SCIENTIFIC PRESENTATION AT O&G DEPARTMENT OF FEDERAL MEDICAL CENTER KATSINA, KATSINA STATE NIGERIA

1. B Y
D R A L I Y U Y U S U F B I N D A W A
RESIDENT DOCTOR
O B S T E T R I C S A N D G Y N A E C O L O G Y D E P A R T M E N T
F M C K A T S I N A
S U P E R V I S O R : D R O B I
V E N U E : M C H L I B R A R Y , F M C K T
D A T E : 2 6 T H M A R C H , 2 0 1 8
1
MALARIA IN PREGNANCY

2. OUTLINE
2
 INTRODUCTION
 EPIDEMIOLOGY
 LIFE CYCLE
 AETIOPATHOGENESI
S
 IMMUNOLOGY
 CLINICAL FEATURES
 DIFFERENTIAL DX
 INVESTIGATIONS
 COMPLICATIONS
 TREATMENT
 FOLLOW UP
 PREVENTION AND
CONTROL
 DISCUSSIONS AND
CONTROVERSIES
 CONCLUTION

3. INTRODUCTION
3
 Malaria is a parasitic infectious disease caused by
parasites of the genus plasmodium and is transmitted
by female anopheles mosquitoes.
 Malaria is the most prevalent parasitic disease in sub-
Saharan Africa and it is of public health importance.
 It is associated with a lot of morbidity and mortality in
pregnant women.

4. EPIDEMIOLOGY-I
4
 Approximately 300 million people are affected in
Africa, Asia, Oceania, Central and South America.
 Malaria accounts for about 1million death yearly in
Africa alone.
 90% of all Malaria death occur in Sub Saharan
Africa.
 The major problem:
1. Resistant P. falciparum
2. No recommended vaccine

5. EPIDEMIOLOGY-II
5
 Malarial mortality and serious morbidity is mainly
affecting women and children.
 It account for 2-15% of maternal anaemia and 5-14% of
low birth weight in Sub Sahara Africa.
 Malaria affects 5 times as many people as AIDS,
Leprosy, Measles & TB combined
 1 person in Africa dies of malaria every 10s

6. EPIDEMIOLOGY-III
6
 The global distribution of malaria is closely related to
that of SCDx, thalasemias and G-6-PD deficiency
before the introduction of the control measures.
 The mechanism by which the above conditions
protect the patient from having severe infection is
not well understood except in the case of
melanessian ovalocytosis.

7. EPIDAEMIOLOGY-IV
7
 >25 million African women in malaria endemic areas
get pregnant and are at risk of infection with
Plasmodium falciparum
OVERVIEW OF ILLNESS IN NIGERIA
 Malaria is:
 Responsible for 63% of all clinic attendance
 Causes 25% of infant mortality
 30% of all childhood deaths
 Associated with 11% of all maternal deaths and 70.5%
of morbidity in pregnant women

8. EPIDAEMIOLOGY
(Malaria endemicity)
TYPE PARASITE
RATE
(Among
children aged
2-9yrs)
SPLEEN
RATE
(Among
children aged
2-9yrs)
Hypoendemic ≤10% ≤10%
Mesoendemic 11-50% 11-50%
Hyperendemic >50%, low in
adults(>25%)
>50%, low in
adults(>25%)
Holoendemic >75%, Low in
adults
>75%, Low in
adults
8

9. LIFE CYCLE-I
9

10. AETIOPATHOGENESIS-I
10 Five species of Plasmodium causes malaria in
humans
1. P. falciparum (worldwide)
2. P. malariae (worldwide)
3. P. ovale (West Africa and Islands of Western
Pacific)
4. P. vivax (Asia, Latin America, some part of
Africa)
5. P. knowlesi (Forested regions of S/E Asia)

11. AETIOPATHOGENESIS-II
11
 Mode of transmission
1. Infected female anopheles mosquito
2. Vertical transmission
3. Blood transfusion
4. Contaminated syringe

12. AETIOPATHOGENESIS-III
12
 Hepatic invasion
 Invasion of RBCs
 Adhesive molecules and cytokines
 Cytoadherance
 Rosettes formation
 Clumping and sequestration
 Hydrolysis of Hb and consumption of oxygen by the
parasite
 Placental and congenital malaria

13. IMMUNOLOGY-I
13
 Epidemics do not occur in a population with
constant repeated infection due to the high level of
immunity among the populace.
 Asymptomatic parasitaemia is common in endemic
areas.
 The immunity develops over 5-10yrs and it is
partial.
 Initially, non-immune individual responds non-
specifically.
 Involves both cellular and humoral components.

