Science study

1. Malaria in Pregnancy
DR CHISHIMBA
KALANDANYA

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Epidemiology
 Endemic in all 9 provinces of Zambia
 95-98% of cases caused by P falciparum
 Contributes to over 20% of maternal deaths
 In high transmission areas MIP is mainly
asymptomatic

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Diagnosis
 Fever, headache or convulsions
 Thick film –detects parasites
 Thin film –identifies species
 Antigen tests

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Pathophysiology of MIP
 Immunity to malaria is altered in pregnancy
 Particular problem in primigravida who have
high parasitemia
 Placenta is main site for malaria infestation
 Pregnant women susceptible to malaria due
to placenta being an immunologically
priveledged site.

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Placental Immunity
 Development of local (utero-placental)
specific immunity within a malaria-naïve
environment
 General pregnancy-related immune
suppression

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Placental Immunity
 Mechanical sequestration of a sub population
of parasites to Chondroitin Sulphate A in
trophoblastic tissue
 Local synthesis of immunosuppressive
factors

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Chemoprophylaxis- Intermittent
Presumptive Treatment (IPT)
 Intermittent - at specific intervals during the
second and third trimesters
 Presumptive - assumes that pregnant women
are infected, even without symptoms
 Treatment - treats them to clear the placenta
of malaria, to reduce maternal anaemia and
improve fetal development

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Chemoprophylaxis- Intermittent
Presumptive Treatment (IPT)
 Sulfadoxine-pyrimethamine (SP)= Fancidar is the
drug of choice
 Contains 500mg of sulfadoxine and 25mg of
pyrimethamine in each tablet
 Single dose consists of three tablets taken at once
as DOT
 Given from 16 weeks gestation (after quickening)
at one month intervals for maximum of three doses

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Chemoprophylaxis- Intermittent
Presumptive Treatment (IPT)
 In Zambia ALL pregnant women are
recommended to receive IPT due to the
endemicity of malaria and the high HIV sero
prevalence rate (16% general pop, much
higher in antenatals)

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Case Management Guidelines for
Uncomplicated Malaria
 In the first trimester, oral quinine is the first
line drug
 SP is not given in the first trimester as it is an
antifolate

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Case Management Guidelines for
Uncomplicated Malaria
 SP is the first line treatment for pregnant
women during the second and third
trimesters
 Folic acid supplementation should be
delayed for a week after treatment with SP
as it antagonizes sulfadoxine action.

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Case Management Guidelines for
Uncomplicated Malaria
 Co-Artem is the first line treatment for
uncomplicated malaria in the general
population
 Since Co-Artem has not been widely tested
in pregnancy it is not recommended in
pregnancy and children less than 10kg body
weight

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Case Management Guidelines for
Complicated Malaria
 Artesunate and quinine are the drug of
choice for case management of severe
malaria
 Artesunate dose ; 2.4mg per kg @0,12,24hrs
 Conversion to Cortem after clinical
improvement.

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Effects of MIP on fetal and
Newborn Morbidity
 Parasitaemia may impair nutrient transfer to
the fetus, negatively affect fetal nutrient use
or stimulate early delivery
 Lowered nutrient transfer to the fetus may be
caused by damage to the placenta caused
by parasites or their toxins

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Effects of MIP on fetal and New
born Morbidity
 Increased use of nutrients by parasites, poor
oxygen and glucose transfer from parasitized
red blood cells, while maternal anaemia from
malaria may reduce the supply of oxygen in
the amniotic fluid
 Malaria is a serious cause of fetal death,
stillbirths, low birth weight and early infant
deaths

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Congenital Malaria
 Maternal to child transmission of malaria
seems to be rare.
 An estimated 0.3% of infants are born with
congenital malaria and most likely affects the
umbilical cord

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Congenital Malaria
 Mothers passively transfer a degree of
immunity to their newborns
 The persistence of fetal Hb during the first 3
months of life can retard the growth of P
falciparum

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HIV and MIP
 HIV seems to hinder a woman’s ability to
control P falciparum infections during
pregnancy
 HIV positive pregnant women have higher
parasite prevalence and densities and a
greater risk of placental parasitaemia than
HIV negative women

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HIV and MIP
 HIV seems to lower pregnancy specific acquired
immunity, as malaria infections in HIV positive
women are equally serious in all gravidae
 Infants of all HIV positive women are also at risk. An
infant whose mother is HIV positive and had
placental parasitaemia has 3-4x greater chance of
death in the first year of life than one whose mother
has HIV but does not have placental densities

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IPT and HIV
 In areas of high sero-prevalence, ALL
gravidae need IPT with SP as HIV appears to
reduce immune response to malaria
 Zambia HIV seroprevalence of 16% is very
high
 A minimum of three doses of SP is effective
in clearing placental malaria to the same
rates as HIV negative women

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Malaria complications in Pregnancy
 Malaria is a major cause of anaemia in
pregnancy in tropical Africa along with iron
deficiency, folate deficiency and HIV/AIDS
 Anaemia negatively affects the immune
system and increases susceptibility to
infections, including malaria

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Malaria complications in Pregnancy
 In mesoendemic areas, anaemia is most
severe in the second trimester for all
gravidae
 Severe anaemia is also an important cause
of low birth weight
 Iron supplementation during pregnancy
improves maternal iron stores post-partum
for up to six months

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complications
 Increased risk of miscarriage
 Increased abortion risk
 Hypoglycemia
 Pulmonary oedema
 Coma