Malaria in Pregnancy

Malaria in
Pregnancy
Prof.Surendra Nath Panda, M.S.

Department of Obstetrics & Gynaecology
M.K.C.G.MEDICAL COLLEGE
BERHAMPUR, ORISSA, INDIA
Malaria Menance
 World wide 103 countries with 2.5 billion people,
developing countries worst affected.
 40 % of world’s population in shadow of Malaria.
 Deaths- Under estimated/Unknown,1.1 to 2.7
million per year
 Gender related mortality - Females more
 Malaria in Pregnancy: -
 Mutually aggravating
 Mortality is double
 Primigravidae - 60-70%
 Highest prevalence in second half.
 Plasmodium Falciparum – More common.
10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 2

Malaria in Pregnancy :
Sinister
Coincidence
 Malaria and pregnancy are mutually aggravating conditions.
 The physiological changes of pregnancy and the
pathological changes due to malaria have a synergistic
effect on the course of each other, thus making life difficult
for the mother, the child and the treating physician.
 P. falciparum malaria can run a turbulent and dramatic
course in pregnant women.
 The non- immune, primigravidae are usually the most
affected.
 In areas where malaria is endemic, 20-40% of all babies
born may have a low birth weight.

Double
 More common. Trouble
 Malaria is more common in pregnancy compared to the
general population probably due to Immuno suppression
and loss of acquired immunity to malaria.
 More atypical.
 In pregnancy, malaria tends to be more atypical in
presentation probably due to the hormonal ,
immunological and haematological changes of
pregnancy.
 More severe.
 Probably for the same reason, the parasitemia tends to
be 10 times higher and as a result, all the complications
of falciparum malaria are more common in pregnancy
compared to the non-pregnant population.
Double
 More fatal Trouble
 P. falciparum malaria in pregnancy being more severe, the mortality
is also double (13 % ) compared to the non-pregnant population
(6.5%).
 Selective treatment
 Some anti malarials are contra indicated in pregnancy and some
may cause severe adverse effects.
 Therefore the treatment may become difficult, particularly in cases
of severe P. falciparum malaria.
 Other problems
 Management of complications of malaria may be difficult due to the
various physiological changes of pregnancy.
 Careful attention has to be paid towards fluid management,
temperature control, etc.
 Decisions regarding induction of labour may be difficult and
complex.
 Foetal loss, IUGR, and premature labour are common.

Pathology of Malaria in
Pregnancy
 P. falciparum malaria can run a very turbulent
course in pregnancy, particularly the first and
second pregnancies.
 These complications are more common and
severe in hyperendemic areas for falciparum
malaria.
 Physiologic changes of pregnancy contribute to the
aggravation of malarial infection.
 Changes in the hormonal milieu,
 Increase in the body fluid volume,
 Decrease in haemoglobin level and other changes add

to the severity.

Pathology of Malaria in
Pregnancy
 There is a generalised immunosuppression in
pregnancy with reduction in gamma globulin
synthesis and inhibition of reticulo endothelial
system, resulting in
 Decrease in the levels of anti malarial antibodies and
loss of acquired immunity to malaria.
 This makes the pregnant woman more prone for malarial
infection and the parasitemia tends to be much higher.

Changes in Placenta
 Placenta is the preferred site of sequestration and
development of malarial parasite.
 Intervillous spaces are filled with parasites and
macrophages, interfering with oxygen and nutrient
transport to the foetus.
 Villous hypertrophy and fibrinoid necrosis of villi
(complete or partial) have been observed.
 All the placental tissues exhibit malarial pigments
(with or even without parasites).

Clinical features
Atypical manifestations of malaria are more common in
pregnancy, particularly in the 2nd half of pregnancy.
 Fever :
 Patient may have different patterns of fever - from afebrile to
continuous fever, low grade to hyper pyrexia.
 In 2nd half of pregnancy, there may be more frequent paroxysms
due to Immunosuppression.
 Anemia :
 In developing countries, where malaria is most common, anemia is
a common feature of pregnancy.
 Malnutrition and helminthiasis are the commonest causes of
anemia.
 In such a situation, malaria will compound the problem.
 Anemia may even be the presenting feature of malaria and
therefore all cases of anemia should be tested for M.P.
 Anemia as a presenting feature is more common in partially
immune multigravidae living in hyper endemic areas.