14. IMMUNOLOGY-II
14
 Merozoites attaches to receptors on RBCs.
 P. vivax attaches to Duffy antigen Fya and Fyb.
 Most people of African decent have Duffy Negative-
FyFy genotype.
 Augmentation of splenic function
 Destruction of parasitised RBCs in circulation
 Activation of macrophages
 Mononuclear cell derived cytokines (TNF & IL I) are
also released.
 Causes fever and temperature of 40 degree Celsius is
schizonticidal.

15. CLINICAL FEATURES-I
15
HISTORY
 Residence, parity, gestational age
 Fever
 Chills, rigors, anorexia, malaise, vomiting and
headache
 History of travels
 Features of complications.
 Socioeconomic status

16. CLINICAL FEATURES-II
16
 Non-specific features on examination
Acutely ill looking, febrile, pale, icteric
Tachypnoea, Tachycardia,
Hepatosplenomegaly,

17. DIFFERENTIAL DIAGNOSIS
17
 Enteric fever
 UTI
 RTI
 Eclampsia
 Meningitis

18. INVESTIGATIONS-I
18
 Microscopy
 RDT for malarial parasite
 Parasite LDH
 PCR
 Ultrasound scan
 FBC
 U,E and Cr
 Investigations to rule out differential diagnosis

19. COMPLICATIONS-I
19
 The severity of malaria depends on:
1. Infecting specie
2. Level of parasitaemia
3. Immune status of the individual to malaria
 Simple or uncomplicated malaria
 Severe or complicated malaria

20. COMPLICATIONS-II
20
 Almost all deaths are due to falciparum malaria
 P. falciparum infect all RBCs, P. vivax and ovale
infect reticulocytes and P. malariae infects older
RBCs.
 Maternal complications
 Fetal complications

21. EFFECTS OF MALARIA ON PREGNANCY
21
Serial number Maternal Fetal
1 Anaemia Hypoglycaemia
2 Hyperpyrexia Abortion
3 Preterm labour Prematurity
4 Haemorrhage Placental malaria
5 Hypoglycaemia IUGR
6 Convulsion and loss
of consciousness
IUFD
7 Death Low birth weight

22. COMPLICATIONS-IV
22
EFFECTS OF PREGNANCY ON MALARIA
 Loss of acquired immunity to malaria
 Increase susceptibility to complications of malaria
 Rapid development of hypoglycaemia

23. TREATMENT-I
23
 There is insufficient information on the safety and
efficacy of the currently recommended antimalarials in
pregnancy, especially during the first trimester.
 Available evidence has placed artesunate above all
other available and recommended treatments of severe
malaria.
UNCOMPLICATED MALARIA
 First trimester: Quine and clindamycin or CQ
Antipyretic
 2nd and 3rd trimesters: ACT + Antipyretic

24. TREATMENT-II
24
 Artemisinin-based combination therapy
1. Artemether-Lumefantrine
2. Artesunate-Amodiaquine
3. Dihydroartemisinin-Piperaquine
4. Artesunate-Mefloquine
5. Artemisinin-Piperaquine

25. TREATMENT-III
25
 Complicated malaria
 Treatment of life threatening complications
 Specific malarial treatment
 Specific malarial treatment
 Injectable artesunate
 Artemether
 Parenteral quinine
 Full course of ACT after the last dose of parenteral
drug and the patient can take orally

26. TREATMENT-IV
26
 Treatment of life threatening complications
 It is an emergency and the patient must be admitted.
1. Multiple convulsions
2. Severe Anaemia
3. Severe hypoglycaemia
4. Metabolic acidosis (plasma HCO3- <15mmol/L)
5. Cerebral malaria
6. Respiratory failure
7. Shock

27. TREATMENT-V
27
8. Haemoglobinuria
9. Renal impairment (serum Cr <265mg)
10. Hyperparasitaemia
11. Prostration
12. Severe jaundice

28. TREATMENT-VI
28
 SOP for the preparation and administration of injection
artesunate using 60mg vial.
1. Weigh the patient and record the weight
2. Determine the number of 60mg vials needed
3. Calculate the dose and millilitres of artesunate needed
to administer
4. Gather materials
5. Reconstitute using 1ml of 5% NaHCO3 and shake until
clear for 2-4min

29. TREATMENT-VII
29
6. Dilute the reconstituted artesunate with normal
saline: 2ml for IM and 5ml for IV
7. Re-check the dose calculation and withdraw the
required dose for the route of administration
8. Administer the injectable artesunate
9. Plan the dosing schedule

30. TREATMENT-VIII
30
 Doses and schedules of antimalarials in treatment of
severe malaria
 2.4mg of artesunate/Kg body weight give at 0hr, 12hr
and 24hr; then daily until patient can tolerate orally
 3.2mg of IM artemether/Kg body weight start then
1.6mg/Kg daily until patient can tolerate orally
 Quinine: 20mg/Kg (max. of 1.2g) in 10ml/Kg of
isotonic fluid over 4hrs. Skip 8hrs before commencing
the maintenance of 10mg/Kg over 4hrs 8hrly until the
pt can tolerate oral.

