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PYELONEPHRITIS

The term “Pyelonephritis” originates from Greek:

“Pyelum” (or “Pyelos”) meaning renal pelvis.
“Nephros” meaning kidney.
“-itis” meaning inflammation.

Pyelonephritis is an inflammation of the kidney parenchyma (the functional tissue) and the renal pelvis (the collecting system).

It is fundamentally an upper urinary tract infection (UTI). It most commonly results from an ascending infection, where bacteria travel upwards from the lower urinary tract (bladder – cystitis, urethra – urethritis) to infect the kidney(s). Less commonly, it can result from hematogenous (bloodstream) spread from another infection site.

Epidemiology of Pyelonephritis

More common in females than males, largely due to anatomical factors (shorter urethra, proximity to the anus).
Incidence peaks in young, sexually active women, pregnant women, and older adults (often associated with comorbidities like BPH or neurogenic bladder).
Significant cause of morbidity and healthcare expenditure, including hospitalizations.

Pathophysiology of Pyelonephritis

Ascending Route (Most Common):

Colonization: Uropathogenic bacteria (most often from the fecal flora) colonize the periurethral area.
Urethral Ascent: Bacteria ascend the urethra into the bladder, often facilitated by factors like sexual intercourse or catheterization.
Bladder Multiplication: Bacteria multiply within the bladder (cystitis).
Vesicoureteral Reflux (VUR): Normally, the ureterovesical junction prevents urine backflow. If this mechanism is incompetent (due to congenital abnormality, inflammation, high bladder pressures, or obstruction), infected urine refluxes up the ureter(s) to the renal pelvis.
Intrarenal Reflux: Infected urine can then reflux further from the renal pelvis into the renal tubules, particularly at the poles of the kidney where papillae structure may be more permissive.
Parenchymal Invasion & Inflammation: Bacteria invade the renal interstitium, triggering an acute inflammatory response involving neutrophils, edema, and cytokine release. This leads to tubulointerstitial nephritis.

Hematogenous Route (Less Common):

Occurs when bacteria from another infected site (e.g., endocarditis, osteomyelitis) travel through the bloodstream and seed the kidneys.
Often associated with specific organisms (e.g., Staphylococcus aureus, Candida spp.) and may result in multiple small abscesses.
Bacterial Virulence Factors: Certain bacterial characteristics enhance their ability to cause pyelonephritis, e.g., P-fimbriae in E. coli promote adherence to uroepithelial cells.
Host Defense Mechanisms: Include flushing action of urine flow, urine pH and osmolality, anti-adherence factors (Tamm-Horsfall protein), secretory IgA, and the integrity of the ureterovesical junction. Impairment of these defenses increases risk.

Etiology (Causative Organisms)

Gram-Negative Bacteria (Most Common):

Escherichia coli (E. coli): Responsible for 75-95% of cases, especially community-acquired.
Proteus mirabilis: Often associated with kidney stones (struvite) due to urease production.
Klebsiella pneumoniae: More common in hospital-acquired or complicated cases.
Enterobacter spp.
Pseudomonas aeruginosa: Often seen in catheter-associated or recurrent infections.

Gram-Positive Bacteria (Less Common):

Staphylococcus saprophyticus: Particularly in young, sexually active women.
Enterococcus faecalis: More common in hospitalized patients or those with prior instrumentation.
Staphylococcus aureus: Suggests possible hematogenous spread.

Risk Factors of Pyelonephritis

Female Gender: Shorter urethra, proximity to rectum.
Urinary Tract Obstruction: Anything blocking urine flow increases stasis and risk of infection (e.g., kidney stones, benign prostatic hyperplasia (BPH), tumors, strictures, pregnancy-related compression).
Vesicoureteral Reflux (VUR): Especially important in children and chronic pyelonephritis.
Instrumentation: Urinary catheters, cystoscopy, surgery.
Sexual Activity: Particularly in women (increases risk of urethral colonization).
Pregnancy: Hormonal changes cause ureteral dilation and decreased peristalsis; mechanical compression by the uterus.
Neurogenic Bladder: Incomplete bladder emptying (e.g., spinal cord injury, spina bifida, multiple sclerosis).
Diabetes Mellitus: Impaired immune function, glucosuria (promotes bacterial growth), autonomic neuropathy affecting bladder emptying.
Immunosuppression: HIV/AIDS, chemotherapy, long-term steroid use, organ transplant recipients.
Congenital Abnormalities: Of the urinary tract.
Previous UTIs: History of recurrent infections.

Classification & Specific Types of Pyelonephritis

ACUTE PYELONEPHRITIS

This is characterized by acute inflammation of the parenchyma(core substance of the kidney/kidney tissue) and the pelvis of the kidneys, Characterized by a sudden onset of symptoms.

The disease may be bilateral or unilateral. This usually results from untreated bacterial cystitis and may be associated with pregnancy, trauma of the urinary bladder, and urinary obstruction Also Ascending and Descending infections.

Can range from mild, manageable outpatient cases to severe infections requiring hospitalization, potentially complicated by sepsis or abscess. Severity can be increased in the elderly, immunocompromised individuals (e.g., cancer, AIDS), or those with underlying structural abnormalities.

Morphology:

Gross Anatomy: Kidney(s) are often enlarged and swollen due to inflammation and edema. The capsule may be tense. On the cut section, characteristic yellowish, raised, discrete abscesses or streaks of pus may be visible on the cortical surface and extending into the medulla, often following the path of collecting ducts. The renal pelvis and calyces may show hyperemia (redness) and purulent exudate.
Microscopic Examination: Shows characteristic tubulointerstitial inflammation. Neutrophils infiltrate the interstitial tissue and accumulate within tubular lumens (forming pus casts). There is associated tubular necrosis and destruction. Glomeruli are typically spared initially, although surrounding inflammation can occur. Blood vessels usually show resistance to infection but can be involved in severe cases or vasculitis.

Clinical Features of Acute Pyelonephritis

Systemic Symptoms: Fever (often high-grade >38.5°C), chills, rigors, malaise, nausea, vomiting.
Localizing Symptoms: Flank pain or back pain (typically unilateral, localized to the costovertebral angle – CVA tenderness on examination is a key sign).
Lower UTI Symptoms (May or May Not be Present): Dysuria (painful urination), frequency, urgency. Absence doesn’t rule out pyelonephritis.
Urine: May appear cloudy or malodorous; hematuria (blood in urine) can occur.
Examination Findings: Fever, tachycardia, CVA tenderness. Abdominal tenderness may be present. Signs of dehydration. In severe cases, signs of sepsis (hypotension, altered mental status).
Laboratory Findings: Urinalysis typically shows pyuria (pus/WBCs), bacteriuria, often hematuria, mild proteinuria, and crucially, WBC casts (formed in tubules, indicating renal parenchymal involvement). Urine culture confirms the diagnosis and identifies the organism (>10^4 or >10^5 CFU/mL typically significant). Blood tests show leukocytosis (high WBC count) with a left shift (increased neutrophils), elevated inflammatory markers (ESR, CRP). Blood cultures should be drawn if sepsis is suspected (positive in 15-30% of cases).

Presentation; flunk tenderness,

fever, chills
Dysuria
Urgency
frequency

Complications of Acute Pyelonephritis

Papillary Necrosis: Ischemic necrosis of the renal papillae, more common in diabetics, those with obstruction, or sickle cell disease. Can lead to sloughing of papillae, obstruction, and worsening renal function.
Pyonephrosis: Pus collection within an obstructed renal collecting system, essentially converting the kidney into a sac of pus. Requires urgent drainage.
Perinephric Abscess: Collection of pus in the space surrounding the kidney, between the renal capsule and Gerota’s fascia. Often requires drainage (percutaneous or surgical).
Intrarenal Abscess: Abscess formation within the kidney parenchyma.
Sepsis/Urosepsis: Systemic inflammatory response syndrome (SIRS) due to infection originating in the urinary tract. Can lead to septic shock and multi-organ failure.
Emphysematous Pyelonephritis: A rare, life-threatening necrotizing infection characterized by gas formation within the kidney parenchyma. Often associated with diabetes and requires aggressive management, sometimes nephrectomy.
Renal Scarring: Can occur even after a single episode, especially if treatment is delayed or infection is severe.
Acute Kidney Injury (AKI): Temporary decline in kidney function due to infection and inflammation.

Chronic pyelonephritis

A chronic, ongoing, or recurrent inflammatory process leading to irreversible scarring of the renal parenchyma (specifically tubulointerstitial damage), and deformity of the pelvicalyceal system.

This occurs due vesicoureteral reflux ( back flow of urine from the bladder to the ureters allowing spread of infection upwards to the kidneys. The condition is also called reflux nephropathy(This can lead to kidney distention called Hydronephrosis)

It implies chronic tubulointerstitial disease resulting from repeated or persistent kidney infection, often superimposed on underlying structural abnormalities.

Etiopathogenesis: Usually arises from recurrent acute infections, often linked to:

Chronic Obstructive Pyelonephritis: Persistent or recurrent obstruction (stones, BPH, tumors, congenital anomalies like posterior urethral valves) leads to urinary stasis, predisposing to infection and increased pressure, which damages the kidney over time. Obstruction can be unilateral or bilateral.
Reflux Nephropathy (Reflux Pyelonephritis): Chronic vesicoureteral reflux (VUR), often congenital, allows repeated episodes of infected urine reaching the kidney parenchyma, particularly during voiding (micturition). This is a major cause, especially in children, leading to characteristic polar scarring. Infection superimposed on reflux causes the damage.

Morphology:

Gross Anatomy: Kidney(s) are often small and contracted (atrophic). Scarring is typically irregular and asymmetric (unlike the diffuse, symmetrical scarring of vascular disease like nephrosclerosis). Scars are often broad, flat-based, depressed areas overlying deformed, dilated (blunted) calyces, particularly at the upper and lower poles (characteristic of reflux). The capsule may be adherent to the cortex over scarred areas. The renal pelvis may be dilated and thickened.
Microscopic Examination: Shows patchy interstitial fibrosis and chronic inflammation (lymphocytes, plasma cells, sometimes macrophages). There is marked tubular atrophy in scarred areas. Some remaining tubules may become dilated and filled with pink, homogenous colloid-like material (thyroidization – resembling thyroid follicles). Periglomerular fibrosis and eventual glomerulosclerosis occur. Arteriosclerosis (thickening of blood vessel walls) is common.

Clinical Features:

Often insidious onset; patients may be asymptomatic for long periods or present late with complications.
Recurrent UTIs (may be subtle).
Vague symptoms: Flank pain (less severe than acute), malaise, low-grade fever, fatigue, decreased appetite, unintentional weight loss.
Signs of infection (fever, pyuria, bacteriuria) may be present during acute exacerbations.
Hypertension: Often develops as a consequence of renal scarring and renin-angiotensin system activation.
Progressive loss of renal function: Leading to Chronic Kidney Disease (CKD) and eventually end-stage renal disease (ESRD).
Polyuria and nocturia (due to impaired tubular concentrating ability).
Proteinuria (usually mild to moderate, reflecting tubular and glomerular damage).

It clinical presents with

bacteriuria,
hypertension,
flunk tenderness,
septic shock,
dizziness fainting and signs of renal insufficiency

Diagnosis: Often suggested by imaging findings (ultrasound, CT, IVP – historically) showing small, scarred kidneys with blunted calyces and cortical thinning, especially if asymmetric or polar. Urinalysis may show pyuria, bacteriuria (especially during exacerbations), proteinuria. Renal function tests (creatinine, BUN, GFR) assess the degree of CKD. Voiding cystourethrogram (VCUG) can identify VUR.

Diagnosis (General Approach)

History: Symptoms (fever, chills, flank pain, dysuria, frequency, urgency, nausea/vomiting), duration, previous UTIs, risk factors (diabetes, stones, VUR history, pregnancy, catheter use, immunosuppression).

Physical Examination: Vital signs (fever, tachycardia, hypotension?), CVA tenderness assessment, abdominal examination (tenderness, masses).

Laboratory Examination:

Urinalysis (UA): Key initial test. Look for:

Leukocyte esterase (positive suggests pyuria)
Nitrites (positive suggests Enterobacteriaceae)
White Blood Cells (WBCs) / Pyuria (>10 WBCs/hpf or per mm³)
Red Blood Cells (RBCs) / Hematuria
Bacteria
WBC Casts: Highly suggestive of renal parenchymal involvement (pyelonephritis) vs. lower UTI.
Proteinuria (usually mild)

Urine Dipstick Test: Rapid screening tool for leukocyte esterase and nitrites. Useful but less sensitive/specific than microscopy. A negative test in a symptomatic patient (especially pregnant women) does not rule out infection; microscopy and culture are needed.

Urine Culture & Sensitivity: Essential to confirm bacteriuria, identify the causative organism, and determine antibiotic susceptibility.

Culture Criteria: Colony counts >10^5 CFU/mL are traditionally considered significant, but lower counts (e.g., >10^4 or even >10^3 CFU/mL) can be significant in symptomatic patients, especially if pyuria is present. Specific criteria can vary (e.g., >10^2 CFU/mL in women with dysuria/pyuria, >10^3 CFU/mL in men).

Blood Tests:

Complete Blood Count (CBC): Shows leukocytosis with neutrophilia (left shift). Anemia may be present in chronic cases (XGP, CKD).
Basic Metabolic Panel (BMP): Assesses renal function (BUN, Creatinine) and electrolytes. Important for drug dosing and assessing severity (AKI).
Inflammatory Markers: C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR) are elevated.
Blood Cultures: Obtain in hospitalized patients or if sepsis is suspected

Imaging: Not always required for uncomplicated acute pyelonephritis in women responding to therapy. Indicated for:

Severe illness or suspected sepsis
Lack of clinical improvement after 48-72 hours of appropriate antibiotics
Suspected complications (obstruction, abscess, pyonephrosis, emphysematous pyelonephritis)
Recurrent pyelonephritis
Atypical presentation or diagnostic uncertainty
Male patients (higher likelihood of underlying abnormality)
Known urinary tract abnormalities
Renal Ultrasound (US): Good initial modality. Can detect hydronephrosis (suggesting obstruction), stones, large abscesses, pyonephrosis. May show kidney enlargement or altered echogenicity in acute pyelonephritis, but can be normal. Useful in pregnancy.

Computed Tomography (CT) Scan: More sensitive and specific, especially contrast-enhanced CT. Considered the gold standard for evaluating complicated pyelonephritis. Can show:

Focal or diffuse areas of decreased enhancement (inflammation/edema)
Striated nephrogram
Abscesses (perinephric, intrarenal)
Gas (emphysematous pyelonephritis)
Obstruction (stones, masses)
Scarring and caliectasis (chronic pyelonephritis)
Findings suggestive of XGP (enlarged kidney, low-density masses, central stone).

Intravenous Pyelography (IVP): Largely replaced by CT/US, but historically used. Shows pelvicalyceal system anatomy, can detect obstruction, scarring (blunted calyces).

Voiding Cystourethrogram (VCUG): Used primarily in children or selected adults to diagnose VUR.

Nuclear Renal Scan (DMSA scan): Can detect acute inflammation (photopenic defects) and quantify differential renal function and scarring, particularly useful in pediatric reflux nephropathy assessment.

Management of Pyelonephritis

Aims of management:

Eradicate the infection.
Relieve symptoms (pain, fever).
Prevent complications (sepsis, abscess, renal damage).
Identify and address any underlying structural or functional abnormalities.

General Measures:

Hydration: Encourage adequate fluid intake (oral or intravenous) to maintain urine flow, unless contraindicated.
Analgesia: Pain relief with acetaminophen or NSAIDs (use NSAIDs cautiously if renal function is impaired). Opioids may be needed for severe pain.
Antipyretics: For fever control (e.g., acetaminophen).

Antibiotic Therapy: Cornerstone of treatment.

Empiric Therapy: Initial antibiotic choice based on likely pathogens, local resistance patterns, severity of illness, patient factors (allergies, comorbidities, pregnancy, prior antibiotic use), and whether treatment is inpatient or outpatient.

Outpatient (Mild-Moderate, Non-pregnant, Able to tolerate PO): Oral fluoroquinolones (ciprofloxacin, levofloxacin – use declining due to resistance/side effects), Trimethoprim-sulfamethoxazole (TMP-SMX – if local resistance <20%), oral cephalosporins (e.g., cefpodoxime, cefixime), or sometimes an initial IV dose (e.g., ceftriaxone, gentamicin) followed by oral therapy.
Inpatient (Severe illness, Sepsis, Unable to tolerate PO, Pregnant, Comorbidities, Suspected resistance): Intravenous antibiotics initially. Options include fluoroquinolones, extended-spectrum cephalosporins (ceftriaxone, cefepime), aminoglycosides (gentamicin, tobramycin – often in combination initially for broad coverage, requires monitoring), piperacillin-tazobactam, carbapenems (meropenem, ertapenem – reserved for suspected highly resistant organisms or severe sepsis).

Tailored Therapy: Adjust antibiotics once culture and sensitivity results are available to the narrowest-spectrum, effective agent.
Duration: Typically 7-14 days for acute pyelonephritis. Longer courses may be needed for complicated cases, bacteremia, or slow response. Fluoroquinolones may allow shorter courses (5-7 days) in some uncomplicated cases. TMP-SMX often requires 14 days.

