This document provides information on malaria epidemiology, causative organisms, life cycle, diagnosis and management in pregnancy. Some key points: - Malaria affects over 40% of the world's population, with India contributing 70% of cases in Southeast Asia. It is a leading cause of infectious death. - Plasmodium falciparum is the most dangerous species and a major cause of mortality. It is transmitted via the bite of infected Anopheles mosquitoes. - Malaria in pregnancy leads to worse outcomes for both mother and baby, including higher mortality, anemia, low birth weight, stillbirth and neonatal mortality. - Diagnosis involves blood smear microscopy, antigen detection tests and

1. EPIDEMIOLOGY
• 40 % of world’s population affected by Malaria.
(WHO)
• Of the 2.5 million reported cases in the South East
Asia, India alone contributes about 70% of the total
cases.
• >25million woman are at risk of malaria(WHO)
• Maiaria is 2nd most common cause of infectious
death after T.B.
• Deaths- Under estimated/Unknown,1.1 to 2.7 million
per year
• India most affected area are
UP,Bihar,Karnataka,Rajasthan MP
• Gender related mortality - Females more

2. Malaria in Pregnancy:
•Mutually aggravating
•Mortality is double
•Primigravidae - 60-70%
•Highest prevalence in second half.
•Plasmodium Falciparum – More common

3. Gravidity and malaria
• Primigravida have no pre-existing immunity to placental
parasites and are highly susceptible.
• In high transmission areas, primigravida develop
immunity to placental parasites and are protected in
subsequent pregnancies.
• In low transmission areas, multigravida are unexposed
and unprotected

4. CAUSATIVE ORGANISM
• Malaria vector borne disease caused by
protozoan plasmodium
1.P.falciparum(most dangerous account for
90%death d/t malaria)
2.P.vivax(most widely spread species)
3.P.malariae
4.P.ovale
5.P.knowlesi(malaria in macaques but can
infect human)

5. • Malaria transmitted by
mosquito female
Anopheles
1.Bite of infected
mosquito
2.Congenital infection
3.Blood transfusion
4.Contaminated needle
5.Organ transplantation

6. SOME FACTS ABOUT ANOPHELES
 They choose their victim by odor.
 Males are more frequently bitten.
 Most common time of bite is late evening to early
morning with peak at midnight.
 Stylets cut & proboscis probe for tiny blood vessels in
the skin. If it does not strike blood proboscis is withdrawn
and struck again at different angle.
 They can fly for few Km.
 Their life span is 2–3 weeks.
 Human blood is needed to lay eggs and nourish eggs.

7. LIFE CYCLE OF PLASMODIUM
• Human - intermediate host(asexual cycle)
• Mosquito-definitive host(sexual cycle)
• Infective form for human-sporozoite(in
salivary gland of mosquito)

8. • P.vivax affect young RBC
• P.falciparum- all stages RBC
• P.malariae-old RBC

10. Malaria in Pregnancy : Double
Trouble
• Malaria is more common in pregnancy
compared to the general population.
• Malaria in pregnancy tends to be more
atypical in presentation. This could be due
to the hormonal, immunological and
hematological changes of pregnancy.
• The parasiteamia tends to be 10 times higher.
• P. falciparum malaria in pregnancy being
more severe, the mortality is also double (13
%) compared to the non-pregnant population
(6.5%).

11. • During normal pregnancy, the cellular immune response
(Th1) is suppressed to prevent fetal rejection.
• Malaria stimulates the Th1 response  intrauterine
growth retardation.
• Malaria stimulates expression of an HIV co-receptor
(CCR5) in the placenta.
• 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.
-more prone for malarial infection and the parasitemia
tends to be much higher.

12. Change 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
• All the placental tissues exhibit malarial
pigments

13. TYPES OF MALARIA
1.UNCOMPLICATED
2.COMPLICATED

14. CLINICAL FEATURES
FEVER
• Stage 1-Cold stage
• Chills for 15 mt to 1 hour
• Caused due to rupture from the host red cells escape
into Blood
• Preset with nausea, vomitting,headache
– Stage 2-Hot stage
• Fever may reach upto 400
c may last for several hours
starts invading newer red cells.
• Stage 3-Sweating stage
Patent starts sweating, concludes the episode.
Cycles are frequently Asynchronous
Paroxysms occur every 48 – 72 hours
In P.malariae pyrexia may last for 8 hours or more and
temperature my exceed 410C

15. • Interval between fever
• 48hrs -Malaria tertiana (P.vivax,P.ovale)
• 72hrs -Malaria quartiana(P.malariae)
• Irregular high grade fever(P.falciparum)

16. • 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 hyper
endemic areas.

