CS, vacuum nor forceps
    2. less likely to use pain relief
    3. more likely to be satisfied
    4. had slightly shorter labours.
    5. their babies were less likely to have low five minute Apgar scores
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
75
Q

Partograph

  • What is it?
  • What is the evidence for benefit?
A
  • “simple inexpensive tool providing a continuous pictorial overview of labour” used to identify and manage obstructed labour inc referral and transfer.
  • a good thing, however systematic review 2013:
    • no diff between partograph and non-partograph use in CS, instrumental vag delivery, Apgar score
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
76
Q

Assessing Progress in Labour

  • What are the 4 p’s?
  • What are NICE (2007) parameters for 1st stage of labour?
A
  • power, passage, passenger, psyche
  • should include:
    • cervical dilatation of 2 cm in 4 hrs
    • descent and rotation of fetal head
    • changes in strenght, duration and frequency of contractions
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
77
Q
  • Amniotomy/Rupturing of Membranes
  • Role in Normal Labour?
  • Effects?
A
  • Not part of normal labour
    • ​increased risk of Mat to Child Transmission of HIV
    • increased risk of infection
    • not effective method of shortening spont labour
    • increases risk of CS
    • Increases risk FH abn
    • increased pain following ROM
  • if labour slowing, use benign methods first: movement, change of position
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
78
Q
  • Intermittent auscultation vs continuous cardiotocography
A
  • CTG associated with fewer neonatal seizures BUT
  • no diff in cp, infant mortality or other standard measures of neonatal well-being
  • CTG associated with increased rated of CS and instrumental delivery
  • no evidence for CTG for low risk pregnancy
  • if no risk factors for fetal hypoxia intermittent auscultation is recommended
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
79
Q

What are WHO recommendations for recording fetal heart in labour?

A
  • 1st stage: q 30 minutes for 60 sec after a contraction
  • 2nd stage: q 5 min
  • good practice to record mat pulse with every FH recording
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
80
Q

Nutrition in Labour

  • Cochrane review Singata et al 2013: what are the findings?
A
  • no benefit or harm from eating & drinking in labour in women at low risk of anesthesia
  • eating and drinking allows woman to feel normal and healthy
  • fasting/denial of food and drink may result in dehydration & acidosis
  • combined with fatigue leads to increased risk of augmentation of labour and instrumental delivery so
  • EAT DRINK AND BE MERRY
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
81
Q

Harmful Practices in first stage

List them (7)

A
  1. vag exam without indication
  2. vag exam without consent
  3. routine rupture of membranes
  4. perineal shaving
  5. enemas
  6. pinching abdomen
  7. abusive behaviour
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
82
Q

Second Stage of Labour

  • how should women push?
  • effect of upright positions?
  • harmful practices?
A
  • no evidence to suggest woman needs to be taught to push: should be encouraged to push spontaneously
  • a “no noise” rule is unacceptable
  • upright positions lead to:
    • shorter 2nd stage
    • less instrumentation
    • fewer episiotomies
  • harmful to push down on fundus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
83
Q

Care of the perineum

  • suggestions
  • harmful practices
  • antenatal perineal massage?
A
  • application of warm compresses may reduce perineal trauma
  • inconclusive evidence re benefit of flexion of presenting part
  • hands off or hands poised technique
  • continuous sutures best for repair
  • promote pelvic floor exercises
  • harmful:
    • ​perineal stretching
    • routine episiotomy
  • antenatal perineal massage by woman or partner in 3rd trimister is effective in reducing perineal trauma for 1st vag delivery
84
Q

Active Management of 3rd Stage

  • Cochrane review 2015 findings
  • Active management means?
A
  • coch review: active vs expectant management of 3rd stage reduces risk of severe primary PPH (RR 0.34)
  1. oxytocin 10 iu iv/im
    • if no Skilled Birth Attendant or oxytocin, give misoprostol 600 mcgm daily
  2. Controlled Cord Traction by SBA recommended
  3. assess pp uterine tone abdominally to r/o atony
  4. CCT recommended method for removal of placenta at CS
85
Q

Immediate Care of Newborn

A
  • deliver baby onto abdomen or into arms of mum
  • immediate thorough drying with warm clean towel
  • assess breathing and if required manage resuscitation
  • wipe eyes
  • skin to skin contact (keep warm) + hat or head cover
  • delay cord clamping 1-3 min
  • early start of breastfeeding and exclusive breastfeeding
  • Vit K 1 mg IM
86
Q

What are the Stages of the Demographic Transition?

A
  • Stage 1: High birth rate, fluctuating high death rate
  • Stage 2: Declining death rate, continuing high birth rates.
  • Stage 3: Declining birth and death rates
  • Stage 4: Low death rates and low, but fluctuating birth rates
87
Q

Sustainable Dev Goal wrt Family Planning.

A
  • By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes.
88
Q
  • Measures to improve fertility
  • Measures to reduce fertility
A
  • Improve fertility
    • baby bonuses
    • family allowances
    • maternal and parental leave
    • subsidize childcare, tax incentives
    • subsidized housing
    • flexible work schedules
    • campaigs to promote the sharing of parenting and household work between spouses
  • Reduce fertility
    • integrate FP programmes into PHC systems
    • provide access to RH services
    • promoting the responsibility of men in SRH
    • raising the minimum legal age at marriage
    • improving female education and employment opportunities
    • discouraging son preference
    • providing low cost, safe and effective contraception
89
Q

Unsafe Abortions

  • How many per year?
  • How many deaths?
A
  • 21.6 million women worldwide, 18.5 million in LMIC
  • 47,000 deaths
90
Q

What is the Pearl Index?

A
  • method used to determine pregnancy failure rate
  • PFR = # of pregnancies x 100 women/12 mo of use
91
Q

Three Delays Model

What is it?

A
  • a model at looking at barriers to access
92
Q

Diarrhea & Dysentery

What are WHO definitions?

A
93
Q

For deaths under 5, what percent occur in the first month?

A
  • 46% in first month
    • 16% preterm complications
    • 11% intrapartum-related events
    • 7% meningitis
    • 5% congenital
    • 1% tetanus
    • only 0.3% diarrhea
    • 3% other
  • 54% from 1-59 months
    • 13% pneumonia
    • 8% diarrhea
    • 6% injury
    • 5% malaria
    • 4% congenital
    • 2% meningitis
    • 2% preterm birth complications
    • 1% measles
    • 12% other
94
Q

Burden and causes of diarrhea in under 5’s

  • How common?
  • Who gets it?
  • How much pathogen attributable?
    • which pathogens?
A
  • 1 episode of moderate/severe diarrhea/5 children/yr
  • greatest frequency in infants
  • 90% pathogen attributable
  • 40% had 2 or more pathogens identified
  • 75% attributable to 6 pathogens
    • Shigella spp
    • Rotavirus
    • adenovirus 40/41
    • heat stable enterotoxin producing E. coli (ST-ETEC)
    • cryptosporidium spp.
    • campylobacter spp.
95
Q

Consequences of diarrhea under 5 from Global Enteric Multicenter Study

A
  • 60 days f/u 2% cases vs 0.3% controls died OR 8.5)
  • most (61%) occurred > 1 wk after diarrhea (when no longer receiving care)
  • 56% of deaths occurred at home
  • diarrhea associated with subsequent growth faltering
96
Q

Headline figures 2014 for weight/ht for worlds under 5’s.

  • Wasting and Stunting, how defined?
  • How many stunted? %age?
  • How many wasted?
  • Overweight? How many and how defined.
A
  • WHZ score <-2
  • Stunted:
    • 159 million stunted
    • in Africa, though percentage falling 23.8%, total number of stunted children is rising because population increasing
  • Wasting:
    • 50 million, 7.5% severely wasted
  • Overweight (z score>2)
    • 41 million
    • Industrialized countries 15%
    • Africa 7%, Asia 5%
97
Q

What is Enteric Environmental Dysfunction (EED)

or Environmental Enteropathy?

