Infection

International

MALARIA IN PREGNANCY
 Infection
International

Objectives

• Describe epidemiology of malaria

• Describe maternal and fetal complication
• Principle of management and preventive
strategies
 Infection
International

Global Effect
• Affects 300-500 million people yearly
• Causes 1 to 2.7 million deaths
• 90% of deaths occur in Sub -Saharan
Africa

(approximately 3000 deaths each day)

 Infection
International
Size of problem in Africa
(WHO 1999)
• Population: 564
• Annual births: 24.7
• Exposed to malaria: 93%
• ANC coverage: 63%
• Low birth weight: 16%
• Malaria attributable fraction to LBW:12-50%
 Infection
International

Scope of Focused ANC

Majority of pregnant women
Core components of basic care:
need these services only to maintain normal pregnancy

Some pregnant women require Additional care:

these services also to address common
discomforts and special needs

Initial specialized
care: to address
Fewer pregnant women require life-threatening
these services complications
 Infection
International

Anopheles Mosquito

Anopheles mosquitoes differ from other mosquitoes in the way

their body is positioned. The body of the Anopheles points up in the
air in one line, but in other mosquitoes, the rear end is bent and
points down.
 Infection Malaria Ecology and Burden
International Clinical Manifestations
Hypoglycemia
Anemia
Acute Severe illness Respiratory Death
febrile distress
illness
Cerebral malaria
Infected
Mosquito

Anemia
Chronic Neurologic/ Impaired
Malnutrition
effects cognitive growth and
Infected development
Developmental
Human

Fetus Low birth weight Infant mortality

Pregnancy
Acute illness
Maternal Impaired
Anemia productivity
 Infection
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Factors Affecting Transmission

• Breeding sites
• Parasites
• Climate
• Population
 Infection
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Insecticide-Treated Nets
Untreated Nets
• Provide some protection
against malaria
• Do not kill or repel
mosquitoes that touch net
• Do not reduce number of
mosquitoes
• Do not kill other insects like
lice and bedbugs
• Are safe for pregnant women,
young children and infants
Insecticide-Treated Nets
• Provide a high level of
protection against malaria
• Kill or repel mosquitoes that
touch the net
• Reduce number of mosquitoes
in/outside net
• Kill other insects such as lice
and bedbugs
• Are safe for pregnant women,
young children and infants
 Infection
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Insecticide-Treated Nets

ITN tucked under a bed ITN tucked under a mat

 Infection
International

Effect of malaria on pregnancy

Related to Level of transmission and
immunity of individual exposed

• In areas of high transmission ,

endemic or stable malaria area.
• In areas of low transmission or
non endemic or unstable areas
 Infection
International

Maternal complication
In Endemic areas In non-Endemic
• malaria related areas
anaemia • Greater risk of
• Febrile illness severe disease
• Placental • Higher risk of
sequestration death
• Anaemia,
hypoglycemia,
pulmonary
oedema, renal
failure
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International

Anaemia
Multi factorial:affects 50-60% pregnant women in
Sub-Saharan region
• Haemolysis
• Increased immune clearance of infected and non
infected RBCs
• Malarial hyperactive splenomegaly
• Nutritional & hookworm infestation
• Increased risk in pregnancy to Post -partum
Hemorrhage & Heart failure
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International

Severe malaria
• Cerebral malaria: Unrousable coma
with asexual peripheral parsitaemia or
placental infection.
• Hypoglycemia
• Pulmonary edema (ARDS)
• Acute renal failure
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Fetal complications
In endemic areas In non-endemic areas
• Low birth weight • Abortions
• Intra-uterine growth • preterm delivery
retardation • Congenital malaria
• Low birth weight
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Malaria Diagnosis
• Usually based on signs and symptoms of the
patient, clinical history and physical
examination and/or laboratory confirmation
of the malaria parasite, if available.
• Prompt and accurate diagnosis leads to:
– Improved differential diagnosis of febrile illness
– Improved management of non-malarial illness
– Effective case management of malaria
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 Infection
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Methods of Diagnostic Testing

• The two methods of diagnostic testing for malaria
are light microscopy and rapid diagnostic testing
(RDT).
• Once the woman presents with malaria symptoms
and is tested, results should be available within a
short time (< 2 hours). When this is not possible,
she must be treated on the basis of clinical
diagnosis (WHO 2006).
 Infection
International
Indications for
Diagnostic Testing
• For pregnant women, a parasitological diagnosis is recommended
prior to starting treatment:
– Those who live in or have come from areas of unstable transmission are
the most likely candidates for severe malaria, which can be life-threatening
• As a test of cure in clients who have been treated for malaria but
still have symptoms:
– If treatment was adequate, clients may have been reinfected or have
another problem causing similar symptoms
– Counterfeit or poor quality drugs may also be a the cause of treatment
failure
 Infection
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Clinical Diagnosis

• Based on the patient's symptoms and on physical

findings at examination
• The first symptoms of malaria and physical findings
are often not specific and are common to other
diseases
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Types of Malaria
• Uncomplicated:
– Most common
• Severe:
– Life-threatening, can affect brain
– Pregnant women more likely to get severe
malaria than non-pregnant women
 Infection
Recognizing Malaria in
International
Uncomplicated Malaria
• Fever
• Shivering/chills/rigors
• Headaches
• Muscle/joint pains
• Nausea/vomiting
• False labor pains
Pregnant Women
Severe Malaria
Signs of uncomplicated malaria PLUS one or
more of the following:
• Confusion/drowsiness/coma
• Fast breathing, breathlessness, dyspnea
• Vomiting every meal/unable to eat
• Pale inner eyelids, inside of mouth,
tongue, and palms
• Jaundice
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Combination Therapy
• Plasmodium falciparum has become resistant to
single-drug therapy, resulting in ineffective
treatment and increased morbidity and mortality
• WHO now recommends that countries use a
combination of drugs to fight malaria
• Drug resistance is far less likely with combination
therapy than with single-drug treatments
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Types of Combination Therapy

Artemisinin-based Combination Therapy (ACT):

• The simultaneous use of drugs that includes a
derivative of artemisinin along with another anti-
malarial drug
• This combination is currently the most effective
treatment for malaria
• For second and third trimesters, ACTs should be
the first-line treatment if available and in line with
local protocol
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Selecting Treatment

• Follow local guidelines regarding which

combination therapies to use (if any) and how to
use them
• For uncomplicated malaria in the 1st trimester
and for severe malaria in any trimester, quinine
is the drug of choice
• If ACTs are the only effective treatment
available, they can be used in the first trimester
 Infection
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Treating Uncomplicated Malaria

First trimester:
• Quinine 10 mg salt/kg body weight three times daily +
clindamycin 10 mg/kg body weight twice daily for 7 days
– If clindamycin is not available, use quinine only
• ACT can be used if it is the only effective treatment available
Second and third trimesters:
• Use the ACT known to be effective in the country/region, OR
• Artesunate + clindamycin (10 mg/kg body weight twice daily) for
7 days, OR
• Quinine + clindamycin for 7 days
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Treating Uncomplicated Malaria

• Observe client taking anti-malarial drugs
• Advise client to:
– Complete course of drugs
– Return if no improvement in 48 hours
– Consume iron-rich foods
– Use ITNs and other preventive measures

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 Infection
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Conclusions
• Improve implementation of existing
strategies and health delivery system with
emphasis on integration in existing services
• Improve on Health education to community
on dangers of malaria and early ,regular
ANC attendance.