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 addresslife-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 BurdenClinical Manifestations

Infected Mosquito

Infected Human

Chronic effects

Anemia

Neurologic/ cognitive

Developmental

Impaired growth and development

Malnutrition

Acute febrile illness

Severe illness

Hypoglycemia

Anemia

Cerebral malaria

DeathRespiratory distress

Pregnancy

Fetus

MaternalAcute illness

Anemia

Impaired productivity

Low birth weight Infant mortality

Infection

International

• Breeding sites

• Parasites

• Climate

• Population

Infection

International

Untreated 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

Insecticide-Treated 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

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

Infection

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

Uncomplicated Malaria

• Fever

• Shivering/chills/rigors

• Headaches

• Muscle/joint pains

• Nausea/vomiting

• False labor pains

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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• 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 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

Infection

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• 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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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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• 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.