A

Food Nutr Bull. 2015 Mar;36(1 Suppl):S76-87.

Environmental enteric dysfunction: an overview.

Crane RJ, Jones KD, Berkley JA.

Abstract

BACKGROUND:

Environmental enteric dysfunction (EED) refers to an incompletely defined syndrome of inflammation, reduced absorptive capacity, and reduced barrier function in the small intestine. It is widespread among children and adults in low- and middle-income countries. Understanding of EED and its possible consequences for health is currently limited.

OBJECTIVE:

A narrative review of the current understanding of EED: epidemiology, pathogenesis, therapies, and relevance to child health.

METHODS:

Searches for key papers and ongoing trials were conducted using PUBMED 1966-June 2014; ClinicalTrials.gov; the WHO Clinical Trials Registry; the Cochrane Library; hand searches of the references of retrieved literature; discussions with experts; and personal experience from the field.

RESULTS:

EED is established during infancy and is associated with poor sanitation, certain gut infections, and micronutrient deficiencies. Helicobacter pylori infection, small intestinal bacterial overgrowth (SIBO), abnormal gut microbiota, undernutrition, and toxins may all play a role. EED is usually asymptomatic, but it is important due to its association with stunting. Diagnosis is frequently by the dual sugar absorption test, although other biomarkers are emerging. EED may partly explain the reduced efficacy of oral vaccines in low- and middle-income countries and the increased risk of serious infection seen in children with undernutrition.

CONCLUSIONS:

Despite its potentially significant impacts, it is currently unclear exactly what causes EED and how it can be treated or prevented. Ongoing trials involve nutritional supplements, water and sanitation interventions, and immunomodulators. Further research is needed to better understand this condition, which is of likely crucial importance for child health and development in low- and middle-income settings.

98
Q

What pathogens appear to be associated with enteropathy and growth faltering?

A

Pathogens associated with enteropathy and growth faltering

Colonisation with mucosal damage – rather than overt diarrhoea:

  • • Campylobacter
  • • EAEC (enteroaggerative E. coli)
  • • Giardia

Kosek MN. Causal Pathways from Enteropathogens to Environmental Enteropathy: Findings from the MAL-ED Birth Cohort Study. EBioMedicine 2017;18:109-117.

99
Q

Malnutrition - Summary

  • What are the major types of malnutrition and what are their % prevalences?
  • Undernutrition contributes to what percentage of deaths?
  • Emerging interest on pathophysiology leading to …?
A

Major types of malnutrition are
– Stunting (chronic; 24% world’s children)

– Wasting (acute; 7.5%)
– Overweight / obesity (6%)
– Plus micronutrient deficiency

Undernutrition underlies 45% of all deaths; most occurring in mild/moderate undernutrition

Multiple/interlinked underlying causes – but recent focus on effect of enteropathogens on gut health/function

100
Q

WHO Definitions of Adolescence

what are they?

A
  • • Adolescence: 10-19
  • • Youth: 15-24
  • • Young people: 10-24
101
Q

Define Reproductive Health

A
  • A state of complete physical, mental and social well being (not merely the absence of disease and infirmity) in all matters relating to the reproductive system and to its functions and processes.
102
Q

Risk Factors/Threats to Reproductive Health

A
  • Risk factors concepts….
  • – Individual level
  • Maritalstatus
  • Age
  • Employment
  • Alcohol
  • Educationalattainment
  • Ability to discuss with an appropriate other
  • – Peer/partner level
    • • Sexually activepeers or • History of forced sex
    • • Olderpartner
  • – Family level
    • ▪ Residence
    • ▪ Orphan status
    • ▪ Perceived parental strictness
  • – Societal level
103
Q

Gillick Competence (UK)

What is it?

A
  • Gillick Competence

“As a matter of Law the parental right to determine whether or not their minor child below the age of sixteen will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed.” Lord Scarman 1985

104
Q

Fraser Guidelines (UK)

What are they?

A
  • “It is lawful for doctors to provide contraceptive advice and treatment without parental consent provided the YP:
    • – will understand the professional’s advice;
    • – cannot be persuaded to inform their parents;
    • – is likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment;
    • – is likely to suffer physical or mental harm if not prescribed
    • – best interests require them to receive contraceptive advice or treatment with or without parental consent
105
Q

What is the mnemonic and approach to emergency assessment and management of convulsing or comatose child.

A
  • Airway
  • Breathing
  • Circulation
  • Coma
  • Convulsions
  • Dehydration
  • Require Immediate Treatment
106
Q

C-Coma and Convulsions

A
  • A - Alert? If not
  • V - respond to Voice? if not
  • P - respond to Pain?
  • U - unresponsive
  • P & U means Coma
  • then
    • ​give O2
    • if glucose <2.5 mmol/L (or <3 if malnourished) then
    • give 5 ml/kg 10% dextrose
    • recheck glucose after 30 min
    • if still low, repeat
  • Seizure? (child>2 wk)
    • if IV access give Diazepam 0.25 mg/kg IV
    • if not then give Diazepam 0.5 mg PR
    • wait 10 min
    • Diaz 0.3 mg/kg IV or 0.5 mg/kg PR
    • wait 10 min
    • Phenobarbitone 20 mg/kg IM
    • wait 20 min
    • Phenobarbitone 20 mg/kg IM
    • wait 20 min
    • Phenytoin 18 mg/kg over 20 min IV
    • or
    • Paraldehyde 0.4 ml/kg PR or 0.2 mg/kg IM
  • *
107
Q

Assessment of Coma

Outline 2 simple scoring systems

Advantages and disadvantages of each

A
  • AVPU simple, quick, broad categories, good for triage, less for monitoring over time
  • Blantyre Coma Scale more complicated but quick
    • more detailed scoring better for monitoring over time
    • good for cerebral malaria or meningoencephalitis
108
Q

Status Epilepticus

Define (Int League Against Epilepsy 2015)

A
  • Abnormally prolonged seizures after t1; and long term consequences after t2
    • ​Generalized: t1=5 min; t2**=30 min
    • Focal: t1=10 min; t2=60 min
  • 60% of children neurologically healthy prior to first episode of SE
    *
109
Q

Febrile Child with altered concsciousness or neurological signs DDx

A
  • Febrile convulsion with intercurrent illness eg malaria, viral or bacterial infection (6 mo to 6 yr)
  • cerebral malaria
  • intracranial infections: meningitis, cerebral abscess, encephalitis
  • hypoxia of any cause
  • hypoglycemia of any cause
  • other elyte or metabolic disturbances
  • cerebrovascular accidents
  • head injury/trauma
  • seizure disorder (epilepsy)
  • hypertensive encephalopathy
  • poisoning eg etoh, tricyclics, organophosphates
110
Q

Common causes of COMA without convulsions

A
  • subclinical seizures (nb v common in cereb malaria)
  • post-ictal
  • hyperglycemia
  • renal failure
111
Q

DDx of seizure-like episodes

A
  • reflex-anoxic seizure/breath holding attack leading to seizure e.g. after stress
  • “pseudo-seizures”
  • rigors: all over the place
  • tetanus/muscle spasms
  • Rabies (agitation and spasms)
112
Q

Treatment pathway for seizures

Outline

1st and 2nd line with or without iv access

A
  • First line - no iv access
    • Diazepam rectal
    • Paraldehyde rectal or im
    • lorazepam rectal or intranasal, IM
    • midazolam oral, intranasal, IM
  • If IV acces:
  • First Line: diazepam IV or lorazepam IV
  • Second Line after twice benzos:
    • IV valproate
    • IV Phenobarb
    • IV Phenytoin
    • IM Phenobarb
    • (IV Levetiracetam)
113
Q

