Malaria in pregnancy

Mr. Nkole J
 Introduction
• Malaria is a number one public health problem in Zambia. It is a
major contributor to morbidity and mortality in the country.
• It accounts for 32% health centre admission and 35-65% of
hospital admissions respectively (MoH, HMIS, 2005).
• It is a disease that affects all age groups with children under
five years of age, pregnant women are the most susceptible.
• Malaria in pregnancy is frequently asymptomatic. Even if a
woman has malaria, she may still test negative for parasites in
the blood, as the parasites tend to go into the placenta.
• Placental malaria can have a serious impact on both the mother
and the child. Malaria in pregnancy is associated with low-birth-
weight infants, increased anaemia, loss of pregnancy and death.
 Definition
• Malaria is a protozoa infection of the red blood cells
transmitted by an infected female anopheles mosquito
characterised by fever, headache and generalised body pains.
• Malaria is a protozoa infection of the genus plasmodium
transmitted through a bite of an infected female anopheles
mosquito characterised by fever, joint pains, nausea and
vomiting.
 Routes of malaria transmission
1. Bite from an infective female anopheles mosquito
2. Blood transfusion from infected persons
3. Use of contaminated needles and syringes
4. Congenital transmission from infected mother
5. Organ transplant from an infected person
 Types of Plasmodium
 There are four types of plasmodium that are capable of causing
infection in human. These are:
i. Plasmodium falciparum
ii. Plasmodium vivax
iii. Plasmodium ovale
iv. Plasmodium malariae.
 Of these species, Plasmodium falciparum is the most prevalent
and virulent malaria parasite, which is responsible for high
mortality and morbidity rates in Zambia.
• Malaria that affects anyone else is the same, except this time it
is occurring in a pregnant mother who is susceptible of the
infection because of her supressed immunity.
• In pregnancy the parasite has a tendency of hiding in the
placenta where it causes destruction and impairs the function
of the placenta, hence posing danger to the growing fetus.
• Malaria in pregnancy is frequently asymptomatic. Even if a
woman has malaria, she may still test negative for parasites in
the blood, as the parasites tend to go into the placenta.
• Placental malaria can have  Intra-uterine growth retardation
serious impact on both the mother  Congenital malaria in neonate
and the fetus. These serious  Jaundice in neonate.
impacts include
i. Maternal anaemia
ii. Maternal death
iii. Spontaneous abortion
iv. Cerebral malaria
v. Still birth
vi. Prematurity
vii. Low birth weight babies
 Life Cycle Of Malaria Parasite
 The life cycle of the plasmodium
parasite has two phases;
 Sexual cycle known as sporogony
which takes place within the
intestinal tract of a mosquito; and
an
 Asexual cycle known as
schizogony (the infective form
takes place in an infected human).
 Life Cycle Of Malaria Parasite
Mosquito
Sporozoite bites man
s moves to and Sporozo
the gut of injects ites
the salivary sporozoit invades
gland of es the liver
the cells
mosquito
Oocytes Sporozoite
(zygote) s develop
develop in to in to
sporozoites schizonts

