2. Epidemiology
Major public health problem in tropical and
subtropical regions
– Pregnant women are the main risk group
– 90% of global malaria burden in Africa south of
the Sahara
– Burden mainly due to Plasmodium falciparum
(most common species in Africa)
• (also P. vivax, P malariae, P. ovale)
5. Continuum of intensity of transmission and
immunity in pregnant women (I)
Epidemic or low (unstable) malaria transmission
– Adult women not acquired significant immunity
and become ill when infected with P. Falciparum.
– 2-3X higher risk of developing severe disease
compared to non-pregnant adults
– Death due to severe malaria or malaria-related
severe anaemia
– Adverse pregnant outcomes:
• Spontaneous abortion
• Neonatal death
• Low birth weight
Risk
6. Continuum of intensity of transmission and
immunity in pregnant women (II)
High and moderate (stable) malaria transmission
– Most adult women have acquired enough immunity
and even when infected with P. Falciparum. do not
have clinical symptoms
but
– Principal impact on pregnancy:
• Malaria-related anaemia
• Presence of parasites in placenta
– Poor fetal nutrition (LBW)
– In areas of Africa with stable malaria as many as
10,000 maternal deaths, 8-14% of LBW and 3-8% of
infant deaths
8. Public health response to malaria
National Malaria Control Centre (NMCC); strategies:
• Intermittent preventive treatment
– The current drug recommended for use for IPT is sulfadoxine-pyrimethamine
(SP).
– three courses of SP taken one month apart at prenatal visits in the last six
months of pregnancy
• Insecticide treated nets
– long-lasting insecticide-treated mosquito nets
• Other vector management
– strategy focuses on indoor residual spraying of insecticide and insecticide-
treated bednets as the main emphases for vector control.
– augmented by the implementation of simple and appropriate environmental
management practices, including winter larviciding, source reduction, and
mosquito proofing of buildings in urban and peri-urban areas.
• Indoor residual spraying
– Spray activities are coordinated by districts and are conducted annually prior
to the malaria transmission season, usually from October to December.
• Case management
– of pregnant women with febrile illness (especially in areas of unstable P. falc.
transmission)
9. Malaria in Pregnancy
• More common
Malaria is more common in pregnancy compared to the general population. Immuno
suppression and loss of acquired immunity to malaria could be the causes.
• More atypical
In pregnancy, malaria tends to be more atypical in presentation. This could be due to the
hormonal, immunological and hematological changes of pregnancy.
• More severe
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.
• More fatal
P. falciparum malaria in pregnancy being 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 some may cause severe adverse
effects. 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. Careful attention has to be paid towards fluid management,
temperature control, etc. Also decisions regarding induction of labour may be difficult and
complex. Fetal loss, IUGR, and premature labour are common.
10. Pathophysiology
• The pathophysiology of malaria in pregnancy is
greatly due to the altered immunity
• Modulated by the presence of placenta in pregnancy
– A dramatic breakdown of acquired immunity occurs in
pregnancy, especially in primigravidae.
• (Paradoxically, fully effective antimalaria immunity is
transferred to the child)
• Hypothesis: Loss of antimalarial immunity is
consistent with the general immunosupression of
pregnancy
– renders the pregnant woman susceptible to infection.
– But does not fully explain the diminished susceptibility to
malaria experienced by multigravid women.
11. Clinical features
Atypical manifestations of malaria are more common in pregnancy,
particularly in the 2nd half of pregnancy.
• Fever: Patient may have different patterns of fever - from afebrile to
continuous fever, low grade to hyper pyrexia. In 2nd half of pregnancy,
there may be more frequent paroxysms due to immunosuppression.
• 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 MP. Anemia as a
presenting feature is more common in partially immune multigravidae
living in hyperendemic areas.
• Splenomegaly: Enlargement of the spleen 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: Complications tend to be more common and more severe
in pregnancy. A patient may present with complications of malaria or they
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
12. Anemia
Malaria can cause or aggravate anemia. It could be due to the
following causes:
– Hemolysis of parasitised red blood cells.
– Increased demands of pregnancy.
– Profound hemolysis can aggravate folate deficiency.
– Anemia due to malaria 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.
– 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.
13. Acute pulmonary oedema
• 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.
• It can develop suddenly in immediate post-partum period due
to auto transfusion of placental blood with high proportion of
parasitised RBC’s and 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.
14. Hypoglycemia
This is another complication of malaria that is peculiarly more common in pregnancy.
The following factors contribute to hypoglycemia:
• Increased demands of hypercatabolic state and infecting parasites.
• Hypoglycemic response to starvation.
• Increased response of pancreatic islets to secretory stimuli (like quinine) leads to
hyperinsulinemia and hypoglycemia..
• Hypoglycemia in these patients 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. 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.
15. Immunosuppression
• Immunosuppression in pregnancy poses special
problems. It makes malaria more common and more
severe. 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. Malaria is more severe with
higher parasitemia. Patient may have more frequent
paroxysms of fever and frequent relapses.
• Secondary infections (UTI and pneumonias) and algid
malaria (septicaemic shock) are more common in
pregnancy due to immunosuppression.
16. Risks for the fetus
• Malaria in pregnancy is detrimental to the fetus. High
grades of fever, placental insufficiency, hypoglycemia,
anemia and other complications can all adversely affect
the fetus. Both P. vivax and P. falciparum malaria can
pose problems for the fetus, with the latter being more
serious.
• The prenatal and neonatal mortality may vary from 15 to
70%. In one study, mortality due to P. vivax malaria
during pregnancy was 15.7% while that due to P.
falciparum was 33%.