Risks and beneftis of anticonvulsants, adverse effects

A
  • Diazepam
    • resp depression 15%; efficacy 51%
  • Lorazepam
    • resp depression 3%; efficacy 76%
  • Valproate 76% efficacy
    • smaller risk of cardiorespiratory adverse effects, broad spectrum
    • risk of hepatooxicity and pancreatitis in long-term use
  • Phenobarb 74% efficacy
    • eheap, available, risk of resp depression
    • IM ltd evidence except for cerebral malaria but limited evidence
  • Phenytoin 50% efficacy
    • risk of arrhythmia and hypotension
    • difficult to administer
114
Q
  • Viral CNS infection in children from malaria - endemic area of malawi study 2013
  • what were broad findings?
A
  • mortality 18% overall
  • 32% P. falciparum parasitemia of whom 21% died
  • 26% at least one virus of whom 33% died
    • mostly adenovirus; mumps, human herpes virus 6, rabies, cytomegalovirus, herpes simplex virus 1, and enterovirus were also important
    • 9% had both cerebral malaria and viral infection
  • A third of the children who met the case definition for cerebral malaria had viral infections, including a quarter of the children who had the characteristic retinal changes thought to be diagnostic of cerebral malaria. Although fewer patients had viral infection than parasitaemia, more children with viral infection died, even when patients with rabies—which is uniformly fatal—were excluded.

Lancet Glob Health. 2013 Sep;1(3):e153-60.

Viral CNS infections in children from a malaria-endemic area of Malawi: a prospective cohort study.

Mallewa M, Vallely P, Faragher B, Banda D, Klapper P, Mukaka M, Khofi H, Pensulo P, Taylor T, Molyneux M, Solomon T.

Abstract

BACKGROUND:

Fever with reduced consciousness is an important cause of hospital admission of children in sub-Saharan Africa, with high mortality. Cerebral malaria, diagnosed when acute Plasmodium falciparum infection and coma are recorded with no other apparent reason, is one important cause. We investigated whether viruses could also be an important cause of CNS infection in such patients, and examined the relative contribution of viral pathogens and malaria parasitaemia.

METHODS:

We did a prospective cohort study in Blantyre, Malawi. From March 1, 2002, to Aug 31, 2004, we enrolled children aged between 2 months and 15 years who were admitted to hospital with suspected non-bacterial CNS infections. Children with a cerebrospinal fluid (CSF) white cell count of less than 1000 cells per μL and negative bacterial microscopy and culture were deemed to have suspected viral CNS infection. Blood was examined for asexual forms of P falciparum. PCR was done on CSF or on post-mortem brain biopsy specimens to detect 15 viruses known to cause CNS infection.

FINDINGS:

Full outcome data were available for 513 children with suspected viral CNS infection, of whom 94 (18%) died. 163 children (32%) had P falciparum parasitaemia, of whom 34 (21%) died. At least one virus was detected in the CNS in 133 children (26%), of whom 43 (33%) died. 12 different viruses were detected; adenovirus was the most common, affecting 42 children; mumps, human herpes virus 6, rabies, cytomegalovirus, herpes simplex virus 1, and enterovirus were also important. 45 (9%) of the 513 children had both parasitaemia and viral infection, including 27 (35%) of 78 diagnosed clinically with cerebral malaria. Children with dual infection were more likely to have seizures than were those with parasitaemia alone, viral infection only, or neither (p<0·0001). 17 (38%) of the 45 children with dual infection died, compared with 26 (30%) of 88 with viral infection only, 17 (14%) of 118 with parasitaemia only, and 34 (13%) of 262 with neither (p<0·0001). Logistic regression showed children with a viral CNS infection had a significantly higher mortality than did those who did not have a viral CNS infection (p=0·001).

INTERPRETATION:

Viral CNS infections are an important cause of hospital admission and death in children in Malawi, including in children whose coma might be attributed solely to cerebral malaria. Interaction between viral infection and parasitaemia could increase disease severity.

115
Q

Global and Child Health

  • 2016: how many deaths under 5
  • what proportion neonatal?
  • leading causes neonatal period?
  • what proportion of newborn deaths occur on 1st day of life?
  • What are SDG’s for 2030 for child health
  • What is neonatal mortality rate in 2016
    • globally, in SSA and SA?
  • What are under 5 rates?
A
  • 5.6 million, most in dev countries, preventable
  • neonatal deaths now 46% of all under 5 deaths, most preventable
  • pneumonia and diarrhea leading causes
  • 36% newborn deaths occur on 1st day of life
  • SDG end preventable deaths for neonates and under 5’s by 2030
    • neonatal mortality to 12/1000 live births
    • under 5 to 25/1000 live births
  • Currently nnmr NA & E 3, globally 19/1000, SSA & SAsia 28
  • under 5’s NA 6, globally 41/1000 but SSA 79 and SAsia 47
116
Q

What is IMCI?

what are its aims?

components?

A
  • Integrated Management of Childhood Illness
  • integrated approach to child health that focuses on well-being of whole child
  • aims
    • to reduce death, illness and disability and to promote improved growth and development
  • components
    • improve overall health systems
    • improve family and community health practices
    • improve case management skills of health care staff
117
Q

Does IMCI work?

Cochrane Review 2016 comparing IMCI to usual practice shows?

A
  • infant and child mortality may be reduced (low certainty evidence)
  • otherwise
    • no evidence of better vaccine and vit a coverage
    • no evidence of consistent effect on prescribing
    • little/no effect on stunting
    • no studies to assess parent/carer satisfaction
118
Q

Child Health terminology: Define

  • preterm
  • term
  • post-term
  • Birthweight
    • LBW
    • VLBW
    • ELBW
  • Neonate
    • Early
    • Late
  • Infant
  • Toddler
  • Child
  • Adolescent
A
  • Child Health terminology: Define
  • preterm: <37 wk
  • term: 37-42 wk
  • post-term: >42 wk
  • Birthweight
    • LBW: <2500 gm
    • VLBW: <1500 gm
    • ELBW: <1000 gm
  • Neonate: 0-28 days
    • Early: 0-7 days
    • Late: 7-28 days
  • Infant: 1-11 months
  • Toddler: 1-3 yrs
  • Child: <18 yrs (but varies by country)
  • Adolescent: 10-19 yrs
119
Q

Save the Children End of Childhood Report 2017

What are the 8 major risks to childhood and adolescence?

A
  1. under five mortality
  2. malnutrition
  3. out-of-school children
  4. child labour
  5. early marriage
  6. adolescent births
  7. displacement by conflict
  8. child homicide
120
Q

SDG’s directly relevant to Child Health

What are they?

what are the targets for stunting, wasting?

neonatal and under 5 mortality?

A
  • by 2025 reduce number of stunted under 5’s by 40%
  • reduce and maintain childhood wasting to <5%
  • neonatal mortality to at least <12%
  • under 5 mortality to at least <25%
121
Q

Take Home Messages for Global Child Health

A
  • remarkable progress in reducing < 5 survival
  • but 5.6 million under 5 deaths in 2016, most in dev countries, most preventable
  • neonatal deaths now 46% of all under 5 deaths and proportion rising (mostly in low birth weight children)
  • pneumonia & diarrhea leading causes of death in neonatal period
  • “First 1000 days” critical for improving outcomes in children
  • SDG’s set ambitious targest for child survival and nutrition but many countries unlikely to meet targets
122
Q

Evaluation of Febrile Child: Red Flags

A

Clinical features with good “red flag” value

• Globalassessment/behaviour

– Parental concern LR+ 14.4

– Clinician instinct LR+ 23

• Temperature

– T >=40C in low prevalence setting

– In high prevalence setting, raised temperature no rule in value, and absence of fever had good rule out value

• Circulatory & respiratory

– Cyanosis LR+ 3 to 52
– Rapid breathing LR+ 1.3 to 10
– Shortness of breath LR+ 1.1 to 9
– Poor peripheral circulation LR+ 1.5 to 39

Clinical features with good “red flag” value

Meningeal irritation LR+ 2.6 to 275

Petechial rash LR+ 6 to 84

Several clinical features need to be considered to r/o SBI

Effective safeguards to ensure children w/o red flags are not missed

(van den Bruel A, Lancet 2010)

123
Q

How well do vital signs identify children with serious infections in pediatric emergency care?