Schizonts
Ookinates rapture in
develops in to
to occytes merozoite
s

Fusion
takes Merozoite
place s invades
producing the red
ookinates blood cells
Mosquito Merozoite
bites and s develop
ingests the in in to
male and (Trophoz male and
female oite in female
gametes red blood gametes
cells)
 Life Cycle Of Malaria Parasite
• Mosquito Saliva containing infective
sporozoites is injected into the blood
stream of humans through the
mosquito proboscis.
• After circulating in the peripheral
blood for about 20-30 minutes. The
following events take place;
• 1. The sporozoites enter the
parenchyma cells of the liver, where
they begin to multiply.
• This stage is called pre-erythrocytic
stage.
• 2. These cells divide until mature
tissue schizonts are formed.
• Schizonts contain thousands of
daughter merozoites.
• 3.The liver schizonts rupture after
about 6-14 days, releasing the
merozoites into the blood circulation.
• 4.Merozoites invade erythrocytes
(RBCs). This stage is also known as
erythrocytic stage.
• Within the erythrocytes the parasite
goes through a series of asexual
developmental stages.
 Life Cycle Of Malaria Parasite
• 6. At this stage patient experiences
• 5. This leads to the development
several body chill, fever and other
of “ring form” called Trophozoite,
typical signs of malaria
which mature into schizonts
containing more merozoites. • 7. After several erythrocytic cycles
have taken place, some of the
• The schizonts rupture in the
merozoites transform
erythrocytes and merozoites are
(differentiate) into sexual form
released in the circulation.
called macrogametocyte (female)
• These merozoites then re-invade and microgametocyte (male).
other un infected erythrocytes and
the cycle continues.
 Life Cycle Of Malaria Parasite
• 8. The gametocytes (male & female)
are ingested by anopheles mosquito
during a blood meal when it bites
human infected with plasmodium
parasites.
• 9. While in the mosquito stomach,
the microgametes penetrate the
macrogametes forming the zygotes
(sexual reproduction).
• 10. The zygote in turn becomes
motile and elongates which is called
ookinates.
• 11. These ookinates then enter the
mid gut wall of mosquito where they
develop into oocyst.
• 12. The oocysts will grow then
break releasing the sporozoites
• The sporozoites migrate to the
salivary glands of the mosquito.
• 13. The inoculation of sporozoites
into a new human host will begin the
malaria.
 Life Cycle Of Malaria Parasite
• When the mosquito bites a new host, sporozoites are squeezed
from the salivary glands and injected through the proboscis into
the human host. And the cycle begins.
 SIGNS AND SYMPTOMS

• Malaria is classified as either

uncomplicated or complicated
based on the signs and symptoms
as;
• Signs and symptoms of
uncomplicated malaria
o Fever due to parasitaemia
o Headache due to toxins and
cerebral hypoxia.
 Signs and symptoms of uncomplicated malaria

o Joint pains due to ischemia o Nausea due to GIT involvement

o Sweating due to fever
o Chills due to interference with the
temperature control centre
o Body pains due to tissue hypoxia.
o Acute gastroenteritis due to
parasitaemia
o vomiting due to GIT involvement
o Dehydration due to fever
o Diarrhea due to GIT involvement
o extreme weakness due to tissue
hypoxia
 Signs and symptoms of Severe and complicated malaria

• This classification presents with  Unconsciousness due to

the following clinical features; interruption of blood supply to the
 Severe anaemia due to brain by occlusion
haemolysis  Change in behavior e.g. confusion
 Jaundice due to severe due to cerebral malaria
haemolysis  Hepatosplenomegaly due to
 Drowsiness or lethargy due to excessive destruction of RBCs and
cerebral hypoxia sequestration of blood in the
spleen
 Stages of fever

1. Cold stage 2. Hot stage

• Patient feels intensely cold and
shivers with teeth usually
chattering.
• Temperature is rapidly elevated
reaching its highest at 40 Degrees
Celsius. Vomiting and headache
frequently occur in this stage.
• It lasts 15 minutes to 1 hour
• The patient feels very hot and may
be confused, delirious and may
even be in coma.
• It occurs 30 minutes after the cold
stage. Vomiting may continue.
• The patient may complain of heat in
the body and simultaneously feeling
cold on the outside.
• It lasts 2-6 hours.
 Stages of fever

3. Sweating stage
• After about 1-6 hours, the patient sweats profusely, the
temperature drops and the patient becomes relatively
comfortable.
• The fever reoccurs after 48-72 hours depending on the
periodicity characteristics of the infecting species.
 MANAGEMENT
• MEDICAL MANAGEMENT
Aims of management
• To isolate the causative organism
and treat it
• To bring the pregnancy to term
and ensure a healthy live baby
being delivered.
• To offer psychological care to the
client.
• To prevent complications
• INVESTIGATIONS
 History of travel to a malaria
endemic place
 Clinical picture such as fever,
nausea vomiting and general
body weakness (Unreliable)
 RDT: detect parasite-specific
antigens or enzymes that are
either genus or species specific
 MANAGEMENT