Clinical features
Atypical manifestations of malaria are more common in
pregnancy, particularly in the 2nd half of pregnancy.
 Splenomegaly :
 Enlargement of the spleen may be variable. It may be absent or
small in 2nd half of pregnancy.
 A pre-existing enlarged spleen may regress in size in pregnancy.
 Complications :
 Complications tend to be more common and more severe in
pregnancy.
 A patient may present with complications of malaria or they may
develop suddenly.
 Acute pulmonary edema, hypoglycemia and anemia are more
common in pregnancy.
 Jaundice, convulsions, altered sensorium, coma, vomiting /
diarrhoea and other complications may be seen.
Complications of Malaria in
Pregnancy
Anemia:
 Malaria can cause or aggravate anaemia due to:
 Hemolysis of parasitised red blood cells.
 Increased demands of pregnancy.
 Profound hemolysis can aggravate folate deficiency.
 Anemia due to malaria is more common and

severe between 16-29 weeks.
 It can develop suddenly, in case of severe malaria
with high grades of parasitemia.
 Pre existing iron and folate deficiency can exacerbate the
anemia of malaria and vice versa.

Pregnancy
Anemia:
 Anaemia increases perinatal mortality and
maternal morbidity and mortality.
 It also increases the risk of pulmonary oedema.
Risk of post-partum haemorrhage is also higher.
 Significant anemia (Haemoglobin < 7-8 g%) may
have to be treated with blood transfusion.
 In view of the increased fluid volume in pregnancy,
it is better to transfuse packed cells than whole
blood.
 Rapid transfusion, particularly whole blood, may
cause pulmonary oedema.

Pregnancy
cute pulmonary oedema:
 Acute pulmonary oedema is also a more common
complication of malaria in pregnancy compared to the non-
pregnant population.
 It may be the presenting feature or can develop suddenly
after several days. It is more common in 2nd and 3rd
trimesters.
 It can develop suddenly in immediate post-partum period.
This is due to
 Auto transfusion of placental blood with high proportion of
parasitised RBC’s
 Sudden increase in peripheral vascular resistance after delivery.
 It is aggravated by pre existing anaemia and hemodynamic
changes of pregnancy.
 Acute pulmonary oedema carries a very high mortality.
Pregnancy
Hypoglycaemia:
 This is another complication of malaria that is
peculiarly more common in pregnancy.
 The following factors contribute to hypoglycemia:
 Increased demands of hypercatabolic state and infecting
parasites.
 Hypoglycaemic response to starvation.
 Increased response of pancreatic islets to secretory
stimuli (like quinine) leads to hyperinsulinemia and
hypoglycemia..

Pregnancy
Hypoglycaemia:
 Hypoglycaemia in these patients can remain
asymptomatic and may not be detected, because:
 all the symptoms of hypoglycemia are also caused by
malaria viz. tachycardia, sweating, giddiness etc.
 Some patients may have abnormal behaviour,
convulsions, altered sensorium, sudden loss of
consciousness etc.
 These symptoms of hypoglycemia may be easily
confused with cerebral malaria.
 Therefore, in all pregnant women with falciparum
malaria, particularly those receiving quinine, blood sugar
should be monitored every 4-6 hours.

Pregnancy
Hypoglycaemia:
Hypoglycaemia can be recurrent and

therefore constant monitoring is needed.
In some, it can be associated with lactic
acidosis and in such cases mortality is very
high.
Maternal hypoglycemia can cause foetal
distress without any signs.

