medical conditions in pregnancy

1. MALARIA IN
PREGNANCY
GICHANA ELVIS

2. Introduction
 The physiological changes of pregnancy and the
pathological changes due to malaria have a
synergistic effect on the course of each other, thus
making the life difficult for the mother, the child
and the treating physician.
 Malaria and pregnancy are mutually aggravating
conditions.
 P. falciparum malaria can run a turbulent and
dramatic course in pregnant women.

3. Introd.cont
 The non- immune, primigravidae are
usually the most affected.
 In Africa, perinatal mortality due to malaria
is at about 1500/day.
 In areas where malaria is endemic, 20-40%
of all babies born may have a low birth
weight.

4. Introd. cont
 Malaria is more common in pregnancy
compared to the general population.
 Immuno- suppression and loss of acquired
immunity to malaria could be the causes.
 In pregnancy, malaria tends to be more
atypical in presentation. This could be due
to the hormonal , immunological and
hematological changes of pregnancy

5. Introduction continues
 Due to the hormonal and immunological changes,
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.
 P. falciparum malaria in pregnancy being more
severe, the mortality is also double (13 % )
compared to the non-pregnant population (6.5%).

6. Introd. Cont.
 Some anti malarials are contra indicated in
pregnancy and some may cause severe adverse
effects. Choice of medication becomes difficult.
 Management of complications of malaria may be
difficult due to the various physiological changes
of pregnancy. Careful attention has to be paid
towards fluid management, temperature control,
etc. Also decisions regarding induction of labour
may be difficult and complex. Foetal loss, IUGR,
and premature labour are common.

7. Pathology:malaria in pregnancy
 Physiologic changes of pregnancy
contribute to the aggravation of malarial
infection.
 There is a generalised immunosuppression
in pregnancy with reduction in gamma
globulin synthesis and inhibition of reticulo
endothelial system, resulting in decrease in
the levels of anti malarial antibodies and
loss of acquired immunity to malaria.

8. Pathology:malaria in pregnancy
 This makes the pregnant woman more
prone for malarial infection and the
parasitemia tends to be much higher.
Changes in the hormonal melieu, increase in
the body fluid volume, decrease in
hemoglobin level and other changes add to
the severity.

9. Changes in placenta
 Placenta is the preferred site of sequestration and
development of malarial parasite. Intervillous
spaces are filled with parasites and macrophages,
interfering with oxygen and nutrient transport to
the foetus.
 Villous hypertrophy and fibrinoid necrosis of villi
(complete or partial) have been observed. All the
placental tissues exhibit malarial pigments (with
or even without parasites).

10. Clinical features
 Atypical manifestations of malaria are more
common in pregnancy, particularly in the
2nd half of pregnancy.
 Fever : May have different patterns - from
afebrile to continuous fever, low grade to
hyper pyrexia. In 2nd half of pregnancy,
there may be more frequent paroxysms due
to immunosuppression.

11. Clinical features cont.
 Anemia : In developing countries, where malaria
is most common, anemia is a common feature of
pregnancy.
 Malnutrition and helminthiasis are the commonest
causes of anemia. In such a situation, malaria will
compound the problem. Anemia may even be the
presenting feature of malaria and therefore all
cases of anemia should be tested for M.P.
 Anemia as a presenting feature is more common in
partially immune multigravidae living in
hyperendemic areas.

12. Clinical features cont.
 Splenomegaly : may be variable. It may be absent
or small in 2nd half of pregnancy. A preexisting
enlarged spleen may regress in size in pregnancy.
 Complications : Tend to be more common and
more severe in pregnancy,may develop suddenly.
 Acute pulmonary edema, hypoglycemia and
anemia are more common in pregnancy. Jaundice,
convulsions, altered sensorium, coma, vomiting /
diarrhoea and other complications may be seen.

13. Complications of malaria in pregnancy
 Anemia: It could be due to:
(1.) Hemolysis of parasitised RBCs. (2.) Increased
demands of pregnancy. (3.) Profound hemolysis
can aggravate folate deficiency4.BM supression
by malaria toxin.
 Anemia is more common and severe between 16-29
weeks. It can develop suddenly, in case of severe malaria
with high grades of parasitemia. Pre existing iron and
folate deficiency can exacerbate the anemia of malaria and
vice versa

14. Complications cont.
 Anemia increases perinatal mortality and maternal
morbidity and mortality. It also increases the risk
of pulmonary oedema. Risk of post-partum
haemorrhage is also higher.
 Significant anemia (Hemoglobin < 7-8 g%) may have to be
treated with blood transfusion. In view of the increased
fluid volume in pregnancy, it is better to transfuse packed
cells than whole blood. Rapid transfusion, particularly
whole blood, may cause pulmonary oedema.

15. Complications cont.
 Acute pulmonary oedema:
 Is also a more common complication of
malaria in pregnancy compared to the non-
pregnant population.
 It may be the presenting feature or can
develop suddenly after several days. It is
more common in 2nd and 3rd trimesters.