Blood slide for Microscopy: Thick and thin blood smear will
reveal malaria parasites
FBC count will show low Hb, leukocytosis and high ESR
LP to r/o meningitis in severe cases
Blood Glucose estimation for patients with altered consciousness
 Treatment uncomplicated malaria in pregnancy
• Treatment of uncomplicated • Supportive treatment
malaria in the first (1st ) Analgesics/Antipyretics
trimester paracetamol 1g t.d.s for 3/7
• A pregnant woman with Haematenics - Folic acid 5mg o.d
uncomplicated malaria should be for 14/7
treated with; Multivit 2tablets b.d for 7/7
 Quinine
• Dose; 10mg/kg or 600mg orally
• Frequency; 8 hourly for 5 – 7
days
 Treatment of uncomplicated malaria in 2nd & 3rd trimesters

• Treatment of uncomplicated Analgesics/Antipyretics

malaria in 2nd & 3rd trimesters Paracetamol 1g t.d.s for 3/7
Artemether 20mg – Haematenics - Folic acid 5mg o.d
Lumefantrine 120mg (Coartem) for 14/7
• Dose; 4 tablets stat then repeat Multivit 2tablets b.d for 7/7
after 8hrs from the initial dose
• Then 12hrly for 2days. ( a total
of 3days)
 Treatment of complicated malaria
• The drug of choice is Artesunate.
• 2.Analgesics/Antipyretics
• 1. Artesunate Paracetamol 1g t.d.s for 3/7
• Dosage : 2.4Mg/Kg dilute with 1ml • 3. Haematenics –
of 5% sodium bicarbonate then
• Folic acid 5mg o.d for 14/7
5ml of 5% dextrose or N/S i.v to
give slowly over 5 minutes.
• Frequency: Repeat another dose
after 12hrs and then b.d until the
patient is able to take orally then
switch to Coartem oral. Coartem
should be given as a full course.
• Artesunate package contains
1.A vial of 60mg powder crystalline
2. Sodium bicarbonate 5% 1mil
3. And Sodium chloride 0.9% 5mils (5% dext. or N/S can be
used).
 Artesunate Preparation (60mg)
• Injection Artesunate has two (2) steps dilution
• Step 1
• The powder for injection should be diluted with 1 ml of 5% sodium
bicarbonate solution (provided in the box) and shaken vigorously 2-
3 minutes for better dissolving till the solution becomes clear.
• Step 2
• For slow intravenous infusion ; add 5 mls of 5% dextrose or NS to
obtain Artesunate concentration of 10 mg/ml.
• For deep intra-muscular injection; Add 2mls of 5%Dex or NS to
obtain Artesunate concentration of 20 mg/ml
 NURSING CARE
• AIM
• 1. To prevent complications such as cerebral malaria
• 2. To promote rest and comfort
• 3. To promote nutrition
• Environment
• Admit the patient in the acute bay for easy observation
• Ensure that the environment is well ventilated and clean to
prevent cross infection
• Ensure that the environment has all the required resuscitative
equipment in case she goes into coma
Position
• The patient should be let to lie in a comfortable position they
want but should avoid supine hypotension.
• Psychological care
• The patient may be anxious and therefore, it is important to
offer psychological care to her so as to allay anxiety and
reduce fears.
• Assure them that they will be okay and everything is being done
to the best of her interest.
• Observations
• Observe vital signs that is, temperature, pulse, respiration and
blood pressure.
• This will be done 4 hourly to determine if the condition is
improving and if so, then the interval of observations will switch
to 12 hourly.
• Observe also the skin, sclera and conjunctiva for pallor and
yellow discoloration to rule out anaemia and jaundice indicating
excessive destruction of red blood cells and increased levels of
unconjugated bilirubin.
• Monitor the fetal wellbeing through auscultation of the fetal
heart sounds (normal range 120 – 160 b/m).
• Monitor also fetal movements in the mother using fetal kick
charts if the mother is conscious and the pregnancy is above 16
weeks of gestation. She should report any increase or reduction
in fetal movement, abdominal pains, vaginal bleeding.
• The client will be observed for commencement of labour pain
such as backache, regular rhythmic uterine contractions, as well
as per vaginal bleeding or draining as such may predispose her
to abortion or premature delivery. If present, a doctor is
informed immediately.
• Do urinalysis - focusing on presence of proteins, ketones and
glucose.
Nutrition
• A balanced diet should be given to ensure good health. Monitor
the intake and output.
• Encourage glucose intake to prevent hypoglycaemia.
• Hygiene
• Her daily hygienic needs of hair care, nail care, bathing, mouth
care and make up should be encouraged to promote a sense of
well being and good health. If she is unable to provide self care
then help will be given accordingly.
Elimination
• Monitor intake and out put monitor kidney function
• Help the patient to go to the toilet and encourage roughage
and fluid diet to avoid constipation.
Exercise
• These should be encouraged to promote blood circulation so that
there is delivery of nutrients and oxygen to all parts of the body
and also to prevent deep vein thrombosis.
Advice
• Health education is given to the patient on prevention of
malaria. They must know where mosquitoes breed and harbour
and how to control mosquito bites
 Complication of malaria on pregnancy