• Spontaneous abortion, premature birth, still birth,
placental insufficiency and IUGR (temporary / chronic),
low birth weight, fetal distress are the different problems
observed in the growing fetus.
• Transplacental spread of the infection to the fetus can
result in congenital malaria.
17. Congenital malaria
• It is very rare and occurs in < 5% of affected pregnancies.
• Placental barrier and matenal Ig G antibodies which cross the placenta may
protect the fetus to some extent.
• However, it is much more common in non-immune population and the
incidence goes up during epidemics of malaria.
• Fetal plasma quinine and chloroquine levels are about one third of
simultaneous maternal levels and this subtherapeutic drug level does not
cure the infection in the fetus.
• All four species can cause congenital malaria, but it is proportionately more
with P. malariae.
• The new born child can manifest with fever, irritability, feeding problems,
hepato splenomegaly, anemia, jaundice etc.
• The diagnosis can be confirmed by a smear for MP from cord blood or heel
prick, anytime within a week after birth (or even later if post-partum,
mosquito-borne infection is not likely).
• Differential diagnoses include Rh. incompatibility, infections with CMV,
Herpes, Rubella, Toxoplasmosis, and syphilis.
19. P. vivax malaria in pregnancy
• There are very few documented studies on P. vivax
malaria in pregnancy.
• It appears to be more common in primigravidae than
multigravidae.
• Parasite densities are similar in pregnant and non-
pregnant states.
• It may be associated with mild anaemia and increased
risk of low birth weight and not associated with abortion,
stillbirth or a reduction of the duration of pregnancy.
• Benefit of chemoprophylaxis has not been established.
20. Management of Malaria in Pregnancy
– Treatment of malaria
– Management of complications
– Management of labour
21. Treatment of malaria
Treatment of malaria in pregnancy should be energetic, anticipatory and careful.
Energetic: Don't waste any time.
• It is better to admit all cases of P. falciparum malaria.
• Assess severity- General condition, pallor, jaundice, BP, temperature, hemoglobin,
Parasite count, SGPT, S. bilirubin, S. creatinine, Blood sugar.
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.
• RBS 4-6 hourly; hemoglobin and parasite count 12 hourly; S. creatinine; S. bilirubin
and Intake / Output chart daily.
Careful: The physiologic changes of pregnancy pose special problems in management
of malaria. In addition, certain drugs are contraindicated in pregnancy or may
cause more severe adverse effects. All these factors should be taken into
consideration while treating these patients.
• Choose drugs according to severity of the disease/ sensitivity pattern in the
locality.
• Avoid drugs that are contraindicated
• Avoid over / under dosing of drugs
• Avoid fluid overload / dehydration
• Maintain adequate intake of calories.
23. Zambia: malaria first line treatment
• In 2004, Zambia changed its policy to artemether-
lumafantrine (brand name = Coartem®) for use as first-line
treatment for uncomplicated malaria.
• Coartem® is a highly effective artemisinin-based combination
therapy.
• In cases of complicated malaria, the recommended drug is
quinine.
• This policy change suggests national confidence in its ability to
reduce malaria burden rapidly to the extent that shouldering
these costs is a reasonable public health decision. (NMCC)
24. 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.
• Anemia: Packed cells should be transfused if hemoglobin is <5g/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. 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).
25. 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 fetus.
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 fetal parameters is extremely important and
pregnant women with severe malaria are better managed in an intensive care unit.
• 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 fetal tachycardia, bradycardia or late deceleration in relation to uterine
contractions, indicating fetal distress. All efforts should be made to rapidly bring
the temperature under control, by cold sponging, 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 fetus. In cases of very high parasitemia, exchange transfusion may have
to be carried out.
• If the situation demands, induction of labour may have to be considered. Once the
patient is in labour, fetal or maternal distress may indicate the need to shorten the
2nd stage by forceps or vacuum extraction. If needed, even caesarian section must
be considered.
26. Treatment of vivax malaria in pregnancy
• In pregnancy, use of primaquine is contraindicated. Primaquine
is also contraindicated in lactating mothers.
• Therefore to prevent the relapse of vivax malaria from
reactivation of hypnozoites in the liver, suppressive
chemoprophylaxis with chloroquine is recommended.
• Tablet Chloroquine 500 mg weekly should be administered to all
such patients until stoppage of lactation.
• At that point, a complete treatment with full therapeutic dose of
chloroquine and primaquine should be administered.
27. Chemoprophylaxis in pregnancy
• Malaria being potentially fatal to both the mother and the fetus, 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 in areas of high transmission of malaria.
• 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. However, 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.
• Vaccine against malaria in pregnancy: Although a general malaria vaccine appears
to be a distant possibility, there is much hope for a vaccine against placental
malaria. The administration of excessive soluble CSA to pregnant women has
proven to drastically reduce parasite adhesion; however, in excess levels, this
soluble protein is severely nephrotoxic. Studies have demonstrated that the
administration of chondroitinase AC can effectively reduce parasite adhesion by
95%. This preliminary data is being further tested in combination with therapeutic
use of monoclonal antibodies to CSA
28. Obstetrics Emergency
Cerebral malaria
• Can be a rapid progression from malaria to severe malaria to
cerebral malaria
• Presentation:
– altered consciousness (drowsiness, confusion, coma)
– focal or generalised convulsions
– abnormal neurological signs (decerebrate etc)
– abnormal breathing
– Hypoglycaemia
• Management - transfer
antiparasitic drugs (IV quinine)
supportive therapy
fluid balance
anticonvulsants
antipyretics (paracetamol)
29. If you can do an
HB and MPS
You can get
the result
