Prevent Malaria Pregnancy Guide

Division of National Malaria Programme – Komesha Malaria, Okoa Maisha
Ministry of Health
Module 2 Learning Unit 3
Prevention and Management of Malaria in
Pregnancy
Training of Malaria Case Management
Master Trainers

Learning Unit 3: Prevention and Management of Malaria in
Pregnancy
Basic facts about malaria in pregnancy
Brainstorming session

Learning Objectives
By the end of the session, the participants should be able to:
1. Identify basic facts and effects of malaria in pregnancy
2. Recommend appropriate preventive strategies and prescribe
Intermittent preventive treatment of malaria (IPTp) according to
guidelines
3. Manage uncomplicated malaria in pregnancy
4. Manage severe malaria in pregnancy

Introduction to Malaria in pregnancy
• Malaria infection during pregnancy is a major public health problem, with substantial
risks for the mother, her fetus and the newborn
• During pregnancy there is altered/suppressed immune response to malaria
especially in primi- and secundi-gravidae and those that are HIV infected
• The levels of immunity is determined by immunity status before pregnancy which
in turn is determined by the levels of malaria transmission in the area
• In low transmission areas all women are affected while in high transmission areas
the adverse events occur especially in primi- and secundi-gravidae

Introduction cont’d
• To prevent the irreversible, negative consequences of malaria during
pregnancy, it is critical to encourage pregnant women to:
• Sleep under LLINs and
• Start IPTp-SP regimen as early as possible in the second trimester
• WHO and partners recommend initiating malaria prevention efforts
beginning at 13 weeks to achieve major benefits
• The period between 13 and 20 weeks is critical because this is the time
when the placenta is forming and the parasite densities are highest

Adverse events in MIP
• Malaria in pregnancy can cause maternal and fetal complications:
• Maternal complications:
• In areas of low transmission Malaria in Pregnancy will lead to:
abortion, hypoglycaemia, miscarriage, pulmonary oedema, cerebral
malaria and even progression of UM to severe illness which may lead
to death
• In areas of high transmission, pregnant women have low levels of
asymptomatic parasitaemia which concentrates mainly within the
placenta and may lead to maternal anaemia

Adverse events in MIP cont’d
• Fetal complications:
• Parasite sequestration in placenta results in poor transport of nutrients and oxygen to
fetus leading to the following complications:
• Low birth weight
• Intrauterine growth retardation
• Stillbirth
• Congenital infection (rare)-transplacental spread
• Prematurity

Current MOH Policy and Strategy on Malaria in Pregnancy
• Intermittent preventive treatment in pregnancy using Sulfadoxine-
Pyrimethamine (IPTp-SP)
• Long Lasting Insecticidal Nets (LLINs)
• Effective case management
• Education and communication

PART 2
Preventive Strategies
• IPTp-SP
• Long lasting insecticidal nets (LLINs)

IPTp in pregnancy
• What is IPTp?
• Anti-malarial given in treatment doses at defined intervals
• Assumes every woman in a malaria endemic area has malaria parasites in blood
or placenta
• Prevents placental malaria infection, low birth weight associated with early infant
mortality
• Where should IPTp be implemented?
• MoH policy recommends implementation of IPTp in all endemic counties/sub
counties
• Currently Sulfadoxine-Pyrimethamine (SP) is the most effective medicine for IPTp
despite its increased resistance to p. falciparum

Division of National Malaria Programme – Komesha Malaria, Okoa Maisha 11
Uptake of IPTp-SP
11

IPTp in Lake Endemic and Coast Endemic Zones
80
65
48
76
62
44
82
66
50
IPTp 1+ IPTp 2+ IPTp 3+
Total Urban Rural
Percent of women age 15-49 in Lake endemic and Coast endemic zones with a live birth
in the two years before the survey who received at least 1, 2, or 3 doses of SP/Fansidar

Programmatic Performance - Proportion of Pregnant women who
received at-least one, two and three or more doses of IPTp in malaria
endemic counties (KHIS)
72%
58%
43%
72%
57%
44%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
IPTp1 IPTp2 IPTp3
Proportion of Pregnant women who received at-least one, two and three or more doses of IPTp in
malaria endemic counties
Year 2021 Year 2022 (Jan to May)

Brainstorming
• Is SP effective forIPTp

Continued Use of SP for IPTp
• Recent studies in East and Central Africa show that the ability of SP to
clear peripheral parasites and to prevent new infections during
pregnancy is compromised in areas with:
• >90% prevalence of plasmodium falciparum dihydopterase synthetase
mutations (Pfdhps)

