Malaria in pregnancy_documentation

1. Malaria in pregnancy
By Akugizibwe Solomon
BMS 3.2

2. Definition
• Malaria is an acute febrile condition caused by protozoa, of the
plasmodium species, transmitted from one person to another
through the bite of an infected female anopheles mosquito
• The diagnosis is confirmed by the detection of malarial parasites in
peripheral thick blood smear.

3. Etiology of malaria
There are five Plasmodium species of malaria parasites which infect
humans namely:
• P. falciparum
• P. vivax
• P. ovale
• P. malariae
• P. knowlesi
P. falciparum is the most virulent and also the most common malaria
parasite in Uganda.

4. Clinical classification of malaria
• Uncomplicated malaria( asymptomatic, mild)
• Complicated malaria(severe)

5. Clinical features of uncomplicated malaria
• Fever: above 37.5°C (taken from the axilla ) or history of fever, chills
and rigors.
• Loss of appetite, mild vomiting, diarrhea
• Weakness, headache, joint and muscle pain
• Mild anemia (mild pallor of palms and mucous membranes)
• Mild dehydration (dry mouth, coated tongue, and sunken eyes)
• Enlarged spleen (in acute malaria it may be minimally enlarged, soft
and mildly tender)

6. Clinical features of complicated malaria
• Confusion
• Hypoglycemia
• Repeated Convulsions
• Coma
• Heamoglobinuria
• Shock /Circulatory collapse
• Severe anemia
• Difficulty in breathing (due to
pulmonary edema)
• Vomiting all feeds
• Complete Refusal to feed
• Severe Dehydration and Electrolyte
Imbalance
• Renal Failure
• Spontaneous Bleeding
• Jaundice
• Hyperpyrexia (Temp>39.50C)
• Hyperpasitaemia
• Prostration

7. Effects of malaria in pregnancy on fetus
• Miscarriage
• Preterm labor
• Prematurity
• IUGR
• Congenital malaria
• IUFD

8. Differential diagnosis
• Urinary tract infections
• Typhoid fever
• Pneumonia
• Meningitis
• Threatening abortion
• Viral infections
• Eclampsia

9. Investigations
• Rapid Diagnostic test (RDT) or thick blood slide for diagnosis of
malaria
• CBC
• Random blood sugar
• Thin film for parasite identification
• HIV serology
• Urinalysis

10. Prevention of Malaria in pregnancy
• Give all pregnant women intermittent preventive treatment (IPTp)
with sulfadoxine/pyrimethamine (SP) once a month starting at 13
weeks of gestation until delivery – Except in allergy to sulphonamide.
• Prompt diagnosis and effective treatment of malaria in pregnancy.

11. Management of uncomplicated malaria
First line :
• Artemether/Lumefantrine 80/480 mg 12 hourly for 3 days
First line alternative :
• Dihydroartemisinin/ Piperaquine 3 tablets (1080 mg) once daily for 3
days
• Give analgesic and antipyretic, paracetamol, 1gm 8-hourly for 3 days

12. Management of Uncomplicated malaria cont..
• If the patient is not responding to oral ACTs e.g. due to vomiting, IV
Artesunate is given, and the dose is 2.4mg/kg at 0 hours ,12hours and
24hours.
• Assess to see if the patient is able to swallow; if the patient is able to
swallow change to ACTs. If the patient is unable to swallow, continue
with IV Artesunate given once a day for 6 more days.

13. Management of Complicated malaria in
pregnancy
• If having convulsions or delirious, give Diazepam, IV. It should be given
slowly for 1 minute at a dose of 0.2mg/kg or rectal at 0.5mgs/kg.
Repeat the dose if the convulsions don’t stop after 10minutes. In case
the convulsions don’t stop with Diazepum, use other anticonvulsants
like Phenobarbitone.
• IM/IV Artesunate 2.4 mg/kg at 0, 12 and 24 hours, then once a day
until mother can tolerate oral medication. Complete treatment with 3
days of oral ACT

14. Complicated malaria in pregnancy
• First line alternative IM artemether 3.2 mg/kg loading dose then 1.6
mg/ Kg once daily until mother can tolerate oral medication.
Complete treatment with 3 days of oral ACT
• Alternative: Give quinine dihydrochloride parentally 10mg/kg in
500mls of 5% Dextrose over a period of 4 hours 8 hourly until the
patient can tolerate oral Quinine 600 mg 8 hourly for 7 days to
complete course of treatment.

15. Management of complicated Malaria in
pregnancy cont.…
Assess for and manage hypoglycemia with IV glucose:
• 50% Dextrose 25-50mls
• 25% Dextrose 50-100mls
• 10% Dextrose 125-250mls
• If no IV glucose is available, give sugar water by mouth or Nasogastric
tube. To make sugar water, dissolve 4 level teaspoons of sugar (20g) in
a 200mls cup of clean water.
• Note: 50% Dextrose solution is irritating to veins. Dilute it with an equal quantity of sterile
water or saline to produce 25% glucose solution.

16. References
• DC Dutta’s Textbook of obstetrics, 9th edition.
• Williams Obstetrics, 24th edition.
• Essential Maternal and Newborn Clinical Care Guidelines for Uganda,
May 2022.
• Uganda Clinical Guidelines 2020.