5.7 Cholera and pregnancy | MSF Medical Guidelines

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5.7.1 Features of cholera in pregnant women

Pregnant women are not at any greater risk of being infected by Vibrio cholerae, nor developing symptoms than the general population. Cholera may affect women at any stage of pregnancy.

The symptoms and complications of cholera (mild to severe dehydration, hypovolaemic shock, etc.) are identical to those of other patients, but dehydration can also lead to foetal complications in a significant proportion of cases (spontaneous abortion, pre-term labour, intra-uterine foetal death).

Objectives of treatment are to:

Prevent or correct maternal dehydration using the fluid volume needed for effective rehydration.
Protect the foetus by maintaining the maternal systolic blood pressure above 90 mmHg to ensure adequate uterine blood flow.

5.7.2 Initial clinical evaluation

In the first trimester, the initial evaluation is the same as for all other patients.
In the second and third trimester, place the woman in the supine position on her left side a Citation a. Avoid positioning the patient on her back: as pregnancy progresses, the increasing weight and positional rotation of the uterus will compress the inferior vena cava reducing blood flow to the heart and decreasing cardiac output. and:
- Use the standard criteria to determine the degree of dehydration (Section 5.2); perform the skin pinch under the clavicles, rather than the gravid abdomen.
- Measure the systolic blood pressure (SBP).
- Measure body weight, whenever possible (on admission or as soon as the patient is able to stand safely).

5.7.3 Treatment

In the first trimester, rehydration and clinical surveillance are standard.

In the second or third trimester: see Table 5.7.

Table 5.7 - Treatment and surveillance in the second or third trimester

Initial diagnosis	Treatment and surveillance
Severe dehydration (regardless of SBP) OR SBP ≤ 90 (regardless of the degree of dehydration)	Treatment Immediate: Bolus of 30 ml/kg (a) Citation a. If the patient cannot be weighed on admission, administer a bolus as for a 60 kg adult (2 litres in 30 minutes). Once stable, measure the patient’s weight if possible to adjust the fluid volume for the remainder of the IV infusion. of RL over 30 minutes Repeat the bolus if: the pulse remains weak, or SBP remains ≤ 90, or consciousness remains altered Once the patient has stabilized: Continue with 70 ml/kg of RL over 3-4 hours + If little or no vomiting (b) Citation b. If the patient is vomiting frequently or is otherwise unable to retain ORS, on-going fluid losses can be replaced via the IV route (add at least 250 ml of RL for each stool). : at least 250 ml of ORS after each stool single dose antibiotherapy within 4 hours or as soon as possible Surveillance Standard surveillance (Section 5.3.2) + SBP every 30 minutes during the first 4 hours. If the SBP is again ≤ 90 or danger signs reappear, repeat boluses of 30 ml/kg over 30 minutes until the SBP is > 90 and/or danger signs resolve then, resume the previous infusion of 70 ml/kg. Subsequently, adapt the surveillance of maternal SBP, according to the severity of fluid loss from diarrhoea.
Some dehydration AND SBP > 90	Treatment Oral rehydration: 75 ml/kg ORS over 4 hours + at least 250 ml of ORS after each stool + single dose antibiotherapy If the patient has difficulty drinking ORS, pass rapidly to IV rehydration (75 ml/kg of RL). Surveillance Standard surveillance (Section 5.4.2) + SBP every 30 minutes. If the SBP is ≤ 90 or signs of severe dehydration appear, start IV therapy for severe dehydration.
No dehydration AND SBP > 90	At least 250 ml of ORS after each stool under observation for 4-6 hours + single dose antibiotherapy

Initial diagnosis

Treatment and surveillance

Severe dehydration
(regardless of SBP)
OR
SBP ≤ 90 (regardless
of the degree of
dehydration)

Treatment

Immediate:

Bolus of 30 ml/kg (a) Citation a. If the patient cannot be weighed on admission, administer a bolus as for a 60 kg adult (2 litres in 30 minutes). Once stable, measure the patient’s weight if possible to adjust the fluid volume for the remainder of the IV infusion. of RL over 30 minutes

Repeat the bolus if:

the pulse remains weak, or
SBP remains ≤ 90, or
consciousness remains altered

Once the patient has stabilized:

Continue with 70 ml/kg of RL over 3-4 hours

If little or no vomiting (b) Citation b. If the patient is vomiting frequently or is otherwise unable to retain ORS, on-going fluid losses can be replaced via the IV route (add at least 250 ml of RL for each stool). :

at least 250 ml of ORS after each stool
single dose antibiotherapy within 4 hours or as soon as possible

Surveillance
Standard surveillance (Section 5.3.2) + SBP every 30 minutes during
the first 4 hours.
If the SBP is again ≤ 90 or danger signs reappear, repeat boluses of
30 ml/kg over 30 minutes until the SBP is > 90 and/or danger signs
resolve then, resume the previous infusion of 70 ml/kg.
Subsequently, adapt the surveillance of maternal SBP, according to
the severity of fluid loss from diarrhoea.

Some dehydration
AND
SBP > 90

Treatment
Oral rehydration: 75 ml/kg ORS over 4 hours
+ at least 250 ml of ORS after each stool
+ single dose antibiotherapy
If the patient has difficulty drinking ORS, pass rapidly to IV
rehydration (75 ml/kg of RL).

Surveillance
Standard surveillance (Section 5.4.2) + SBP every 30 minutes.
If the SBP is ≤ 90 or signs of severe dehydration appear, start IV
therapy for severe dehydration.