Current/New Information
• Nonetheless, in these high-resistance areas, IPTp-SP use remains beneficial as
shown by increases in birth weight and maternal hemoglobin (Desai et al. 2018)
• In addition, recent studies have shown that SP is protective against curable
STIs/RTIs and other unspecified causes of adverse birth outcomes (Chico et al.
2017)

Additional Literature
• A systematic review and meta-analysis by Kayentao et al. (2013) showed
that 2 doses of IPTp-SP may not provide protection during the last 4 to
10 weeks of pregnancy, a pivotal period for fetal weight gain
• Thus concluding that among pregnant women in sub-Saharan Africa,
intermittent preventive therapy with 3 or more doses of sulfadoxine-
pyrimethamine was superior to the previous standard 2-dose regimen
(with no difference in adverse events)

IPTp Dosage
• SP single dose of three tablets
under directly observed therapy
(DOT) in Antenatal Care (ANC) clinic
• Can be taken on an empty stomach
• It is safe
• It is effective

Simplified Schedule for IPTp-SP in New ANC Contact
Framework
Timing of Contact Dose #
1: Up to 12 weeks
1a: 13-16 weeks IPTp-SP dose 1 (additional contact)
2: 20 weeks IPTp-SP dose 2
6: 36 weeks No SP, if last dose received <1 month ago
7: 38 weeks IPTp-SP dose 6 (if no dose in past month)
8: 40 weeks
DNMP

IPTp-SP Timing
• Administer IPTp –
SP with each ANC
visit and or
contact starting as
early as possible in
the second
trimester
beginning at 13
weeks of gestation
• The doses should
be given at least
four weeks apart
• Pregnant women
should receive a
minimum of three
doses of SP
Timing of Contact Dose #
1: Up to 12 weeks
1a: 13-16 weeks IPTp-SP dose 1 (additional contact)
6: 36 weeks No SP, if last dose received <1 month ago
7: 38 weeks IPTp-SP dose 6 (if no dose in past month)
8: 40 weeks

IPTp-SP Timing (2)
• The last dose of IPTp with SP can be
administered safely up to the time of
delivery
• IPTp-SP should be administered as
DIRECT OBSERVED THERAPY (DOT)
• Three tablets of SP (each tablet containing
500mg/25mg SP) giving the total required
dosage of 1,500mg /75mg SP
• If a woman presents at antenatal care
clinic with symptoms of malaria, these
symptoms should be investigated before
the administration of IPTp-SP

IPTp timing (3)
• If she tests positive for malaria she should be treated according to the
national malaria case management guidelines
• If she is negative, she should receive IPTp-SP
• Note:
• IPTp should not be given together with high dose folic acid (5mg) due to drug
interaction effects that increases the chances of parasite survival
• The folic acid should be discontinued for two weeks following SP administration
• Low dose folic acid (0.4 – 0.6 mg) may be administered concurrently with SP

SP for IPTp and HIV- positive women
• HIV positive pregnant women in malaria endemic areas who are on daily Co-
trimoxazole prophylaxis should NOT be given SP for IPTp due to a high risk of
adverse events

Determination of Gestational Age (GA) for the first dose of SP
• Taking client history
• Last normal menstrual period (LNMP)
• Quickening
• Primi (18-20 weeks)
• Multi-gravindae (around 16 weeks or earlier)
• Potential Challenges
• Uncertainity of women about their LNMP
• Breastfeeding and progestin-only contraception can have anovulatory vaginal
bleeding
• Variation in quickening among individuals

Determination of Gestational Age (GA) for the first dose of SP
cont’d
• Physical examination
• First trimester:
• Uterus not palpable abdominally
• Second trimester (beginning at 13 weeks)
• Uterus palpable – 3 fingerbreadths above Symphysis pubis
•Other methods
• Pregnancy tests
• Symphysis pubis-Fundal height (SFH) –generally only used after
20-24 weeks gestation

Determination of Gestational Age (GA) for the first dose
of SP cont’d
• Other methods:
• Ultrasound scan (US)
• US can be superior to dating via LNMP or physical examination
depending on clinical circumstances, but dating precision
decreases with GA and Ultrasound machines are not universally
available

Exercise (brainstorm)
A pregnant woman living in a malaria endemic area received her IPTp 1 at 18 weeks of
pregnancy. She comes to the ANC clinic for the following visits;
• Visit at 20 weeks for routine care
• Visit at 24 weeks-----TCA given for TT
• Visit at 28 weeks-------TCA for TT, and has UTI
• visit at 34 weeks for routine care
• Visit at 38 weeks with complaint of backache
In which of the visits is she eligible for IPTp?