16. Pulmonary edema cont.
 It can develop suddenly in immediate post-
partum period. This is due to 1. Auto
transfusion of placental blood with high
proportion of parasitised RBC’s and 2.
Sudden increase in peripheral vascular
resistance after delivery.
 It is aggravated by pre existing anemia and
hemodynamic changes of pregnancy.
 Acute pulmonary oedema carries a very
high mortality.

17. Compl. Cont:-Hypoglycemia:
 This is another complication of malaria that
is peculiarly more common in pregnancy.
The following factors contribute to
hypoglycemia:
 (1.) Increased demands of hypercatabolic
state and infecting parasites. (2.)
Hypoglycemic response to starvation. (3.)
Increased response of pancreatic islets to
secretory stimuli (like quinine) leads to
hyperinsulinemia and hypoglycemia..

18. Hypoglycemia-cont.
 Can remain asymptomatic and may not be
detected. This is because, all the symptoms
of hypoglycemia are also caused by malaria
viz. tachycardia, sweating, giddiness etc.
Some patients may have abnormal
behaviour, convulsions, altered sensorium,
sudden loss of consciousness etc.
 These symptoms of hypoglycemia may be
easily confused with cerebral malaria.

19. Hypoglycemia cont.
 Therefore, in all pregnant women with
falciparum malaria, particularly those
receiving quinine, blood sugar should be
monitored every 4-6 hours. Hypoglycemia
can be recurrent and therefore constant
monitoring is needed.
 In some, it can be associated with lactic
acidosis and in such cases mortality is very
high. Maternal hypoglycemia can cause
fetal distress without any signs.

20. Immuno suppression:
 Immunosuppression makes malaria more
common and more severe. And to add to the
woes, malaria itself suppresses immune
response.
 Hormonal changes of pregnancy, reduced
synthesis of immunoglobulins, reduced
function of reticulo endothelial system are
the causes for immunosuppression in
pregnancy. This results in loss of acquired
immunity to malaria, making the pregnant
more prone for malaria.

21. Immuno suppression
 Malaria is more severe with higher
parasitemia. Patient may have more
frequent paroxysms of fever and frequent
relapses.
 Secondary infections (U.T.I. and
pneumonias) and algid malaria (septicaemic
shock) are more common in pregnancy due
to immunosuppression.

22. Malaria - Effects on Perinatal and Neonatal Mortality
• In 1994, 45 million pregnant women were living in
malarious areas, with over 23 million in Sub-
Saharan Africa;
• Malaria may cause up to 30% of preventable low
birth weight, and 3-5% of neonatal mortality in
highly endemic areas, and
• Malaria is also associated with an increased risk
of spontaneous abortions and stillbirths

23. Risks for the foetus
 High grades of fever, placental
insufficiency, hypoglycemia, anemia and
other complications can all adversely affect
the foetus.
 Both P. vivax and P. falciparum malaria can
pose problems for the foetus, with the latter
being more serious. The prenatal and
neonatal mortality may vary from 15 to
70%.

24. Risks for the foetus
 In one study, mortality due to P. vivax
malaria during pregnancy was 15.7% while
that due to P. falciparum was 33%.
 Spontaneous abortion, pre mature birth, still
birth, placental insufficiency and I.U.G.R.
(temporary / chronic), low birth weight,
fetal distress are the different problems
observed in the growing foetus.
Transplacental spread of the infection to the
foetus can result in congenital malaria.

25. Risks for the foetus- Congenital malaria:
 It is very rare
 Occurs in < 5% of affected pregnancies.
 Placental barrier and matenal Ig G antibodies
which cross the placenta may protect the foetus to
some extent.
 It is much more common in non-immune
population and the incidence goes up during
epidemics of malaria.
 Fetal plasma antimalarial levels are about 1/3 of
simultaneous maternal levels and this level does
not cure the infection in the foetus.

26. Congenital malarial cont.
 All four species can cause congenital
malaria, but it is more with P. malariae.
 The new born child can manifest with fever,
irritability, feeding problems, hepato
splenomegaly, anemia, jaundice etc.
 The diagnosis:-A smear from cord blood or
heel prick, anytime within a week after birth
 Differential diagnoses include Rh. Incomp.,
infections with C.M.V., Herpes, Rubella,
Toxoplasmosis, and syphilis.

27. Management of Malaria in
Pregnancy
1. Management of complications
2. Treatment of malaria
3. Management of labour
Treatment of malaria in pregnancy should be
energetic, anticipatory and careful.
 Energetic: Don't waste any time.
Assess severity- General condition,
pallor,jaundice, B.P., temperature, hemoglobin,
Parasite count, S.G.P.T., S .bilirubin,
S.creatinine, Blood sugar.

28. Mngt of malaria in pregnancy
 Anticipatory: Malaria in pregnancy can
cause sudden and dramatic complications.
Therefore, one should always be looking for
any complications by regular monitoring.
 Monitor maternal and fetal vital parameters
2 hourly.
 R.B.S. 4-6 hourly; hemoglobin and parasite
count 12 hourly; S. creatinine; S. bilirubin
and Intake / Output chart daily.