Pregnancy
mmunosuppression:
 Immunosuppression in pregnancy poses special
problems.
 It makes malaria more common and more severe.
And to add to the woes, malaria itself suppresses
immune response.
 Hormonal changes of pregnancy, reduced
synthesis of immunoglobulins, reduced function of
reticulo endothelial system are the causes for
Immunosuppression in pregnancy.

Pregnancy
mmunosuppression:
 This results in loss of acquired immunity to
malaria, making the pregnant more prone for
malaria.
 Malaria becomes more severe with higher
parasitemia.
 Patient may have more frequent paroxysms of
fever and frequent relapses.
 Secondary infections (U.T.I. and pneumonias) and
algid malaria (septicaemic shock) are more
common in pregnancy due to Immunosuppression.

Risks for the foetus
 Malaria in pregnancy is detrimental to the foetus
due to: -
 high grades of fever,
 placental insufficiency,
 hypoglycaemia,
 anaemia and other complications.
 Both P. vivax and P. falciparum malaria can pose

problems for the foetus, with the latter being more
serious.

Risks for the foetus
 The prenatal and neonatal mortality may vary from
15 to 70%.
 In one study, mortality due to P. vivax malaria during
pregnancy was 15.7% while that due to P. falciparum
was 33%.
 Spontaneous abortion, pre mature birth, still birth,
placental insufficiency and I.U.G.R. (temporary /

chronic), low birth weight, foetal distress are the different
problems observed in the growing foetus.
 Transplacental spread of the infection to the foetus can
result in congenital malaria.

Risks for the foetus Congenital
 It is very rare and occurs inmalaria:
< 5% of affected
pregnancies. Placental barrier and matenal Ig G
antibodies which cross the placenta may protect
the foetus to some extent.
 However, it is much more common in non-immune
population and the incidence goes up during
epidemics of malaria.
 Fetal plasma Quinine and Chloroquine levels are
about one third of simultaneous maternal levels
and this subtherapeutic drug level does not cure
the infection in the foetus.
Risks for the foetus Congenital
 All four species can cause malaria:
congenital malaria, but
it is proportionately more with P. malariae.
 The new born child can manifest with fever,
irritability, feeding problems, hepato splenomegaly,
anaemia, jaundice etc.
 The diagnosis can be confirmed by a smear for
M.P. from cord blood or heel prick, anytime within
a week after birth (or even later if post-partum,
mosquito-borne infection is not likely).
 Differential diagnoses include Rh. incompatibility,
infections with C.M.V., Herpes, Rubella,
Toxoplasmosis, and syphilis.
Diagnosis
 High level of awareness
 Peripheral blood smear
 Antigen detection techniques : (PfHPR-2)

 Fluorescent staining
 PCR based assay
 Antibody test
 Placental blood smear
Indicators of Poor Prognosis
 Hyper parasitemia: - >5% erythrocytes infested.
 Peripheral schizotaemia.
 Leucocytosis >12,000/ cmm.
 Hb< 7.1 gm%.
 PCV <20 %.
 Blood urea >60 mg / dL
 Creatinine >3 mg / dL.,
 Blood glucose <40 mg / dL.
 High lactate and low sugar in CSF.
 Low antithrombin III level.
Management of Malaria in
Pregnancy
 Management of malaria in pregnancy
involves the following three aspects and
equal importance should be attached to
all the three.
 Treatment of malaria
 Management of complications
 Management of labour

Treatment of Malaria in
Pregnancy
Should Be Energetic, Anticipatory and Careful.
Energetic:
 Don't waste any time.
 It is better to admit all cases of P.
falciparum malaria.
 Assess severity-
 General condition, pallor, jaundice, B.P.,
temperature, haemoglobin, Parasite count,
S.G.P.T., S .bilirubin, S.creatinine, Blood sugar.

Pregnancy
Anticipatory:
 Malaria in pregnancy can cause sudden and
dramatic complications. Therefore, one should
always be looking for any complications by regular
monitoring.
 Monitor maternal and foetal vital parameters 2
hourly.
 R.B.S. 4-6 hourly; haemoglobin and parasite
count 12 hourly; S. creatinine; S. bilirubin and
Intake / Output chart daily.