Hospitalization Criteria:

Severe illness (high fever, intractable vomiting, dehydration, hemodynamic instability, sepsis).
Inability to maintain hydration or take oral medications.
Pregnancy.
Significant comorbidities (diabetes, immunosuppression, known renal disease).
Suspected urinary tract obstruction or complication (abscess).
Diagnostic uncertainty.
Failure of outpatient therapy.
Social factors precluding safe outpatient management.

Management of Complications:

Obstruction: Requires relief (e.g., ureteral stent, percutaneous nephrostomy tube).
Abscess/Pyonephrosis: Often requires percutaneous or surgical drainage in addition to antibiotics.
Emphysematous Pyelonephritis: Aggressive medical management, often requires urgent nephrectomy or drainage.

Follow-up:

Monitor clinical response closely. Improvement expected within 48-72 hours.
Repeat urine culture after treatment completion may be considered in some cases (e.g., pregnancy, recurrent infections) to ensure eradication, but not routinely necessary for uncomplicated cases with resolution of symptoms.
Investigate for underlying causes (stones, obstruction, VUR) in patients with recurrent pyelonephritis, males, children, or atypical features.

Nursing Care & Interventions

Risk for Infection related to the presence of bacteria in the kidneys:

Assessment: Monitor vital signs frequently (temperature, heart rate, blood pressure, respiratory rate) – especially temperature every 4 hours initially. Report temperature >38.5°C or signs of sepsis promptly. Assess for worsening flank pain, changes in urine characteristics (color, odor, clarity, presence of blood/pus).

Interventions:

Administer antibiotics as prescribed, on time, ensuring correct route and dose.
Monitor response to antibiotics (defervescence, symptom improvement).
Monitor urine culture and sensitivity results and collaborate with medical team regarding antibiotic adjustments.
Encourage fluid intake (2-3 liters/day unless contraindicated) to promote urinary flow and flushing of bacteria. Monitor intake and output accurately.
Instruct patient on proper perineal hygiene (wiping front to back for females).
Provide perineal care, especially if incontinent or bedridden, keeping the area clean and dry to prevent ascending infection.
Instruct patient to empty bladder completely and regularly (every 2-4 hours) to prevent urine stasis and bladder distension.
Maintain sterile technique for any urinary catheterization or instrumentation. Provide routine catheter care if indwelling catheter is present. Advocate for catheter removal as soon as possible.
Educate patient on signs/symptoms of worsening infection or recurrence to report.

Rationale: Early detection of deterioration (fever spike, sepsis signs) allows prompt intervention. Adequate hydration helps flush bacteria. Proper hygiene and complete bladder emptying reduce bacterial load and stasis. Monitoring response ensures treatment effectiveness.

Acute Pain related to inflammation and infection of the kidney:

Assessment: Assess pain intensity (using a standardized scale like 0-10), location (flank, back, abdomen), quality (aching, sharp, colicky), and factors that aggravate or relieve it. Assess for CVA tenderness. Monitor non-verbal pain cues.

Interventions:

Administer analgesics (acetaminophen, NSAIDs cautiously, opioids if severe) as prescribed and assess effectiveness.
Provide comfort measures (positioning, back rub if tolerated, quiet environment).
Encourage adequate rest periods to reduce metabolic demands and promote comfort. Balance rest with activity levels that can be tolerated to prevent complications of immobility.
Encourage fluid intake (can sometimes help dilute inflammatory mediators).
Reassure patient that pain should decrease as the infection is treated.
Educate on non-pharmacological pain relief techniques (relaxation, distraction).

Rationale: Accurate pain assessment guides management. Analgesics block pain pathways. Rest reduces muscle tension and conserves energy. Treating the underlying infection is key to resolving the inflammatory pain.

Risk for Deficient Fluid Volume related to fever, nausea, vomiting, decreased intake:

Assessment: Monitor intake and output strictly. Assess for signs of dehydration (dry mucous membranes, poor skin turgor, tachycardia, hypotension, decreased urine output, concentrated urine). Monitor daily weights if indicated.

Interventions: Encourage oral fluid intake. Administer IV fluids as prescribed if unable to tolerate oral intake or significantly dehydrated. Administer antiemetics as needed for nausea/vomiting. Provide frequent oral care.

Rationale: Maintaining hydration is crucial for renal perfusion, flushing bacteria, and overall physiological stability.

Deficient Knowledge related to condition, treatment, and prevention:

Assessment: Assess patient’s understanding of pyelonephritis, its causes, treatment plan, potential complications, and prevention strategies.

Interventions: Explain the disease process in simple terms. Educate on the importance of completing the full course of antibiotics, even if feeling better. Teach signs/symptoms of recurrence or complications to report. Discuss prevention strategies (see below). Explain rationale for prescribed medications, fluid intake, and follow-up.

Rationale: Patient understanding promotes adherence to treatment and empowers self-care and prevention.

Prevention

General Measures:

Adequate Fluid Intake: Maintain good hydration daily to promote regular flushing of the urinary tract.
Proper Hygiene: Females wipe front to back after urination and bowel movements.
Voiding Habits: Void regularly, especially after sexual intercourse (females). Avoid delaying urination. Ensure complete bladder emptying.

Specific Measures:

Treat Lower UTIs Promptly: Prevent ascension.
Manage Underlying Conditions: Control diabetes, treat BPH, manage neurogenic bladder, treat/remove kidney stones, surgically correct significant VUR or obstruction.
Probiotics/Cranberry: Consuming blueberry/cranberry juice or products, and fermented milk products containing probiotic bacteria (e.g., Lactobacillus) may help inhibit bacterial adherence and reduce UTI recurrence in some individuals, but evidence is mixed and should not replace standard medical care or prevention strategies. Discuss with healthcare provider.
Antibiotic Prophylaxis: Low-dose antibiotics may be considered for individuals with frequent, recurrent UTIs/pyelonephritis, especially if associated with sexual activity or known structural issues, but benefits must outweigh risks (resistance, side effects).
Avoid Catheterization: When possible, or remove catheters as soon as medically feasible. Use strict aseptic technique during insertion and care.

Prognosis

Acute Pyelonephritis: Generally good with prompt and appropriate antibiotic treatment. Most patients recover fully without long-term renal damage. However, prognosis is worse with delayed treatment, severe sepsis, underlying complications (obstruction, abscess), resistant organisms, or in patients with significant comorbidities or immunosuppression.
Chronic Pyelonephritis: Prognosis depends on the underlying cause, extent of scarring, presence of hypertension, and degree of renal impairment at diagnosis. Can lead to progressive CKD and ESRD over time. Managing the underlying cause (e.g., correcting VUR/obstruction) and controlling blood pressure are crucial.

Summary / Key Takeaways

Pyelonephritis is an infection of the kidney parenchyma and pelvis, usually ascending from the lower urinary tract.
E. coli is the most common pathogen.
Risk factors include female sex, obstruction, VUR, instrumentation, pregnancy, diabetes, and immunosuppression.
Acute pyelonephritis presents with fever, chills, flank pain, CVA tenderness, and often lower UTI symptoms. WBC casts in urinalysis are highly suggestive.
Chronic pyelonephritis results from recurrent infection/inflammation leading to scarring, often related to obstruction or reflux, and can cause CKD and hypertension.
Diagnosis relies on clinical presentation, urinalysis (pyuria, bacteriuria, WBC casts), urine culture, and often imaging (US or CT) for complicated cases or diagnostic uncertainty.
Management involves antibiotics (empiric then tailored), hydration, analgesia, and addressing underlying causes or complications (obstruction, abscess).
Prompt treatment is crucial to prevent complications like sepsis, abscess, papillary necrosis, and renal scarring.
Nursing care focuses on monitoring, administering treatment, managing pain and fluids, preventing complications, and patient education.
Prevention strategies target hygiene, voiding habits, fluid intake, and managing underlying risk factors.

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Medicine Day 3 Quiz ii

Medicine Day 3 Quiz ii Read More »

General Paralysis of the Insane (GPI)

General Paralysis of the Insane (GPI), also known as general paresis, paralytic dementia, or syphilitic paresis, is a severe neuropsychiatric disorder classified as an organic mental disorder.

It is a late-stage manifestation of untreated syphilis, resulting from chronic meningoencephalitis and progressive cerebral atrophy.

GPI primarily affects the frontal and temporal lobar cortex, leading to profound cognitive, behavioral, and motor impairments.

The condition was once a leading cause of psychiatric institutionalization before the advent of penicillin treatment.

It still persists in areas with limited access to healthcare, affecting approximately 7% of individuals with untreated syphilis, with a higher prevalence in men than women.

Signs and Symptoms of General Paralysis of Insane

The onset of GPI typically occurs 10 to 30 years after initial syphilis infection and progresses in stages, beginning with subtle neurological symptoms and culminating in severe dementia and motor dysfunction.

1. Early Signs and Symptoms

The initial phase is often subtle and nonspecific, leading to misdiagnosis in its early stages. Symptoms may include:

Neurasthenia (nervous exhaustion) with:

Chronic fatigue
Headaches
Dizziness
Insomnia (sleep disturbances)
Generalized muscle weakness

2. Progressive Neuropsychiatric Symptoms

As the disease advances, cognitive and personality changes become apparent, including:

Cognitive Dysfunction

Gradual impairment of judgment
Short-term memory loss
Diminished concentration and attention span
Confusion and disorientation

Personality and Behavioral Changes

Loss of social inhibitions → inappropriate behavior, impulsivity
Euphoria → periods of excessive joy or excitement
Mania → abnormally elevated mood, hyperactivity, grandiosity
Depression → persistent sadness, loss of interest, suicidal ideation
Apathy → lack of interest or concern about surroundings
Irritability and aggression

Psychotic Features

Delusions, which may be:

Grandiose: exaggerated sense of self-importance (e.g., believing oneself to be a ruler or deity)
Paranoid: irrational fears of persecution
Nihilistic: belief in one’s own death or the end of the world
Melancholic: overwhelming guilt, self-blame, or extreme self-deprecation
Hypochondriacal: bizarre beliefs about non-existent physical illnesses

Speech and Motor Symptoms

Subtle shivering or tremors
Dysarthria → slurred, difficult speech due to motor dysfunction
Fine motor skill deterioration → difficulty in writing or grasping objects
Gait disturbances → difficulty walking, imbalance

3. Late-Stage Symptoms

Without treatment, severe neurological deterioration sets in, often leading to complete disability.

Severe Motor Dysfunction

Intention tremors → worsens with voluntary movement
Hyperreflexia → exaggerated reflex responses
Myoclonic jerks → involuntary, irregular muscle twitching
Seizures, including status epilepticus (life-threatening prolonged seizures)
Severe muscle wasting (cachexia)
Loss of bladder and bowel control

Cognitive and Psychological Deterioration

Profound memory loss
Severe confusion and disorientation
Complete inability to recognize family or surroundings
Mutism (inability to speak)

End-Stage Complications

Bedridden state → high risk of pressure sores, infections
Aspiration pneumonia → due to difficulty swallowing
Progressive malnutrition → weight loss, muscle atrophy
Fatal systemic complications → pneumonia, sepsis, or organ failure

Eventually, the patient succumbs in a state of extreme frailty, confusion, and neurological dysfunction.

Diagnosis of GPI

1. Clinical Evaluation

Detailed medical history, particularly of untreated syphilis
Neurological examination → assessing motor, cognitive, and psychiatric symptoms

2. Laboratory Tests

Serologic Testing for Syphilis:

Venereal Disease Research Laboratory (VDRL) test
Rapid Plasma Reagin (RPR) test
Treponema pallidum particle agglutination (TP-PA) test

Cerebrospinal Fluid (CSF) Analysis:

CSF VDRL test → definitive for neurosyphilis
Elevated protein levels and pleocytosis (increased white blood cells)

3. Neuroimaging

MRI and CT scans to detect cerebral atrophy, ventricular dilation, and frontal/temporal lobe degeneration
Electroencephalography (EEG) → may reveal diffuse slowing

4. Neuropsychological Testing

Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA) to assess cognitive decline

Comprehensive Treatment of General Paralysis of the Insane (GPI)

Aims of Management

The treatment of General Paralysis of the Insane (GPI) requires a multidisciplinary approach focusing on;

eradicating the syphilitic infection,
managing neurological and psychiatric symptoms,
preventing complications, and rehabilitation.

While antibiotic therapy halts disease progression, neurological and psychiatric damage is often irreversible, necessitating long-term supportive care.

1. Antibiotic Therapy (Primary Treatment)

Since GPI is caused by Treponema pallidum, antibiotics remain the cornerstone of treatment.

First-Line Treatment: Intravenous (IV) Penicillin G

Penicillin G (IV, aqueous crystalline) is the most effective treatment.
Standard dose: 18-24 million units/day, administered every 4 hours or via continuous infusion for 10-14 days.
After completing IV therapy, an additional intramuscular (IM) dose of Benzathine Penicillin G (2.4 million units weekly for 3 weeks) may be recommended to ensure eradication.

Alternative Treatments (for Penicillin-Allergic Patients)

Ceftriaxone (IV/IM) 2 g daily for 10-14 days – Preferred alternative to penicillin.
Doxycycline (oral) 200 mg daily for 28 days – Used when IV therapy is not an option, but less effective.
Azithromycin or Tetracyclines – Considered in cases where penicillin and ceftriaxone cannot be used, though efficacy is debated.

Jarisch-Herxheimer Reaction

Some patients experience a systemic inflammatory reaction 6-12 hours after starting antibiotics, characterized by:

Fever, chills
Headache, muscle aches
Worsening neurological symptoms (temporary)

Managed with antipyretics (e.g., ibuprofen, acetaminophen) and supportive care.

2. Corticosteroid Therapy (For Inflammation and Immune Response Modulation)

Corticosteroids (e.g., Prednisone, Dexamethasone) are often administered before or alongside antibiotics to reduce inflammation and brain swelling caused by the immune response to Treponema pallidum.

Indications for corticosteroids:

Patients with severe neurosyphilis symptoms, including brain edema and increased intracranial pressure.
Those at high risk of Jarisch-Herxheimer reaction.

Typical regimen:

Prednisone 40-60 mg/day for 3-5 days, then taper gradually over 1-2 weeks.

3. Neurological and Psychiatric Symptom Management

GPI causes significant neuropsychiatric complications, requiring medications to manage mood disorders, psychosis, and motor symptoms.

Cognitive and Neuropsychiatric Treatment

Cholinesterase inhibitors (e.g., Donepezil, Rivastigmine) – May provide modest cognitive improvement.
Memantine (NMDA receptor antagonist) – Used to slow cognitive decline.

Mood Disorders (Depression, Mania, Apathy, Euphoria)

Selective serotonin reuptake inhibitors (SSRIs) (e.g., Sertraline, Fluoxetine) – For depression and anxiety.
Mood stabilizers (e.g., Lithium, Valproate, Carbamazepine) – For mania and euphoria.

Psychotic Symptoms (Delusions, Hallucinations, Agitation)

Atypical antipsychotics (e.g., Risperidone, Quetiapine, Olanzapine) – Manage delusions and hallucinations.
Benzodiazepines (e.g., Lorazepam, Clonazepam) – Used short-term for agitation and anxiety.

Seizure Management

Anticonvulsants (e.g., Levetiracetam, Valproate, Phenytoin) – Prevent seizures and myoclonic jerks.

Motor Dysfunction Management

Dopaminergic agents (e.g., Levodopa, Amantadine) – May help in managing motor dysfunction if parkinsonian features emerge.
Baclofen or Tizanidine – For spasticity and hyperreflexia.

4. Supportive and Symptomatic Treatment

Pain Management

Neuropathic pain can occur due to nerve damage.
Gabapentin, Pregabalin, or Amitriptyline may be used for neuropathic pain relief.
NSAIDs (e.g., Ibuprofen, Naproxen) or Acetaminophen for general discomfort.

Bladder and Bowel Dysfunction Management

Intermittent catheterization or indwelling urinary catheter for neurogenic bladder.
Laxatives (e.g., Lactulose, Bisacodyl) to prevent constipation due to immobility.

Speech and Swallowing Therapy

Dysarthria (speech difficulties) and dysphagia (swallowing issues) require speech therapy.
Patients with severe swallowing difficulties may need feeding tube placement.

5. Rehabilitation and Long-Term Care

Physical and Occupational Therapy

Gait training and muscle strengthening exercises help maintain mobility.
Assistive devices (e.g., canes, walkers, wheelchairs) aid in movement.
Occupational therapy focuses on daily living skills and cognitive retraining.

Psychosocial Support and Caregiver Training

Psychological counseling to help patients and families cope with the diagnosis.
Social services involvement to assist with long-term care planning.

Preventing Complications in Advanced GPI

Bedridden patients require frequent repositioning to prevent pressure ulcers.
Aspiration precautions should be taken in patients with difficulty swallowing.
Respiratory therapy may be needed to prevent pneumonia and aspiration-related complications.

6. Preventive Strategies and Public Health Measures

Syphilis Screening and Early Treatment

Routine screening in at-risk populations (e.g., sex workers, people with multiple partners, men who have sex with men).
Testing during pregnancy to prevent congenital syphilis.

Education and Awareness

Public health programs should focus on increasing awareness of syphilis symptoms and importance of early antibiotic treatment.