29. Management continues- Careful:
 The physiologic changes of pregnancy pose
special problems in management of malaria.
 Certain drugs are contra indicated in
pregnancy .
 Choose drugs according to severity of the
disease/ sensitivity pattern in the locality.
 Avoid drugs that are contra indicated
 Avoid over / under dosing of drugs
 Avoid fluid overload / dehydration
 Maintain adequate intake of calories.

30. Anti malarials in pregnancy
 All trimesters: Chloroquine; Quinine;
Artesunate / Artemether / Arteether
 2nd trimester: Mefloquine; Pyrimethamine /
sulfadoxine
 3rd trimester: Mefloquine; ?Pyrimethamine /
sulfadoxine
 Contra indicated: Primaquine; Tetracycline;
Doxycycline; Halofantrine

31. Management of complications
Acute Pulmonary Oedema: Careful fluid
management; back rest; oxygen; diuretics;
ventilation if needed.
 Hypoglycemia: 25-50% Dextrose, 50-100 ml I.V.,
followed by 10% dextrose continuous infusion. If
fluid overload is a problem, then Inj. Glucagon
0.5-1 mg can be given intra muscularly. Blood
sugar should be monitored every 4-6 hours for
recurrent hypoglycemia.

32. Management of complications
 Anemia: Packed cells should be transfused if
hemoglobin is <5 g/dl.
 Renal failure: Renal failure could be pre-renal
due to unrecognised dehydration or renal due to
severe parasitemia. Treatment involves careful
fluid management, diuretics, and dialysis if
needed.
 Septicaemic shock: Secondary bacterial
infections like urinary tract infection, pneumonia
etc. are more common in pregnancy associated
with malaria.

33. Management of complications
 Some of these patients may develop septicaemic
shock, the so called 'algid malaria'. Treatment
involves administration of 3rd generation
cephalosporins, fluid replacement, monitoring of
vital parameters and intake and output.
 Exchange transfusion: Exchange transfusion is
indicated in cases of severe falciparum malaria to
reduce the parasite load. Patient’s blood is
removed and it is replaced with packed cells. It is
especially useful in cases of very high parasitemia
(helps in clearing) and impending pulmonary
oedema (helps to reduce fluid load).

34. Management of labour
 Anemia, hypoglycemia, pulmonary oedema, and
secondary infections due to malaria in full term
pregnancy lead to problems for both the mother
and the foetus.
 Severe falciparum malaria in full term pregnancy
carries a very high mortality.
 Maternal and fetal distress may go unrecognised in these
patients.
 Therefore, careful monitoring of maternal and foetal
parameters, severe malaria are better managed in an
intensive care unit.

35. Management of labour
 Falciparum malaria induces uterine contractions,
resulting in premature labour. The frequency and
intensity of contractions appear to be related to the
height of the fever.
 Fetal distress is common and often unrecognised.
Therefore only monitoring of uterine contractions and fetal
heart rate may reveal asymptomatic labour and foetal
tachycardia, bradycardia or late deceleration in relation to
uterine contractions, indicating fetal distress.

36. Management of labour
 All efforts should be made to rapidly bring
the temperature under control, by tepid
sponging and anti pyretics like paracetamol
etc.
 Careful fluid management is also very
important. Dehydration as well as fluid
overload should be avoided, because both
could be detrimental to the mother and/or
the foetus. In cases of very high
parasitemia, exchange transfusion may have
to be carried out.

37. Management of labour
 If the situation demands, induction of labour
may have to be considered.
 Once the patient is in labour, foetal or
matenal distress may indicate the need to
shorten the 2nd stage by forceps or vacuum
extraction.
 If needed, even caesarian section must be
considered.

38. Chemoprophylaxis in pregnancy
 Malaria being potentially fatal to both the
mother and the foetus, all pregnant women,
who remain in the malarious area during
their pregnancy, should be protected with
chemoprophylaxis against malaria.
 This is a most important part of antenatal
care-IPT 20thwk and 32wk GA.

39. In Kilifi District, Kenya, an area of high malaria
transmission, Shulman et al presumptively treated
pregnant women with Fansidar which reduced
Perinatal deaths by 22%
Neonatal deaths by 38%
Shulman CE et al, Lancet 1999 Feb 20; 353(9153):632-6
Malaria Prophylaxis

40. Choice of anti malarials for
chemoprophylaxis
 Chloroquine being the safest drug in pregnancy, it
should be the first choice. 500 mg of chloroquine
should be administered once every week, use of
chloroquine may be restricted due to the wide
spread resistance to this drug.
 In areas with known resistance to chloroquine,
pyrimethamine/ sulphadoxine or mefloquine can be used.
But these drugs should be started in early 2nd trimester.
 Dose of mefloquine may have to be increased in the last
trimester, in view of the accelerated clearance of the
drug.

41. Thank you for listening