Pregnancy
Careful:
 The physiologic changes of pregnancy pose special
problems in management of malaria.
 In addition, certain drugs are contra indicated in pregnancy
or may cause more severe adverse effects. All these
factors should be taken into consideration while treating
these patients.
 Choose drugs according to severity of the disease/
sensitivity pattern in the locality.
 Avoid drugs that are contra indicated
 Avoid over / under dosing of drugs
 Avoid fluid overload / dehydration
 Maintain adequate intake of calories.
Pregnancy
Choice of Anti malarials in pregnancy
 All trimesters:
First line - Chloroquine; Quinine;
Second line - Artesunate / Artemether / Arteether
 2nd / 3rd trimester: with caution
Pyrimethamine + sulphadoxine; Mefloquine
 Contra indicated:
Primaquine; Tetracycline; Doxycycline; Halofantrine

Pregnancy
Dose of Anti malarials
 Chloroquine:
 600mg (base) start, 300mg after 6 hours, 24 hours & 48 hours
 Quinine:
 IV - 20mg/kg infusion over 4 hours, repeat 8 hourly. Maintenance:
10mg over 4 hours, 8 hourly. Follow with oral medication after
clinically stable.
 Oral – 600mg 8hourly ( maximum 2 gm / day) for 7 days.
 Artesunate:
 Oral-100mg BD on day 1, then 50mg BD for 4-6 days (Total dose
10mg/kg).
 IM / IV-120mg on Day 1 followed by 60mg daily for 4 days. In
severe cases an additional dose of 60mg after 6 hours on Day 1.

Pregnancy
Dose of Anti malarials
 Artemether:
 Six amp (480mg) IM in 5 / 3 days. 1x2x1+1x1x4 OR 1x2x3.
 Arteether:
 One amp (150mg) IM / day for3 consecutive days.
 Pyrimethamine 25mg+sulphadoxine 500mg tablets:
 Three tablets single dose.
 Mefloquine:
 15mg / kg body wt., up to 1 Gm in a single dose. OR
 Tablets of 250mg, 3 tab start, then 2 tab after 6-8 hours. With body
wt >60kg, a third dose of 1 tab after 6-8 hours.

Management of complications
 Acute Pulmonary Oedema:
 Careful fluid management; back rest; oxygen; diuretics; ventilation if
needed.
 Hypoglycaemia:
 25-50% Dextrose, 50-100 ml I.V., followed by 10% dextrose
continuous infusion.
 If fluid overload is a problem, then Inj. Glucagon 0.5-1 mg can be
given intra muscularly.
 Blood sugar should be monitored every 4-6 hours for recurrent
hypoglycemia.
 Anemia:
 Packed cells should be transfused if haemoglobin is <5 g%.
 Renal failure:
 Renal failure could be pre-renal due to unrecognised dehydration or
renal due to severe parasitemia.
 Treatment involves careful fluid management, diuretics, and dialysis
if needed.

Management of complications
 Septicaemic shock:
 Secondary bacterial infections like urinary tract infection, pneumonia
etc. are more common in pregnancy associated with malaria.
 Some of these patients may develop septicaemic shock, the so
called 'algid malaria'.
 Treatment involves administration of 3rd generation cephalosporins,
fluid replacement, monitoring of vital parameters and intake and
output.
 Exchange transfusion:
 Exchange transfusion is indicated in cases of severe falciparum
malaria to reduce the parasite load. Patient’s blood is removed and
it is replaced with packed cells.
 It is especially useful in cases of very high parasitemia (helps in
clearing) and impending pulmonary oedema (helps to reduce fluid
load).
Management of Labour
 Anaemia, hypoglycaemia, pulmonary oedema, and
secondary infections due to malaria in pregnancy
lead to problems for both the mother and the
foetus.
 Severe falciparum malaria in term pregnancy
carries a very high mortality.
 Maternal and foetal distress may go unrecognised
in these patients.
 Therefore, careful monitoring of maternal and
foetal parameters is extremely important.
 Pregnant women with severe malaria are better
managed in an intensive care unit.
 Falciparum malaria induces uterine contractions,
resulting in premature labour. The frequency and
intensity of contractions appear to be related to the
height of the fever.
 Fetal distress is common and often unrecognised.
Therefore only monitoring of uterine contractions
and fetal heart rate may reveal asymptomatic
labour and foetal distress.
 All efforts should be made to rapidly bring the
temperature under control,
 By tepid sponging (cold sponging causes cutaneous
vasoconstriction and can result in core hyperpyrexia).
 Anti pyretics like paracetamol etc.