Vaccination and Additional Health Measures

No vaccine exists for syphilis, but safe sex practices and routine STI screenings can reduce the risk.

Prognosis

Early antibiotic treatment can halt progression but does not reverse existing neurological damage.
Without treatment, GPI is fatal within 2-5 years.
Cognitive and motor deficits often persist, requiring long-term supportive care.
Early diagnosis and multidisciplinary treatment significantly improve quality of life and life expectancy.

Nursing Care Plan: General Paralysis of the Insane (Neurosyphilis)

Assessment

Nursing Diagnosis

Goals/Expected Outcomes

Interventions

Rationale

Evaluation

Patient presents with cognitive impairment, psychotic symptoms, tremors, weakness, speech disturbances, and personality changes. History of untreated syphilis.

Impaired Cognitive Function related to neurosyphilitic degeneration as evidenced by memory loss, confusion, and disorganized thoughts.

– Patient will demonstrate improved orientation and cognitive function.

– Patient will engage in structured activities to enhance cognitive ability.

– Patient will be able to follow simple instructions and recall basic information.

1. Assess cognitive function using tools like the Mini-Mental State Exam (MMSE).

2. Provide a structured routine to reduce confusion.

3. Use simple, clear language for communication.

4. Engage patient in cognitive stimulation activities (puzzles, memory games).

5. Collaborate with a neurologist and psychiatrist for medical management.

1. Helps track the progression of cognitive decline.

2. Reduces anxiety and enhances understanding.

3. Improves communication and comprehension.

4. Maintains cognitive function as much as possible.

5. Ensures multidisciplinary care for better symptom control.

– Patient shows improved attention and recall.

– Patient responds to structured routines.

– Patient engages in cognitive stimulation activities.

Patient exhibits hallucinations, delusions, and erratic behavior. Displays paranoia and emotional instability.

Disrupted Thought Processes related to central nervous system syphilitic infection as evidenced by hallucinations, delusions, and impaired judgment.

– Patient will demonstrate reduced psychotic symptoms with treatment.

– Patient will differentiate between reality and hallucinations.

– Patient will remain safe from self-harm.

1. Monitor for signs of psychosis and escalating agitation.

2. Provide reassurance and reality orientation techniques.

3. Administer prescribed antipsychotic medications as indicated.

4. Ensure a safe environment by removing potential hazards.

5. Engage patient in psychotherapy and structured activities.

1. Prevents exacerbation of psychotic symptoms.

2. Helps patient stay grounded in reality.

3. Reduces hallucinations and delusions.

4. Minimizes the risk of self-harm or injury.

5. Supports mental stabilization and recovery.

– Patient shows reduced psychotic symptoms.

– Patient interacts appropriately with others.

– Patient remains free from harm.

Patient demonstrates difficulty in walking, tremors, muscle weakness, and incoordination.

Impaired Physical Mobility related to neuromuscular degeneration as evidenced by tremors, unsteady gait, and weakness.

– Patient will demonstrate improved mobility with assistance.

– Patient will use assistive devices safely.

– Patient will participate in physical therapy.

1. Encourage physical therapy and daily mobility exercises.

2. Provide assistive devices like walkers or canes.

3. Assist patient with activities of daily living (ADLs) as needed.

4. Monitor for falls and ensure a safe environment.

5. Administer medications to manage neurological symptoms as prescribed.

1. Helps maintain muscle strength and coordination. 2. Promotes independence and mobility.

3. Ensures patient safety and hygiene.

4. Reduces fall risk and prevents injuries.

5. Aims to slow neuromuscular degeneration.

– Patient engages in mobility exercises.

– Patient uses assistive devices safely. – Patient remains free from falls.

Patient is unable to perform basic self-care due to cognitive and motor decline. Requires assistance with dressing, feeding, and hygiene.

Self-Care Deficit related to cognitive and neuromuscular impairment as evidenced by inability to perform ADLs.

– Patient will participate in self-care activities with assistance.

– Patient will use adaptive techniques to maintain independence.

– Caregivers will provide necessary support without compromising dignity.

1. Assist with ADLs while promoting independence.

2. Encourage the use of adaptive utensils and clothing.

3. Educate caregivers on safe and effective patient care.

4. Maintain a structured daily routine to enhance participation.

5. Provide emotional support to reduce frustration.

1. Ensures patient maintains a level of independence.

2. Facilitates easier self-care activities.

3. Prevents caregiver burnout and ensures optimal care.

4. Helps the patient anticipate and engage in daily activities.

5. Reduces psychological distress related to dependency.

– Patient engages in ADLs with assistance.

– Caregivers demonstrate effective support.

– Patient maintains dignity in care.

Patient expresses frustration, sadness, and withdrawal from social interactions.

Risk for chronic confusion related to disease progression and cognitive decline as evidenced by social withdrawal and feelings of helplessness.

– Patient will verbalize feelings and coping strategies.

– Patient will engage in social interactions and therapy.

– Patient will demonstrate improved mood and reduced distress.

1. Encourage expression of emotions and frustrations.

2. Provide a supportive and nonjudgmental environment.

3. Engage patient in social activities and support groups.

4. Administer prescribed antidepressants if indicated.

5. Monitor for suicidal ideation and refer to psychiatric care if needed.

1. Helps process emotions and reduces distress.

2. Promotes trust and comfort.

3. Prevents isolation and enhances emotional well-being.

4. Supports mental stability and recovery.

5. Ensures early intervention for severe depression.

– Patient verbalizes emotions and coping strategies.

– Patient engages in social activities.

– Patient reports improved mood.

NANDA 2024-26

General Paralysis of the Insane (GPI) Read More »

Traction in Nursing

TRACTION

Traction is a pull exerted on the part of the limb against a pull of compared strength in the opposite direction.

This is a system in fracture management in which a continuous pull is applied and maintained on a limb or other parts of the body by the use of cords and weights.

It involves applying a pulling force to a part of the body in order to realign bones, relieve pressure on joints, or stretch muscles and soft tissues. This method is commonly used to stabilize fractures, reduce dislocations, and alleviate pain.

Indications for Traction

Traction is indicated in a variety of clinical situations, including:

Fractures: To realign fractured bones and facilitate proper healing.
Dislocations: To reduce dislocations and restore proper joint alignment.
Muscle Spasms: To relieve muscle spasms by stretching the affected muscles.
Deformities: To correct skeletal deformities, such as scoliosis or leg length discrepancies.
Joint Pain: To alleviate pain associated with arthritis or other joint conditions.
Post–Surgical Stabilization: Following surgical procedures to maintain proper alignment and support healing.
Preoperative or Postoperative Care: To prepare for or support recovery from surgical interventions.
Joint Deformities: To correct joint deformities effectively.
Separation of Joint Surfaces: To prevent further spread of infection, such as tuberculosis of the joints (e.g., hips, knees).
Prevention of Muscle Spasms: To help alleviate muscle spasms.
Prevention of Bone Overriding: To maintain bones in the correct position during the healing process.

Types of Traction

Traction can be classified into several types based on the method of application and the area of the body affected:

1. Skeletal Traction: Involves the insertion of pins, wires, or screws into the bone, which are then attached to weights to apply traction.

2. Skin Traction: Utilizes adhesive strips or traction bands applied to the skin to distribute the pulling force.

Hamilton Russell Traction: A specific type of skin traction often used for lower limb conditions.
Gallows Traction: A technique primarily used in paediatrics for maintaining alignment in lower limb fractures.

3. Pulp Traction: This is the type of traction used for management of displaced phalanges, metacarpals and metatarsal fractures. .

4. Halo Traction: A specialized system involving a halo device that encircles the head, used for cervical spine stability.

5. Skull Tongs Traction: Involves the application of tongs inserted into the skull to provide traction to the cervical spine.

6. Fixators: Devices used to stabilize fractures or deformities.

Internal Fixators: Implanted devices within the body to hold bones in place.
External Fixators: Devices applied externally to stabilize fractures through the skin.

SKELETAL TRACTION

Skeletal traction is the type of traction in which a pin, nail, or wire is passed through a bone. This type of traction is mainly used for the treatment of fractures and works better for well-built strong persons.

Common sites for introducing the pins include:

The condyles of the femur
The tubercles of the tibia
Calcaneus at the heels of the foot

Metallic equipment used in skeletal traction:

Steinmann’s pins: This is a rigid steel pin passed through a bone and attached to a special stirrup. Because of the presence of the stirrup, the surgeon is able to alter the line of the pull without moving the pin.

Kirschner wire: This is a narrow steel wire which is not rigid unless pulled on by a stirrup. When the stirrup is rotated, it can move the wire, increasing the risk of infection. Therefore, it is not as commonly used compared to Steinmann’s pin.

Preparation of the patient for skeletal traction:

Explain the procedure to the patient and provide reassurance to allay anxiety
Shave the area if the patient is hairy
Administer premedication if prescribed
Establish an intravenous line

After preparation, the patient is taken to the theater with the leg in a Thomas splint with skin traction applied. The operation is performed under general anesthesia to insert the Steinmann’s pin through the bone. A stirrup is then attached to the pin, and the patient is returned to the ward.

Requirements for Setting up Skeletal Traction

Top Shelf	Bottom Shelf	At the Bedside
– Extension cord	– Knee piece for Thomas’ splint	– Balkan Beam
– 6-8 metal pulleys	– Foot piece for Thomas’ splint	– Bed blocks
– Cotton wool in a gallipot	– Strong slings, safety pins	– Fracture boards
– Receiver of forceps and scissors Gallipot of gauze	– Weights in various kilograms

Procedure

Steps	Action	Rationale
1	The patient is prepared and taken to theatre when the Thomas’ splint and skin traction are applied.	To immobilize the fractured bones and promote healing.
2	The pin: Observe for signs of inflammation, discharge, or movement of the pin to the nurse in charge.	To detect infections and take appropriate intervention.
3	Traction: Observe the cords and pulleys to ensure they are free and smoothly running.	To ensure accurate counterbalance and function of the traction.
4	Inspection: – Check the patient’s foot and leg for signs of inflammation. – Make sure the stirrup is not placing on the patient’s skin.	To detect infections and take appropriate intervention.

General Nursing Care of a Patient on Traction

Action	Rationale
1. The patient is nursed on fracture boards on the bed, and the foot of the bed elevated at all times with bed blocks.	Foot of the bed elevated to aid venous return.
2. Weights must not be lifted or removed unless required.	To provide constant traction.
3. Traction must be maintained 24 hours a day.	Sudden cessation of traction irritates diseased joints, causes displacement in a fracture, and is very painful for the patient.
4. Lubricate with a drop or two of oil if necessary.
5. Keep a cork on the sharp point of the pin.	So that it’s not loose.
6. See that the patient’s bed is provided with an overhead lifting pole and chain.	To help the patient lift himself/herself.
7. When giving a bed pan, ask the patient to lift him/herself or get another nurse to help.	Patient lifting himself makes participation more active.
8. Change the bottom sheet from top to bottom.	To provide comfort.
9. Make patient participate in activities of daily living (e.g., bathing in bed, feeding, active exercises, etc.).

SKIN TRACTION

It involves applying splints, bandages, or adhesive tapes to the skin directly below the fracture. Once the material has been applied, weights are fastened to it. The affected body part is then pulled into the right position using a pulley system attached to the hospital bed.

Preparation of the Patient for Skin Traction

Provide relevant explanations to the patient to ensure cooperation. It is important to explain the procedure to the relatives as well, who may consider the apparatus cruel.
Ensure the bed has a firm base and a comfortable mattress.
Ensure privacy for the patient, then wash the leg and dry it thoroughly. Observe for any abrasions and report them immediately.
Shave the leg if necessary, taking care not to cause any skin damage.
Paint the skin with tincture of benzoin compound to prevent allergic reactions to the strapping and to enhance its adhesive properties.
Protect the bony prominences by applying adhesive felt, latex foam, or orthopedic wool.

Bed Setup:

The bed should have a firm base; use fracture boards if necessary.
Use a soft mattress to ensure patient comfort.
Arrange bedclothes in separate packs for the trunk and the limb not in traction.
Keep the patient warm and ensure the bed remains tidy at all times, as this helps maintain the patient’s morale.
Use a bed cradle if both legs are in traction to ensure that the bedclothes do not interfere with the efficiency of the traction.
If there is an overhead beam, attach a trapeze to allow the patient to lift themselves, helping to prevent pressure sores and hypostatic pneumonia.
Bedclothes are necessary if the patient’s own weight is used as counter traction.

Requirements

Top Shelf

Bottom Shelf

Bedside

– Shaving tray

Receiver containing:

– A pair of dressing forceps, 21 dissecting forceps

– Bowl containing swabs

– Extension plaster

– A pair of scissors

– Crepe bandages

– Tape measure

– Skin pencil

– Receiver for used swabs

– Spreader

– Cordially, Brown wool or sorbo pads

– Tincture of benzoin co.

– Dressing mackintosh and towel

– A small blanket to cover the limb

– Balkan Beam

– Bed blocks

– Hand washing equipment

– Screens

– Bucket for used equipment

– Weights in various kilograms

– On the bed: Pulleys, Fracture board

Procedure for Skin Traction

Steps	Action	Rationale
1	Explain procedure to the patient.	Explanation encourages patient’s cooperation and relieves anxiety.
2	Inspect the limb for sores. If skin has no lesions, put a mackintosh under the limb.	To prevent soiling the bed linen.
3	Gently wash and dry the limb.	To prevent infections.
4	Shave the part where the extension is to be applied.	To prevent loose hair entering into the wound.
5	Apply tincture benzoin co. on the limb.	Benzoin co. reduces the irritating effect that strapping has on a sensitive skin.
6	Measure the patient’s legs from the head of the tibia to above the malleoli line.	This will prevent the extension from sticking to the ankle.
7	Cut an adequate extension strap, to fit on each side of the limb. Place a large wooden spreader in the middle of the limbs.	A wide spreader bar prevents the traction tape from rubbing on the patient’s bony prominences which can lead to sores.
8	Position the limb gently and firmly while the doctor or Orthopaedic officer applies the strapping.	To maintain bone alignment and promote healing.
9	Apply crepe bandage over the strapping leaving the malleoli free. Put a soft padding over the ankles.	To prevent friction that can cause pressure sores.
10	Make a knot at the end of the cord into the hole in the center of the spreader. Pass the cord over the pulley and attach to the weights.	The weights apply the pull for the traction. Properly hanging weights and correct patient positioning ensures accurate counterbalance and function of the traction.

Points to Remember

Traction: Check that the strapping does not slip. Bandages should be secure and unwrinkled to avoid friction.
Inspection: Check the circulation of the foot and toes by noting color, temperature, sensation, and power. Neurovascular assessments aid in early identification of complications.

Gallows Traction(Bryant’s Traction)

This is commonly used in treating fractured femurs in smaller children below 5 years.

Additional Requirement for Skin Traction Procedure

Beam Above the Cot

Steps	Action	Rationale
1	Apply skin traction to both the child’s legs.	To elevate the sacrum.
2	Suspend the legs so that the pelvis is off the bed and a hand can be slipped between the buttocks and the bed.	To reduce the fracture and hold the fragments in position.
3	Observe for adherence and firmness of strapping and bandage respectively.	To avoid friction tightness and loosening of the bandage.
4	Check the bandages regularly.	To avoid exerting uneven pressure that can cause pressure sores and gangrene.
5	Maintain the traction on for approximately 3 weeks or according to prescription.	To allow proper healing.
6	Monitor gentle weight bearing starting at 6 weeks initially in the cot.	To identify gradual weight bearing on the limb using crutches.
7	Physiotherapy: Monitor gentle and gradual weight bearing on the limb using crutches.	To identify blood circulation interference.
8	Observe the circulation of the toes on both limbs by noting their color, edema, pain, and temperature.	To identify blood circulation interference.
9	Respond to child’s cries and restlessness.	This could be the first sign of ischemia or skin irritation.

Management of a Patient with Skin Traction

Acute Management:

1. Documentation of Traction Order:

Ensure the order for skin traction is properly documented by the orthopedic team, including the weight to be applied in kilograms.

2. Preparation of Equipment:

Gather all necessary equipment before starting the procedure.

3. Pain Relief:

A femoral nerve block is the preferred method for pain management and should be administered in the emergency department before admission to the ward.
Diazepam and Oxycodone should always be charted and used alongside the femoral nerve block.

4. Distraction and Education:

Explain the procedure to both the patient and their parents before starting.
Plan appropriate distraction activities, such as play therapy, or involve parents and nursing staff.

5. Application of Traction:

Ensure the correct amount of water is added to the traction weight bag as per the medical order.
Fold the foam stirrup around the heel, ankle, and lower leg of the affected limb. Apply a bandage, starting at the ankle and wrapping up the lower leg using a figure-8 technique. Secure with sleek tape.
Place the rope over the pulley and attach the traction weight bag. Trim the rope if necessary to ensure the bag is suspended in the air and not resting on the floor.

Ongoing Management:

6. Maintain Skin Integrity:

Monitor the patient’s legs, heels, elbows, and buttocks for potential pressure areas due to immobility and bandages.
Place a rolled-up towel or pillow under the heel to relieve pressure.
Encourage the patient to reposition themselves or perform pressure area care every four hours.
Remove the foam stirrup and bandage once per shift to relieve pressure and inspect the skin condition.
Keep the sheets dry.
Document the condition of the patient’s skin in progress notes and the care plan.
Assess and document the pressure injury prevention score and plan.

