Malaria and Dengue are two major cause of Preventable Indirect Maternal Mortality in India.

1. MALARIA & DENGUE
IN PREGNANCY

2. Dr. Niranjan Chavan
MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H
Chairperson, FOGSI Oncology and TT Committee (2012-2014)
Treasurer, MOGS (2017- 2018)
Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016)
Chief Editor, AFG Times (2015-2017)
Editorial Board, European Journal of Gynecologic Oncology
Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters
Member, Managing Committee, IAGE (2013-2017)
Member , Oncology Committee, AOFOG (2013 -2015)
Recipient of 6 National & International Awards
Author of 15 Research Papers and 19 Scientific Chapters
Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of
Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. MALARIA IN
PREGNANCY

4. HISTORY
 Malaria is Italian for "bad air," mal'aria.
 In 2700 BC, several characteristic symptoms of what would
later be named malaria were described in the Nei Ching, The
Canon of Medicine). Nei Ching was edited by Emperor Huang
Ti.
 Susruta, attributed malaria to the bites of certain insects.
 In 340 CE, the antifever properties of Qinghao (Artemisia
annua) were first described by Ge Hong of the East Yin
Dynasty.

5. GLOBAL BURDEN
 There were an estimated 212 million new cases of
malaria and 429 000 malaria-related deaths in
2015.
 Approximately 90% of malaria cases and 92% of
deaths occurred in the WHO African Region.
 Thirteen countries, mainly in sub-Saharan Africa,
accounted for 76% of malaria cases and 75%
deaths globally.
* WHO World Malaria Report 2016

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2011 -12 2012 -13 2013 - 14 2014 -15 2015 -16
DEATHS IN MUMBAI DUE TO MALARIA
Series 1
Decreasing
Trends in no of
cases and
deaths in
Mumbai

9. CAUSATIVE AGENT
 Malaria is a protozoan disease caused by genus
Plasmodium.
 Four subspecies have been identified vivax,
falciparum, malariae and ovale.
 Most common is Plasmodium vivax.
 VECTOR: Female Anopheles Mosquito.

12. VECTOR
 Malaria is transmitted by bite of female Anopheles
mosquito.
 First described and named by J. W. Meigen in 1818.
 Different species are seen in different areas in
India.

13. Map of India showing distribution of major malaria vectors in relation to
physiogeographic regions

14. LIFE CYCLE OF PLASMODIUM
Incubation period is
 9 to 14 days for Plasmodium (P.)falciparum.
 12 to 18 days for P. vivax and P. ovale.
 18 to 40 days for P. malariae.

16. CLINICAL PRESENTATION
 Malaria may be uncomplicated or complicated.
 In high-transmission settings, where levels of acquired immunity
tend to be high, P. falciparum infection is usually asymptomatic
in pregnancy.
 In low-transmission settings, malaria in pregnancy is associated
with anaemia, an increased risk of severe malaria.
 Infection with P. vivax, as with P. falciparum, leads to chronic
anaemia and placental malaria infection, reducing the birth
weight and increasing the risk of neonatal death.

17. CLINICAL PRESENTATION
 Uncomplicated malaria is defined as fewer than 2% parasitised
red blood cells in a woman with no signs of severity and no
complicating features.
 Complicated malaria : The parasitaemia of severe malaria can be
more than 2%. Pregnant women with 2% or more parasitised red
blood cells are at higher risk of developing severe malaria and
should be treated with the severe malaria protocol.

19. ● Prostration
● Impaired consciousness
● Respiratory distress (acidotic breathing, acute respiratory distress
syndrome)*
● Pulmonary oedema (including radiological)*
● Multiple convulsions
● Circulatory collapse, shock (blood pressure <90/60 mmHg)
● Abnormal bleeding, disseminated intravascular coagulopathy
● Jaundice
● Haemoglobinuria (without G6PD deficiency)
Clinical and laboratory findings of severe or complicated malaria in
adults

20. DIAGNOSIS
 The diagnosis of malaria in pregnancy, as in non-pregnant
patients, relies on microscopic examination (the current gold
standard) of thick and thin blood films for parasites.
 Rapid detection tests may miss low parasitaemia, which is more
likely in pregnant women, and rapid detections tests are relatively
insensitive in P. vivax malaria.
 In a febrile patient, three negative malaria smears 12–24 hours
apart rules out the diagnosis of malaria.