31. TREATMENT-IX
31
 If intravenous quinine is required for more than 48hrs,
then the maintenance dose should be reduced to 5-
7mg/Kg or just reduce the dosing frequency from 8hrly
to 12hrly.
 12hrs after the last dose of injectable artesunate, full
course of ACT must be given to achieve total clearance of
parasite. It is also applicable to those treated with
quinine and artemether.
 There is insufficient data on artemotil and arteether,
hence not recommended for treatment of severe malaria.

32. TREATMENT-X
32
 Patient Monitoring during treatment
1. Level of consciousness
2. Fetomaternal vital signs
3. Uterine contraction
4. Input and output charts & urine colour and specific
gravity
5. Blood glucose
6. Parasitaemia
7. Haematocrit
8. Occurrence of convulsions

33. TREATMENT-XI
33
 Assessment of recovery
1. Improvement in level of consciousness
2. Falling temperature
3. Falling parasite count
4. Patient can eat, drink, talk, sit, stand and walk
5. Neurological examination
6. Assess vision and hearing
7. Check PCV on day 7, 14 and 28 after symptom free

34. TREATMENT-XII
34
TREATMENT FAILURE (TF)
 WHO(2006)
 TF is basically the failure to clear malaria parasitaemia
or to resolve clinical disease following treatment.
ANTIMALARIAL DRUG RESISTANCE
 Ability of a parasite strain to survive and/or multiply
despite administration and absorption of a drug given
in doses equal to or higher than those usually
recommended but within tolerance of the subject.
(WHO 1973)

35. TREATMENT-XIII
35
FACTORS CONTRIBUTING TO TREATMENT
FAILURE
1. Incorrect dosing, vomiting
2. Non compliance with duration of dosing regimen
3. Poor drug quality
4. Drug interaction
5. Poor or erratic absorption
6. Misdiagnosis
7. Drug treatment failure

36. TREATMENT-XIV
36
 Non-falciparum malaria
Chloroquine 10mg/Kg on days 1 & 2 the 5mg/Kg on
day 3.

37. SIDE EFFECTS OF COMMONLY USED
ANTIMALARIALS
37

38. FOLLOW UP
38
 Day 2
 Assess compliance and side effects of drugs
 Reassess the patient’s clinical progress
 Microscopy
 Day 7
 Reassess and microscopy may be repeated
 Day 14
 Reassess and do microscopy and PCV
 At 3 month: PCV

39. PREVENTION AND CONTROL-I
39
 A lot of countries have succeeded in eliminating
malaria. There are 34 malaria eliminating countries, 6
of them are African countries; Botswana, Cape Verde,
South Africa, Swaziland, Namibia and Sao Tome and
Pricipe.
 Malaria is said to be controlled in a country if it
records fewer than 1 case per 1000 population at risk
per year
 Elimination: zero incidence in a country
 Eradication: zero incidence worldwide

40. PREVENTION AND CONTROL-II
40
 PRIMORDIAL PREVENTION
Prevention of risk factors through policies and
researches. Eg; NMCP, RBM
 PRIMARY PREVENTION
Modification of the established risk factors
General health promotion and H/education

41. PREVENTION AND CONTROL-III
41
 Primary prevention
 Integrated vector management like environmental
sanitation, larvicides, IRS, ITN, mosquito repellents
etc.
 Malaria chemoprophylaxis eg IPT
 Vaccination
 Secondary prevention
 Early diagnosis and proper treatment
 Tertiary prevention
 Management of complication and rehabilitation

42. CHEMOPROPHYLAXIS
 CAUSAL PROPHYLAXIS: preventing the infection
from being established
 SUPPRESSIVE PROPHYLAXIS: through
suppressing the clinical symptoms of the disease
 The choice of any chemoprophylaxis is determined
by safety, cost and sensitivity of such drug

43. CHEMOPROPHYLAXIS CONT
 Proguanil (paludrine) –causal
 Pyrimethamine (Daraprim) -causal
 Chloroquine - suppressive
 Doxycycline - suppressive
 Mefloquine - suppressive

44. Chemprophylaxis contd
 Combination Formula
 Pyrimethamine + Sulphonamide
 Pyrimethamine + Mefloquine
 Proguanil + Chloroquine

45. INTERMITTENT PREVENTIVE TREATMENT
(IPT)
45
 Based on the assumption that every pregnant woman
living in an area of high malaria transmission has
malaria parasites in her blood or placenta, whether or
not she has symptoms of malaria
 WHO recommend IPT-SP from early 2nd trimester and
continues 4weekly until delivery
 IPTp-SP should be administered as DOT using 3 tablets
of sulphadoxine/pyrimethamine (500mg/25mg).