7. Traction Care:

Ensure the traction weight bag hangs freely and does not rest on the bed or floor.
Replace frayed ropes.
Ensure the rope stays in the pulley tracks.
Check that the bandages are free from wrinkles.
Tilt the bed if necessary to maintain counter traction.

8. Observations:

Perform neurovascular observations on the patient hourly and record the findings in the medical record.
If the bandage is too tight, it can slow blood circulation. Monitor for swelling of the femur to detect compartment syndrome.
If neurovascular compromise is detected, remove the bandage and reapply it more loosely. If circulation does not improve, notify the orthopedic team immediately.

9. Pain Assessment and Management:

Pain assessment is crucial to ensure that the right analgesic is administered for effective relief.
Paracetamol, Diazepam, and Oxycodone should be charted and administered as needed.
Pre-emptive analgesia should be considered, especially before pressure area care, to manage the patient’s pain effectively.
Assess and document the outcomes of pain management strategies.

10. Activity:

The patient can sit up in bed and engage in quiet activities such as crafts, board games, and watching TV. Play therapy can be beneficial for long-term traction patients.
Non-pharmacological activities and distractions will help improve patient comfort.
The patient can move in bed as tolerated to complete hygiene care.
Long-term traction patients may require referral to the education department.

11. Transport to Theatre:

The patient should be transported to the operating theatre in traction to reduce pain and maintain proper alignment.

Special Considerations:

The foam stirrup, bandage, and rope are for single-patient use only.

Potential Complications:

Skin Breakdown/Pressure Areas: Pressure from the traction or immobilization can lead to skin damage.
Neurovascular Impairment: Monitor for issues with circulation, oxygenation, and nerve function in the limbs.
Compartment Syndrome: Increased pressure in muscle compartments can affect muscles and nerves, requiring urgent care.
Joint Contractures: Prolonged immobility may result in stiffening of the joints.
Constipation: This can result from immobility and the use of analgesics.

PULP TRACTION

This is the type of traction used for management of displaced phalanges, metacarpals and metatarsal fractures. A structure is put through the pulp of the fingers and fastened to an extension wire which is incorporated in the plaster.

Skull Tongs Traction

Skull tongs traction is used to immobilize the cervical spine in cases of unstable fractures or dislocations of the cervical vertebrae.

Types of Skull Tongs Traction:

Crutchfield Tongs
Gardner-Wells Tongs: More commonly used, as it is less likely to pull out compared to Crutchfield tongs.

Procedure

Steps	Action	Rationale
1	Prepare the patient for surgery (see pre-operative care).
	Following surgery
2	Nurse the patient in supine position on a special frame instead of the regular hospital bed.	In order to maintain the neck in position.
3	Assist the patient with any turning movements if a hospital bed is used. Elevate the head of the bed if necessary.	To prevent twisting of the neck that can result in complications.
4	Apply the same precautions to all patients on traction.	To prevent complications.

Head of the bed raised, bed on castors so that it can be wheeled to the X-ray department.

After the Procedure:

The patient is placed on a special bed with a therapeutic mattress and frames.
The patient remains in a complete supine position with a small pillow under the head.
As patients are in this traction for extended periods, similar precautions used for skeletal traction are applied.
The head of the bed is elevated to provide counter-traction.
Castors are placed on the bed for easy movement, such as for X-rays.

Points to Remember:

Assist with daily activities as the patient will have difficulty performing them independently.
Prevent infection at the tong sites through regular cleaning.
Suggest recreational or occupational activities to address restlessness and boredom.
Teach the patient range of motion exercises.
Ensure proper nutrition.

Halo Traction

Halo traction is similar to skull tongs traction but includes a vertical frame that extends to the body, allowing the patient to move out of bed without disrupting its function. The pin is inserted into the skull, and the frame provides stabilization for fractured cervical vertebrae.

The frame is not removable, as any movement of the vertebrae could damage the spinal cord.

Fixators

Fixators are metallic rods passed through a bone to ensure stability.

Types:

1. External Fixation Devices:

A frame of metal rods that connect skeletal pins. These rods provide traction between the pin sites.
External fixators can be simple with 2-3 rods or complex with many rods arranged at different angles to maintain fractured bone fragments.

Advantages:

Useful for immobilizing many bone fragments.
Used in cases with open wounds to reduce infection risk, a concern with casts.

2. Internal Fixators:

Metallic devices used to replace or treat certain bones or fractures.
Can be temporary or permanent, such as replacing a dead bone like the femoral head.

General Nursing Care of a Patient on Traction

Traction should be applied during the day.
The patient is nursed with fracture boards on the bed to maintain firmness.
Elevate the foot or head of the bed, depending on the traction site (skull or limbs).
Do not lift, move, or remove weights unless instructed by a doctor.
Ensure cords are always pulling and that weights do not rest on the bed.
Traction is maintained 24/7 because sudden cessation can cause displacement of the fracture, leading to pain.
Cords must run freely over regularly oiled pulleys.
Check the color of the toes to ensure satisfactory circulation.

Care for Skeletal Traction:

Keep the puncture site clean and dry.
Seal the wound with tincture of benzoin.
Ensure free movement of the screws on either side of the pin and lubricate if necessary.
Keep a cork on the sharp pin end to prevent injury.
Provide an overhead lifting pole and chain to help the patient move.
Assist with bathing where needed, especially for areas like the back and legs.
Pay close attention to pressure areas, especially around the ring of the Thomas splint.
Maintain a full diet and encourage foods rich in vitamins and minerals such as iron, milk, and liver.
Teach daily muscle exercises, particularly moving the knee and ankle joints.
Provide psychological support through regular reassurance.
Offer indoor games to keep the patient occupied.

Care of Plaster of Paris (P.O.P.)

Elevate the limb on a pillow and the foot of the bed.
Wash plaster powder off the toes.
Expose the P.O.P. to room temperature.
Check toes for good blood supply and encourage the patient to move them regularly.
Conduct half-hourly pressure checks for signs of nerve compression.
Observe the color, temperature, and any swelling of the toes.
Monitor for pain, numbness, or tingling, which may indicate nerve pressure.
Check for blood stains on the P.O.P., which may indicate bleeding.

Physiotherapy:

Encourage deep breathing exercises.
Promote limb movement for the affected site.

Traction in Nursing Read More »

SUTURING OF THE WOUND

Suturing

Suturing is the process of closing a wound by stitching the wound edges together using a surgical needle and thread.

It is a fundamental technique in wound management and surgical procedures to facilitate healing, prevent infection, and restore tissue integrity.

Purpose of Suturing

The primary goals of suturing are:

To approximate wound edges until healing occurs.
To speed up the wound healing process by stabilizing the tissue.
To minimize the risk of infection by reducing the open surface area.
To improve cosmetic outcomes and minimize scarring.
To provide additional support in high-tension areas or deep wounds.

Types of Sutures

Sutures are broadly categorized into interrupted and continuous sutures.

1. Interrupted Sutures

In interrupted suturing, each stitch is placed individually and tied separately.
This is the most commonly used wound closure technique.
The individual stitches are not connected, reducing the risk of wound dehiscence if one stitch fails.

Advantages:
Easy to place.
High tensile strength.
Individual stitches can be removed if infection occurs without affecting the entire closure.

Disadvantages:
Takes more time to place compared to continuous sutures.
Requires more suture material.
Each knot increases the risk of infection.

2. Continuous Sutures

A single thread runs through the wound in a series of stitches and is tied only at the beginning and end.
The stitches are connected, making it faster for long wounds or surgical incisions.

Advantages:
Faster than interrupted sutures.
Requires less suture material.
Distributes tension evenly along the wound.

Disadvantages:
If the suture breaks, the entire closure may fail.
Increased risk of dehiscence in high-tension areas.

Retention Sutures:
These are large interrupted sutures placed in addition to standard skin sutures.

They support deep incisions, particularly in obese patients or high-risk wounds where dehiscence is likely.
Often reinforced with rubber tubing to prevent the sutures from cutting into the skin.
Retention sutures are typically removed after 14–21 days (longer than regular sutures).

Suturing Patterns

Based on the pattern of suturing, stitches can be classified as:

Suturing Pattern	Description
Plain Interrupted	Single, unconnected stitches; most common technique.
Plain Continuous	One continuous stitch running along the wound, tied at both ends.
Mattress Interrupted	Provides deeper support, with stitches looping through multiple layers.
Mattress Continuous	A continuous version of mattress suturing for stronger wound closure.
Blanket Continuous (Locking Stitch)	Each stitch loops into the previous one, creating a stronger hold.

Suturing Technique Tip: Each suture should be placed as deep as it is wide, and the distance between the sutures should be equal to the depth and width of the wound to ensure proper healing.

Suture Materials

A suture material is the thread used to stitch a wound.

These materials vary in absorption, strength, and application.

Suture materials are classified into:

Type	Examples	Usage
Absorbable Sutures	Surgical gut (catgut)	Used for internal tissues (e.g., beneath the skin) where the sutures dissolve naturally.
Non-Absorbable Sutures	Silk, Nylon, Dacron, Stainless Steel	Used for skin closure, removed after healing.

1. Absorbable Sutures

Absorbable sutures naturally break down and are absorbed by the body over time.

Advantages:
No need for suture removal.
Ideal for internal tissues (e.g., intestines, muscles, and subcutaneous tissues).
Available in multiple sizes (ranging from 0000000 to No. 5).

Disadvantages:
May cause an inflammatory reaction as they degrade.
Not suitable for long-term wound support.

Types of Absorbable Sutures

Type	Absorption Time	Description
Plain Catgut	5–10 days	Rapid absorption, used in fast-healing tissues.
Chromic Catgut	10–40 days	Coated with chromium salts to prolong absorption and reduce irritation.

2. Non-Absorbable Sutures

Non-absorbable sutures do not dissolve and need to be manually removed once the wound has healed.

Advantages:
High tensile strength – they do not easily break.
Minimal tissue reaction, reducing inflammation.
Can be used for ligatures to tie off blood vessels.

Disadvantages:
Requires removal after healing.
Can cause irritation if left in place too long.

Common Non-Absorbable Suture Materials

Material	Properties	Usage
Silk	Soft, flexible, easy to handle	Used in skin closure and ligatures.
Nylon	High tensile strength, minimal reactivity	Used for skin sutures and deep tissue repair.
Dacron/Polyester	Strong, durable	Used in cardiovascular and orthopedic procedures.
Stainless Steel	Extremely strong, resistant to infection	Used for bone repair and surgical staples.

Ligature (Tie Sutures):
A ligature is a free piece of suture material used to tie off blood vessels that have been clamped with artery forceps to prevent bleeding.

Suture Removal Guidelines

The time for removing sutures varies depending on the wound location and type.

Wound Location	Suture Removal Time
Face	3–5 days
Neck	5–7 days
Scalp	7–10 days
Trunk & Upper Limbs	10–14 days
Lower Limbs & Joints	14–21 days
Retention Sutures	14–21 days

Nursing Considerations in Suturing

Choose the appropriate suture material based on wound type, location, and required tensile strength.
Use absorbable sutures for internal tissues to avoid the need for removal.
Use non-absorbable sutures for skin closure, ensuring proper follow-up for suture removal.
Place sutures evenly to distribute tension and prevent scarring.
Monitor for infection (redness, swelling, pus formation) and remove affected sutures if needed.
Ensure wound edges are well-approximated but not overly tight to avoid necrosis.

Suture Needles

Suture needles are essential tools in wound closure and are classified based on their shape, function, and method of attachment to the suture material.

1. Classification Based on Shape

Type of Needle	Description	Common Uses
Straight Needles	Used without a needle holder	Suturing skin layers and easily accessible wounds
Curved Needles	Require a needle holder; allow precise control	Deep wounds, internal tissues, and confined spaces
Half-Circle Needles	A variation of curved needles, providing greater maneuverability	Used in deeper surgical procedures

Straight Needles: Are used for superficial wounds where access is easy. They are often manipulated without a needle holder, making them suitable for skin closure.

Curved Needles: Preferred for deeper wounds or when working in confined spaces. They require a needle holder for precise placement and controlled passage through tissue. Curved needles are further categorized by the degree of curvature (e.g., 1/2 circle, 3/8 circle).

2. Classification Based on Function

Needle Type	Description	Common Uses
Cutting Needle	Three-edged triangular needle; sharp enough to cut through dense tissue	Used for skin, tendons, and the cervix
Reverse Cutting Needle	Has the cutting edge on the outside curve	Reduces risk of sutures pulling through the tissue
Non-Cutting Needle (Round Body Needle)	Rounded tip; does not cut through tissue	Used for delicate tissue like intestines, blood vessels, and subcutaneous tissues

Cutting Needles: Characterized by three-edged, triangular points designed to cut through dense tissues. Commonly used for skin, tendons, and the uterine cervix.

Non-Cutting (Round Body) Needles: Feature a rounded point that separates rather than cuts through tissues. Ideal for delicate tissues beneath the skin, reducing trauma and the risk of tearing.

3. Classification Based on Suture Attachment

Needle Type	Description	Advantages
Traumatic Needle (Eye Needle)	Has an eye/opening at one end to thread the suture	Can use different suture materials; cost-effective
Atraumatic Needle (Swaged Needle)	Suture material is pre-attached to the needle	Minimizes tissue trauma and provides better handling

Traumatic (Eyed) Needles: These needles have an eye through which the suture material is threaded. The suture diameter is larger than the needle, causing more tissue trauma during passage.

Atraumatic (Swaged/Eyeless) Needles: In these needles, the suture is directly attached to the needle during manufacturing. This results in a suture diameter equal to or smaller than the needle, minimizing tissue trauma. Atraumatic needles are preferred for delicate tissues like intestines, brain, mucous membranes, and nerves.

Wound Suturing

In addition to standard dressing materials, the following sterile equipment is required for wound suturing:

Sterile gloves
Sterile drapes (hole sheet)
Sterile needle holder
Sterile round needle(s)
Sterile cutting needle(s)
Sterile suture material (silk, catgut, etc.)
Sterile tissue forceps
Sterile suture scissors
Sterile dressing forceps
Antiseptic solution (e.g., iodine)
Local anesthetic

Nurse’s Responsibilities in Wound Suturing

In most healthcare settings, suturing is the responsibility of doctors. However, in some hospitals, nurses may be responsible for suturing small wounds, depending on institutional policies.

Preliminary Wound Assessment Before Suturing

Assessment Factor	Purpose
Circumstances of injury	Helps determine wound contamination risk.
Nature of the wound	Identifies if it is caused by a sharp or blunt object, influencing suturing decisions.
Time elapsed since injury	Older wounds are at higher risk of infection and may need debridement.
Patient’s medical history	Conditions like diabetes can affect healing.
Previous wound healing history	Assesses abnormal bleeding, keloid formation, or past wound dehiscence.
Medications	Drugs like corticosteroids delay healing.
Allergy history	Checks for allergic reactions to local anesthesia.
Tetanus immunization status	Tetanus toxoid should be given if necessary.
Wound depth and location	Determines whether general anesthesia is required.
Foreign bodies	Must be removed before suturing to prevent infection.
Devitalized tissues	May need debridement before closure.
Bleeding control	Bleeding points should be ligated before suturing.
Associated complications	Identifies fractures, nerve damage, or tendon injuries requiring further intervention.

Preliminary Assessment

Assess the circumstances under which the wound was produced. This will help to evaluate the possibility of wound contamination.
Assess the nature of the wounding object e.g., blunt, sharp, etc. this will help to assess the depth of penetration of the object and also to identify the puncture wounds.
Assess the duration of time after the injury. This will help to assess the healing process. If the wound is exposed for a prolonged period, there always is the possibility of wound infection.
Check the presence of existing illness in the patient that may influence the healing process e.g. Diabetes mellitus.
Prior healing history is to be assessed. This will help us to find out abnormal bleeding time, wound dehiscence in the past, formation of excessive scar tissue etc.
Check the drugs, the injured person has been taking e.g., cortico-steroids. This will delay the healing process.
Take a history of allergies in the past, especially allergic reaction to local anaesthetics.
Date of most recent tetanus immunization. All patients with a roadside injury should be given tetanus toxoid to prevent tetanus.
Wound location and the type of wound. A penetrating wound should be sutured under general anaesthesia. There is the possibility of injury of the underlying organs.
Watch for the presence of foreign bodies, presence of penetrating objects etc. penetrating objects should not be disturbed until everything is ready for suturing, for fear of bleeding.
Assess the presence of devitalized tissues. This necessitates debridement prior to suturing.
Presence of bleeding. The bleeding points have to be ligated before suturing to prevent further bleeding.
Presence of complications such as fractures, shock, tendon injuries, nerve injuries etc. this necessitates further treatment.
Check the consciousness of the patient and the ability to follow.