17. ANAEMIA
• Malaria can cause or aggravate anaemia due to:
– 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.

18. • Splenomegaly :
– Enlargement of the spleen may be variable.
• 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
– anemia are more common in pregnancy.
– Jaundice, convulsions, altered sensorium, coma, vomiting /
diarrhoea and other complications may be seen.

19. COMPLICATIONS
• Hyperpyrexia
• Anaemia(d/t haemolysis &increased demand)
• Jaundice
• Hypoglycaemia
• Folate deficiency(haemolysis)
• ARF
• Acute pulmonary edema(2nd &3rd trimester,postpartum period d/t
autotransfusion &increased peripheral vascular resistance)
• Fluid and electrolyte imbalance
• Cerebral malaria
• Circulatory collapse
• Black water fever

20. ACUTE PULMONARY EDEMA
• 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. This
is due to
– Auto transfusion of placental blood with high proportion of
parasitised RBC’s
– Sudden increase in peripheral vascular resistance after delivery.
• It is aggravated by pre existing anaemia and hemodynamic
changes of pregnancy.
• Acute pulmonary oedema carries a very high mortality.

21. 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.
– Hypoglycaemic response to starvation.
– Increased response of pancreatic islets to secretory
stimuli (like quinine) leads to hyperinsulinemia and
hypoglycemia..

22. • Hypoglycaemia in these patients can remain
asymptomatic and may not be detected,
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.

23. CEREBRAL MALARIA
Needs Intensive care
1. ABC of coma care
2. Prompt institution of antimalarials
3. Treatment of hyperpyrexia
4. Management of other complications
5. Treatment of associated infections

24. Effect of malaria on foetus
Malaria in pregnancy detrimental to foetus
due to-
a.high grade fever
b.placental insufficiency
c.hypoglycemia
d.anaemia

25. • There is interesting fact that primigravidas
may develop more clinical symptoms of
malaria, woman with higher immunity may
not demonstrate sympt. but they may
have more placental burden so more fetal
complications

26. Resulting in-
• Spontaneous abortion
• Premature birth
• I.U.G.R.
• Still birth
• Low birth weight
• Congenital malaria<5%(b/c of protection
by maternal IgG) more with P.malariae
• Perinatal and neonatal mortality 15%-70%
(P.vivax 15.7%,P.falciparum 33%)

27. POOR PROGNOSTIC PARAMETER
• Parasitemia >5%
• Packed cell volume <30%
• Hemoglobin <7.1 gm%
• Hypoglycemia :blood glucose <40 mg%
• Low levels of glucose in cerebrospinal
fluid
• Raised venous lactic acid >60 m.mol/L
• Low level of antithrombin 3
• Peripheral schizontemia
• Increased plasma S-nucleotides
• Serum creatinine >3.0mg%

28. CLINICAL
MICROSCOPY
IMMUNOLOGY
MOLECULAR
SEROLOGY
DIAGNOSIS
OF
MALARIA

29. DIAGNOSIS
• High level of awareness
• Peripheral blood smear (Gold standard)
thick smear: rapid diagnosis
thin : species identification
• other advantages
If negative : repeat blood test 6 hourly for 6 times
• Antigen detection techniques : (PfHPR-2)
• Fluorescent staining
• PCR based assay
• Antibody test
• Placental blood smear
• Currently available rapid diagnotic tests are as follows-
• Histidine rich protein two (HRP 2) – asexual stages &
young gametocyte of Pfalciparum
• Parasite lactate dehydrogenas – for all 4 types
• Plasmodium aldolase – for all four types

30. sample collection-any time irrespective to
fever but before administration of
antimalarial drugs
Advantage:-
• can diagnose 5-
10parasites/ml
• identificatin of species
&stage of parasite
• parasite density
• malarial pigment in
neutrophils
&monocyte
• Disadvantage:-
• time consuming
• skilled technician
• in mixed infection one
species suppress

31. THICK AND THIN SMEAR

32. • parasites are not detected at
times in peripheral smear :-
a. sequestration deep vascular bed
b. partially treated patients
c. prophylactic antimalarial t/t
d. inexperienced technician
e. poor quality staining

33. RAPID DIAGNOSTIC TEST
Currently available rapid diagnotic tests are as follows-
Histidine rich protein two (HRP 2) – asexual stages & young gametocyte of
Pfalciparum
Parasite lactate dehydrogenas – for all 4 types
Plasmodium aldolase – for all four types
WHO- A MINIMUM STANDARD OF 95% SENSITIVITY FOR P.FALCIPARUM DENSITIES
OF 100 PARASITES/L OF BLOOD AND A SPECIFICITY OF 95%
HRP-II with parasite density 100/ml of blood -90% - with 10/ml -75%
HRP-II remain positive for 1-3wk.
p LDH remain positive for 5 days.

34. Antigen detection tests
Principle: dipstick antigen capture assay employs a monoclonal
antibody detecting the Pf.HRP-2 antigen in the blood
Rapid, simple, sensitive test
Species specificity Optimal Assay
Control
Plasmodium pan specific
monoclonal antibody
P. falciparum
specific
monoclonal
antibody

35. Antibody detection (not for acute infection)
a.RIA
b.ELISA
=
Antigen-antibody
complex
Patient’s serum
contains specific
and non-specific
antibodies
+
Antigen

36. QBC TEST
Spinning blood in a specialised capillary tubes in
which parasite DNA is stained with acridine
orange.
Detected by ultraviolet microscope
PCR TEST:-
SENSITIVE CAN IDENTIFY DIFFERENT SPECIES
WITHin 48-72 hrs but expensive

37. Diagnosis of
• untreated acute malaria -blood smear
• Chronic malaria-serology
- blood smear
-PCR
Treated recent malaria-serology
-blood smear

38. MANAGEMENT
Management of malaria in pregnancy
involves the following three aspects and
equal importance should be attached to
all the three.
• Treatment of malaria
• Management of complications
• Management of labour

39. 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:
• 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.

40. • Careful:
• The physiologic changes of pregnancy pose special problems
in management of malaria.
• 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.

41. MANAGEMENT OF MALARIA IN PREGNANCY
• Treatment depends on -
a.severity of disease
b.getational age
• WHO recommended -in endemic area t/t
should started within 24hrs after 1st
symptom.
a.uncomplicated malaria -OPD basis t/t
b.complicated malaria-Hospitalisation

42. • DOC in pregnancy(WHO)
a. All trimester
1st line- chloroquine,quinine
2nd line -artesunate,artemether.arteether
b.2nd &3rd trimester
pyrimethamine+sulphadoxine,mefloquine
NIMR GUIDLINE 2010
• Quinine in 1st trimester
• chloroquine for P.vivax
• ACT for t/t of P.falciparum in 2nd &3rd trimester
• ACT containing mefloquine should avoided in cerebral
malaria d/t neuropsychiatric complication

43. Drugs contraindicated in pregnancy
• Tetracycline
– Cause abnormalities of skeletal and muscular growth, tooth
development, lens/cornea
• Doxycycline
– Risk of cosmetic staining of primary teeth is undetermined
– Excreted into breast milk
• Primaquine
– Harmful to newborns who are relatively Glucose-6-Phosphatase-
Dehydrogenase (G6PD) deficient
• Halofantrine
– No conclusive studies in pregnant women
– Has been shown to cause unwanted effects, including death of
the fetus, in animals

44. DRUGS
• Chloroquine:
– 600mg (base) start, 300mg after 6 hours, 24 hours & 48 hours
• Quinine:
– IV - 20mg/kg infusion over 4 hours, repeat 8 hourly.
– Maintenance: 10mg over 4 hours, 8 hourly.
Follow with oral medication after clinically stable.
• Oral – 600mg 8hourly ( maximum 2 gm / day) for 7 days.
• Presently fixed dose combinations of
• Artesunate + amodiaquine
• Blister pack of artesunate +mefloquine

45. Artemisinin compounds(rapid
Schizonticidal)
• Artesunate(Falcigo):
– Oral-100mg BD on day 1, then 50mg BD for 4-6 days (Total
dose 10mg/kg).
– IM / IV-120mg on Day 1 followed by 60mg daily for 4 days. In
severe cases an additional dose of 60mg after 6 hours on Day 1.
• Artemether(Larither):
– Six amp (480mg) IM in 5 / 3 days
– 80mg BD X3 days
• Arteether(Emal inj):
– One amp (150mg) IM / day for3 consecutive days.

46. UNCOMPLICATED MALARIA
• Oral quinine 600mg 8hrly for 7days
OR
• Chloroquine 10mg/kg f/b 10mg/kg at
24 hrs & 5mg/kg at 48 hrs
• Avoid starting t/t on empty stomach
• 1st dose given under observation
• repeat dose if vomitting within 30min
• ask to report back if no improvement/deteriorate

47. COMPLICATED MALARIA
• Signs of uncomplicated malaria, plus:
• Dizziness
• Breathlessness
• Sleepy/drowsy
• Confusion/coma
• Sometimes fits, jaundice, severe dehydration

48. COMPLICATED MALARIA
• Artesunate i.v. 2.4mg/kg at 0,12,24hrs f/b
daily when pt able to take orally
artesunate2mg/kg daily for 7days
• Quinine i.v.20mg/kg in D5% over 4hrs f/b
10mg/kg over 4hrs 8hrly (max dose of
quinine 1.4gm) when pt able to take orallly
quinine 600mg tds for 7 days

49. DRUG RESISTANCE
• Resistance of P. falciparum to antimalarial drugs is an ever
increasing problem
• WHO recommends these combinations,incase of drug
resistance.
• Artemether–lumefantrine,
• Artesunate– amodiaquine,
• Artesunate–mefloquine,
• Artesunate–sulfadoxine–pyrimethamine, area dependent
• Dihydroartemisinin–piperaquine.

50. VIVAX MALARIA
• Chloroquine sensitive
chloroquine base 10mg/kg OD for 2 days f/b
5mg/kg on day 3
• Chloroquine resistant
Quinine salt 10mg/kg BD for 7days
or
Mefloquine 15mg/kg single dose
or
Artesunate 4mg/kg in divided loading dose
f/b 2mg/kg OD for 6 days

51. FALCIPARUM MALARIA
• Chloroquine sensitive
Chloroquine base 10mg/kg OD for 2days f/b 5mg/kg on
day 3
• Chloroquine Resisant
sulfadoxine(500mg)/pyrimethamine(25mg) 3tab single dose
or
Quinine salt 10mg/kg TDS for 7days
or
quinine salt 10mg/kg TDS for 3 days+
sulfadoxine/pyrimethamine 3 tab single dose on 1st day

52. MANAGEMENT OF COMLICATION OF
MALARIA
• Acute Pulmonary Oedema:
– Careful fluid management; back rest; oxygen; diuretics; ventilation if needed.
• Hypoglycaemia:
– 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 haemoglobin is <5 g%.
• Rnal failure:
• Reenal 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(ALGID MALARIA)
– Secondary bacterial infections like urinary tract infection, pneumonia
etc. are more common in pregnancy associated with 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.
– It is especially useful in cases of very high parasitemia (helps in
clearing) and impending pulmonary oedema (helps to reduce fluid load).

53. • Radical Cure:-
for prevention of relapse of P.vivax
Tab chloroquine 300mg/wk untill stoppage
of lactation,complete therapeutic t/t given
at that time chloroquine & primaquine
given for 14 days
• Mixed infection :-
std therapy for uncomplicated/complicated
malaria f/b course of primaquine

54. DURING LABOUR
• Careful monitoring of maternal &fetal
parameters because fetal distress
common and remained unrecognised
• All efforts should made to bring temp.
under control by cold
sponging,antipyretics

55. MALARIA CONTROL DURING PREGNANCY
• Antenatal care & health education
• Intermittent preventive treatment
• Use of insecticide treated net
• case management of malarial disease

56. Intermittent preventive treatment
INTERMITTENT PRESUMTIVE TREATMENT
• Based on an assumption that every pregnant woman in
a malaria-endemic area is infected with malaria
• Recommends that every pregnant women receive at
least two treatment doses of an effective antimalarial
drug
• Sulfadoxine-pyrimethamine (SP) currently considered
the most effective drug for IPT
sp should avoid during first 16weeks

57. Doses for IPT
• Chloroquine: - 300mg base, administered once
every week.
• Pyrimethamine-25mg + Sulphadoxine-500mg: -
One tablet once weekly.
• Mefloquine: -250mg weekly.
– Dose may have to be increased in the last trimester,
in view of the accelerated clearance of the drug.
• Proguanil: - 150-200mg / day.

58. Chemoprophylaxis during pregnancy
• Malaria being potentially fatal to both the mother and the
foetus, this should be an important part of antenatal care
in areas of high transmission.
– All pregnant women, who remain in the malarial endemic area :
during their pregnancy, should be protected with
chemoprophylaxis.
• Choice of anti malarials for chemo prophylaxis
– Chloroquine being the safest drug in pregnancy, should be the
first choice
– In areas with known resistance to Chloroquine
• Pyrimethamine + Sulpha, Mefloquine or Proguanil can be
used.
• But these drugs should be started only after 1st trimester
only.

59. Doses for chemoprophylaxis
• Chloroquine: - 300mg base, administered once
every week.
• Pyrimethamine-25mg + Sulphadoxine-500mg: -
One tablet once weekly.
• Mefloquine: -250mg weekly.
– Dose may have to be increased in the last trimester,
in view of the accelerated clearance of the drug.
• Proguanil: - 150-200mg / day.

60. VACCINE
• Malaria vaccines in development.
• No licensed vaccine against malaria
currently exists
• The parasite has evolved a series of
strategies that allow it to confuse, hide,
and misdirect the human immune system.
• The parasite changes through several life
stages even while in the human host,
presenting a different subset of molecules
for the immune system to combat at each
stage.

61. THANKS