Malaria with pregnancy presentations diagnosis Sever Malaria presentations Management of uncomplicated Malaria and management of sever Malaria

1. Alawia Hisham Omer Ahmed
Houseofficer/ Unit 4
*Malaria in
pregnancy

2. Introduction:
*Malaria is a major public health problem in sudan
*In 2021 malaria was the leading cause of outpatient
attendance, hospital admissions and inpatient deaths in
sudan
*Plasmodium falciparum is the most common infective
species accounting for more than 87.6% of cases followed
by plasmodium vivax 8.1% while mixed infections
( falciparum + vivax ) totaled 4.3%.
*It is important to early diagnose and optimally treat
malaria by proper use of antimalarial therapy based on
the patients weight. The aim is to provide effective
treatment within 24 to 48 hours of the onset of
symptomes to prevent major complications.

3. Diagnosis of Malaria:
*Malaria is suspected when a patient presents with fever
or with a history of fever (with or without symptomes)
and signs suffestive of malaria
*The diagnoses is confirmed by parasitological diagnosis
which are quality assured microscopy and rapid
daignosic tests (RTDs).
*Quality assured microscopy is the gold standard, Giemsa
stained thick and thin blood films should be tested.
*Advantages of light microscopy include high sensitivity
and specificity and the ability to determine the type of
the parasite and its density.

4. Malaria in pregnancy:
*Malaria causes high morbidity and mortality to the mother
and her fetus. The infection contributes to maternal
anemia, fetal loss, premature delivery, intrauterine growth
retardation and low birth weight.
*Malaria in pregnancy symptoms can be confused with early
pregnancy morning sickness.
*In addition to parasitological testing, CBC is mandatory for
hemoglobin and platelets count.
*Uncomplicated malaria:
*The first line treatment for uncomplicated malaria in all
trimesters is artemether- lumefantrine in the form of
tablets (80 mg artemether 480 mg lumefantrine). It should
be taken with fatty food or milk to optimize absorption
and the dose should be repeated if the drug is vomited
within 30 minutes.

5. *Side effects inculde: GI upset, headache, dizziness and
muscle pain.
*Treatment failure is considered qhwn fever and
parasitemia persist or recur within 4 weeks after initial
treatment
*Treatment failure must be confirmed parasitologically
as RDTs remain positive for weeks after the initial
infection even with effective treatment
*The second line treatment in the second and third
trimesters is dihydroartimisinin+ piperaquine ( DHAP)
*It is available as 20/160 mg for pediatrics and 40/320
for adults. It is given once daily for three consecutive
days. Fatty meals should be avoided as the alter
absorption.

6. *Side effects include GI upset and dizziness.
*DHAP is contraindicated in patients with congenital or
acquired QT prolongation.
*Treatment of uncomplicated vivax malaria:
*The objective of treatment is to cure the acute blood stage
and to clear hypnozoites from the liver to prevent relapses.
*The blood stage of vivax malaria is susceptible to the first
line treatment ( AL ).
*The hypnozoite clearance, AL must be followed by
Primaquine. Tablets available contains 15 and 30mg of
primaquine. Adults takes 15mg daily for 14 days, while
children 0.25mg per kg for 14 days.
*Primaquine is contraindicated in pregnant and
breastfeeding mothers as well as infants less than 6
months.

7. *Management of severe malaria:
*Severe malaria is defined as parasitologically confirmed
malaria plus one or more of the following:
Clinical manifestations lab findings
GCS < 11 in adults Severe anaemia, HB < 5 in
children or hb< 7 in adults
Multiple convulsions in 24
hours
Hypoglycemia < 40 mg/dl
Jaundice Metabolic acidosis, plasma
bicarbonate< 15
Pulmonary edema Hyperlactecemia > 5 mmol
Respiratory distress with
acidotic breathing
Renal impairment
( s.creatinine > 265
micromol/l or urea > 20
mmol/l
Abnormal bleeding
Hemoglobinuria or
myoglobinuria

8. *Iv artesunate is the treatment of choice for severe
malaria.
*The drug is available as 30, 60, 120 mg vials which are
packed together with sodium bicarbonate for
reconstitution and normal saline for dilution.
*Dose is 2.4mg/kg ( or 3mg/kg in children less than 20
kg) given at 0,12, and 24 hours then once daily until
* the patient can tolerate oral medication. It is followed
by full course of AL treatment.
*Side effects include hypersensitivity, GI upset, cough,
rash, arthralgia and dizziness
*The most significant side effect is hemolysis.

9. *Treatment with quinine:
*Quinine is available as 300mg/ml or 600mg/2ml vials
*Rapid iv administration is dangerous. 10mg/kg quinine
must be diluted in either 5% or 10% dextrose and given
as slow infusion over 4 hours at 8 hour intervals. Drop
rate is 42 drop/minute.
*It should be continued for at least 24 hours and until the
patient can take oral medication.
*A full course of oral AL should be given as soon as the
patient can tolerate oral medication. If contraindicated
a 7 days course of oral quinine can be given.
*Hypoglycemia is the most serious and common side
effect, others include hypotension and cinchonism.

10. *General management of patients with severe
malaria:
*ABCs
*Take a quick blood smear
*Establish the patients hydration status, assess fluid
requirements and replace accordingly
*Control fever with Iv or paracetamol.
*Control convulsions and hypoglycemia ( diazepam/
phynatoin??? )
*Start antimalarial therapy for severe malaria as before.
*Deal with complications:
1. Algid malaria: malaria associated with gram negative
septicemia, give broad spectrum antibiotics
2. Consider the need for blood transfusion.
3. In case of black water fever continue antimalarial and
transfuse fresh blood

11. *Exclue common infections that presents as
severe malaria:
1. Severe UTI, do urine analysis
2. Lumbar puncture in patients presented with coma,
cerebral malaria is not associated with signs of
meningeal irritation
*Monitor the following:
1. GCS
2. Fluid input and output
3. Vital signs 6 hourly
4. Level of parasitemia

12. Intermittent preventive treatment of malaria in
pregnancy:
*It is recommended for pregnant women in gigh
transmission settings in Sudan.
*The drug of choice is Sulfadoxine- pyrimethamine given
as a direct observed therapy with three tablets each
containing 500mg/25mg SP for atotal dose of
1500mg/75mg SP.
*It should be started in the second trimester and should
be given at each scheduled ANC visit until the time of
delivery. At least three doses should be given during
pregnancy.

13. *Contraindications:
1. Pregnant women before week 13 of pregnancy
2. Pregnant women with allergy to any component of
the drug.
3. Patients receiving co-trimoxazole.

14. *Thank You