Preparation of the Patient and the Environment

Explain the procedure to win the confidence and co-operation of the patient. Explain the sequence of the procedure and tell the patient how he can cooperate with you. Reassure the patient and his relatives.
Get the signature of the patient or his guardian in case anaesthesia is to be given.
Prepare the wound area for a surgical procedure. Shave the hairy regions. Clean the surrounding skin thoroughly with an antiseptic. While shaving and cleaning the area, place a sterile cotton pad or gauze piece over the wound to prevent future contamination of the wound.
Give analgesics if the patient is in pain.
Provide privacy with curtains and drapes, if necessary.
Protect the bed with a mackintosh and towel.
Call for assistance if necessary e.g., to hand over the sterile supplies, to restrain the patient etc.
Place the patient in a comfortable position. See that the doctors or the nurse are also in a comfortable position to do the procedure.
Apply restraints in case of children.
See that the unit is in order with no unnecessary articles. Clear the bedside table or over-bed table and arrange the articles conveniently.
See that there is sufficient light. Adjust the spot light to provide maximum light in the wound area.
Turn the patient’s head away from the wound to prevent the patient from seeing the wound and getting worried.

Wound Suturing Procedure

Step	Action	Rationale
1	Explain procedure to patient	To reduce anxiety and gain patient cooperation.
2	Adjust light	To provide optimal visualization of the wound.
3	Wash your hands	To reduce the risk of infection.
4	Clean the wound thoroughly	To remove debris and bacteria from the wound site.
5	Wash your hands again	To further minimize the risk of infection before donning sterile gloves.
6	Put on sterile gloves	To maintain a sterile field.
7	Drape the wound with the hole-sheet	To create a sterile field around the wound and isolate the area.
8	Infiltrate the edges of the wound to be sutured with local anesthesia.	To minimize patient discomfort during the procedure.
9	Approximate the edges of the fascia with the help of the tissue forceps and using the round needle and cat-gut. Suture the fascia layer first.	To close the deeper tissue layers and provide support.
10	Using the cutting needle and silk, suture the outer layer of skin approximating the edges with the help of the tissue forceps.	To close the skin edges and promote healing.
11	Clean with iodine and cover with sterile gauze.	To disinfect the wound and protect it from infection.
12	Remove the hole-sheet	To remove the drapes.
13	Make patient comfortable	To ensure patient well-being.
14	Remove all equipment, wash and return to its proper place or send for sterilization.	To maintain a clean environment and prepare instruments for future use.

After Care of the Patient and the Articles

Following wound closure, clean the wound again and apply a multilayered dressing to absorb drainage and to arrest bleeding by exerting pressure.
Secure the dressings with a roller bandage or adhesive tapes. As far as possible, avoid covering the wound area with adhesive straps, completely, because it may foster accumulation of moisture and subsequent maceration of the wound edges.
Keep the wound as dry as possible.
Remove the mackintosh and towel. Replace the bed linen. Change the garments if necessary. Make the patient comfortable by adjusting his position in bed.
Ask the patient to rest in bed to prevent fainting attacks.
Elevate the injured part above the heart level to minimize the oedema and pain. Mild analgesics may be given to reduce pain.
Take all the articles to the utility room. Discard the soiled dressing and send it for incineration. Wash and clean the articles first in the cold water and then with warm water and soap. Wash them thoroughly and dry them. Reset the suturing tray and send for autoclaving. Replace all articles to their proper places.
Wash hands. Record on the nurses record with date and time the type of the wound, the number of sutures applied, type of drainage tube applied, if any etc.
Return to the bedside to assess the comfort of the patient and to observe the condition of the wound. Watch for any bleeding from the wound area. Change the dressing if there is excessive bleeding. Report to the doctor.
Watch for the vital signs regularly to detect early signs of shock and collapse on the first day and signs of infection on subsequent days.
Unless signs of infection occur, the dressing should be left undisturbed until time for suture removal. Changing the dressing frequently causes friction on the wound edges and increases the possibility of the wound infection.
Inject tetanus toxoid, if it is not given previously.
On discharge of the patient, the patient should be given the instructions about the care of the wound, and the time when he has returned for the removal of sutures.

Suture Removal Guidelines

Sutures should be removed based on wound location and healing progress. In all cases the surgeon gives the written order for the removal of the sutures.
The sutures may be removed by the surgeons or by the nurses according to the hospital customs.

Wound Location	Suture Removal Time
Face & Scalp	2–5 days
Abdominal wounds	7–10 days
Lower limbs	10–14 days

General Instructions

Confirm the doctor’s orders for the removal of the sutures.
The suture removal is done in conjunction with a dressing change.
Toothed dissecting forceps and a pair of scissors with a short, curved, cutting tip that readily slide under the suture are used.
The suture line is cleansed before and after suture removal.
While removing interrupted sutures, alternate ones are removed first. The remaining sutures are removed a day or two later. If wound dehiscence occurs, the remaining sutures may then be left in place.
Suture material that is beneath the skin is considered free from bacteria, and those visible outside are in contact with the resident bacteria of the skin. It is important that no part of the stitch which is above the skin level enters and contaminates the tissues under the skin.
Suture material left beneath the skin acts as a foreign body and elicits the inflammatory response. While removing sutures, care to be taken to remove them completely. Each suture should be examined for its completeness. Every interrupted suture will have one knot and four ends when removed completely. The number of sutures should be counted before and after removal.
If wound dehiscence occurs during the removal of the sutures, inform the surgeon immediately. In case of abdominal wounds, resuturing is imperative to prevent evisceration. In other places, if resuturing is not necessary, adhesive tapes should be applied to approximate the wound edges as closely as possible.
After the removal of sutures, even if the wound is dry, a small dressing is applied for a day or two to prevent infection. The patient should be told about the care of the wound. He is advised to take rest after removal of sutures of an abdominal wound. The patient should be told not to strain the part e.g., not to cough or lift heavy weight after removal of sutures from the abdomen. This will prevent wound dehiscence.
If wound discharge occurs, the patient should be instructed to contact the surgeon. Presence of pain and swelling at the wound line are the signs of complications.
Abdominal belts or many tailed bandages may be applied on the abdomen after removal of abdominal sutures in obese patients to prevent wound dehiscence and evisceration.

Suture Removal Technique

To remove the interrupted sutures, grasp the suture at the knot with a toothed forceps and pull it gently to expose the portion of the stitch under the skin. Cut the suture with sharp scissors between the knot and the skin on one side either below the knot or opposite the knot. Then pull the thread out as one piece. The suture which is already above the skin should not be drawn under the skin.
After removal of sutures, every suture should be examined for its completeness. The number of sutures should be counted before and after removal. (it is not uncommon to find some sutures
laid bury under the skin).
Mattress interrupted sutures have two threads underlying the skin. The visible part of the suture opposite the knot should be cut and the suture is removed by pulling it in the direction of the knot.
If a continuous suture is applied, it is cut through, close at each skin orifice on one side and the cut sections are removed through the opposite side by gentle traction.

Clips (Metal Sutures) in Wound Closure

Clips, also known as metal sutures or surgical staples, are used to close the skin after a surgical procedure or deep wound.

Unlike traditional sutures, clips provide a fast, secure, and uniform wound closure, minimizing tissue trauma.

Purpose of Clips in Wound Closure

The primary objectives of using clips are similar to those of suturing with stitches, including:

To approximate wound edges until healing occurs.
To speed up wound closure and healing.
To reduce the risk of infection by minimizing handling.
To provide a strong and secure closure, especially for long surgical incisions.
To improve cosmetic outcomes by minimizing scarring.
To reduce operation time compared to conventional suturing.

Equipment Required for Clip Removal

In addition to standard equipment for dressing a septic wound, the following specialized instruments are required for removing clips:

Equipment	Purpose
Sterile Clip Removal Forceps	Specially designed to safely remove surgical clips without causing tissue trauma.
Receiver	Used to collect removed clips.
Benzene or Ether	Used to clean the surrounding skin and remove adhesive residue.
Sterile Gauze	To receive and hold the removed clips.
Antiseptic Solution	Used for cleansing the wound.
Adhesive Tape or Bandage	Secures dressing after clip removal.

Procedure for Removing Clips

Pre-Procedure Preparation

Explain the procedure to the patient to gain cooperation and reduce anxiety.
Gather and organize all necessary equipment.
Position the patient comfortably and drape appropriately for privacy.
Protect the bedding with a rubber sheet and cover to prevent contamination.
Remove the old dressing and discard it properly.

Clip Removal Procedure

Clean the wound using an antiseptic solution, starting from the cleanest area to the most contaminated part.
Place a sterile gauze pad near the wound to collect removed clips.
Hold the clip removal forceps in the right hand and the dissecting forceps in the left hand.
Insert the lower blade of the clip remover under the center of the clip.
Use the dissecting forceps to hold the clip in place as the removal forceps are squeezed.
Gently press the forceps together – this action bends the clip outward, disengaging it from the skin.
Carefully remove the clip and place it on the sterile gauze.
Repeat the process until all clips are removed.
Apply iodine or antiseptic to the puncture sites to prevent infection.
Dress the wound if necessary and secure the dressing with adhesive tape or a bandage.
Ensure patient comfort and adjust their position as needed.
Document the procedure, noting the appearance of the scar, wound healing progress, and any complications.
Dispose of all used materials properly and return reusable instruments for sterilization.

Post-Procedure Care and Monitoring

Assess the wound for signs of infection or delayed healing.
Monitor for bleeding or wound dehiscence (reopening of the wound).
Advise the patient to avoid excessive movement that could stress the healing wound.
Provide pain relief if needed.
Instruct the patient on proper wound care and when to seek medical attention.

Clinical Appearance of the Wound Bed

The appearance of the wound bed provides insight into healing progress and potential complications.

Wound Bed Type	Description	Clinical Significance
Granulating	Healthy red/pink moist tissue with newly formed collagen, elastin, and capillary networks. Tissue is well vascularized and bleeds easily.	Indicates active healing and proper blood supply.
Epithelializing	Pink or whitish thin layer forming on top of granulation tissue.	Sign of wound closure and final healing stage.
Sloughy	Yellowish devitalized tissue, composed of dead cells and fibrin, often misinterpreted as pus.	Requires debridement to promote healing.
Necrotic	Black, hard, or dry tissue with greyish dead connective tissue. Prevents healing and may lead to infection.	Needs immediate debridement and intervention.
Hypergranulating	Granulation tissue grows above the wound margin, caused by bacterial imbalance or excessive irritation.	Delays wound healing and requires adjustments in wound care.

SUTURING OF THE WOUND Read More »

Medicine Day 3 Quiz

Medicine Day 3 Quiz Read More »

HIV AND PREGNANCY

HIV (Human Immunodeficiency Virus) is a virus that attacks the body\’s immune system, specifically the CD4 cells (T cells), which are important for immune defence.

If untreated, HIV can lead to AIDS (Acquired Immunodeficiency Syndrome), a condition where the immune system is severely weakened.

HIV is a lenti-virus (slow and long acting) and belongs to the Retroviruses group. HIV invades the helper T cells to replicate itself thereby limiting the body’s ability to fight infection . HIV is the virus that causes AIDS, and it has no cure

Types of HIV

HIV-1: This is the most common and widespread type of HIV, accounting for the vast majority of HIV infections globally. It is highly infectious and has several subtypes (or clades), labelled A through K. HIV-1 is the primary cause of the global HIV pandemic and is more aggressive in its progression to AIDS compared to HIV-2.
HIV-2: This type is less common and primarily found in West Africa. It is less transmissible and generally progresses more slowly to AIDS than HIV-1. There are fewer subtypes of HIV-2, labelled A through H.

Modes of HIV Transmission

1. Sexual Contact:

Unprotected Vaginal Sex: HIV can be transmitted through vaginal fluids and semen during unprotected vaginal intercourse..

2. Blood-to-Blood Contact:

Sharing Needles: Using contaminated needles or syringes, common among intravenous drug users, can transmit HIV.
Blood Transfusions: Although rare in countries with stringent blood screening, HIV can be transmitted through infected blood transfusions.
Exposure to Contaminated Blood: Health care workers can be at risk through needle stick injuries or contact with open wounds.

3. Mother-to-Child Transmission:

During Pregnancy: HIV can cross the placenta from mother to baby.
During Childbirth: The baby can be exposed to HIV in the mother\’s blood and vaginal fluids during delivery.
Breastfeeding: HIV can be transmitted through breast milk from an infected mother to her child.

4. Other Modes:

Contaminated Medical Equipment: Use of non-sterile instruments during medical or dental procedures can transmit HIV.
Organ and Tissue Transplants: Transplantation of infected organs or tissues, though rare due to screening practices, can transmit HIV.

5. Less Common Modes:

Tattooing and Piercing: If non-sterile needles are used, there is a risk of HIV transmission.
Contact Sports: Although extremely rare, transmission can occur if both participants have open wounds.

Factors That Facilitate Mother-to-Child Transmission of HIV

Maternal Factors:

1. Viral Load and Immune Status:

High Viral Load: Higher levels of HIV in the mother’s blood increase the risk of transmission to the baby.
Low CD4 Count: A weakened immune system due to low CD4 counts enhances transmission risk.
Maternal Acquisition of HIV: New HIV infections during pregnancy or lactation significantly increase transmission risk.

2. Infections and Inflammation:

Vaginal Infections: Infections such as bacterial vaginosis can elevate the risk of HIV transmission.
Chorioamnionitis: Inflammation of the foetal membranes due to infection can facilitate HIV transmission.

3. Access to Antiretroviral Therapy (ART):

Lack of ART: Mothers who do not receive ART are more likely to transmit HIV.
Poor Adherence to ART: Inconsistent use of ART reduces its effectiveness in preventing transmission.
Timing of ART Initiation: Starting ART late in pregnancy or not at all reduces its preventive benefits.

4. Socioeconomic Factors:

Lack of Healthcare Access: Limited access to prenatal care and HIV testing can lead to missed opportunities for prevention.
Education and Awareness: Lack of knowledge about HIV transmission and prevention strategies among pregnant women.

5. Nutritional Status:

Poor Maternal Nutrition: Malnutrition can weaken the mother’s immune system, increasing the risk of transmission.

Labour and Delivery Factors:

6. Delivery Method:

Vaginal Delivery: Higher risk of transmission compared to elective caesarean section, especially if the mother has a high viral load.
Prolonged/Difficult Labour: Increased exposure to maternal fluids during extended or complicated labour can raise the risk.

7. Prematurity:

Premature Birth: Prematurity can increase the risk of transmission due to underdeveloped immune systems in infants.

8. Membrane Rupture:

Prolonged Rupture of Membranes (PROM): Rupture lasting more than 4 hours before delivery increases the risk of HIV transmission.

9. Invasive Monitoring and Procedures:

Use of invasive monitoring or procedures during labour can increase the risk of HIV transmission.

Postnatal Feeding Factors:

10. Breastfeeding Practices:

Prolonged Breastfeeding: Longer duration of breastfeeding increases the risk of HIV transmission.
Breast Health: Conditions like sore nipples, abscesses, or mastitis can increase the risk.
Mixed Feeding: Combining breastfeeding with other foods or fluids increases transmission risk. Exclusive breastfeeding for the first 3-6 months does not show excess transmission compared to formula feeding alone.

11. Exclusive Breastfeeding:

Exclusive breastfeeding means providing breast milk only, without additional fluids, water, food, teats, or pacifiers, and involves on-demand feeding.

12. Oral Health in Infants:

Oral Thrush: Presence of oral thrush in breastfed infants can increase the risk of HIV transmission.

$\"Phases$

Phases of HIV Entry into Host Cells

Binding: The HIV virus first attaches to the CD4 receptors on the surface of the host cell, typically a type of immune cell called a CD4+ T lymphocyte. HIV\’s envelope protein, gp120, specifically binds to the CD4 receptor. This interaction triggers a conformational change in gp120 that allows it to also interact with a co-receptor, usually CCR5 or CXCR4, on the host cell surface. This dual receptor binding is essential for the virus to proceed to the next step.
Fusion: After binding, the HIV viral envelope fuses with the host cell membrane, allowing the viral contents to enter the host cell. The conformational change in gp120 caused by CD4 and co-receptor binding exposes another viral protein, gp41. gp41 facilitates the merging of the viral envelope with the host cell membrane, creating a fusion pore through which the viral capsid containing the viral RNA and enzymes can enter the host cell cytoplasm.
Reverse Transcription: Once inside the host cell, the viral RNA genome is reverse transcribed into DNA. The enzyme reverse transcriptase, carried within the viral capsid, converts the single-stranded viral RNA into double-stranded DNA. This process is error-prone, leading to a high mutation rate which contributes to the virus’s ability to evade the immune system and develop drug resistance.
Integration: The newly synthesized viral DNA is integrated into the host cell’s genome. The viral DNA is transported into the host cell nucleus, where the enzyme integrase integrates it into the host cell’s DNA. This integrated viral DNA is known as a provirus and can remain dormant for a period before becoming active.
Replication: Once integrated, the viral DNA can be transcribed and translated to produce new viral RNA and proteins. The host cell’s machinery reads the integrated viral DNA and begins to produce viral RNA. Some of this RNA will serve as genomes for new viral particles, while others will be used to produce viral proteins through the process of translation.
Assembly: New viral particles are assembled within the host cell. The newly made viral RNA and proteins are transported to the host cell’s surface, where they assemble into new immature viral particles. This assembly process involves the gathering of viral components into a budding virion.
Budding: The new viral particles bud off from the host cell, acquiring an envelope from the host cell membrane in the process. The immature viral particles bud off from the host cell, during which they incorporate a portion of the host cell’s membrane as their envelope. The viral enzyme protease then cleaves certain viral precursor proteins into their mature forms, resulting in a fully mature and infectious virus ready to infect other cells.