Thompson M, Arch Dis Child 2009; 94:888-893

A
  • Children with serious/intermediate infections were significantly more likely than those with minor infections to have
    • temp >390C
    • tachycardia
    • saturations < 94%
    • cap refill time >2 s
  • Having >1 of these was 80% sensitive and 39% specific for serious or intermediate infection
124
Q

What is the FEAST PET score?

A
  • a risk score using 8 clinical variables to assess the risk of death in African Children
    1. temp
    2. hr
    3. cap refill time
    4. conscious level
    5. severe pallor
    6. resp distress
    7. lung crps
    8. weak puls volume
  • shown to be good (AUROC of 0.77-0.86) in African op hospital setting
  • Georg EC, BMC Medicine 2015
125
Q

Fever and rash in Child DDX

A
  • common presentation in children
  • Bacterial
    • meningococcus, pneumococcus, scarlet fever
    • also rickettsiea, enteric fevers
  • Viral
    • measles, rubella, parvovirus, adenovirus, HHV6, enterovirus, paraechovirus
      • HHV6-sixth disease, roseola infantum or exanthem subitum
      • Parvovirus B19-fifth disease, slapped cheek syndrome
    • also arboviruses
126
Q

Meningoccoccal disease

Which form of the disease has highest mortality?

Diagnosis?

A
  • life threatening meningococcal disease rarely presents as meningitis but mostly as septicemia, often with a rash
  • approx 70% of cases of meningococcal disease have septicemic component
  • approx 20% of those with septicemia present with maculopapular rash
  • 50% with MPR progress to petechial purpuric rash
  • mortality now greatest in those with MPR alone (i.e. no signs of meningitis)
  • Diagnosis:
    • ​sx and signs +
    • culture from csf or blood
    • microsopy: gram stain from csf or skin lesions
    • Ag detection: latex agglutination
    • DNA detection: PCR better than blood culture
127
Q

Non-malarial Fever

  • What has been effect of decline in malaria incidence in children and adults?
  • what infections are often underdiagnosed and should be considered?
A
  • non-malaria febrile illness more common with decline in malaria
  • decline in malaria associated decline in invasive disease esp Non-typhoid Salmonella (note also assoc with leprosy, HIV and NTS)
  • need to know causes of NMRI in order to guide tx
  • child mortality also declining due to HiB, pneumococcal vaccines
  • effect of improved malaria dx with RDT has been increased Antibiotic use
  • most common cause of NMFI is resp tract inf
  • need more sensitive RDT for malaira in context of low malaria transmission
  • malaria overdiagnosed
  • consider Bacterial zoonoses (leptospirosis, Q fever, spotted fever rickettsioses, brucellosis) and arboviruses e.g. Chikungunya
    • Crump JA PLoS Negl Trop Dis 2013
128
Q

Non-malarial fever in Children and URI’s

Elfving K, Plos One 2016, northern tanzania, diagnostic study of under 5’s

A
  • compared dx and tx of uncomplicated febrile illness in <5 yr with IMCI guidelines and final dx using PCR, np and rectal PCR
  • majority of infections were viral uri’s similar to Western setting
    • RSV, inf A/B, rhinovirus
    • GAS, Shigella
    • 74% had abx but only 22% had infections considered to require abx according to IMCI
    • concluded precision of IMCI to guide abx use was low
129
Q

Non-Malarial Fever in under 10’s

D’Acrmeno V, NEJM 2014

A
  • diagnostic study of under 10’s at op centre in northern Tanzania
  • of all comers, only 9% malaria
    • of 11% with systemic infection HHSV6 and parvovirus B19 most common
    • others CMV, Rickettsia, Leptospira, Coxiella, toxo, EBV, chickepox
  • about 1/10th of total had severe illness, of whom most common dx were Malaria, pneumonia, URI, typhoid, gastroenteritis, bronchiolitis
130
Q

Measles epidemiology

How many cases 2016?

Is eradication feasible? Why or why not?

Effect of vaccination?

A
  • approx 90,000, first time under 100,00
  • yes, no animal reservoir, no chronic infection, single serotype, safe and effective vaccine
  • WHO goal to eliminate by 2020
  • 79% drop in measles deaths btw 2000 and 2014
  • 2014 85% of children had one dose by 1st bday
  • from 2000 to 2014 measles vaccination prevented about 17 million deaths: one of best buys in public health
131
Q

Describe course and Natural Hx of Measles

A
  • incubation 7-21 days
  • fever cough coryza conjunctivitis
  • Kopliks spots - small white lesions on buccal mucosa might be visible during prodrome
  • rash lasts 3-5 days
  • malnourished kids: pigmented rash that desquamates during recovery
  • in uncomplicated measles, clinical recovery begins soon after appearance of rash
  • complications in up to 40% of patients. Risk of complication in very young and malnourished.
132
Q

What mneumonic is useful for remembering how many days after rash various exanthems appear?

A
  • Really Sick Children Must Take No Exercise
  1. Rubella (alt Varicella for Very for shingles)
  2. Scarlet Fever
  3. Chicken Pox
  4. Measles
  5. Typhus
  6. Nothing
  7. Enteric Fever (Typhoid, paratyphoid)
133
Q

Complications develop partially due to temporary immune suppression.

List 10 and the signs by which they present.

A
  1. Pneumonia: cough and tachypnea
  2. Croup, necrotising tracheitis: stridor when quiet
  3. Dehydration: severe diarrhea
  4. Malnutrition: recent severe wt loss
  5. Possible blindness: corneal damage or Bitot spots
  6. Otitis media: ear pain or discharge
  7. Encephalitis: sleepy, convulsions, focal signs
  8. Dehydration: diarrhea, inability to eat or drink
  9. Dysentery: blood in stools
  10. Cancrum oris: severe stomatitis
134
Q

Measles Encephalitis: 3 presentations

what are they,

who do they affect

and what is their time course

A
135
Q

Management of Measles

  1. Mild
  2. Severe
  3. Prevention and F/U
A
  1. Mild Measles
    • small, frequent feeds
    • acetaminophen
    • saline gtts for blocked nos
    • oral hygeine for rinsing mouth
    • ocular hygeine
    • Vitamin A capsule (2 doses in 2 days)
    • 200,000 IU/day>12m, 100,00 IU 6-12 m, 50,000 IU<6m
    • oral rehydration solution
    • use oral antibiotic
    • Admit if signs or symptoms of severe measles
  2. Severe measles
    • iv antibiotics
    • O2 for pneumonia
    • tx croup with nebulized adrenaline
    • diarrhea: oral rehydration and antibiotics if bloody stool
    • otitis media: antibiotics and regular aural hygeine
    • xeropthalmia: protective eye pad and aural hygeine
    • malnutrition. treat to SAM guidelines
    • encephalopathy
  3. Prevention and f/u
    • adequate nutrition
    • watch for TB, often seen after measles
    • chronic persistent diarrhea
    • gammaglobulin (if available) for susceptible contacts if <1 yr old
    • improve vaccination coverage
136
Q

Measles Diagnosis

A
  • measles specific IgM-blood/saliva, >4 da after onset of rash
  • PCR virus RNA throat swab, saliva, blood, urine
137
Q

Centor Criteria

What are they?

