This document discusses malaria in pregnancy, including its causes, clinical features, effects on the mother and fetus, diagnosis, treatment, and prevention. Some key points: - Malaria is caused by Plasmodium parasites transmitted by mosquitoes and affects over 2 billion people worldwide, especially pregnant women. - It can cause severe complications in the mother like anemia, pulmonary edema, renal failure, and death. In the fetus it can lead to abortion, preterm labor, growth restriction, and stillbirth. - Diagnosis is made through blood tests and treatment depends on severity, with uncomplicated cases using artemether-lumefantrine and severe cases treated with injectable artesunate. -

1. MALARIA IN PREGNANCY
DR RUKIA (MD)

2. OBJECTIVES
• Introduction of malaria
• Causative of malaria
• Clinical future of malaria
• Effect of malaria to the mother and fetus
• Diagnosis
• Differential diagnosis
• Investigations
• Treatment
• preventions

3. BACKGROUND
Burden of the disease:
o2 billion people affected worldwide.
o1-2.5 million deaths annually (mostly
pregnant women, infants 0-5 years and HIV
patients).
 Greatest challenge: increasing resistance
to ant malarial medicines.

4. Etiology
• Intracellular Plasmodium protozoa transmitted
by female Anopheles mosquito.
• 5 species of plasmodium
–Plasmodium falciparum
–Plasmodium malariae
–Plasmodium vivax
–Plasmodium ovale
–Plasmodium knowless

5. CLINICAL FEATURES
I. Uncomplicated Malaria
Clinical features include:
 Headache, lassitude, fatigue, abdominal
discomfort and muscle and joint aches,
 Followed by fever, chills, anorexia,
vomiting and worsening malaise.

6. CLINICAL FEATURES cont
II. Severe Malaria
One or more of the following criteria PLUS
the presence of asexual parasitaemia defines
severe malaria.
Cerebral malaria/ unarousable coma
oat least for 30min
Metabolic acidosis

7. CLINICAL FEATURES cont
 Severe haemolytic anaemia/black water
fever
o Usually is normocytic normochromic
anaemia.
 Hypoglycaemia
 Acute renal failure
 Pulmonary oedema / adult respiratory
distress syndrome

8. CLINICAL FEATURES cont
 Disseminated intravascular coagulation
(DIC),
 Hypotension
 Convulsions
NOTE: If untreated, severe malaria is almost
always fatal.

9. Other manifestations of severe malaria, which
do not by themselves define the condition
 Severe weakness
Patient cannot sit or walk with no obvious
neurological explanation.
 Hyperparasitaemia
 Hyperpyrexia
Temperature above 40° C (104° F) in adults
and children.

10. V. MATERNAL EFFECTS OF MALARIA
1. Anaemia in pregnancy
oMore common and severe in young
primigravidae
oStarts in mid trimester btn 16 – 24th
weeks of GA

11. V. MATERNAL EFFECTS OF MALARIA
Mechanisms (theories)
a. Haemolysis and sequestration of infected
RBCs into the RES.
b. Haemolysis of non-parasitized RBCs
Non-parasitized RBCs may be opsonized and
develop auto-antibodies that make them prone
to haemolysis. Such opsonized RBCs are
sequestrated into the spleen and removed
from circulation by lympho-macrophages

12. c. Bone marrow suppression and
dyserythropoiesis (ineffective
erythropoiesis):
• Tumor necrosis factor (TNF) is thought to
mediate bone marrow suppression by
inducing dyserythropoiesis and reducing
erythroid proliferation.
d. Loss of appetite

13. MATERNAL EFFECTS OF
MALARIA
• Anemia
• Pulmonary edema
• Hypoglycemia
• Acute renal failure
• Disseminated intravascular coagulation (DIC)
• Hypotension

14. VI. FETAL EFFECTS cont
1. Pyrexia is associated with
– Induction of uterine
contractions leading to
Abortions, preterm labour,
– IUFD and fetal distress.

15. VI. FETAL EFFECTS cont
2. Placental Parasitization
• Presents with clogging of the intervillous
spaces with macrophages (Placental
Reaction), which is most marked during
the second half of pregnancy:
• Ultimate effect of placental parasitization:
• IUGR, LBW, IUFD, SB

16. FETAL EFFECTS OF MALARIA
• Spontaneous abortion
• Preterm labor
• Intrauterine growth restriction
• Low birth weight
• Fetal distress
• Intrauterine fetal death
• Congenital malaria

17. VII. IMMUNITY IN ENDEMIC AREAS
1. Maternal immunity
 Generally, immunity declines in
pregnancy.
Probably due to increased levels of cortisol, hence
increased susceptibility to falciparum malaria in
pregnancy
 Immunity for malaria decrease is more marked
in primes and younger women particularly in
the third trimester, than in multips and older
women.

18. 2. Fetal immunity in endemic areas
Protective mechanisms of the fetus in utero
a. Immune mother transmits passive immunity
(antimalarial IgG) to the fetus.
The few parasites that succeed are destroyed by the
antimalarial IgG
b. The placenta greatly limits the number of
parasites gaining access into the fetal circulation.
c. Falciparum parasites do not grow well in fetal
RBC containing Hb F.

19. Fetal immunity… cont
IMPORTANT NOTE:
1. Most protective mechanisms wane
after birth.
2. In non-endemic areas usually there is low
maternal immunity, hence no protection
against development of congenital
malaria. Therefore, such babies may be
stillborn or suffer ENND

20. Diagnosis
• History and examinations

21. Differential diagnosis
For severe malaria
• Meningitis
• Encephalitis
• Electrolyte imbalance
• Hypoglycemia
• Brain abscess
• Tetanus
• Brain tumor

22. Differential diagnosis cont
For uncomplicated malaria
• Urinary tract infection
• Typhoid fever
• Amoebiasis

23. Investigations
• MRDT/BS for Mps
• CSF analysis
• RBG
• Hb level
• Serum creatinine
• Serum electrolyte
• Urinalysis
• Widal test
• Stool analysis
• CT-SCAN
• MRI
• EEG

24. Treatment of Uncomplicated
Malaria in Pregnancy
• First ,Second and Third Trimester
o During All trimesters of pregnancy Artemether-
Lumefantrine should be used as medicine of
choice for treatment of uncomplicated malaria
(Based on new National guideline of malaria
treatment 2020)

25. Treatment of Severe Malaria in
Pregnancy
• First ,Second and Third Trimester of Pregnancy:
o Injectable Artesunate is the medicine of choice;
does not differ from the treatment of severe
malaria in other adult patients.
• Artesunate 2.4mg/kg bw i.v or i.m. given on
admission (time =0), then at 12hr and 24hr, then once
a day until patient is able to tolerate medication when
an ACT is given

26. WHO package of interventions for the
prevention and control of malaria during
pregnancy
1. Use of insecticide treated nets (ITNs) to prevent
infection
2. Intermittent Preventive Treatment in
pregnancy(IPTp)
To prevent asymptomatic infections among
pregnant women living in areas of moderate or
high transmission of P. falciparum
3. Effective management and prevention of malaria
illness and anaemia.

27. IPTp cont
 Drug of choice: Sulfadoxine/pyrimethamine
(SP)
 Doses: 3 tablets twice during pregnancy
 First dose: between 20 – 24 weeks
 Second dose: between 28 – 32 weeks
 Third dose:
 Preferably given as DOT

28. IPTp cont
 Where IPTp is recommended at each
scheduled ANC visit the first IPTp dose should
be administered as early as possible during the
2nd trimester of gestation and repeated at four
weekly intervals until the time of delivery