$\"\"$

Clinical Manifestations of HIV/AIDS

The World Health Organization (WHO) has established a staging system to classify HIV infection and disease progression:

Clinical Stage I:

Asymptomatic: No symptoms of HIV-related illness.
Persistent Generalized Lymphadenopathy: Enlargement of lymph nodes lasting more than three months.
Performance Scale 1: Asymptomatic with normal activity level.

Clinical Stage II:

Moderate Weight Loss: Less than 10% of presumed or measured body weight lost.
Minor Muco-cutaneous Manifestations: Skin conditions like seborrheic dermatitis, prurigo, or fungal nail infections.
Herpes Zoster: History of shingles within the last five years.
Recurrent Upper Respiratory Tract Infections: Such as bacterial sinusitis, tonsillitis, or otitis media.
Performance Scale 2: Symptomatic but normal activity level.

Clinical Stage III:

Severe Weight Loss: More than 10% of presumed or measured body weight lost.
Unexplained Chronic Diarrhoea: Lasting more than one month.
Unexplained Prolonged Fever: Constant or intermittent, lasting more than one month.
Oral Candidiasis: Oral thrush, a fungal infection.
Oral Hairy Leukoplakia: White patches on the tongue or mouth.
Pulmonary Tuberculosis: Active TB infection.
Severe Bacterial Infections: Such as pneumonia, pyomyositis, or bacteremia.
Acute Necrotizing Ulcerative Gingivitis: Severe gum disease.
Unexplained Anaemia, Neutropenia, or Thrombocytopenia: Abnormal blood counts.
Performance Scale 3: Bedridden for less than 50% of the day during the last month.

Clinical Stage IV:

HIV Wasting Syndrome: Weight loss of more than 10% with chronic diarrhoea or prolonged fever.
Pneumocystis Pneumonia (PCP): A severe fungal lung infection.
Toxoplasmosis of the Brain: Brain infection caused by the Toxoplasma parasite.
Cryptosporidiosis: Parasitic infection causing prolonged diarrhea.
Cytomegalovirus Infection: A viral infection affecting various organs.
Progressive Multifocal Leukoencephalopathy (PML): Brain infection causing neurological symptoms.
Lymphoma: Cancer of the lymphatic system.
Kaposi’s Sarcoma: Cancerous skin lesions caused by a herpesvirus.
HIV Encephalopathy: Cognitive and/or motor dysfunction due to HIV infection.
Atypical Disseminated Leishmaniasis: Parasitic infection affecting multiple organs.
Symptomatic HIV-Associated Nephropathy or Cardiomyopathy: Kidney or heart disease associated with HIV.
Performance Scale 4: Bedridden for more than 50% of the day during the last month.

Diagnostic Measures for HIV/AIDS

Pre and Post-Counselling and Consent: Essential for all diagnostic procedures unless in specific circumstances:

Testing of very sick, unconscious, symptomatic, or mentally ill individuals by healthcare teams for better patient management.
Routine testing for individuals likely to pose a risk of HIV infection to others, such as pregnant and breastfeeding mothers, sexual offenders and survivors, and blood or organ donors. These individuals must still be given the opportunity to know their status.

Criteria for Diagnosis: Diagnosis based on:

Clinical Staging Criteria.
Positive HIV Blood Test: Confirmation of HIV infection through serological (antibody) testing.

Testing Protocol: Testing for Adults and Children >18 Months:

Serological (Antibody) Testing: Most common method. Due to the window period between infection and antibody production, negative individuals should be re-tested after three months if exposed.
Reactive Rapid Test: Requires confirmation before diagnosis.

Diagnostic Tests

Screening Tests:

ELISA (Enzyme-Linked Immunosorbent Assay) AglAb Tests: Commonly used to screen blood donations to exclude those in the window period.

Molecular Tests:

PCR (Polymerase Chain Reaction) Tests: Nucleic-Acid Amplification Testing (NAT) detects genetic material of HIV itself, not antibodies or antigens.

Considerations: Testing should consider:

Clinical status, medical history, and risk factors of the individual being tested.
Use of tests in conjunction with patient assessment for accurate diagnosis and appropriate care.

Immediate Connection to HIV Care

If positive, immediate referral to HIV care services for management and treatment initiation.

HIV Testing Provision Protocol

Step 1: Pre-Test Information and Counseling

Provide information on HIV transmission, prevention measures, and testing benefits.
Discuss potential test results, available services, and ensure consent and confidentiality.
Conduct individual risk assessment and complete necessary documentation.

Step 2: HIV Testing

Perform blood-based testing.

For infants below 18 months: Use DNA PCR testing.
For individuals above 18 months: Conduct antibody testing as per testing algorithms.

Step 3: Post-Test Counseling (Individual/Couple)

Assess readiness to receive results and deliver them simply.
Address concerns, provide guidance on disclosure, partner testing, and risk reduction.
Offer information on basic HIV care, ART, and complete documentation.

Step 4: Linkage to Other Services

Provide information on available services and assist in completing referral forms.
Upon enrollment in services, record pre-ART enrollment numbers and transfer relevant information to ART registers.

Principles of HIV Testing Services (HTS)

Confidentiality: Ensure privacy and confidentiality of test results.
Consent: Obtain informed consent from individuals before testing.
Counselling: Offer supportive counselling before and after testing.
Correct Test Result: Ensure accuracy of test results through proper testing procedures.
Connection to Other Services: Facilitate access to appropriate services for individuals testing positive.

Linkage from HIV Testing to Prevention, Care, and Treatment

Linkage is the process of connecting individuals who test positive for HIV to the necessary services.

Successful linkage to care ensures that patients receive the services they need. For HIV-positive clients, linkage should occur promptly, within seven days if within the same facility, and within 30 days for referrals between facilities or from the community. Lay providers are recommended as linkage facilitators.

Types of Linkages:

Internal Facility Linkage: Connecting patients within the same facility.
Inter-Facility Linkage: Connecting patients to another facility.
Community-Facility Linkage: Connecting clients from the community to a health facility.

Internal Facility Linkage Steps:

Post-Test Counselling: Provide accurate results and information about available care.
Next Steps Discussion: Describe the care and treatment process, emphasizing early treatment benefits.
Address Barriers: Identify and overcome any obstacles to linkage.
Involvement: Involve the patient and family in decision-making.
Documentation: Complete client and referral forms.
Escort to Clinic: A linkage facilitator escorts the client to the ART clinic.
Enrollment: Register the patient, open an ART file, and provide preparatory counselling.
Initiation: Start ART if ready, and continue with counselling support.
Integrated Care: Coordinate other services if needed.
Follow-Up: Ensure the patient attends appointments.

Inter-Facility and Community-Facility Linkages:

Inter-Facility Linkage: Refers to connecting patients to another facility. The referring facility should track referred patients and ensure enrollment within 30 days.
Community-Facility Linkage: Connects clients from the community to a health facility. Utilize community health systems and mobilize peer leaders for outreach and follow-up. Linkage should occur within 30 days after diagnosis.

Treatment Modalities of HIV/AIDS

Treatment Modality	Description
Antiretroviral Therapy (ART)	Suppresses viral load to undetectable levels, reducing morbidity, mortality, and transmission of HIV.
Treatment of Acute Bacterial Infections	Addresses immediate bacterial infections.
Prophylaxis and Treatment of Opportunistic Infections	Prevents and manages opportunistic infections.
Maintenance of Good Nutrition	Ensures adequate nutrition to support overall health.
Immunization	Administers vaccines to prevent opportunistic infections.
Management of AIDS-Defining Illnesses	Addresses specific illnesses associated with advanced HIV infection.
Psychological Support for the Family	Provides emotional support and guidance for affected families.
Palliative Care for the Terminally Ill	Offers comfort and support for patients nearing the end of life.

Antiretroviral Drug Treatment

Goal of ART: Suppress viral load to undetectable levels, reducing morbidity, mortality, and transmission of HIV.

When to Initiate ARV:

All HIV-infected children below 12 months.
Clinical AIDS
Mild to moderate symptoms and immunosuppression.

Process of Starting ART:

Assess for opportunistic infections, defer ART if TB or cryptococcal meningitis present.
Offer ART on the same day through an opt-out approach.
If not ready for same-day initiation, agree on a timely ART preparation plan.

Available ARVs in Uganda

Drug Class	Examples
Nucleoside Reverse Transcriptase Inhibitors (NRTIs): Incorporate into the DNA of the virus, thereby stopping the building process.	Tenofovir (TDF), Zidovudine (AZT), Lamivudine (3TC), Abacavir (ABC)
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs): stop HIV production by binding directly onto the reverse transcriptase enzyme, and prevent the conversion of RNA to DNA.	Efavirenz (EFV), Nevirapine (NVP), Etravirine (ETV)
Integrase Inhibitors: interfere with the HIV DNA’s ability to insert itself into the host DNA and copy itself.	Dolutegravir (DTG), Raltegravir (RAL)
Protease Inhibitors (PIs): prevent HIV from being successfully assembled and released from the infected CD4 cell.	Atazanavir (ATV), Lopinavir (LPV), Darunavir (DRV)
Entry Inhibitors: prevent the HIV virus particle from infecting the CD4 cell.	Enfuvirtide (T-20), Maraviroc

Recommended First Line Regimens in Adults, Adolescents, Pregnant Women and Children

HIV management guidelines are constantly being updated according to evidence and public policy decisions. Always refer to the latest official guidelines.

The 2022 guidelines recommend DOLUTEGRAVIR (DTG) an integrase inhibitor as the anchor ARV in the preferred first and second-line treatment regimens for all HIV infected clients; children, adolescents, men, women (including pregnant women, breastfeeding women, adolescent girls and women of child bearing potential).

Patient Category	Preferred Regimens	Alternative Regimens
Adults and Adolescents
Adults (including pregnant women, breastfeeding mothers, and adolescents ≥30Kg)	TDF + 3TC + DTG	– If DTG is contraindicated: TDF + 3TC + EFV400 – If TDF is contraindicated: TAF + FTC + DTG – If TDF or TAF is contraindicated: ABC + 3TC + DTG – If TDF or TAF and DTG are contraindicated: ABC + 3TC + EFV400 – If EFV and DTG are contraindicated: TDF + 3TC + ATV/r or ABC + 3TC + ATV/r
Children
Children ≥20Kg – <30Kg	ABC + 3TC + DTG	– If DTG is contraindicated: ABC + 3TC + LPV/r (tablets) – If ABC is contraindicated: TAF + FTC + DTG (for children >6 years and >25Kg) – If ABC and TAF are contraindicated: AZT + 3TC + DTG
Children <20Kg	ABC + 3TC + DTG	– If intolerant or appropriate DTG formulations are not available: ABC + 3TC + LPV/r granules – If intolerant to LPV/r: ABC + 3TC + EFV (in children >3 years and >10Kg) – If ABC is contraindicated: AZT + 3TC + DTG or LPV/r

Notes:

Contraindications for DTG include known diabetics, patients on anticonvulsants (carbamazepine, phenytoin, phenobarbital) – use the DTG screening tool prior to DTG initiation.
Contraindications for TDF and TAF include renal disease and/or GFR <60ml/min, weight <30Kg.
TAF can be used in subpopulations with bone density anomalies.
Children will be assessed individually for their ability to correctly take the different formulations of LPV.

Notes from Ministry of Health

For clients on an ABC-3TC-DTG based regimen weighing >25 kg, use the fixed-dose combination of Abacavir/Lamivudine/Dolutegravir 600/300/50 mg instead of the separate pills of Abacavir/Lamivudine 600/300 mg plus Dolutegravir 50 mg.
Use Abacavir/Lamivudine 600/300 mg for patients on the following regimens: ABC-3TC-ATV/r, ABC-3TC-LPV/r, and ABC-3TC-DRV/r.
Use the single pill of Dolutegravir 50 mg for patients on AZT-3TC-DTG based regimens.
For eligible patients on ATV/r and LPV/r, optimize to Dolutegravir.
For PrEP, while the guidelines provide options for the use of either TDF/3TC 300/300 mg or TDF/FTC 300/200 mg, use TDF/FTC 300/200 mg for PrEP in terms of programmatic implementation.

Monitoring of ARV Treatment

The monitoring of patients on antiretroviral therapy (ART) serves several purposes:

Assess Response to ART and Diagnose Treatment Failure
Ensure Safety of Medicines: Identify Side Effects and Toxicity
Evaluate Adherence to ART

Methods of Monitoring ARV Treatment

1. Clinical Monitoring: Involves medical history and physical examination.

2. Laboratory Monitoring: Includes various laboratory tests.

Viral Load Monitoring: Preferred for assessing response to ART and diagnosing treatment failure.
CD4 Monitoring: Recommended in specific scenarios.
Other Minor Laboratory Tests: Includes tests for specific indications.

Viral Load Monitoring

Preferred method for monitoring ART response. A patient who has been on ART for more than 6 months and is responding to ART should have viral suppression (VL <1000 copies/ml) irrespective of the sample type (either DBS or plasma).
Provides an early and more accurate indication of treatment failure and the need to switch from first line to second-line drugs, hence reducing the accumulation of drug resistance mutations and improving clinical outcomes.
Early and accurate indication of treatment failure.
Differentiates between treatment failure and non-adherence.
Recommended frequency: Every six months for children and adolescents under 19 years.

CD4 Monitoring

Baseline CD4 count is essential for assessing opportunistic infection risk.
Recommended for patients with high viral load or advanced clinical disease.

Other Laboratory Tests

Tests	Indication
CrAg	Screen for cryptococcal infection
Complete Blood Count (CBC)	Assess anaemia risk
TB Tests	Suspected tuberculosis
Serum Creatinine	Assess kidney function
ALT, AST	Evaluate liver function
Lipid Profile, Blood Glucose	Assess metabolic health

HIV AND PREGNANCY

In 2004, the WHO reported that 40 million people were infected with HIV/AIDS, including 17.6 million women, 2.7 million children, and 13 million orphans worldwide. In 2005, 700,000 children became infected with HIV, with approximately 95% arising from mother-to-child transmission of HIV (MTCT). Ninety percent of new infections in children occur in Africa due to the near non-existence of PMTCT interventions.

Mother-to-child transmission (MTCT) is the vertical transmission of HIV from mother to child that occurs during pregnancy, childbirth, and breastfeeding. The most probable point of transmission occurs in the late third trimester and even more so during the intrapartum period. In some areas of the world, MTCT has been virtually eliminated thanks to the availability of specific interventions to reduce the risk of transmission. These interventions include:

Effective voluntary and confidential testing and counselling.
Access to Antiretroviral Therapy (ART).
Safe delivery practices.
Availability and safe use of breast milk substitutes.

Factors Affecting Perinatal Transmission

HIV-related Factors:

Viral load: The higher the viral load, the greater the risk of transmission.
Strain variation (genotype): HIV1 or 2.
Biological growth characteristics.
CD4 cell count: Lower CD4 count or decreased CD4
ratio is associated with increased risk of transmission.

Maternal and Obstetric Factors:

Clinical stage: Primary infection with greater viremia is associated with increased risk.
STDs: Increased HIV shedding in genital tract epithelial disruption is associated with an increased risk of transmission.
Sexual behavior: Unprotected sex with multiple partners is associated with increased risk.
Placental abruption: Disruption of fetal-placental barriers increases exposure to the fetus.
Duration of membrane rupture: The transmission rate is directly proportional to the increased duration of rupture of membranes, with a 2% increase for each hour increment.
Gestational age at delivery: Prematurity is associated with increased risk.
Invasive procedures in labor such as episiotomy, vacuum delivery, artificial rupture of membranes.
Modes of delivery: A study in developed countries shows that elective cesarean section done prior to rupture of membranes and labor significantly reduces the risk of perinatal transmission. Planned cesarean section surgery must be considered in the context of the woman’s life and availability of local resources.
Knowledge of HIV status combined with accessibility to and acceptance of ART decreases transmission.
Substance abuse: Substance use during pregnancy is associated with increased risk.

Maternal and Neonatal Factors:

Immature immune system (especially in preterm babies).
Genetic susceptibility.

Breastfeeding:

Without ART, the risk of transmission through breastfeeding by an infected mother may increase the risk to a total of 20-45%.
Where breastfeeding is common and prolonged, transmission through breastfeeding may account for up to half of HIV infections in infants and young children.
Early findings show a low rate of transmission through breastfeeding in the first 3 months in infants receiving prophylaxis with either Lamivudine or Nevirapine.
The risk can be reduced to under 2% by a combination of antiretroviral prophylaxis during pregnancy and delivery, and to the neonate, with elective cesarean section and avoidance of breastfeeding.
Availability of safe breast milk substitutes must be considered, including a safe water supply, when educating and counseling women to avoid breastfeeding.

Strategies for Prevention of Mother-to-Child Transmission (PMTCT):

Primary prevention of HIV among prospective parents.
Prevention of unwanted pregnancy among HIV-infected women.
Prevention of MTCT among HIV-infected mothers through:

Provision of voluntary confidential counseling and testing.
Antiretroviral agents.
Safe delivery practices.
Safe infant feeding practices.
Support for the affected family and the community at large. Education and counseling services may help the woman’s family understand the issues and thus support the woman in her choice to prevent transmission of HIV to her baby.