21. MANAGEMENT
 The World Health Organization (WHO) now
recommends that all women in the second or third
trimester of pregnancy who have uncomplicated P.
falciparum malaria should be treated with
artemisinin-based combination therapy.
 For the post-treatment prophylactic effect: The
longer-acting partner drug (i.e., lumefantrine,
piperaquine, amodiaquine, or mefloquine).
 Complicated Malaria should be manged in ICU
setting.
*Greentop Guidelines no 54B: Mangement of patient

22. MANAGEMENT
 P. falciparum Uncomplicated malaria: During the first trimester, the
World Health Organization (WHO) recommends treatment of
uncomplicated P. falciparum malaria with quinine plus clindamycin for
seven days. WHO considers as acceptable alternatives: artemisinin
combination regimen (ACT) or oral artesunate plus clindamycin.
 P. falciparum Uncomplicated malaria: During the second and third
trimesters, treatment of uncomplicated P. falciparum malaria consists of
artemisinin combination therapy (ACT) for a three-day course.
 P. falciparum Complicated malaria: Parenteral artesunate is the
treatment of choice in all trimesters with intensive care management.

23. • In the PREGACT trial, involving 3428 pregnant women with uncomplicated P.
falciparum malaria in four African countries (Burkina Faso, Ghana, Malawi, and
Zambia), cure rates of 94.8 to 99.2% were achieved after treatment with four
different antimalarial drug combinations (artemether–lumefantrine,
amodiaquine–artesunate, mefloquine–artesunate, and dihydroartemisinin–
piperaquine).
• Rates of placental infection were only 15%.
• All these were found to be safe in pregnancy.

24. MANAGEMENT
Non-falciparum malaria
 Pregnant women with chloroquine-sensitive non-falciparum malaria in
the first trimester should be treated with chloroquine; those in the
second or third trimester may be treated with chloroquine or ACT.
 Women with chloroquine-resistant non-falciparum malaria in the first
trimester should be treated with quinine; those in the second or third
trimester should be treated with ACT.
 Anti-Relapse therapy: Chloroquine prophylaxis: 300 mg base (= 500 mg
salt) orally once weekly for the duration of the pregnancy; to be initiated
following completion of antimalarial therapy.

25. SUPPORTIVE MANAGEMENT DURING
PREGNANCY
Supportive management in pregnancy:
 Treatment of anaemia
 Correction of electrolyte imbalance
 Oxygen and diuretics for pulmonary oedema
 Anti-convulsant for complicated malaria
 Monitoring foetal growth with weekly doppler
and biweekly NST for early diagnosis of IUGR.

26. COMPLICATIONS OF MALARIA IN
PREGNANCY
 Hypoglycaemia : it can be profound and persistent
in malaria in pregnancy and can be exacerbated by
quinine.
 Pulmonary oedema and acute respiratory distress
syndrome :assessment of jugular venous or central
venous pressure, aimed at keeping right arterial
pressure less than 10 cm H2O
 Severe anaemia
 Secondary bacterial infection : especially gram
negative septicaemia

27. OBSTETRICS COMPLICATION
 Risk of abortion
 Preterm labour
 Foetal growth restriction
 Foetal heart rate abnormalities
 Abnormal Doppler studies with increased
resistance in Umbilical artery
 IUFD &Stillbirth
 Postpartum haemorrhage

29. CONGENITAL MALARIA
 Congeital Malaria occurs due to vertical transmission.
 Vertical transmission to the fetus can occur particularly when
there is infection at the time of birth and the placenta and cord
are blood film positive for malaria.
 Prevalence of congenital malaria varies from 8% to 33%.
 All neonates whose mothers developed malaria in pregnancy
should be screened for malaria with standard microscopy of
thick and thin blood films at birth and weekly blood films for
28 days.

30. RECURRANCE OF MALARIA IN
PREGNANCY
 Polymerase chain reaction (PCR)-confirmed prolonged
submicroscopic carriage with subsequent recurrence in pregnant
women for months following drug treatment for uncomplicated P.
falciparum.
 Most recurrence is around day 28–42 but late reported recurrence,
so far unique to pregnancy, has been reported to occur at 85 days
with quinine,28 98 days with artesunate, 63 days with artemether-
lumefantrine 30 and 121 days with mefloquine.