Long lasting Insecticidal Nets (LLINs)
• All pregnant women living in malaria endemic areas should sleep under LLINs
every night.
• They should continue to use LLINs after delivery
• Use of both IPTp and LLIN is beneficial to the mother, fetus and newborn

Presentation of Malaria in pregnancy
• Clinical presentation
• Signs and symptoms of malaria
• Signs of anaemia
• Severe disease
• Similar presentation to non-pregnant
• Subclinical presentation
• Often parasitaemic but asymptomatic especially in endemic areas

Management of uncomplicated malaria in pregnancy
• Clinical signs and symptoms same as in non-pregnant individuals
• Parasitological diagnosis is recommended
• If parasitological diagnosis is not available and other causes of illness have been
eliminated treat as malaria

Treatment of uncomplicated malaria
• First trimester
• Oral quinine - 7 days
• Avoid AL in the first trimester (Concerning safety)
• Do not withhold AL in the 1st trimester if quinine is not available
• 2nd or 3rd trimester
• AL
• Oral Quinine if AL is not available

Severe malaria in pregnancy
• In all suspected cases of severe malaria;
• parasitological confirmation is recommended
• If no parasitological diagnosis or delay is anticipated, treat for severe malaria on clinical
grounds

Treatment of severe malaria
• IV Artesunate
• If artesunate is not available IV quinine can be administered
• Dextrose is the preferred infusion solution when using IV Quinine
• IM artemether can be used if artesunate and quinine aren’t available

Artesunate administration
• Dissolve artesunic powder with 5% sodium bicarbonate (provided with
vial)
• Dilute resultant solution with 5mls normal saline(provided with vial) or
5%dextrose
• Administer 2.4 mg/kg by slow IV
• Repeat the same at 12hrs and 24hrs
• Thereafter administer daily until patient can take orally, then
• Give a complete course of AL

Quinine administration
• Loading dose of 20mg/kg (maximum of 1200mg) in 5% dextrose to run over 4
hours
• If 5% dextrose is not available, use normal saline
• Omit loading dose if any quinine has been given in the last 24 hours
• Maintain with 10mg/kg (maximum of 600mg) infusion 8 hourly until the
patient is able to take oral medication

Follow on treatment after parenteral therapy
• Once all patients are able to take oral medication:
• Give a full course of artemether-lumefantrine

Supportive treatment
• Prevent hypoglycaemia (Give dextrose )
• Correct fluid and electrolyte imbalance
• Correct anaemia
• Give antipyretics
(Discuss care of the unconscious patient)
NB: It is the supportive care that actually matters in management of
severe malaria

Follow up
• Facility level: care should be done at antenatal care clinic
• Community level: to be done at household level by CHVs whereby
identification of PW, counseling and necessary referral will be done

Brainstorm (3 minutes)
• What are the issues and concerns of malaria in the post natal period?

Post-natal
• Issues and concerns in post-natal period:
• Increased risk of malaria in the first two months post-natally
• Anaemia
• Supportive care is very important
• Provision of LLINs for mother and infant
NB: Post-partum fever is not always due to malaria
• Rule out other causes of fever, including puerperal sepsis
• Post natal examination is required

Brainstorm (3 minutes)
• Which antimalarial drugs are safe to use in a nursing mother?

Antimalarial drugs safe for use by a
breast feeding mother
• AL
• Artesunate
• Quinine

Client counseling about IPTp
• Since women are used to starting IPTp-SP later in pregnancy, service
providers must counsel on the importance of dosing as early as possible
in the second trimester because:
• Malaria parasites can attack the placenta in the first trimester
• If parasites are not cleared with SP, they can affect placental development and
fetal growth very early in pregnancy

Client counseling about IPTp cont’d
• Women concerns must be addressed
• Counsel on nightly net use and explore barriers to use
• Advise that the client return to the facility if they develop danger signs of
malaria

Community approaches to scale up IPTp uptake
• Sensitization of pregnant women (PW) to take IPTp-SP as early as
possible in the second trimester
• CHVs to identify PW, register them, and refer them to the health providers for
skilled services
• Tracking PW monthly to ensure they attend schedule ANC visits

Thank You
46

Malaria Free KENYA
Elimination
SMEOR
Case Mgmt SBC
Vector Control
MIP
Prog
Mgmt
47

Prevent Malaria Pregnancy Guide

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