Components of a Comprehensive HIV Prevention Program:

Health education, provision of information, and counseling on HIV prevention and care, including MTCT.
Voluntary confidential counseling and testing services that are acceptable and accessible.
Quality and focused antenatal care.
Safe delivery practices.
Support and counseling on infant feeding practices.
Family planning services.
Community mobilization and education to decrease stigma and discrimination against, as well as to increase support for, HIV-positive clients.

HIV AND PREGNANCY Read More »

Tuberculosis in Pregnancy

PULMONARY TUBERCULOSIS

Pulmonary Tuberculosis is an infectious disease of the lungs caused by acid-fast bacilli known as Mycobacterium.

INCIDENCE:

The incidence ranges between 1% and 2% amongst the hospital deliveries in the tropics, being confined predominantly to the underprivileged sectors of society. Incidence of tuberculosis is rising worldwide with the rising prevalence of HIV infected patients. In 2000, WHO showed the emergence of multidrug resistant tuberculosis (MDR-TB) all over the world. It is a “global health emergency”.

Causes of Tuberculosis in Pregnancy:

TB is caused by the bacterium Mycobacterium tuberculosis. This bacteria spreads through the air when an infected person coughs, sneezes, talks, or sings, releasing tiny droplets containing the bacteria. When a healthy person inhales these droplets, the bacteria can enter the lungs and cause infection.

Incubation Period:

The time between exposure to M. tuberculosis and the onset of symptoms is usually 4-6 weeks, but it can vary widely depending on individual factors.

Mode of Spread:

Droplet Infection: The primary mode of transmission is through airborne droplets released when an infected person coughs, sneezes, talks, or sings. These droplets contain the bacteria, which can be inhaled by a healthy person.
Sputum in Open Air Spaces: The presence of infected sputum in shared spaces can also facilitate transmission.
Drinking Unpasteurized Milk: While less common, bovine tuberculosis can be transmitted through unpasteurized milk.
Inhalation: Inhalation of contaminated dust containing M. tuberculosis can also lead to infection.

Types of Tubercle Bacterium:

Human Tuberculosis: This is the most prevalent form of TB, primarily spread through person-to-person contact through droplet infection.
Bovine Tuberculosis: This form is spread through infected animals, primarily cattle, and can be transmitted to humans through consumption of unpasteurized milk or contact with infected animals.

Types of Tuberculosis:

Pulmonary TB: This is the most common form of TB, affecting the lungs.

Signs & Symptoms:

Persistent Cough: A cough that lasts for more than 3 weeks, often with the production of sputum.
Sputum: Sputum may be purulent (containing pus), blood-stained (hemoptysis), or both.
Evening Fevers: Fluctuations in body temperature, with fever typically occurring in the evening.
Low-grade Fever and Malaise: Feeling unwell with a persistent low-grade fever and fatigue.
Night Sweats: Excessive sweating during the night.
Weight Loss: Significant and unexplained weight loss.
General Lymphadenopathy: Swelling of lymph nodes throughout the body.
Loss of Appetite: Decreased appetite and difficulty eating.
Pleural Effusion: Fluid accumulation in the space between the lungs and the chest wall.
Anemia and Massive Hemoptysis: Severe blood loss from the lungs, along with a decrease in red blood cells.
Enlargement of Cervical Glands: Swelling of lymph nodes in the neck.
Family History of Tuberculosis: Having a close family member with a history of TB increases the risk of infection.
Amenorrhea: Absence of menstruation, particularly in women who are of reproductive age.

Extra Pulmonary TB: This form of TB affects organs other than the lungs. While less common than pulmonary TB, it can be serious and life-threatening.

Affected Areas:

Meninges (Meningitis): Inflammation of the membranes surrounding the brain and spinal cord.
Abdominal Pelvic Organs: Can affect the intestines, stomach, liver, and reproductive organs.
Peritoneum: Inflammation of the membrane lining the abdominal cavity.
Spine (Tuberculous Spondylitis): Infection of the vertebrae, often resulting in pain, stiffness, and deformity.
Lymph Nodes: Swelling and inflammation of lymph nodes, particularly in the neck, armpits, and groin.
Bones: Can affect bones throughout the body, leading to pain, swelling, and joint dysfunction.

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Risk Factors for Tuberculosis in Pregnancy:

Pre-existing TB infection: A previous history of TB infection, even if treated, increases the risk of reactivation during pregnancy.
Exposure to infected individuals: Living with or working closely with someone who has TB increases the risk of infection.
Weakened Immune System: Pregnancy can temporarily suppress the immune system, making it easier for the TB bacteria to take hold and multiply.
Malnutrition and Anaemia: Pregnant women who are malnourished or anaemic have a weaker immune system, making them more susceptible to TB infection.
HIV Infection: HIV infection weakens the immune system significantly, increasing the risk of TB infection and making the disease more difficult to treat.
Other Underlying Health Conditions: Conditions like diabetes, chronic kidney failure, and alcoholism can weaken the immune system and increase the risk of TB infection.
Socioeconomic Factors: Poverty, overcrowding, poor sanitation, and inadequate access to healthcare can all contribute to the spread and development of TB.
Environmental Factors: Exposure to dust, smoke, and other airborne irritants can irritate the lungs, making them more susceptible to TB infection.

Diagnosis of Tuberculosis in Pregnancy:

Tuberculin Skin Test (TST): The TST involves injecting a small amount of purified protein derivative (PPD) under the skin. A positive reaction (induration ≥ 5 mm) indicates exposure to TB, especially in high-risk individuals (e.g., those with HIV).
Chest X-ray: A chest X-ray can reveal abnormalities in the lungs consistent with TB infection. However, it is usually performed after 12 weeks of pregnancy to minimize potential risks to the fetus.
Sputum Culture: Early morning sputum samples are collected for three consecutive days and examined for the presence of acid-fast bacilli (AFB), the hallmark of TB.
Gastric Washings: For individuals who cannot produce sputum, gastric washings can be analyzed for AFB.
Diagnostic Bronchoscopy: In some cases, a bronchoscopy, a procedure that allows for visualization of the airways, may be necessary to obtain tissue samples for diagnosis.
Extrapulmonary TB Diagnosis: TB can affect other organs like lymph nodes and bones (although rare in pregnancy).
Direct Amplification Tests: These tests, like PCR (polymerase chain reaction), amplify DNA specific to M. tuberculosis, allowing for sensitive and specific detection.

Investigations:

Sputum examination will reveal the bacilli.
Examination of aspirates for pleural effusion.
Tuberculosis skin test (to show whether the patient has been in contact with tuberculosis bacilli).
Biopsy, e.g., of lymph nodes.
Serology for HIV.
Blood smear for malaria parasites.
Chest X-ray examination.
Erythrocyte sedimentation rate (ESR).
Haemoglobin (HB).
Urinalysis.
Stool examination.

Management in Maternal/Child (M/C) Care:

Aims:

Health education about the disease.
Promote healing.

Procedure when a Mother Comes:

Create a nurse-patient relationship and take history (family, social, medical, and obstetrical).
Observations: Take TPR (temperature, pulse, respiration) and BP (blood pressure).
Conduct general and abdominal examinations.
Reassure the mother, document all findings, and refer her to a hospital.

In Hospital: During Pregnancy:

If sputum is negative, she can be treated as an outpatient before delivery, under the care of a physician and obstetrician.
She should visit ANC (Antenatal Care) regularly.
If she is infectious, she should be admitted to an isolation room.
Histories and observations (BP, TPR) are taken.
General and abdominal examinations are done, and the doctor is informed.
Prepare an examination tray for taking specimens for observations.
When the doctor comes, he examines the patient.

Medical Treatment: New Cases:

2EHRZ 6EH

Ethambutol (E) 25mg/kg.
Isoniazid (H) 300mg.
Rifampicin (R): <50kg: 450mg; ≥50kg: 600mg.
Pyrazinamide (Z): <50kg: 1.5g; ≥50kg: 2.0g.

Other Treatment for TB:

Relapse: Patients treated before, who had initial care but the disease reoccurred later.
Defaulters: Patients who stop treatment regardless of the reason.
Treatment: 2SE (HR) Z/IE (HR) Z/5EHR. Streptomycin 60 injections dose 0.75g (not given in pregnancy due to side effects).

Failures: Patients with positive sputum 2 months after starting treatment.

Treatment: 2 months SE (HR) Z/E (HR) 5 months SE (HR).

Side Effects of Drugs:

Some other drugs: pyridoxine, prednisone for TB meningitis, codeine phosphate to reduce the rate of spread of infectious bacteria.
All patients must be counseled before starting treatment to ensure understanding of the number of drugs, duration of treatment, and expected side effects.

Nursing Care:

Isolation room should be ventilated.
Diet: Plenty of protein and fluids; intake and output should be well recorded.
Rest and sleep: Important during day and night, with occupational therapy.
Hygiene: Daily bath, oral hygiene, spitting in a sputum mug (emptied and disinfected regularly), using disposable handkerchiefs that should be burned, changing and disinfecting bed sheets.
Exercise: Teach deep breathing to expand the lungs.
Position: Sitting up if dyspneic.
Observations: Take T, R, P, and BP; assess general condition and fetal well-being twice a week.
Bowel and bladder: Encourage regular bowel and bladder function.
Reassurance: Provide support and encouragement to the mother.

During Labour: Problems May Include:

Fatigue
Reduced lung function

Doctor\’s Case:

Inform the doctor, physician, obstetrician, and paediatrician once labour starts.
Manage the first stage as usual, with Oxygyen if ordered by the doctor. Use sitting up position if dyspneic.
In the second stage, use episiotomy, forceps, or vacuum extraction to reduce over-straining from pushing.
Perform C-section only for specific obstetrical indications, e.g., fetal distress.
Actively manage the third stage to prevent unnecessary blood loss.

During Puerperium:

Manage as other mothers.
If the mother has an active infection, she should breastfeed with a mask, and the baby should be taken back to the nursery.
No Contraindication: Breastfeeding is not contraindicated when a woman is taking anti-tuberculous drugs.
Avoidance: Breastfeeding should be avoided if the infant is also receiving anti-tuberculosis medications to prevent drug accumulation.
Active Lesions: Breastfeeding is contraindicated in cases of active TB. The infant should be isolated from the mother after delivery and given prophylactic isoniazid (10-20 mg/kg/day) for 3 months.
Chemotherapy: If the mother has been on effective chemotherapy for at least two weeks, there is no need to isolate the baby.
If the mother’s sputum is positive, give the baby BCG at birth and protect with isoniazid syrup (2.5mg/kg/day). The vaccine becomes effective in 3-6 weeks; if any family member is infected, separation is advised.
Mantoux test is carried out after 6 weeks.
If the mother is negative or inactive, she can stay with her baby.
Advise rest and sleep, and a well-balanced diet to avoid recurrence of active disease.
Avoid pregnancies until the disease has been controlled for 2 years.
Long-term medical and social follow-up is necessary to monitor the disease and its treatment.

Effects of TB on Pregnancy:

Maternal Effects on Pregnancy:

General Debilitation: TB weakens the mother\’s overall health, making it challenging to cope with the demands of pregnancy.
Placental Insufficiency: TB can impair placental function, leading to:

Premature Labor: Increased risk of delivering before term.
Intrauterine Fetal Death: Loss of the fetus during pregnancy.
Intrauterine Growth Retardation (IUGR): The fetus fails to grow at an appropriate rate due to inadequate nutrient and oxygen supply.

Fetal Hypoxia: Reduced oxygen levels in the fetus due to placental insufficiency.
Asphyxia: Severe oxygen deprivation in the fetus, potentially leading to brain damage or death.

During Labour:

Increased Risk of Assisted Deliveries: TB-related complications can increase the need for interventions like forceps or vacuum extraction.
Maternal and Fetal Distress: Both the mother and the fetus may experience complications during labor, such as heart rate abnormalities, due to TB-related physiological changes.
High Prenatal Mortality Rate: The risk of stillbirth is significantly elevated in mothers with TB.

Note: Pregnant or breastfeeding women with TB should be treated with short-course chemotherapy (e.g., Rifampicin, Isoniazid, Pyrazinamide, Ethambutol).

Effects on Puerperium:

Anaemia: TB can worsen existing anaemia or lead to new iron deficiency in the postpartum period.
Poor Lactation: TB can impair breast milk production, impacting infant nutrition.
Lowered Resistance to Infection: The mother\’s immune system is compromised, increasing her susceptibility to infections during the postpartum period.

Prevention:

In the Community:

Sensitize and mobilize the community to create awareness about TB.
Health education on ensuring well-ventilated homes, avoiding overcrowding, proper disposal of sputum, covering the mouth when coughing/sneezing, and screening family members.
Encourage good nutrition, drinking pasteurized milk products, disinfecting patients’ belongings, and immunizing children with BCG.
Ensure adequate management of chest infections and encourage mothers to attend ANC.

In Hospital:

Encourage mothers to attend ANC for thorough examinations, histories, and investigations for management.
Keep the hospital environment clean and dispose of refuse properly.
Ensure ward cleanliness by scrubbing floors, dusting windows, and cleaning equipment daily.
Health workers should avoid droplet infections, wash hands after every procedure, and isolate TB patients.

Complications:

Spontaneous Pneumothorax: A collapsed lung due to air leaking into the space between the lung and chest wall.
Pleural Effusion: Fluid buildup in the space between the lung and chest wall.
Gastrointestinal TB: TB infection affecting the digestive system.
Massive Hemolysis: Breakdown of red blood cells, leading to anemia and potentially fatal complications.
TB Meningitis: Infection of the membranes surrounding the brain and spinal cord.
TB Pericarditis: Inflammation of the sac surrounding the heart.
Anaemia: Iron deficiency, which can be exacerbated by TB infection.
Death: In severe cases, TB can be fatal, especially in pregnant women who are immunocompromised.
Hemoptysis: Coughing up blood due to lung damage.
High Maternal Mortality Rate: The risk of death from TB is significantly elevated in pregnant women.

Tuberculosis in Pregnancy Read More »

MALARIA IN PREGNANCY

Malaria is a febrile condition/disease caused by a Plasmodium parasite and is the most common cause of pyrexia in tropical regions, usually associated with rigors.

CAUSES

Malaria is caused by Plasmodium parasites (protozoa), which are of four types:

Plasmodium falciparum: This is the most dangerous species, responsible for the majority of malaria deaths worldwide. It can cause severe complications, including cerebral malaria, which can lead to coma and death. During pregnancy, P. falciparum infections are particularly dangerous, increasing the risk of low birth weight, preterm birth, and stillbirth.
Plasmodium vivax: This species is less deadly than P. falciparum but can still cause serious illness. It is characterized by relapses, where symptoms can reappear months after the initial infection. During pregnancy, P. vivax can cause anemia and increase the risk of miscarriage.
Plasmodium ovale: This species is similar to P. vivax in its symptoms and ability to cause relapses. It is less common than P. vivax and P. falciparum.
Plasmodium malariae: This species is the least common and usually causes a milder form of malaria. However, it can cause severe complications in some cases, particularly in pregnant women.

MODE OF ENTRY

Malaria parasites are transmitted by a female Anopheles mosquito. The mosquito spits saliva onto human skin to soften it. Since malaria parasites are stored in the saliva, they are introduced through the proboscis while the mosquito sucks blood, which is used by the female mosquito for egg maturation.

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MALARIA CYCLE

There are two cycles:

Malaria cycle in the mosquito (Sexual stage – union of male and female gametes to form a zygote)
Malaria cycle in humans (Asexual stage)

MALARIA CYCLE IN THE MOSQUITO (SEXUAL STAGE)

When a mosquito bites an infected person, it acquires gametocytes (sexual cells of a malaria parasite). After ingestion, these gametocytes travel through the blood to the mosquito\’s stomach, where they unite and form a zygote on the stomach walls.

Zygote → Ookinete → Oocyst → Sporozoite (mature malaria parasite still within the mosquito).

The sporozoites move to the mosquito\’s salivary glands, ready to be injected into a healthy person.

MALARIA CYCLE IN HUMANS (ASEXUAL STAGE)

An infected mosquito bites a healthy person, introducing sporozoites that spread within the body in approximately 30 minutes. These sporozoites enter the bloodstream and are transported to the liver for further development, known as PRIMARY TISSUE SCHIZONTS. The parasites develop and mature within liver cells, eventually destroying them. After about 7-14 days (incubation period), the parasites rupture from the liver cells as merozoites, entering the bloodstream to infect red blood cells.

Chronic malaria: Merozoites are the mature malaria parasites. They attack and feed on red blood cells until they destroy them completely, releasing waste products and causing the body to react.

CAUSES OF FEVER IN MALARIA

Presence of malaria parasites in the body is recognized as foreign by the immune system.
The rupture of red blood cells as the parasite destroys them triggers a response.
The release of toxins from the parasites causes fever due to waste products and destroyed haemoglobin.

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SIGNS & SYMPTOMS OF MALARIA

They range from mild to severe.