What percent of pts with ARF don’t get sore throat?

A
  • prediction of pharyngeal GAS infection
    1. tonsillar exudate
    2. tender or enlarged ant cervical nodes
    3. absence of cough
    4. history of fever >38
    5. 3-14 yrs old (subtract 1 if >45)
  • presence of 3-4 suggests chance of GABS 40-60%
  • absence of 3 or 4 suggests 80% chance pt doesn’t have infection, likely doesn’t need Abx
  • 2/3 of pts with ARF don’t get sore throat
138
Q

Jones Criteria for diagnosis of acute rheumatic fever.

(but low sensitivity in high risk populations for ARF/RHD)

A
  • Need evidence of preceding GAS/Strep pyogenes (throat swab or rising ASOT) + 2 major or 1 major + 2 minor manifestations. Presence of chorea or carditis many not need evidence of GAS.
  • Major manifestations
    • Carditis: chf with sob, pericarditis with rub or new heart murmur
    • polyarthritis: temp, large joints, usually legs and moving up
    • chorea
    • erythema marginatum: lon lasting rash begins on trunk or arms as macules and spreads out to form snake-like ring while clearing in middle. never starts on face, made worse with heat.
    • subcut nodules: painless firm, over bones or tendons, typically back of wrist, outside elbow, front of knees
  • Minor manifestations
    • arthralgia
    • fever
    • elevated ESR or CRP
    • EKG evidence of prolonged PR interval
139
Q

Treatment of Rheumatic Fever

A
  • anti-inflammatories usually have dramatic effect
    • salicilates 1st line, start at 80-100 mg/kg/d to acheive plasma conc 200-300 mg/L x 2 wks then
    • reduce to 60-70 mg/kg/day for 3-6 wk
    • lab and clinical rebound may happen after 2-3 wk but usually resolves spontaneously
    • do not shorten illness but are analgesis and antipyretic
  • Steroids proven only in severe carditis, appear to reduce mortality during acute attack
  • oral pred 1-2 mg/kg/day (max 80 mg/day)
  • in extreme cases IV methylprednisolone
  • taper after 2-3 wk, overlap with salicilates
  • treat ht failure as needed with
    • ​bed rest, steroids, diuretics, then dig carefully so as not to worsen ht block
    • surgical tx prn for valve dis
  • Chorea
    • ​usually benign, but not always
    • tx Haldol
    • steroids said to be ineffective (but Ann disagrees)
    • plasmapheresis and IVIG in resistant disease
    • long-term antistrep prophylaxis
140
Q
  • What is:
    1. primary prophylaxis of RF?
    2. secondary prophylaxis?
A
  1. active screening for sore throat (not for assymptomatic carriers) and prompt treatment of pharyngitis with oral Abx
  2. regular dosing with abx after RF
    • Rheumatic fever with carditis and residual heart disease (persistent valvular disease†)
      • 10 years or until age 40 years (whichever is longer); lifetime prophylaxis may be needed
    • Rheumatic fever with carditis but no residual heart disease (no valvular disease†)
      • 10 years or until age 21 years (whichever is longer)
    • Rheumatic fever without carditis

5 years or until age 21 years (whichever is longer)

141
Q

What is ETAT?

  • What are the Emergency Signs requiring immediate emergency treatment?
  • What are the Priority signs? ie next in line
A
  • Emergency Triage, Assessment and Treatment
    • a standardized approach to improve emergency care for children
  • Emergency Signs (ABBCCCD)
    1. A: Airway Obstruction
    2. B: Breathing: Central Cyanosis
    3. B: Breathing: Severe Respiratory Distress
    4. C: Circulation: Profound Shock (the most common problem in low resource settings).
    5. C: Coma: Unconscious or only responding to pain
    6. C: Convulsions
    7. D: (severe) Dehydration from severe diarrhea
  • Priority (3TPRMOB) ⇒ front of queue to see ASAP
    1. Tiny Baby: < 2mo old
    2. Temperature: v. high >39.50C
    3. Trauma: major trauma
    4. Pallor: severe palmar pallor
    5. Poisoning: mother reports poisoning
    6. Pain: child in severe pain
    7. Restless/Irritable/Floppy
    8. Respiratory Distress
    9. Referral: has urgent referral letter
    10. Malnutrition/ marasmus
    11. Oedema: of both feet
    12. Burns: severe burns
142
Q

ETAT recommended interventions

Severe resp distress

A
  • Airway
  • Breathing
    • O2, salbutamol neb, adrenalin, steroids
    • bag & mask
143
Q

ETAT: no circulation

A
  • if slow or absent pulse
  • rescue breaths, b&m, chest compressions
  • adrenaline if no better after 4 min
  • glucose 2-5 ml/kg 10% glucose
  • bolus saline or rl 10 ml/kg
  • if shock (weak fast pulse and cap refill >3 s)
144
Q

ETAT: shock & malnutrition

A
  • if unconscious
    • IV fluids 15 mg/kg RL w 5% dextrose
    • over 1 hr
  • if NOT unconscious
    • do NOT use IV fluids
    • give ReSoMal oral/NG 5 ml/kg q 30 min for 1st 2 hrs
145
Q
  • ETAT: shock/sev dehydration & no malnutrition
  • ETAT: Severe Anemia?
  • ETAT: Severe Infection?
A
  • Shock/dehydration
    • RL 30 ml/kg
      • if < 12 mo give over 1 hr
        • then 70 ml/kg over 5 hr
      • if > 12 mo give over 30 min
        • then 70 ml/kg over 2.5 hr
  • Severe Anemia
    • give 10 ml/kg pc or 20 ml/kg whole blood
  • Severe Trauma, needs blood
    • fluid bolus 10 ml/gk while waiting
146
Q
  • ETAT Fluid Guideline 1: Severe Malnutrition with Severe Dehydration or Severely Impaired Circulation
A
  • if tolerates Oral/NGT fluids
    • check blood glucose
    • treat < 3mmol/l with 5 ml/kg D10
    • then
      • ReSoMal 5 ml/kg q 30 min x 2 hr
      • ReSoMal 5-10 ml/kg q hr x 2-10 hr
      • then
        • Refeeding Starter F75
  • if doesn’t tolerate Oral/NG then IV/IO
    • gl <3.0 mmol/L give 5 ml/kg D10
    • Give 15 ml/kg 1/2 strength Darrows wih 5%Dex over 1 hr
    • if no improvement then maintenance fluids 4 ml/kg/hr and
      • Blood ASAP 10 ml/kg over 3 hrs
    • if improvement rpt 15 mls/kg then give ReSoMal 10 ml/kg/hr
      • then refeeding starter F75
147
Q
  • ETAT Fluid Guideline 2: Severe Dehydration without malnutrition +/- Shock
  • 2 or more of
    • lethargy/unconsciousness
    • sunken eyes
    • unable to drink/drinks poorly
    • skin pinch goes back very slowly (>2 sec)
A
148
Q
  • ETAT Fluid Guideline 3: Shock with Sev Anemia
  • Pallor, hgb, lethargy
A
  • give whole blood 20 ml/kg and reassess
  • if not available give backed cells 10 ml/kg
  • give oxygen
  • Treat cause: int or ext bleeding, malaria, infection/sepsis
149
Q
  • ETAT Fluid Guideline 4: Shock due to Severe Infection
A
  • give O2, IV/IO access
  • 10-20 mls/kg 30-60 min
  • Reassess hands, cap refill, pulse, LOC
  • If better start Antibiotics, maint fluids ringers or 0.9% saline with dextrose
  • If no better start Antibiotics
  • 10 ml/kg bolus over 1 hr
    • > 2mo max 4 x 10 ml/kg
    • <2 mo max 2 x 10 ml/kg
  • if still not improving give blood 20 ml/kg over 1 hr
  • (Worsening? think Fluid overload? Anemia? Consider blood or slowing fluid. Consider CPAP.
150
Q

Fluid Guideline 5: Shock due to Trauma

A
  • stop ext bleeding and call surgeons
  • order blood urgently
  • Give 10 ml/kg 0.9% saline over 20 min
  • if improving give maint fluids
  • if not improving
  • rpt 10 ml/kg saline (max 40 ml/kg) if no blood available
  • give blood ASAP 10 ml/kg over 20 min
151
Q

FEAST Trial Lessons

A
152
Q
  • ETAT: Coma and Convulsion
A
153
Q

6 yr old with Headache, Cough, Fever

Convulsions

What is Differential Dx?