31. INTERMITTENT PREVENTIVE THERAPY IN
PREGNANCY
 Use of long-lasting insecticidal nets (LLINs);
 In all areas with moderate to high malaria
transmission in Africa, intermittent preventive
treatment in pregnancy (IPTp) with sulfadoxine-
pyrimethamine (SP), as part of antenatal care
services;
 Prompt diagnosis and effective treatment of malaria
infections.
*Malaria preventive works, lets close the gaps, WHO guide published in June, 2017.

36. DENGUE IN
PREGNANCY

37. HISTORY
 Dengue is derived from the Swahili phrase "Ka-dinga pepo",
meaning "cramp-like seizure caused by an evil spirit".
 The Swahili word "dinga" has origin inSpanish word "dengue"
meaning fastidious which would describe the gait of a person.
 The first record of a case is in Chinese medical encyclopedia from
the Jin Dynasty (265–420 AD) which referred to a “water
poison” associated with flying insects.
 The first confirmed case report dates from 1789 and is by
Benjamin Rush, who coined the term "breakbone fever“.

38. BURDEN
 40% of world’s population live in Dengue prone
zone.
 WHO estimates at least 100million infections occur
every year including 500,000 DHF cases and nearly
22000 deaths.
* WHO data of Global Burden of Dengue 2014

40. CAUSATIVE AGENT
 Dengue is an arbovirus of the Flavi viridae family
and Flavi virus genus.
 There are four serotypes of the dengue virus
(DEN-1, DEN-2, DEN-3, and DEN-4).
 DV-2 was the predominant serotype circulating
in India.
 Indian isolates of DV-2 were classified into
genotype-V. however recently Genotype IV is
more predominant.

42. VECTOR
 Vector is AEDES AEGYPTI
 Breeds near human habitation in relatively fresh
water pools or collection.
 An incubation period of 4–10 days occurs after
the mosquito bites, resulting in an asymptomatic
or symptomatic dengue infection

43. CLINICAL PRESENTATION
 Four main characteristic manifestations of dengue illness are
(i) continuous high fever lasting 2-7 days;
(ii) haemorrhagic tendency as shown by a positive tourniquet
test, petechiae or epistaxis;
(iii) thrombocytopoenia (platelet count <100×109/l); and
(iv) evidence of plasma leakage manifested by
haemoconcentration (an increase in haematocrit 20% above average
for age, sex and population), pleural effusion and ascites, etc.

45. PHASES OF DENGUE
PHASES OF DENGUE MEDICAL COMPLICATIONS
Febrile phase
Dehydration; high fever may cause neurological
disturbances and febrile seizures
Critical phase
Shock from plasma leakage; severe haemorrhage; organ
impairment
Recovery phase
Hypervolaemia (only if intravenous fluid therapy has been
excessive and/or has extended into this period)

46. Dengue is fever is classified into three different phases based
on the symptoms and the severity of the disease presentation.

47. MEDICAL COMPLICATION

48. OBSTETRIC COMPLICATION
 Preterm birth
 Low-birth weight
 Oligohydramnios
 Antepartum and postpartum haemorrhage
 Foetal distress
 Miscarriages
 Intrauterine death
 Neonatal death

49. NEONATAL COMPLICATION
 Vertically transmitted neonatal infection can be detected
by reverse transcriptase polymerase chain reaction (RT-
PCR).
 The reported vertical transmission rate is 1.6 percent with
no difference in the pregnancy outcome of infected
women.
 At or near-term/delivery, severe foetal or neonatal dengue
illness and death may occur when there is insufficient time
for the production of protective maternal antibodies.

