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

Majority of pregnant women

need these services only

Some pregnant women require

these services also

Fewer pregnant women require

these services

Core components of basic care:

to maintain normal pregnancy

Additional care:
to address common
discomforts and special needs
Initial specialized
care: to address
life-threatening
complications

Infection
International

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
International

Malaria Ecology and Burden

Clinical Manifestations
Hypoglycemia
Anemia

Acute
febrile
illness

Severe illness

Respiratory
distress

Death

Cerebral malaria

Infected
Mosquito

Anemia
Chronic
effects
Infected
Human

Neurologic/
cognitive
Developmental

Fetus

Impaired
growth and
development

Low birth weight

Malnutrition

Infant mortality

Pregnancy
Maternal

Acute illness
Anemia

Impaired
productivity

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International

Breeding sites
Parasites
Climate
Population

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International

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
International

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
malaria related
anaemia
Febrile illness
Placental
sequestration

In non-Endemic
areas
Greater risk of
severe disease
Higher risk of
death
Anaemia,
hypoglycemia,
pulmonary
oedema, renal
failure

Infection
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

Infection
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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International

Fetal complications

In endemic areas
Low birth weight
Intra-uterine growth
retardation

In non-endemic areas
Abortions
preterm delivery
Congenital malaria
Low birth weight

Infection
International

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
International

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

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
International

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

Infection
International

Uncomplicated:
Most common

Severe:
Life-threatening, can affect brain
Pregnant women more likely to get severe
malaria than non-pregnant women

Infection
International

Severe Malaria
Signs of uncomplicated malaria PLUS one or
more of the following:

Uncomplicated Malaria

Fever
Shivering/chills/rigors
Headaches
Muscle/joint pains
Nausea/vomiting
False labor pains

Confusion/drowsiness/coma
Fast breathing, breathlessness, dyspnea
Vomiting every meal/unable to eat
Pale inner eyelids, inside of mouth,
tongue, and palms
Jaundice

Infection
International

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

Infection
International

Artemisinin-based Combination Therapy (ACT):

The simultaneous use of drugs that includes a
derivative of artemisinin along with another antimalarial 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

Infection
International

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
International

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

Infection
International

Observe client taking anti-malarial drugs

Advise client to:

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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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International

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.