Medical student Lecture

1. MALARIA IN PREGNANCY
BY
Dr Swati Singh
Dept. Of Obs & Gyn
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2. Malaria Facts
• 300 million malaria cases each year
worldwide
• 9 out of 10 cases occur in Africa
• An African dies of malaria every 10
seconds
• Affects 5 times as many as TB, AIDS,
measles and leprosy combined
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3. Malaria and the Obstetric patient
•
Every minute
– About 12 Nigerian women become pregnant
(WHO)
• All are predisposed to dangers of Mal in Preg
– Asymptomatic / Undetected / Untreated
* Agboghoroma (31%), Isah (3.1%)
•
11% of Maternal death is due to Malaria
Nigeria)
(NPC/UNICEF -
• There are also untoward effects on the unborn child
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4. MALARIA
Malaria is caused by one of 4 protozoan parasites:
Plasmodium falciparum
Plasmodium vivax
Plasmodium ovale
Plasmodium malariae
Malaria is transmitted through the bite of an infected
female Anopheles mosquito
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5. Malaria Parasite Life Cycle
Host
Parasite
Infecting vector
Infected vector
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6. Effects of Pregnancy on Malaria
 More common.
 Malaria is more common in pregnancy compared to the
general population probably due to Immuno
suppression and loss of acquired immunity to malaria.
 More atypical.
 In pregnancy, malaria tends to be more atypical in
presentation probably due to the hormonal ,
immunological and haematological changes of
pregnancy.
 More severe.
 Probably for the same reason, the parasitemia tends to
be 10 times higher and as a result, all the complications
of falciparum malaria are more common in pregnancy
compared to the non-pregnant population.
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7. Effects of Pregnancy on Malaria
 More fatal
 P. falciparum malaria in pregnancy is more severe,
the mortality is also double (13 % ) compared to
the non-pregnant population (6.5%).
 Selective treatment
 Some anti malarials are contra indicated in
pregnancy and therefore the treatment may
become difficult, particularly in cases of severe P.
falciparum malaria.
 Other problems
 Management of complications of malaria may be
difficult due to the various physiological changes
of pregnancy.
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8. Question
•What are the
effects of malaria
on the mother
and unborn
baby?
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9. EFFECTS OF MALARIA ON PREGNANCY
[Species, Transmission pattern, Parity & Others]
 Abortion – placental sequestration (pl sq)
 Anemia
 Cerebral malaria
 Low birth weight (Prematurity, IUGR) – pl sq
 Stillbirth
 Congenital infection
 Puerperal sepsis
 Maternal Mortality
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10. Management of malaria in pregnancy
involves three aspects that are of equal
importance
1. Treatment of the malaria
2. Management of complications
3. Prevention of recurrence
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11. TREATMENT OF MALARIA IN PREGNANCY
•
Depends on severity of the disease
- Simple / Uncomplicated
- Complicated
• Gestational age
- First trimester
- Second trimester
- Third trimester
• Aims at bringing attack/pyrexia to an end.
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12. QUESTION
•How do you
differentiate
simple malaria
from severe
malaria in a
pregnant woman?
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13. Recognizing malaria in
pregnant women
Uncomplicated malaria
•
•
•
•
•
Fever
Shivering/chills
Headaches
Muscle/joint pains
Nausea/vomiting (Can tolerate per
os)
• False labor pains
• + / ++
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14. Recognizing malaria in
pregnant women
Complicated
• Signs of uncomplicated
malaria, plus:
• Dizziness
• Breathlessness
• Sleepy/drowsy
• Confusion/coma
• Sometimes fits,
jaundice, severe
dehydration
• ++ / +++
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15. Simple / Uncomplicated Malaria
 1st trimester = Quinine ( safe and evidence-based)
 2nd and 3rd trimesters
1st Line =
2nd Line =
Arthemeter/Lumefantrine(Coartem)
Artesunate + Amodiquine
Artesunate + fansider
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16. Complicated Malaria
 All trimesters!
 Quinine




Parenteral, then Orals
Loading / maintenance
Hypoglycaemia
Absolutely safe!
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17. Supportive Treatment in Management
of Malaria in Pregnancy
 Adequate calories
 Correction of electrolyte imbalance
 Blood transfusion / EBT in acute and severe cases
 Oxygen + Diuretics in pulmonary oedema
 Anticonvulsants
 ICU for CM
 Dialysis for ARF
 Monitoring of the fetal growth & health
 Deceleration & death (Opare Addo)
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18. PREVENTION & CONTROL PROGRAMS
Available options are:
 Vector control
 Drug prophylaxis

Vaccination
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19. VECTOR CONTROL
• Insecticide Treated Nets (ITNs)
- Promote growth and development of fetus and newborn
- Shulman et al(2000), Isah/Ekele’2006 (?enough)
• Residual house hold spraying
• Environmental management
- Cleanliness is next to Godliness
- Drainage and water flow control
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20. •All pregnant women should receive at least two doses of IPT
after quickening at ANC visits (WHO recommends a schedule of
four visits, three after quickening)
•Intermittent preventive treatment (IPT) given 3 times during
pregnancy is effective for women with HIV/AIDS
•Presently, the most effective drug for IPT is sulfadoxinepyrimethamine (SP) combination
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21. 21
Fetal growth
velocity 
Rx
Rx
Last
month
Quickening
10
Conception
Source: WHO 2002.
16
20
30
Weeks of gestation
Birth
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22. • A single dose is three tablets of sulfadoxine
500 mg + pyrimethamine 25 mg.
(Daraprim, the ‘Sunday-Sunday tablet’ is no longer effective)
• Healthcare provider should dispense dose and
directly observe client taking dose
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23. CANDIDATE VACCINE
I.
PRE- ERYTHROCYTIC VACCINE (SPOROZOITE)
1.
Irradiation Attenuated Sporozoite (IAS)
2.
Circumsporozoite protein (CSP)
Escape of even a single sporozoite leads to failure of
anti-sporozoite vaccine
II. ASEXUAL BLOOD STAGE VACCINE
1.
Merozoite specific antigen (MSA-1)
2.
Erythrocyte binding antigen (EBA)
III INFECTED RED CELLS
Schizont infected cell surface antigen (SICA)
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24. CANDIDATE VACCINE
IV TRNSMISSION-BLOCKING VACCINES
1. Antigametocyte: Pfs 25; Pfs 230; Pfs 48/45
2.
-
Antiookinete
Interferes with fertilization
Prevent maturation of gametocytes
Prevent mosquitoes from being infected
But no effect on those already infected
However even if infection occurs transmission to
another individual is prevented
Hence: Reduce incidence of malaria & prevent
transmission of resistant strains.
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25. CANDIDATE VACCINE
V. MULTIVALENT/MULTISTAGE VACCINE
1. SPf66
-
Developed in Colombia
Made of synthetic peptide from 3 sexual blood stage
MSA
Highly immunogenic & probably predominantly act
by cellular mechanism
Clinical Trials:
Colombia (All age groups): 33.6% efficacy
Tanzania (Age 1-5 years): 31% efficacy
Gambia (Age 6-11 Months): 0%
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26. Conclusion
• Malaria during pregnancy has adverse consequences
for both mother and the baby
• Malaria preventive package includes:
– Intermittent preventive treatment with SP during
antenatal clinic visits
– Use of ITNs throughout pregnancy and in the
postpartum period
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27. Conclusion
• Prevention must be complemented by effective case
management of malaria for all women of reproductive
age
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28. THANK YOU!!!
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29. Thank you
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