Malaria in Pregnancy

Max Brinsmead MB BS PhD

May 2015
 Malaria in PNG
 Endemic & stable in coastal areas
 Highlands subject to epidemics with high mortality
 More than 1.6M cases in 2008 with 23,500
admission and 638 deaths
 About 15% of cases attending health centres or
hospital are confirmed
 70 – 80% are due to P falciparum…
 The remainder are P vivax
 P falciparum has a high rate of Chloroquine
resistance
 Global Fund will spend $US147M 2009 - 2014
 Plasmodium in Pregnancy
 Adults in endemic areas have partial immunity
 And this is transmitted to the fetus
 Thus providing neonatal protection for about 6m
 The placenta acts as a barrier to fetal parasitaemia
 And HBF-containing RBCs are relatively resistant to
Plasmodium
 But malaria still causes a high burden of illness
during pregnancy…
 And this is best studied in the two susceptible
groups:
 The partially immune pregnant woman
 The non immune pregnant woman
 The Partially Immune Gravida
 Immunosupression of pregnancy results renders
malarial attacks more common and severe
 Especially in the young and primigravida
 Older multigravida develop anti-adhesive antibodies
that provide more specific protection
 Parasite density typically increases in pregnancy
 Up to 12x higher than in non pregnant individuals
 Reaches a peak in mid pregnancy with splenic
enlargement
 Then, as the placenta takes on the phagocytic role,
the spleen shrinks and parasite density falls towards
term
 But rebounds again in the puerperium
 But don’t miss a bacterial cause for puerpereal fever
The Partially Immune Gravida(2)
 Malarial attacks are often asymptomatic
 But haemolytic anaemia typically beginning at 16-24
weeks and gets progressively worse
 Is compounded by folate deficiency as erythropoiesis
increases
 In the placenta the parasites cause intervillous
inflammatory change, trophoblastic and BM damage that
is partly immune mediated.
 The results of this placental damage include…
 IUGR secondary to O2 and nutrient deprivation
 Risk of IUFD
 Premature labour perhaps due to the release of toxic cytokines
 Will be aggravated by other causes of maternal anaemia
and HIV
 Non Immune Gravida
 Are at risk of clinically severe malarial attacks
 Including cerebral malaria
 That has up to 50% mortality
 Complications include
 Severe anaemia
 Hypoglycaemia
 Sometimes from Quinine Rx
 Acute pulmonary oedema
 Especially immediately after delivery
 More prone to pneumonia and UTI
 The high fever can cause
 Premature labour
 IUFD
 Fetal distress in labour
 Congenital Malaria
 Notwithstanding the usual placental block to
Plasmodium…
 Up to 15% of babies born to infected mothers have
parasitaemia…
 Presumably due to breaches in the maternal-fetus
interface during labour…
 But they are protected for up to 6m from clinical
disease…
 By antibodies transferred from the mother.
 However, babies born to non immune mothers may
be in trouble
Treatment of Malaria in Pregnancy
 Complicated by resistance of P. falciparum to
Chloroquine
 So follow current local guidelines
 Semi immune women can be treated as outpatients
 Indications for hospitalisation
 Non immune women
 Intolerant of outpatient therapy
 Not responding to outpatient therapy
 Complicated malaria
 Fluid replacement and fever control is important
 Vivax usually responds to Chloroquine
Complicated Malaria in Pregnancy
 Is a medical emergency
 Lumbar puncture to exclude bacterial meningitis
 The prognosis is poor when…
 >5% of RBCs are parasitised
 There is severe leucocytosis
 CSF glucose is low
 HB is <7.0 or Haemotocrit <0.20
 Blood urea is is >11.0
 Assume Chloroquine resistance and treat
parenterally with drugs according to local guidelines
 Begin with a loading dose according to bodyweight
and follow with maintenance therapy
 Complicated Malaria in Pregnancy (2)
 General measures
 Nurse on the side
 Ensure a clear airway
 Reduce body temperature
 Careful fluid balance with IV and IDC
 Monitor blood glucose and renal function tests
 Treating Complications
 IV Diazepam for convulsions
 Transfusion for severe anaemia
 Frusemide for pulmonary oedema
 IV glucose for hypoglycaemia
 Fluid restriction, K-absorbing resins, IV glucose and insulin
or dialysis for renal failure
 Preventing Malaria in Pregnancy
 General measures to reduce mosquito bites
 Especially the use of insecticide-treated nets (ITN) and
indoor residual spraying (IRS)
 Routine chemoprophylaxis with antimalarials, iron
and folate of partially immune gravida has been
shown to reduce the risk of…
 Maternal anaemia
 IUGR and IUFD
 Premature labour
 Especially in young primigravid women
 But at the risk of increasing the incidence of drug
resistance
 It is desirable to begin as early as possible and
certainly before 20w when parasitaemia peaks
Preventing Malaria in Pregnancy (2)
 Non immune mothers…
 Because some antimalarials are teratogenic
and…
 Malaria is such a serious illness…
 Non immune gravidas should avoid travel to
malarial areas if possible
 Especially areas with Chloroquine-resistant P. falciparum
 Follow current chemoproprophylaxis guidelines
 Consult www
 And take general measures to avoid mosquito
bites
 Current WHO Guidelines for
Chemoprophylaxis
 Two doses of Pyrimethamine-Sulfadoxine (Fansidar)
 After quickening
 Not more frequently than monthly
 However…
 This fails to eliminate parasites from peripheral or
placental blood (or both) in ≈ 80% women in endemic
areas
 Resistance is then a real issue
 And partial treatment may be more harmful than no
treatment at all
 But other regimens are associated with
poor rates of compliance
Hyperactive Malarial Spleen Syndrome
 A condition that predates pregnancy
 With massive splenic enlargement
 Severe haemolytic anaemia complicated by bone
marrow suppression of erythropoesis
 So there is leucopenia and thrombocytopenia
 Associated with immunological abnormalities and
overproduction of IgM
 In pregnancy the prognosis is serious
 Admit to hospital and treat with regionally-specific
antimalarial drugs
 Plus folate 5 mg/day
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