 Careful fluid management is also very important.
Dehydration as well as fluid overload should be avoided,
because both could be detrimental to the mother and/or the
foetus.
 In cases of very high parasitemia, exchange transfusion
may have to be carried out.
 If the situation demands, induction of labour may have to be
considered.
 Once the patient is in labour, foetal or matenal distress may
indicate the need to shorten the 2nd stage by forceps or
vacuum extraction.
 If needed, even caesarean section must be considered.

Treatment of Vivax Malaria in
Pregnancy
Radical
cure
 Use of Primaquine & Proguanil are not safe in pregnancy
and also in lactating mothers.
 Therefore to prevent the relapse of vivax malaria,
suppressive chemoprophylaxis with Chloroquine is
recommended.
 Tablet Chloroquine 300 mg (base) weekly should be
administered to all such patients until stoppage of lactation.
 At that point, a complete treatment with full therapeutic
dose of Chloroquine and Primaquine (7.5mg b.I.d. or 15mg
daily, for 14 days) should be administered.
 However in case of resistance, Primaquine or Proguanil
may be given with caution in 2nd half of pregnancy.
Chemoprophylaxis in Pregnancy
 Malaria being potentially fatal to both the mother and the
foetus, this should be an important part of antenatal care in
areas of high transmission.
 All pregnant women, who remain in the malarious area during their
pregnancy, should be protected with chemoprophylaxis.
 Choice of anti malarials for chemo prophylaxis:
 Chloroquine being the safest drug in pregnancy, should be the first
choice.
 However, its use may be restricted due to the wide spread
resistance to this drug.
 In areas with known resistance to Chloroquine
 Pyrimethamine + Sulpha, Mefloquine or Proguanil can be used.
 But these drugs should be started only after 1st trimester only.

Chemoprophylaxis in Pregnancy
DOSAGE –
 Chloroquine: - 300mg base, administered once

every week.
 Pyrimethamine-25mg + Sulphadoxine-500mg: -
One tablet once weekly.
 Mefloquine: -250mg weekly.
 Dose may have to be increased in the last trimester, in
view of the accelerated clearance of the drug.
 Proguanil: - 150-200mg / day.

FOR A HEALTHY MOTHER
AND A HEALTHY BABY

Malaria in Pregnancy

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Malaria in Pregnancy

Uploaded by

Copyright:

Available Formats

Malaria in

Prof.Surendra Nath Panda, M.S.

 Highest prevalence in second half.

 Plasmodium Falciparum – More common.

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 2

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 3

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 5

 Decrease in haemoglobin level and other changes add

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 6

infection and the parasitemia tends to be much higher.

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 7

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 8

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 9

 Profound hemolysis can aggravate folate deficiency.

 Anemia due to malaria is more common and

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 11

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 12

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 14

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 15

Hypoglycaemia can be recurrent and

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 16

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 17

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 18

 anaemia and other complications.

 Both P. vivax and P. falciparum malaria can pose

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 19

placental insufficiency and I.U.G.R. (temporary /

result in congenital malaria.

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 20

 Antigen detection techniques : (PfHPR-2)

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 25

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 26

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 27

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 29

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 30

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 31

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 32

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 35

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 36

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 38

 Chloroquine: - 300mg base, administered once

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 39

10:05 AM 02-11-02 Malaria in Pregnancy - Prof.S.N.Panda 40

You might also like