50. DIAGNOSIS
 NS1 Antigen test, Primary test done
for diagnosis.
 IgM antibody capture ELISA (MAC-
ELISA) comes as diagnostic reagent
strips.
 RT–PCR is confirmatory with 95%
specificity.
* Diagnosis of Dengue, Centre of Disease Control and Prevention

51. DIFFERENTIAL DIAGNOSIS
 Other infections like malaria, leptospirosis, typhoid, typhus, bacterial sepsis
and acute HIV-seroconversion illness
 Gestational thrombocytopenia
 Immune thrombocytopenia
 Preeclampsia
 HELLP syndrome
 Acute fatty liver of pregnancy
 Microangiopathic haemolytic anaemia and thrombocytopenia
 Autoimmune diseases

52. Normal Pregnancy Dengue HELLP
Fever Blunted febrile response + -
Bleeding Bleeding can be due to
obstetrical cause
+ (mild to severe) - (DIVC in severe
disease)
Abdominal pain +/- +/- +/-
Ascites, pleural effusion - + in plasma leakage -
WBC Elevated Leukopenia No specific changes
Thrombocytopenia + + unique FBC changes +
Haematocrit ↓ (haemodilution after the
second trimester)
↑ in plasma leakage Maybe normal / ↓
Haemolysis - - +
Liver enzymes Mild ↑ Mild to severe ↑ Mild to moderate ↑

53. MANAGEMENT
 Symptomatic treatment.
 Intravenous fluid replacement.
 Broad spectrum antibiotics.
 Blood transfusion and Blood component therapy.
 Monitor maternal vital parameters.
 Monitor serum electrolytes.
 Monitor blood coagulation profiles.

54. MANAGEMENT OF LABOUR IN CRITICAL
PHASE OF DENGUE
 Blood and blood products should be cross-matched and saved in
preparation for delivery.
 Trauma or injury should be kept to the minimum if possible.
 It is essential to check for complete removal of the placenta after
delivery.
 Transfusion of platelet concentrates should be initiated during or
at delivery but not too far ahead of delivery, as the platelet count
is sustained by platelet transfusion for only a few hours during
the critical phase.
* Management of dengue in pregnancy,FOGSI protocols published August, 2014

55. MANAGEMENT OF LABOUR IN CRITICAL
PHASE OF DENGUE
 Fresh whole blood/fresh packed red cells transfusion
should be administered as soon as possible.
 Do not wait for blood loss to exceed 500 ml before
replacement, as in postpartum haemorrhage.
 Do not wait for the haematocrit to decrease to low
levels.
* Management of dengue in pregnancy,FOGSI protocols published August, 2014

56. PREVENTION
 Vector control by preventing water accumulation is of utmost
importance.
 Use of larvicidal agents like benzene, hexane, ethyl acetate, methanol
and chloroform leaf extract of Eclipta alba have shown potential for
controlling the disease.
 Dengue Vaccine: the Envelope Domain III tetravalent vaccine
developed using plasmids and adeno virus is promising.
 Public Awareness Programmes.

67. CONCLUSION
 Malaria and Dengue are two major cause of Preventable Indirect
Maternal Mortality in India.
 WHO’s Intermittent Preventive Therapy in pregnancy is promising to
prevent malaria in pregnancy
 National Vector Borne Disease Control Programme should be
implemented more strictly.
 Public Awareness Programmes should be arranged and ANC mothers
should be counselled during her ANC visits to prevent stagnation of
water and local cleanliness.

68. REFERENCES
 Treatment of malaria in pregnancy, Joel Training N Engl J Med 2016; 374:981-982March 10, 2016DOI:
10.1056/NEJMe1601193
 Greentop Guidelines 54 B: Diagnosis and Mangement of Malria in Pregnancy, RCOG 2010
 Greentop Guidelines 54 A: Prevention of Malria in Pregnancy, RCOG 2010
 Malaria preventive works, lets close the gaps, WHO guide published in June, 2017.
 PREGACT Study Group, Pekyi D, Ampromfi AA, Tinto H, Traoré-Coulibaly M, TahitaMC, Valéa I, Mwapasa V,
Kalilani-Phiri L, Kalanda G, Madanitsa M, Ravinetto R,Mutabingwa T, Gbekor P, Tagbor H, Antwi G, Menten J, De
Crop M, Claeys Y,Schurmans C, Van Overmeir C, Thriemer K, Van Geertruyden JP, D'Alessandro U,Nambozi M,
Mulenga M, Hachizovu S, Kabuya JB, Mulenga J. Four Artemisinin-BasedTreatments in African Pregnant Women
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26962727.

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