A
  • Hypoglycemia
  • Acute Bacterial meningitis
  • cerebral malaria
  • tb meningitis
  • encephalitis
  • tetanus
  • rabies
  • cerebral abscess
  • subdural empyema
  • febrile convulsions (look for primary)
  • S. typhi
  • fungal meningitis
  • aseptic meningitis
  • Bacterial endocarditis + embolism
  • non-infectious
    • Tumour
    • toxins
    • venous sinus thrombosis
154
Q
  • Normal Blood Gases
A
  • pH: 7.35 – 7.45
  • pO2: 10 – 14kPa* (75-105 mm Hg)
  • pCO2: 4.5 – 6kPa* (34-45 mm Hg)
  • Base excess (BE): -2 – 2 mmol/l
  • HCO3: 22 – 26 mmol/l

*1kPa = 7.5mmHg. p stands for the ‘partial pressure of…’

155
Q

What are the numbered Exanthems?

A
156
Q

What is this?

what is its significance?

A
  • one of the major Jones criteria for Rheumatic Fever: a long-lasting rash that begins on trunk or arms as macules and spreads outward to form a snake-like ring while clearing in the middle. Never starts on the face and is made worse with heat.
157
Q

What is this?

Typical of what rash?

A

Circumoral Pallor

Scarlet Fever

158
Q

Describe the timeline of the major Jones criteria?

Which come first?

later?

A
  • polyarthritis, carditis and erythema marginatum tend to start in 1st month
  • Chorea and subQ nodules in 2nd and 3rd
  • Erythema marginatum, chorea and nodules may be longer lasting
159
Q

Differentiating Measles from Scarlet Fever.

Associated symptoms

rash texture

A
  • Measles:hoarse voice, barking cough
  • Scarlet Fever
    • sandpaper rash
    • diff eating and drinking
    • ear discharge
    • diarrhea
160
Q

What kind of virus is the measles virus?

A
  • Measles is caused by the measles virus, a single-stranded, negative-sense, enveloped RNA virus of the genus Morbillivirus within the family Paramyxoviridae
161
Q

What are the causes of neonatal mortality?

A
  1. 36% Preterm Birth Complications
  2. 24% Intrapartum-related events
  3. 16% Meningitis
  4. 11% Congenital anomalies
  5. 7% Other
162
Q

Subcategories of preterm births:

What are they?

A
  • Extremely preterm (<28 wks)
  • Very preterm (28-32 wks)
  • Moderate to late preterm (32-37 wks)
163
Q

What causes preterm births?

Contributing Factors?

A
  • Not Known
  • multiple pregnancies
  • maternal infections
  • inadequate birth spacing
  • maternal undernutrition
  • maternal chronic disease
164
Q

Recommendations to improve preterm birth outcomes:

What are they?

A
  • For mother
    • corticosteroids in event of imminent preterm birth from 24-34 wks
    • if at risk of low ca intake, calcium supplementation
  • For babies
    • Kangaroo care esp if <2000 gm at birth
    • CPAP for tx of RDS
    • start 02 therapy with 30% rather than 100%
    • Other:
      • prompt tx of bact infections
      • management of jaundice
      • management of hypoglycemia and seizures
      • management of feeding
165
Q

What is Shown Here?

How do you read it?

A
166
Q

Steroids for preterm labour

What are the benifits?

A
  • Reductions in
    1. mortality
    2. rds
    3. intraventricular hemorrhage
    4. necrotizing enterocolitis
    5. systemic infections in 1st 48 hrs
  • most studies in high income studies
167
Q

Benefits of Ca supplementation to pregnant mothers

A
  • reductions in
    • maternal hypertensive disorders
    • pre-eclampsia
    • pre-term birth
168
Q

Kangaroo Mother Care

What are the components?

Benefits to baby

A
  • Components
    • exclusive and frequent breastfeeding
    • skin to skin contact
    • support for mother-infant
    • early discharge
    • follow-up care
  • Benefits to baby
    • reduced mortality
    • reduced risk of hypothermia
    • reduced nosocomial infection
    • increased wt gain 4 gm/day
    • increased rates exclusive breastfeeding
169
Q

Definitions Low Birth Weight Infants

What area has highest rate of LBW infants?

A
  • LBW: <2500 gm
  • vLBW: 1500 to 2500 gm
  • extremely LBW: <1000 gm
  • South Asia 28% LBW
  • SSA 13%
  • E & NA 6-7%
170
Q

Guidelines on Optimal Feeding of LBW infants in Low and Middle Income Countries

A
  • mother’s own breast milk
  • donor human milk when not available
  • if n/a standard infant formula
  • supplement vLBW infants who fail to gain wt despite adequate breast milk with human-milk fortifier (protein and mineral supplement)
  • LBW infants should be put on breast when stable
  • vLBW should receive enteral feeds from day 1 i.e. breastmilk 10 mg/kg and make up remaining fluid iv. increase feeds by 30 ml/kg/day
    *
171
Q

Benefits of breastmilk v formula to prem newborn?

A
  • improved nutritional, immunological, developmental outcomes
  • reduced incidence infections
  • reduced necrotising enterocolitis
  • better neurodevelopmental outcomes
172
Q

Supportive feeding LBW newborns

How?

A
  • cup, spoon, nasogastric, orogastric feeds
  • expressed breast milk
  • breast milk banks
  • iv fluids/tpn if too unwell to tolerate feeds
  • micronutrient supplementation
    • Vit D, ca, phos
    • fe
    • vit K at birth
173
Q

post discharge outcomes at 23 months for preterm/lbw (Rwanda 2011-13)

med bw 1650 gm, med gest age 33 wk

A
  • alive 54%
  • feeding diff 47%
  • sx of anemia reported by parents 40%
  • stunted 78%
  • wasted 9%
  • abnormal dev screening 67%
174
Q

Factors to consider in discharge of prem, lbw baby

For baby

For mother/carer

A
  • Baby
    • no danger signs or signs of infection
    • gaining weight on breastfeeding alone
    • maintain temp in normal range in open cot
    • all scheduled vaccines?
    • post discharge weekly wt and assessments until reaches 3 kg
  • Mother/carer
    • mother confident and able to care
    • exclusive breastfeeding
    • keeping baby warm
    • aware of danger signs and how to seek care
175
Q
  1. What proportion of vaccines for children is typically wasted?
  2. Measles vaccines need to be kept at what temp?
  3. If vaccines are frozen?
  4. Conjugate meningococcal vaccines available for?
  5. Frozen vaccines?
  6. Source of main costs for vaccines?
  7. GAVI stands for
  8. How do you tell if DPT has been frozen?
A
  1. 30%
  2. 4 to 80 C
  3. Some are spoiled (eg DPT) others not (eg measles, oral polio)
  4. ACW135Y (not B) - Bexsero is a protein based (not polysaccharide conjugate vaccine)
  5. Measles, Oral Polio
  6. bottles
  7. Global Alliance for Vaccines and Immunizations
  8. Use Shake test.
176
Q

What Vaccines are included in the Expanded Programme on Immunization (EPI)?