• Complication on the mother • Complication on the foetus

i. Cerebral malaria
ii. Anaemia
iii. Renal failure
iv. Placental infection
v. Maternal death.
i. Premature birth
ii. Intra Uterine Growth Retardation
iii. Stillbirth
iv. Abortion
v. Fetal death
vi. Low birth weight.
 NURSING CARE PLAN

Identified problems
1. Impaired thermoregulation ( hyperpyrexia)
2. Fluid volume deficit
3. Anxiety
4. Altered nutrition less than body requirements
5. Risk for acquiring nosocomial infection
 PROBLEM DIAGNOSIS GOAL INTERVENTIONS EVALUATION

Impaired Impaired Patient will - I will remove excess clothing to cool the body. Patient’s
thermoregu thermoregul have - I will administer antipyretic drug like Panadol to temperature
lation. ation normal and treat fever hence reducing and maintaining normal reduced by
(hyperpyre related to maintained body temperature. one degree
xia) cerebral thermoregu - I will administer anti-malarial drugs like coartem as within
inversion of lation prescribed to clear the infection. 30minutes
the parasite within 30 - I will do tepid sponging to cool the body and evidenced by
evidenced minutes of reduce the temperature. temperature of
by hospital - I will monitor temperature 2-4 hourly to assess if it 37 degrees
temperature stay is reducing or not as it can cause negative effects to celsius
of 38.7 the fetus.
degrees - I will open nearby windows to allow more air to
celsius. cool the body during the sweating stage.
- I will switch on the fun or air conditioner to cool the
body
 PROBLEM DIAGNOSIS GOAL INTERVENTIONS EVALUATION

Fluid Fluid volume Patient will - I will give a lot of fluids to replace the lost fluids Fluid volume
volume deficit have fluid and quench the thirsty, these may be oral or deficit
deficit related to volume prescribed intravenous fluids e.g. ringers lactate corrected
within 1 hour
diaphoresis, deficit depending on the extent of fluid loss.
of admission
vomiting and corrected - I will monitor fluid intake and output and record evidenced by
diarrhoea within 1 on the fluid balance chart to ensure that the absence of
evidenced hour of correct amount of fluid is given and to avoid thirst and
by excessive admission. overloading the patient with fluids. good skin
thirsty and - I will administer anti emetics to counteract the torgor.
sunken eyes vomiting thereby maintaining normal fluid volume.
- I will encourage the patient to take soft drinks to
replace the lost fluids.
- I will keep the environment clean so as to avoid
bad odour which can contribute to vomiting.
 PROBLEM DIAGNOSIS GOAL INTERVENTIONS EVALUATIO
S N