No dehydration
AND
SBP > 90

At least 250 ml of ORS after each stool under observation for
4-6 hours
+ single dose antibiotherapy

Antibiotic therapy

A dose of antibiotic will be given to all pregnant women, regardless of the stage of pregnancy or the degree of dehydration.
The goal of antibiotic therapy is:
1. Shorten the duration of diarrhoea, thus the period during which the pregnant woman could become dehydrated;
2. Reduce the duration of vibrio excretion in stools (to 48-72 hours in most cases) which will facilitate their admission to a maternity ward in the event of serious obstetrical complications.
Azithromycin PO (1 g single dose) is the antibiotic of choice.

Hypoglycaemia and hypokalaemia

There is no evidence that systematically adding glucose or potassium to rehydration fluid is beneficial for the foetus.
If the mother presents with clinical signs of hypoglycaemia or hypokalaemia, then appropriate therapy should be given (Section 5.10.1).

5.7.4 Obstetrical evaluation

Once the patient’s state of dehydration has been evaluated and the SBP measured (and after the initial bolus in the event of IV rehydration)

A simple obstetrical evaluation can be performed:

1. Estimate the gestational age by measuring the fundal height.
2. Listen for foetal heartbeat (using a Pinard stethoscope or Doppler, if available).

Take a history to determine if there has been any bleeding, pain, contractions, loss of foetal movements. Check for these signs daily to determine if there has been any intervening change.

For more information, see Essential obstetrics and newborn care, MSF.

5.7.5 Responding to obstetrical complications of cholera

Intra-uterine foetal death

Intra-uterine foetal death (suspected in case of loss of foetal movements and absence of foetal heart sounds on auscultation) does not require an emergency transfer. In the absence of any complications that threaten the life of the mother (e.g. eclampsia), transfer to a maternity ward for confirmation of foetal demise and delivery of the stillborn can be organized at discharge from the CTC.

Spontaneous abortion

There is no urgency to transfer the patient to a maternity ward in the absence of persistent significant bleeding.
At discharge from the CTC, refer the patient to a maternity ward to verify if expulsion is complete and evacuate the uterus if the expulsion was incomplete.

Threatened premature delivery

Between 26 and 34 weeks of gestation:
- If the cervix is dilated, transfer to a maternity unit for tocolysis, lung maturation, and neonatal care. Prior to transfer, stabilize the patient haemodynamically with RL (SBP > 90).
- If the cervix is closed, the contractions will likely stop as cholera resolves. If contractions persist after rehydration is completed, transfer to a maternity unit for possible treatment of premature labour.
Allow the labour to continue if gestational age is > 34 weeks, intra-uterine foetal death, or the life of the mother is in danger (e.g. severe pre-eclampsia), or labour has progressed too far.

Post-partum haemorrhage b Citation b. Loss of more than 500 ml (normal volume) of blood within the first 24 hours following delivery.

Organize a rapid transfer to an obstetrical centre. Haemorrhage imposes an immediate threat to the life of the mother and must be managed in a maternity unit with the necessary means (surgery, transfusion, resuscitation).
Depending on the context, arrange for family members who are willing to donate blood to accompany the patient.
Prior to transfer:
- Stabilize the patient haemodynamically with RL.
- Depending on the available means and clinical experience of the medical staff: administer a uterotonic agent (oxytocin if available and kept refrigerated c Citation c. Oxytocin can only be used if it is kept refrigerated, between 2 °C and 8 °C. When it is kept at room temperature, there is a loss of efficacy of the active ingredient and therapeutic effectiveness. Misoprostol has the advantage of being thermostable. or misoprostol); insert Foley catheter to promote uterine contractions, perform uterine massage to expel any clots and aid uterine contraction. For more information, see Essential obstetrics and newborn care, MSF.

There are other severe complications of pregnancy that are not linked to cholera which could occur during the admission of a pregnant woman to a CTC. Certain pathologies such as severe pre-eclampsia or ante-partum haemorrhage are in general too complex to be managed in a standard CTC. These justify a rapid transfer to an obstetrical centre.
In case of premature rupture of membranes, there is not an immediate need of transfer; antibiotics should be started first and transfer arranged when possible. Choice of antibiotic depends on timing of rupture and presence or absence of active labour or infection. For more information, see Essential obstetrics and newborn care, MSF.

If the patient has had no complications during hospitalisation in the cholera facility, direct her when discharged, to ante-natal care if she is not already enrolled.

5.7.6 Managing a normal delivery

For normal delivery, see Essential obstetrics and newborn care, MSF. Wait as long as possible before assisting in the rupture of membranes just prior to delivery.

If the neonate comes into contact with faeces, wash with soap and water (do not use a chlorine solution or other antiseptic solution).

Administration of antibiotic prophylaxis to the neonate for prevention of cholera is unnecessary.

For breast-feeding, the mother should wash her breasts (and hands) with soap and water before putting the neonate to feed (do not use a chlorine solution or other antiseptic solution).

At discharge from the CTC, refer the mother and neonate for post-natal consultation.

Footnotes

(a)Avoid positioning the patient on her back: as pregnancy progresses, the increasing weight and positional rotation of the uterus will compress the inferior vena cava reducing blood flow to the heart and decreasing cardiac output.
(b)Loss of more than 500 ml (normal volume) of blood within the first 24 hours following delivery.
(c)Oxytocin can only be used if it is kept refrigerated, between 2 °C and 8 °C. When it is kept at room temperature, there is a loss of efficacy of the active ingredient and therapeutic effectiveness. Misoprostol has the advantage of being thermostable.

(a)If the patient cannot be weighed on admission, administer a bolus as for a 60 kg adult (2 litres in 30 minutes). Once stable, measure the patient’s weight if possible to adjust the fluid volume for the remainder of the IV infusion.
(b)If the patient is vomiting frequently or is otherwise unable to retain ORS, on-going fluid losses can be replaced via the IV route (add at least 250 ml of RL for each stool).