A case of severe falciparum malaria in pregnancy

Abstract

We present a case of 17 year old primigravida who

Problems: anemia, thrombocytopenia, oligohydramnion,

pre term birth and low birth weight as well as congenital malaria

Introduction

Malaria causes great morbidity and mortality in endemic areas in Indonesia, especially for high risk
groups such as infants, children, and pregnant women. Around 6.4 million pregnancies occur in
areas with P falciparum/P vivax transmission in Indonesia which results in only 3.8 live births.
Most cases, and also the most severe forms are caused by Plasmodium falciparum. [1]
 Pregnant women, due to an extent of immunosuppression are at increased susceptibility towards
severe malaria. This also applies to those residing in low transmission areas with lower levels of acquired
immunity to malaria.[2] Maternal clinical presentation of malaria may be nonspecific and resemble an array of
febrile tropical infectious diseases. A prodrome of flu-like symptoms may arise before the onset of fever.
Intermittent fever, with phases of chills and rigors depending on infecting plasmodium species is characteristic
to malaria, however in falciparum malaria fever is usually persistent, and the pattern is only evident after
several weeks.[3] If not treated with anti malarials, disease may progress into severe forms, presenting as
cerebral malaria, hematologic abnormalities (anemia and thrombocytopenia), acute renal failure or acute lung
edema.[3] These complications of malaria may also be mistaken for other diseases or conditions relating to
pregnancy (eg. HELLP syndrome, gestational thrombocytopenia etc). [4] In falciparum malaria, parasite
sequestration at placental capillaries, as well as maternal anemia, may cause deleterious fetal consequences
which manifests as intrauterine demise, oligohydramnion, pre term birth, stillbirth and congenital infection. [4]

Due to fatal complications that could occur as the disease progresses, any delay in recognising,
diagnosing and treating malaria should therefore be prevented. Diagnosing malaria in pregnancy is however a
challenge and a high clinical suspicion towards malaria have to be implemented on patients with a history of
visiting endemic areas. Here we report a febrile patient at 36 weeks gestation with a history of visiting an
endemic area, who was at last diagnosed with severe falciparum malaria in our referral hospital after seven
days of uneventful supportive treatment at the previous hospital, the patient fortunately improved after
administration of artemisinin-combined therapy.

1. Elyazar IRF, Hay SI, Baird JK. Malaria Distribution, Prevalence, Drug Resistance and
Control in Indonesia Adv Parasitol. 2011 ; 74: 41175. doi:10.1016/B978-0-12-385897-
9.00002-1.
2. WHO. Malaria in Pregnancy. accessed online: http://www.who.int/malaria/areas/
high_risk_groups/pregnancy/en/
3. Alessandro Bartoloni and Lorenzo Zammarchi. Clinical Aspects of Uncomplicated and
Severe Malaria Mediterr J Hematol Infect Dis 2012; 4;
4. Schantz-Dunn J, Nour NM. Malaria and Pregnancy: A Global Health Perspective. Rev
Obstet Gynecol. 2009;2(3):186-192 doi: 10.3909/riog0091]