A
  • BCG - TB
  • OPV - Polio
  • DPT - Diphtheria, Whooping cough and Tetanus
  • Measles
  • Haemophilus influenzae b, pneumococci, Meningococcus A, rotavirus, rabies, Yellow fever, Japanese B encephalitis, HPV
  • Additional booster doses for measles, diphtheria, whooping cough, tetanus
177
Q

Most Basic Immunization Schemes?

Review

A
178
Q

Has Polio been eradicated?

A
  • No but nearly
  • If polio is the next disease to be successfullyeradicated, this will represent only the third time thishas ever been achieved, after smallpox and rinderpest. … Only three countries remain where the disease is endemic—Afghanistan, Pakistan and Nigeria.
  • Rinderpest was eradicated in 2010. Rinderpest is believed to have originated in Asia, later spreading through the transport of cattle. The rinderpest virus (RPV) was closely related to the measles and canine distemper viruses. The measles virus emerged from rinderpest as a zoonotic disease between 1000 and 1100 AD, a period that may have been preceded by limited outbreaks involving a virus not yet fully acclimated to humans.
179
Q

What is this and how do you interpret it?

A
  • Has the diptheria vaccine been frozen?
  • Well maintained vaccine
    • smooth and cloudy
    • no sediment
  • Vaccine frozen
    • not smooth, presence of granules
    • settles faster, sediment
180
Q

Which vaccines are “freeze dried”?

What is their shelf life after reconstitution?

A
  • Measles
  • BCG
  • Yellow Fever
  • 6 hours
181
Q

Which vaccines can not be frozen?

A
  • DPT, DT, TT
  • i.e. Toxoids
182
Q

When was HiB vaccine introduced globally?

What vaccines does Gavi support introduction to Africa?

A
  • Global coverage 64%
  • As Below +
    • MenAfric - conjugated Men A vaccine
    • Rotavirus
    • conjugated pneumococal vaccines
183
Q

Compare combined vs prog only pill in terms of mech of action

A
  • •Combined:
    • most effective method because they inhibit midcycle gonadotropin surge and prevent ovulation
  • •Progestin only pills:
    • do not mainly not inhibit ovulation
  • Both types act by
    • •altering cervical mucus making it thick, viscid and scanty
    • •alter endometrium
    • •alter ovarian responsiveness to gonadotropin stimulation
184
Q

You are supervising the children’s ward in a district hospital in Tanzania.

Mariama, a 4 month old, has just been admiTed from clinic with a diagnosis of severe pneumonia.

This was based on the presence of grunEng, nasal flaring, lower chest wall indrawing a respiratory rate is 72/ minute and no other emergency signs.

She is receiving oxygen, is wearing a bonnet and is wrapped in a blanket.

  • What are the likely pathogens and what initial antibiotic therapy would you prescribe?
A
  • Same as children worldwide
  • Bacterial
    • Strep pneumonia
    • H. flu
    • Staph aureus
    • Klebsiella
  • Viral
    • RSV
    • Influenza A & B
    • Metapneumovirus
    • Adenovirus
185
Q
  1. According to WHO ICMI, what antibiotic therapy would you prescribe for a young child?
  2. Would you do anything differently if child HIV +ve?
A
  • Pneumonia
    • oral amoxicillin 80 mg/kg/day, split bid
    • fast breathing - 3 days (5 if HIV +ve)
    • chest indrawing - 5 days
  • Severe pneumonia
    • IV/IM Ampicillin 50 mg/kg or benzylbenicillin 50,000 U/Kg q 6 hrs x 5d
    • IV/IM gentamycin 7.5 mg/kg daily
    1. If child HIV+ve, for non-sev pneumonia (chest indrawing) use same regimen as for severe pneumonia. Otherwise no different.
186
Q
  • According to ICMI guidelines, what is appropriate supportive care for young child with pneumonia>
A
  • suction to clear secretions
  • treat fever over 390 with acetaminophen
  • if wheeze give bronchodilator; steroids when appropriate
  • daily maint fluids app for age
    • encourage bf and oral fluids
    • only if can’t drink, then ng tube
  • eat asap
187
Q
  • According to ICMI, what should you consider if child with pneumonia remains unwell with persistent fever, not feeding? - dx?
  • What are 2nd line abx?
A
  • complication eg empyema
  • staph pneumonia?
  • Malaria or other infection (eg uti?)
  • Antibiotics give as prescribed?
  • 2nd Line
    • Severe pneumonia
      • IV/IM ceftriaxone
    • HIV +ve
      • IV/IM ceftriasone
    • Staph pneumonia
      • gent 7.5 mg od
      • clox 50 mg/kg qid
188
Q
  • ICMI clinical signs of severe dehydration in child with diarrhea.
  • What are they?
  • How would you rehydrate?
A
  • Diarrhea plus any 2 of
    • ​lethargy
    • sunken eyes
    • very slow skin pinch
    • unable to drink or drinks poorly
  • and check for severe malnutrition
  • IV/IO fluids immediately 100 ml/kg RL or NS as
  • <12 mo 30 ml/kg over 1 hr then 70 ml/kg over 5
  • >12 mo 30 ml/kg over 30 min then 70 ml/kg over 2.5 hr
  • record baseline wt, vs, esp RR, temp, reassess every 15-30 min
189
Q
  • According to ICMI what is plan A and what is it used for ?
  • Home rehydration in child with diarrhea but no dehydration.
A
  • breastfeed frequently and for longer at each feed
  • if exclusively breastfed, then ORS or clean water in addition
  • if not exclusively breastfed, then give one or more of ORS, soup, yoghurt, rice water or clean water
  • fluid additional to usual intake
    • <2 yr: 50-100 ml after each loose stool
    • _>_2 yr: 100-200 ml after each loose stool
  • Zn supplements for 10-14 days
190
Q

According to ICMI, what is plan B and when should it me used?

A
  • prior to discharge from hospital after Plan C rehydration or in child with diarrhea with signs of mild dehydration.
    • 2 or more of
      • restlessness, irritability
      • sunken eyes
      • drinks eagerly, thirsty
      • skin pinch returns slowly (but <2sec)
  • volume of ors by table for wt (or age 2nd best) or wt in kg x 75ml to be given over 4 hrs
  • Zn supplements
  • reassess after 4 hrs and reclassify to Plan A, B, C
191
Q
  • If a severely dehydrated child with diarrhea has a convulsion and seems jittery a few hours after Plan C rehydration, what would you consider?
A
  • suspect hypernatremia if
    • jittery movements
    • increased muscle tone
    • hyperreflexia
    • convulsions
    • drowsiness, coma
  • if so, replace fluid deficit more slowly, over 48 rather than 24 hrs.
  • measure Na more frequently and aim to reduce slowly (<0.5 mmol/L/hr)
192
Q

Define MAM (Moderate Acute Malnutrition) and SAM (Severe Acute Malnutrition).

A
  • MAM and SAM
  • In children aged 6 – 59 months:
    • MAM:
      • MUAC ≥11.5 cms and <12.5 cms and
      • no oedema
    • SAM
      • Weight-for-length/height <-3 SD / z score or
      • MUAC < 11.5 cms or
      • Nutritional oedema (oedema of both feet)
193
Q

What syndrome is this?

What are the clinical features?

A
  • What are the main clinical features?
    • thin, flaccid skin (“little old man” appearance)
    • reduced fat and muscle
    • Alert, irritable
  • p.s. distinguish “Secondary SAM” e.g. inadequate intake due to neurological compromise from “Primary SAM”
194
Q

What syndrome is this?

What are the main clinical features?