MILD TO MODERATE SIGNS & SYMPTOMS

Fever: Low-grade fever, often intermittent or fluctuating
Headache: Often severe and persistent
Joint pain: Muscles and joints may ache
Nausea and vomiting: Feeling sick to the stomach with or without throwing up
Anorexia: Loss of appetite
Abdominal issues: Constipation or diarrhea
Malaise: Feeling generally unwell and weak
Dizziness: Feeling lightheaded or unsteady
Nightmares: Disturbing dreams while sleeping

SEVERE MALARIA SYMPTOMS:

High fever: Persistent high temperature
Severe headache: Intense and unrelenting headache
Confusion and disorientation: Difficulty thinking clearly
Seizures: Uncontrolled muscle spasms
Coma: Loss of consciousness
Jaundice: Yellowing of the skin and eyes
Rapid breathing: Increased breathing rate
Kidney failure: Inability of the kidneys to filter waste
Blood in urine: Blood appearing in the urine
Severe anemia: Low red blood cell count

SEVERE SIGNS AND SYMPTOMS

Can also be characterized in four stages:

COLD STAGE: Patient feels very cold, increased pulse, nausea, and goosebumps.
RIGOR STAGE: Shivering attacks, fast pulse, nausea, and possible vomiting.
HOT STAGE: Temperature rises between 38-40°C, severe headache, vomiting, restlessness, and convulsions in children.
SWEATING STAGE: Temperature lowers, sometimes to normal or subnormal levels, lasting 3-4 hours, with or without treatment.

TREATMENT OF MALARIA

Classified into:

A. Uncomplicated malaria

B. Severe and complicated malaria

C. Intermittent preventive treatment

D. Severe malaria in pregnant women and children under 4 months

Uncomplicated Malaria

Artemether/Lumefantrine (50mg per tablet): Start with 200mg, then 100 mg daily.
Artesunate + Amodiaquine (similar to Artemether).

Second Line

Quinine (300mg per tablet): 600 mg dose every 8 hours for 7 days.

Severe and Complicated Malaria

Artemisinin combination therapies (ACTs)
Parenteral Artemether (IM or IV)
Quinine (600mg, adjusted by body weight)

Intermittent Preventive Treatment

Fansidar (1500mg, 3 tablets taken at once from 4 months or 16 weeks).

Severe Malaria in Pregnancy

Parenteral Quinine (600 mg every 8 hours): Given in the 1st trimester. After the 1st trimester, ACTs can be administered.
For children under 4 months or weighing below 5kg, Quinine is given.

SIGNS OF UNCOMPLICATED MALARIA

Fever: Intermittent or fluctuating fever, may be low-grade or high.
Headache: Often severe and persistent.
Chills: Episodes of shivering and cold sensations.
Sweats: Episodes of profuse sweating.
Muscle aches: Muscle soreness and pain.
Fatigue: Feeling tired and weak.
Nausea and vomiting: Feeling sick to the stomach with or without throwing up.
Diarrhea: Loose stools.
Loss of appetite: Decreased hunger.
Dehydration: Loss of body fluids, leading to dry mouth and skin.
Abdominal pain: Pain in the stomach area.

SIGNS OF COMPLICATED MALARIA

Severe anemia: Low red blood cell count, leading to fatigue, weakness, and pale skin.
Jaundice: Yellowing of the skin and eyes due to bilirubin buildup.
Renal failure: Kidney failure, leading to decreased urine output and waste buildup.
Cerebral malaria: Parasites infect brain cells, causing confusion, seizures, coma, and death.
Pulmonary edema: Fluid buildup in the lungs, leading to difficulty breathing.
Shock: Life-threatening condition where the body is unable to circulate blood effectively.
Metabolic acidosis: Build-up of acid in the blood, leading to various complications.
Hypoglycemia: Low blood sugar, potentially leading to seizures and coma.
Respiratory distress: Difficulty breathing, including rapid breathing and wheezing.
Bleeding: Increased risk of bleeding, including gastrointestinal bleeding.
Behavioural changes: Confusion, disorientation, delirium, and hallucinations.
Prostration: (trying to touch something that isn\’t there)

MANAGEMENT

The midwife manages mild cases of malaria and treats it as an outpatient. She treats malaria between 16-36 weeks of pregnancy due to the new drug policy.

First Line Drug

Refer mothers below 16 weeks and above 36 weeks of pregnancy for hospital management.

Steps for Management:

Welcome the mother, offer a seat, greet, and introduce yourself.
Take history (personal, problem, environment, pregnancy).
Make observations (TPR, BP, weight) and interpret them.
Conduct general and abdominal examinations to decide on treatment or referral.
Treat symptoms like fever, headache, and anaemia.
Administer appropriate medications (e.g., iron supplements, antimalarials).

NEW MALARIA TREATMENT POLICY

Uncomplicated Malaria

First-line treatment: Artemether or Artesunate + Amodiaquine
Second line: Quinine

Severe Malaria

Parenteral Quinine
Parenteral Artemisinin derivatives (ACTs)

Uncomplicated/Severe Malaria in Special Groups

Pregnant women in the first trimester are given Quinine. ACTs can be used after the 1st trimester.
For children under four months, Quinine is given while ACTs are contraindicated.

FOR SEVERE COMPLICATED MALARIA,

Admit the patient
Take history (personal, pregnancy, complications)
Inform the doctor
Prepare for examination and treatment
Administer emergency treatment and anti-malarial medications
Manage complications and provide supportive care

Emergency Treatment

Resuscitation with attention to the airway
IV infusion introduction
Effective anti-malarial medication administration based on body weight
Correct hypoglycemia with Dextrose
Correct/prevent dehydration
Reduce high body temperature with antipyretics
Control convulsions with Diazepam
Determine the need for blood transfusion

Supportive Care

Comfortable bed with a treated mosquito net
Clean environment and proper hygiene
Complete bed rest, daily baths, and tepid sponging
Oral hygiene every 4 hours
Adequate diet with small servings, sweetened foods, fruits, and vitamin supplements
Monitor bowel and bladder functions
Provide passive and active exercises
Regular observations (TPR, BP, fetal heart, weight, jaundice, blood smears)
Discharge with advice on diet, rest, medication, and mosquito net usage

COMPLICATIONS OF MALARIA

Effects on Pregnancy:

To the mother:

Increased Risk of Severe Malaria: Pregnancy significantly increases the susceptibility to severe malaria, putting mothers at higher risk of complications like cerebral malaria, pulmonary edema, and renal failure.
High Temperatures: Fever associated with malaria can cause intense discomfort and dehydration, particularly for pregnant women who are already experiencing hormonal changes and increased body temperature.
Anaemia: Malaria parasites destroy red blood cells, leading to anaemia, which can be exacerbated during pregnancy when blood volume increases. Severe anaemia can lead to fatigue, weakness, and shortness of breath, further jeopardizing the mother\’s health.
Puerperal and Cerebral Malaria: These life-threatening conditions pose a high risk to pregnant women. Puerperal malaria occurs during or after childbirth, while cerebral malaria involves the brain and can lead to coma and death.
Antepartum and Postpartum Haemorrhage: Malaria increases the risk of bleeding before or after childbirth, leading to severe blood loss and potential complications for both mother and baby.
Ill Health and Compromised Immunity: Malaria symptoms, including nausea, vomiting, diarrhoea, and loss of appetite, can affect a pregnant woman\’s health and worsen nutritional deficiencies. The weakened immune system makes her more susceptible to infections.
Jaundice and Dehydration: The buildup of bilirubin, a breakdown product of red blood cells, can cause jaundice, which further compromises the mother\’s health and can impact the baby\’s development. Dehydration, a common symptom of malaria, can lead to complications for both the mother and fetus.

To the baby:

Abortions: Malaria increases the risk of miscarriage, especially during the first trimester.
Prematurity: Malaria can trigger premature labor, leading to babies born before 37 weeks of pregnancy, increasing their risk of health problems.
Intrauterine Fetal Death (IUFD): Malaria can lead to the death of the baby in the womb, especially in the third trimester.
Low Birth Weight: Babies born to mothers with malaria are more likely to have low birth weight, increasing their risk of health problems and long-term developmental issues.
Congenital Malaria: The baby can be infected with malaria parasites in the womb, leading to complications at birth or later in life.
Intrauterine Growth Restriction (IUGR): Malaria can hinder the baby\’s growth in the womb, leading to smaller size at birth, impacting their long-term health and development.

Effects on the Ward:

Extended Hospital Stays: Malaria complications can lead to prolonged hospital stays, burdening healthcare resources and increasing the risk of infections.
Blockage of Space for Urgent Obstetric Cases: Long stays by malaria patients can limit space and resources for urgent obstetric cases, delaying critical care for other mothers.
Ward Congestion and Cross-Infection: Overcrowding due to malaria cases can increase the risk of cross-infection, affecting the health of other patients and healthcare workers.
Financial Strain on Families: Treatment and hospitalization for malaria can strain the finances of families, especially in developing countries where access to healthcare is limited.
Deprivation of Maternal Care for Children at Home: Mothers hospitalized for malaria are unable to care for their other children, potentially leading to neglect and health issues.
Economic Inefficiency: Malaria during pregnancy not only affects individual families but also impacts economic productivity due to lost work days, reduced income, and increased healthcare costs.

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EPILEPSY IN PREGNANCY

Epilepsy is a chronic disorder characterized by recurrent, unpredictable seizures due to temporary dysfunction of the brain\’s neurons producing excessive electrical discharge.

Although it typically presents in childhood, it has a second peak in older adults, with women of childbearing age accounting for 23% of those affected. The prevalence of epilepsy in pregnancy is 0.35%.

$\"Types$

Types of Epilepsy

A. Partial Epilepsy

1. Simple Partial Seizures:

Consciousness remains intact.
Experiences an aura (premonition).
Sensations like pins and needles in the arms or legs.
Pallor or a flushed face with sweating.
Muscle twisting in limbs with some stiffness.

2. Complex Partial Seizures:

Loss of memory of the event.
Hand rubbing.
Chewing and smacking of lips.
Random noises.
Unusual posture.

B. Generalized Epilepsy

1. Absence Seizures:

Staring and blinking.
Daydreaming with loss of awareness for 5-20 seconds (mainly affects children).

2. Myoclonic Seizures:

Brief muscle jerking in an arm or leg, lasting a fraction of a second while remaining conscious.
All body muscles contract for less than 20 seconds without convulsions, causing the individual to fall.

3. Tonic-Clonic Seizures:

Whole body contracts, arms and legs convulse.
Incontinence is possible.
Lasts 1-2 minutes, leaving the individual tired and wanting to sleep.
The most common type of seizure (60% of cases).

4. Atonic Seizures:

Sudden loss of muscle tone, causing the individual to fall limply.
Head injury is probable, but the individual gets up immediately with no confusion.

Causes of Epilepsy in Pregnancy

Idiopathic: Most cases have no underlying cause.
Genetic Predisposition: 30% of cases have a family history of epilepsy.
Secondary Epilepsy: Can be encountered in pregnancy in patients with:

Previous brain surgery.
Intracranial mass lesions (e.g., meningiomas and arteriovenous malformations).
Antiphospholipid syndrome.

Other Causes of Seizures in Pregnancy

Eclampsia.
Cerebral vein thrombosis (CVT).
Thrombotic thrombocytopenic purpura (TTP).
Stroke.
Subarachnoid hemorrhage.
Drug and alcohol withdrawal.
Hypoglycemia.
Infections (e.g., tuberculoma, toxoplasmosis).
Gestational epilepsy (seizures confined to pregnancy).

Diagnosis

Most women are already diagnosed with epilepsy. However, if a first seizure occurs during pregnancy, the following investigations are appropriate:

Blood pressure, urinalysis, platelet count, clotting screen, blood film.
Blood glucose, serum calcium, serum sodium, liver function tests.
CT or MRI of the brain.
EEG (electroencephalogram).

Effects of Epilepsy on Pregnancy

On the Fetus:

No increased risk of miscarriage or obstetric complications unless a seizure results in abdominal trauma. This is a positive aspect, indicating that epilepsy itself doesn\’t inherently increase the risk of these complications.
Fetal malformations: These can include a range of abnormalities affecting various organs and systems.
Intrauterine growth restriction (IUGR): This refers to the fetus not growing at the expected rate, potentially leading to low birth weight.
Oligohydramnios: This is a condition where there is too little amniotic fluid surrounding the fetus, which can be associated with developmental issues.
Preeclampsia: This is a serious condition characterized by high blood pressure and protein in the urine, which can affect both mother and fetus.
Stillbirths: This refers to the death of a fetus before birth.

On the Newborn:

Birth defects are increased two-fold. This could be related to the severity of the disease and also due to the anticonvulsants used. Pattern of abnormalities is related to the type of anticonvulsant drugs (valproate 5.9%, Carbamazepine, 2.3% and Lamotrigine 2.1%).
The malformations include—Cleft lip and/or palate, mental retardation, cardiac abnormalities, limb defects and hypoplasia of the terminal phalanges. Sodium valproate is associated with neural tube defects.
There is chance of neonatal hemorrhage and is related to anticonvulsant induced reduction of coagulation factors (vitamin K dependent). The risk of developing epilepsy to the offspring of an epileptic mother is 10%.

On the Mother:

Increased risk of seizures during pregnancy and postpartum. Hormonal changes and physiological stress associated with pregnancy can trigger seizures.
Potential for worsening of epilepsy. Some women may experience an increase in seizure frequency or severity during pregnancy.
Difficulty in managing epilepsy medication during pregnancy. Many anticonvulsants are teratogenic (can cause birth defects), requiring careful consideration and monitoring.
Increased risk of postpartum depression. This can be exacerbated by the challenges of managing epilepsy and raising a child.
Stress and anxiety associated with pregnancy and childbirth. The fear of seizures and their potential impact on the baby can contribute to maternal stress.

Management of Epilepsy in Pregnancy

Pre-Pregnancy Counseling

1. Control of Epilepsy:

Maximize seizure control with the lowest dose of the most effective treatment.
Review antiepileptic drugs (AEDs) considering the risk of teratogenesis and adverse neurodevelopmental effects.

2. Stopping Treatment:

AEDs should be withdrawn slowly to reduce the risk of withdrawal-associated seizures, particularly important for benzodiazepines and phenobarbitone.
Current recommendations suggest stopping driving from the start of the drug withdrawal period and for six months after cessation of treatment if there are no seizures.

Newer Drugs with Safety Profiles:

Topiramate: 100–400 mg/day.
Levetiracetam: 1–3 gm/day, not an enzyme inducer.

Folic Acid: All women on AEDs should take pre-conception folic acid 4 mg daily starting before pregnancy and continuing throughout pregnancy.

Antenatal Management

1. Medication:

Keep the dose of chosen drugs as low as possible and monitor serum levels regularly.
Commonly used drugs include:

Phenobarbitone (60-100mg daily in divided doses).
Phenytoin (150-300mg daily in divided doses).
Carbamazepine (0.8-1.2g daily in divided doses).

Continue folic acid daily before conception and throughout pregnancy to prevent folate-deficiency anemia.

2. Seizure Control:

IV Phenytoin: Administer a slow loading dose of 15–20 mg/kg for effective, long-duration control with fewer side effects.
Benzodiazepines: 10–20 mg slow IV if phenytoin is not effective.

3. Support:

Educate relatives, friends, and partners on placing the woman in the recovery position to prevent aspiration during a seizure.
Administer Vitamin K (10 mg daily) orally in the last two weeks of pregnancy.
Intrapartum Management

4. Seizure Risk:

The risk of seizures increases around delivery. Women with major convulsive seizures should deliver in a hospital.
Continue anticonvulsant medication throughout labor with regular review by the obstetric team.
Administer short-acting benzodiazepines if seizures recur.

5. Labor and Delivery:

Women should not be left alone during labor, and dehydration, hyperventilation, and exhaustion should be avoided as they can trigger seizures.

6. Vitamin K:

10 mg daily orally to the mother in the last two weeks of pregnancy.
Infant: 1 mg IM at birth to prevent neonatal hemorrhage
Birth can be spontaneous, facilitated by the midwife. Administer vitamin K to the baby promptly after birth to protect against AED-induced hemorrhagic disease.
Caesarean section is only necessary for recurrent generalized seizures in late pregnancy or labor.

Postpartum Management

7. Seizure Risk:

The risk of seizures increases in the first 24 hours after birth, so the woman should remain in the hospital.
Encourage breastfeeding.
Monitor the baby closely and report any concerns to the pediatrician immediately.
Provide safety advice for caring for the baby in case of maternal seizures.

8. Breastfeeding:

There is no contraindication for breastfeeding.
Infant: May be drowsy due to medication.

9. Postpartum Management:

Readjustment of Anticonvulsant Dosage: Reduce to pre-pregnancy levels by 4–6 weeks postpartum.

10. Contraception:

Avoid steroidal contraceptives due to hepatic microsomal enzyme induction.

11. Risk to Infant:

The risk of having epilepsy in an infant born to a mother with a seizure disorder is four times higher compared to infants born to mothers without a seizure disorder.

Complications Associated with Epilepsy

Trauma: During seizures, injuries such as tongue biting and head or limb injuries can occur.
Status Epilepticus: A seizure lasting more than 30 minutes or a series of seizures without regaining consciousness between them.
Sudden Unexpected Death in Epilepsy (SUDEP): An unexplained sudden death in a person with epilepsy.

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