Anxiety Anxiety Patient will - I will allow the patient to verbalize any fears and Anxiety
related to have raised give appropriate psychological care to allay allayed
lack of knowledge anxiety. throughout
knowledge on malaria - I will explain the signs and symptoms like headache hospitalizatio
about the in and dizziness is due to cerebral hypoxia to raise n evidenced
condition and pregnancy the knowledge level and allay anxiety. by patient
strange and - I will get permission before doing any procedure calmness and
hospital allayed on the patient to gain coorperation. resting.
environment anxiety - I will offer diversion therapy such as watching tv
evidenced by throughout and listening to music to shift the patient’s mind
patient hospitalizati from the hospital environment so as to allay
asking too on. anxiety.
many - I will explain the need to adhere to the medication
questions as to eradicate the parasites which if not treated
and early it can cause complications to both the mother
restlessness. and her unborn baby.
PROBLEM DIAGNOSIS GOAL INTERVENTIONS EVALUATION
Altered Altered Patient will - I will encourage frequent mouth wash to promote Patients
nutritional nutrition have appetite. nutritional
status less status less improved - I will remove all unpleasant smell and unsightly items status
than body than body nutritional in the environment that could trigger nausea and improved
requireme requirement status vomiting to promote nutrition. within 1 week
nts related to within 1 - I will give anti emetics such as Plasil to stop the of
anorexia, week of vomiting and hence improving nutrition status. hospitalizatio
nausea, hospitalizat - I will give small but frequent meals to improve n evidenced
vomiting ion nutrition status hence also promoting fetal growth. by weight
and - I will weigh the patient daily to check if the patient gain.
diarrhoea is recovering by weight gain or not.
evidenced
by weight
loss.
PROBLEM DIAGNOSIS GOAL INTERVENTIONS EVALUATION

Risk for Risk for Patient will - I will wash hands before and after doing any No hospital
acquiring acquiring have no procedure on the patient to avoid infections. acquired
nosocomia nosocomial recorded - I will change soiled linen and put clean ones to infection
l infection infection hospital avoid infections recorded
related to acquired - I will dump dust the environment to avoid acquiring throughout
prolonged infection respiratory tract infections hospitalizatio
hospital stay. throughout - I will do assisted baths to eliminate dead epithelial n evidenced
hospitalizati tissues on the patient’s body to prevent infections by a quick
on - As the condition improves , I will allow the patient recovery.
to be doing some exercises to promote blood flow
to the fetus and promote recovery
- I will offer protective foods such as vegetables and
fruits to boost the immune system to prevent other
infection and promote recovery.
 Prevention of malaria

1. Intermittent presumptive treatment (IPT)- all pregnant women

should receive anti-malaria prophylaxis – about 5 adult treatment
doses of Fansidar(SP) with the first dose starting between13 - 16
weeks gestation. Doses are given at 4 weeks interval.
2. Use of insecticide treated mosquito nets
• Encourage the use of insecticide treated mosquito nets (ITNs).
ITNs protect people sleeping under the net by killing mosquitoes
that come in contact with the nets.
3. Indoor residual spraying (IRS) of houses. It is a method of
controlling mosquito vector species that rest indoors by spraying
the inside of houses and other buildings with a residual
insecticide to kill the most mosquitos.
4.Larviciding – it involves regular application of chemical
insecticides to water bodies (bleeding grounds) to kill mosquito
larva.
5. Environmental control measures - This may involve burying
pot holes / pits that hold water to prevent mosquitoes from
breeding in them.
6. Closing window early - This prevent mosquitoes from entering
the houses there by reducing the chances of being bitten by
mosquitoes thereby prevent malaria.
7. Personal protection (Wearing long clothes) - This will prevent
mosquito bites and prevent the chance of acquiring malaria.
The end