A
  • Kwashiorkor
    • oedema (pitting, bilateral; limb, periorbital)
    • flaky-paint dermatitis
    • dry, thin, depigmented hair
    • hepatomegaly
    • apathy, misery, lethargy
195
Q

Appetite Test:

What is it and what is it used for?

A
  • to decide whether or not an acutely malnourished child needs admission or can be managed as an outpatient
196
Q

What is RUTF (Ready to Use Therapeutic Food)?

A
  • developed 1997 Andre Briend
  • peanut paste
  • vegetable oil
  • powdered milk
  • powdered sugar
  • Vitamins (A, B-complex, CDEK)
  • minerals (ca, phosphorus, potassium, mg, zn, cu, fe, iodine, Na, selenium)
  • each 92 gm foil sachet provides 500 kcal or 2.1 MJ
  • palatable, lipid-rich paste
  • no cooking required
  • low water content=shelf-life 3-4 months at ambient tropical temp
  • but take with water
197
Q

In addition to therapeutic feeding, what other interventions should a child between 6 and 59 months receive?

A
  • On intitial presentation
    • broad spectrum oral antibiotic for 7 days (controversial)
    • Vit A, folic acid, antihelminthics (albendazole or mebendazole)
    • antimalarials as required
    • RUTF 200 kcal/kg/day for 1-2 wks
  • F/U q 1-2 wk
    • measure wt gain, growth, resupply RUTF
  • Discharge, (often after minimum of 2 months)
    • WFH/L z score > -2 or MUAC > 12.5 cm and
    • no edema for at least 2 weeks
198
Q

How is the in-patient management of SAM organized into 2 phases and 10 steps?

A
199
Q
  1. How would you assess hydration status in SAM?
  2. What criteria are used for severe dehydration in a child with SAM and diarrhea?
  3. How would you manage severe dehydration in SAM? What oral rehydration solution would you use?
  4. What other common complications would you look out for?
A
  1. Difficult! Signs of dehydration are also signs of SAM?
  2. Same as for non-malnourished - any 2 of
    • lethargy
    • sunken eyes
    • skin pinch > 2 secs
    • unable to drink/drinks poorly
  3. Avoid IV/IO fluids
    • oral rehydratoin using ReSoMal but more slowly than in non-SAM children
  4. Common complications during rehydration
    • hypothermia
    • hypoglycemia
    • infection
    • electrolyte impalance (esp K and Mg def)
    • specific micronutrient deficiencies (e.g. Vitamin A, thiamine)
200
Q

Transition from stabilization phase from SAM

  1. After acute treatment, how would you assess whether or not he has reached the stabilization phase?
  2. What are the main elements of care during this period?
  3. When are children ready for discharge?
A
  1. Reached stabilization phase when
    • return of appetite
    • no hypoglycemia
    • less/resolved edema
    • (+ diarrhea less/resolved)
  2. Elements of care
    • Nutritional rehab (F100/RUTF; macro and micronutrients inc Fe)
    • continue to treat eye probs, skin probs etc
    • sensory stimulation
    • maternal education
    • referral to comm program/fu arrangements
  3. Ready for discharge?
    • clinically well/med probs resolved; alert
    • completed antibiotic course
    • feeding well
    • edema reduced/resolved
201
Q

Rehab Phase of SAM (contd)

  1. What is expected wt gain?
  2. What are likely causes of por wt gain?
A
  1. expected wt gain
    • 10 gm/kg/day
    • poor is < 5 gm/kg/day
  2. causes of poor wt gain: many possible - careful comprehensive review
    • not completing feeds/being fed enough
    • feeds not made up correctly
    • untreated infection (eg TB)
    • persistent diarrhea
    • inadequate stimulation/neglect
202
Q

Publich Health measures to prevent malnutrition.

A
  • prevention lbw
  • delayed cord clamping/vit k at birth (anemia)
  • Nutrition: early start of breast feeding (within 1 hr); exclusive breast feeding to 6 mo; healthy weaning with continued breast feeding
  • vit A supplementation 6-59 months
  • preventive zinc supplementation
  • Water Sanitation Hygeine/prevention of diarrhea
203
Q

Newborn case:

  • A baby is born after 8 months of gestation
  • Mum has had a previous fresh stillbirth after prolonged obstructed labour
  • Mum is HIV negative and has had 3 antenatal care visits
  • She has had tetanus toxoid boosters during pregnancy; blood pressure and urine dipstix were normal
  • Baby was born at 05.00 by Caesarean section due to prolonged labour
  • Rupture of membranes occurred 25 hours before delivery
  • Condition at birth: pale and floppy with heart rate of 40/min and no respiratory effort
  • Required 5 minutes of bag and mask ventilation before establishing spontaneous respirations. Heart rate picked up to over 100/min by 1 minute
  1. What other information do you want?
  2. What are your working diagnoses?
  3. What immediate investigations are required?
  4. What immediate treatments?
  5. What basic equipment?
  6. What complications would you expect?
  7. What will your management plan be for the next few days?
A
  1. Additional info needed
    • Birthweight
    • Did mom have fever?
    • Amniotic fluid foul smelling or purulent?
    • Additional care other than resusc (thermal control, early breast feeding)?
  2. Working dx
    1. late preterm
    2. intrapartum hypoxemia (birth asphyxia)
    3. hypoxic ischemic encephalopathy
    4. neonatal bacterial infection
    5. hypoglycemia
  3. What immediate investigations?
    1. glucose, ca if possible
    2. blood culture (+LP once stable) if possible
    3. CRP, electrolytes, CKMB, serum cr, transaminases if available (unlikely)
  4. What immediate treatments needed?
    • parenteral amp and gent
    • glucose if low, ca if low
    • phenobarb if convulsions
  5. What equipment?
    • IV cannulas and infusion sets, NGT, glucometer, oximeter, oxygen
  6. Expected complications
    • septic shock
    • hypothermia, hypoglycemia
    • convulsions
  7. Management plan
    • parenteral abx
    • try breastfeeding. If unsuccessful, feeding by NGT with expressed breast milk
    • thermal control; skin to skin once fever resolved
    • close monitoring (convulsions, resp distress, feeding tolerance, urinary output)
    • routine care (vit k, vaccines as per national protocol)
204
Q

Considering a case in which baby was born at 8 month gestation after prolonged labour, floppy at birth, septic, continued floppy.

An exercise in constructive review, prevention and control.

  1. What are immediate and antecedent and root causes of this baby’s illness?
  2. How might it have been prevented?
  3. How will you use such cases in training nurses?
  4. What policies can you institute to help in future?
  5. How might these impact the district?
A
  1. Causes
    • prematurity
    • prolonged rom
    • hx of prev obstructed labour, ?risk factor such as short stature?
    • 3 delays: decision, access to facility, timely care provision, quality of care
  2. Prevention?
    • mother should have attended 4 ANC session if possible (now recommending 8)
    • earlier C-section
    • antibiotics to Mom
    • Early initiation of abiotics to baby
    • closer monitoring from birth (esp because APGAR not ok at 5 min)
  3. Use in training
    • review in depth to identify areas for improvement in prevention and management of illness in neonates as it comprises common causes of neonatal mortality and morbidity
    • Ensure no blame culture is in place before reviewing it
    • Ensure decisions taken after review are effectively implemented
  4. Policies arising
      • to improve recognition of danger signs & babies at risk of serious illnesses (ETAT)
      • to allow close monitoring of all babies
      • to improve training of staff in neonatal care
      • to ensure availability of protocols, drugs and med equipment
  5. Impact on district
    • complications of prematurity, infections and birth asphyxia are commonest causes of neonatal mortality. Improving management will contribute in reducing neonatal mortality.
205
Q

Critique of IMCI strategy

A
  • tool for reorganization
206
Q

Critique of IMCI

A

see notes

Tropical Medicine (17 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions