Malaria in Pregnancy and management

1. MALARIA IN PREGNANCY
Dr. Derrick T
MBchB

2. Outline
• Introduction
• Epidemiology
• Etiology
• Pathophysiology
• Management
• Complications

3. Introduction
It’s a protozoal infection caused by genus plasmodium.
The species involved include P.falciparum, P.vivax, P.malariae and
P.ovale.
In pregnancy it’s commonly P.falciparum involved.

4. • Malaria is a public health burden because of
• Increasing resistance of malaria parasites to treatment
• Increasing resistance of anopheles mosquito vectors to
insecticides
• Ecologic and climatic changes favoring survival of mosquitoes
• Increasing international travel to malaria endemic areas by non
immune travelers

5. EPIDEMOLOGY
• Between 2010 & 2015, the incidence of malaria among populations at risk fell by
21% worldwide. Africa disproportionately accounts for 90% of malaria cases & 92%
of malaria deaths globally. (WHO 2017)
• Women become more susceptible to malaria during pregnancy. In endemic areas,
approximately 25 million pregnancies are at risk of p. falciparum infection every year
n 25% of these women have evidence of placental infection at the time of delivery
• Prevalence of malaria in Uganda is high; has 3rd highest global burden of malaria
cases with those more affected being pregnant women & children under 5. General
population 191 cases per 1000 population in 2017/2018 compared to 272 cases with
Mbarara: 80 cases. Infection rate during pregnancy was 30% & maternal anemia 40%
before 2010 .At Mulago, infection rate in pregnancy was 20% in a study carried out
in 2010,recent study at fort portal :16.27% in 2019.
• Between 2016-2018, prevention has increased.ie receiving 2 IPT does from 46% to
72%, 3 doses 17% to 41%....2019 data

6. High risk groups
• People from non-endemic areas
• Children ( <5 years)
• Sicklers
• HIV /AIDS patients
• Pregnant women

7. Why is Malaria in pregnancy Unique?
• High prevalence ( over 62% parasitaemia rates) especially in PGs= 2
fold increase
• Detrimental occultism ( Placental sequestration without parasitaemia
or clinical features of malaria)
• Dual/ multiple effects ( affect both mother and the fetus)

9. Aetiology
• Protozoa of the genus plasmodium
• >120 species are known but only four infect human
• -P.falciparum
• -P.malarae
• -p.ovale
• -p.vivax
• Transmitted through the bite of female anopheles mosquito (
a.gambie, a. funestus)
9

10. Other modes of transmission
• Congenital (vertical/transplacental: <5%, 0.03)
• Through blood transfusion
• Needle stick injuries esp in drug addicts
• NB: Transmission is almost exclusively via bite of infected female
anopheles mosquito

11. Immune mechanisms in the mother
• Humeral IGg ( circulates freely and can cross the placenta into fetal
circulation)
• Anti adhesive Antibodies (aaa). Prevent sequestration of the parasites
in the placenta (Placental site specific antibodies)

12. Protective mechanisms in the fetus
• Acquired passive partial immunity
• Placental mechanisms that limit the entry of parasites into fetal
circulation ( aaa,Phagocytes)
• P. falciparum does not grow well in RBCs containing Hb F.

13. Pathophysiology in Pregnancy
• Placental tissues contain chondroitin sulphate which
are receptors with high affinity for malaria
parasites>> placental sequestration >>multiplication
of distinct population of malaria parasites, expressing
a specific class of Variant Surface Antigens, VSAs, that
mediate adhesion of parasitised erythrocytes to
chondroitin sulphate on syncitiotrophoblast, causing
accumulation of infl leucocytes that cause necrosis of
adjacent placental tissue, interfering with placental
function ( x-change of nutrients/ 02) >> Placental
insufficiency.

14. Clinical features
• -Uncomplicated ( simple)
• -Complicated ( severe)

15. Uncomplicated malaria
• Fever. Headache. Malaise. Loss of appetite. Weakness. Cough.
Dizzness. Nausea. Vomiting. Joint pains. Diarrhoea. Muscle pain.
Bachache. Raised temperature. Shivering. Enlarged spleen. Mild
positive blood slide (+, ++).

16. Severe Malaria
• Symptoms
• Lethargy. Altered mental status. Convulsion. Drowzziness. Fast
breathing. Dark coloured urine
• Signs- as for uncomplicated malaria plus related to above

17. Severe Malaria
• Severe anaemia. Cerebral malaria. Renal failure. Severe jaundice.
Hypoglycaemia. Acidosis. Pulmonary oedema. Shock. Hyperpyrexia.
Fluid/electrolyte imbalance. DIC. Hyperparasitaemia.
Haemoglobinuria.

18. Investigations
• RDT
• Thin film-identification
• Thick film-quantification

19. Investigations
• Complete blood count
• Serum electrolytes
• Urinalysis
• Blood glucose
• Renal function test
• Liver function test

20. Case management
• Simple malaria : 1st line; ACT
• 2nd line; oral quinne
• Iv Quinine for severe malaria
• Till patient can take oral

21. Malaria in pregnancy control strategy
• Part of ANC package
• IPT
• Use of ITN
• Early diagnosis and prompt effective case management
• Indoor residual spraying
• Other Rx..Haematinics, Mebendazole

22. IPT
• Previously 2 doses of SP
• 1st ..16-24 WOA (4-6 mons)
• 2nd .. 28-36 WOA ( 7-8 Mons)
• For special groups eg HIV postive give 3 doses between 16 –36 WOA
at least 1 month apart
• Now: IPT using SP 3 tabs every month from 16 WOA until delivery
• Considering Dihydroartemesinin/Piperaquin

23. Prevention of malaria
• Health education ( from home –Community- --National level)
• Policies and guide lines from MOH

24. Preventive measures
• Clearing bushes
• Emptying cans
• Draining/oil on stagnant water
• In and out door spraying
• Early closure of doors and windows
• Window and ventilator nets

25. Complications
On the fetus
• Abortion
• Preterm labor
• Pre-maturity
• IUGR
• Congenital malaria
• IUFD