46. NEW WHO RECOMMENDATIONS FOR
IPT
46
 SP can be given either on an empty stomach or
with food.
 SP should not be administered to women receiving
co-trimoxazole prophylaxis due to a higher risk of
adverse events.
 WHO recommendation: 0.4mg of folic acid can be
administered concurrently with SP
Folic acid of ≥5mg daily suppose to be suspended
for 7-14days if SP is given so as to maintain the
efficacy of SP as antimalarial

47. 47
Conception Birth
20 3010
Weeks of gestation
16
Fetal growth
velocity 
Quickening
Source: WHO 2002.
Last
month
RxRx
47

48. CHEMOPROPHYLAXIS
 Chloroquine;
In the presence of allergies to sulphonamides,
curative dose of Chloroquine 4 4 2 is used and then 2
tablets weekly till delivery and puerperium.
Proguanil 200mg daily
Mefloquine 250mg weekly.

49. MALARIA VACCINE
49
 Development of effective vaccine against malaria
becomes necessary, because:
 Resistance of malarial parasites to the recommended
drugs
 Resistance of mosquitoes to insecticides
 High cost of current measures of prevention, control
and treatment of malaria.
 #132billion is lost to malaria annually in Nigeria

50. VACCINES-II
50
 Antisporozoite – RTS,S/ASO2 clinical trial in Gambia
(2001) – to prevent all malarial clinical manifestation.
 Pilot study is scheduled to take place in Ghana, Kenya
and Malawi in this year.
 Erythrocytic stage – SPf66 – reduce incidence of severe
malaria and malaria mortality.
 Transmission blocking vaccine – reduce transmission in
low endemic area.

51. BARRIERS TO VACCINE DEVELOPMENT
51
• Poor understanding of host/parasite pathology.
• Poor understanding of host immune protective
mechanism.
• Possible immuno-pathological consequences.
• Antigenic variations.
• Poor research funding.

52. DISCUSSIONS AND CONTROVERSIES-I
52
 Although malaria is the commonest cause of fever in our
environment, other differentials must be ruled out.
 Differentiation of eclampsia from cerebral malaria.
 HIV epidemics and prevalence of malaria
 Non immune subject with malaria should have daily
parasite count until parasite clearance
 Malaria should still be considered despite IPT

53. DISCUSSIONS AND CONTROVERSIES-II
53
 Parasite count should fall by 25% by 48hrs of
commencement of treatment and clearance should
be achieved by day 7.
 Antimalarials can cause abortion and preterm birth.

54. CONCLUSION
54
 Malaria is responsible for 11% of maternal death despite
the ongoing effort towards controlling it.
 Since Africa carries 90% of global malaria burden and
Nigeria being the most populous country in Africa, the
impact of malaria (including its effects in pregnancy) in
Nigeria is probably higher than any other country in the
world. The strategies for control of malaria poses
considerable challenges to most countries in sub-
Saharan Africa.
 More commitment is required for us to join the league of
successful nations with regard to malaria control and
elimination so as add hope towards global malaria
eradication.

55. REFERENCES
55
1. Federal Ministry of Health, National Malaria and Vector Control
Division, Abuja-Nigeria. Training Manual for the Management of
Malaria at Health Facilities in Nigeria; Participant’s Guide 2015
2. Comprehensive obstetrics in the tropics by E.Y Kwawukume et al.
3. United State Embassy in Nigeria economic section. Nigeria
malaria fact sheet 2011. http://nigeria.usembassy.gov
4. Guidelines for the treatment of malaria. 2nd Edition. World Health
Organization. Geneva, 2010. pp 19-21. Available at
http://whqlibdoc.who.int/publications/2010/9789241547925_en
g.pdf
5. WHO. Malaria and HIV interactions and their implications for
Public Health Policy. Reports of a Technical Consultation,
Geneva, 2004.
6. www.makingmalariahistory.org/34-malaria-eliminating-country

56. 56
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