Malaria in pregnancy lec
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MALARIA IN PREGNANCY
BY
Dr Swati SinghDept. Of Obs & Gyn
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Malaria Facts
• 300 million malaria cases each year worldwide
• 9 out of 10 cases occur in Africa
• An African dies of malaria every 10 seconds
• Affects 5 times as many as TB, AIDS, measles and leprosy combined
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Malaria and the Obstetric patient• Every minute
– About 12 Nigerian women become
pregnant (WHO)
• All are predisposed to dangers of Mal in Preg
– Asymptomatic / Undetected / Untreated * Agboghoroma (31%), Isah (3.1%)
• 11% of Maternal death is due to Malaria (NPC/UNICEF - Nigeria)
• There are also untoward effects on the unborn child
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Malaria is caused by one of 4 protozoan parasites:
Plasmodium falciparum
Plasmodium vivax
Plasmodium ovale
Plasmodium malariae
Malaria is transmitted through the bite of an infectedfemale Anopheles mosquito
MALARIA
5Source: http://encarta.msn.com/media_461541582/Life_Cycle_of_the_Malaria_Parasite.html Accessed on 31 March 2008Source: http://encarta.msn.com/media_461541582/Life_Cycle_of_the_Malaria_Parasite.html Accessed on 31 March 2008
ParasiteParasiteHostHost
Infected vectorInfected vector
Infecting vectorInfecting vector
Malaria Parasite Life Cycle
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Effects of Pregnancy on MalariaMore common.
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.
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Effects of Pregnancy on MalariaMore fatal
P. falciparum malaria in pregnancy is more severe, the mortality is also double (13 % ) compared to the non-pregnant population (6.5%).
Selective treatmentSome anti malarials are contra indicated
in pregnancy and therefore the treatment may become difficult, particularly in cases of severe P. falciparum malaria.
Other problemsManagement of complications of malaria
may be difficult due to the various physiological changes of pregnancy.
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Question
•What are the effects of malaria on the mother and unborn baby?
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EFFECTS OF MALARIA ON PREGNANCY [Species, Transmission pattern, Parity & Others]
Abortion – placental sequestration (pl sq)
Anemia
Cerebral malaria
Low birth weight (Prematurity, IUGR) – pl sq
Stillbirth
Congenital infection
Puerperal sepsis
Maternal Mortality
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Management of malaria in pregnancy involves three aspects that are of equal importance
1. Treatment of the malaria 2. Management of complications 3. Prevention of recurrence
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TREATMENT OF MALARIA IN PREGNANCY
• Depends on severity of the disease- Simple / Uncomplicated- Complicated
• Gestational age- First trimester- Second trimester - Third trimester
• Aims at bringing attack/pyrexia to an end.
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QUESTIONQUESTION
•How do you differentiate simple malaria from severe malaria in a pregnant woman?
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Recognizing malaria in pregnant women
Uncomplicated malaria
• Fever• Shivering/chills• Headaches• Muscle/joint pains• Nausea/vomiting (Can
tolerate per os)• False labor pains• + / ++
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Recognizing malaria in pregnant women
Complicated• Signs of
uncomplicated malaria, plus:
• Dizziness• Breathlessness• Sleepy/drowsy• Confusion/coma• Sometimes fits,
jaundice, severe dehydration
• ++ / +++
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Simple / Uncomplicated Malaria
1st trimester = Quinine ( safe and evidence-based)
2nd and 3rd trimesters
1st Line = Arthemeter/Lumefantrine(Coartem)2nd Line = Artesunate + Amodiquine
Artesunate + fansider
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Complicated MalariaAll trimesters!
Quinine Parenteral, then Orals Loading / maintenance Hypoglycaemia Absolutely safe!
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Supportive Treatment in Managementof Malaria in Pregnancy Adequate calories
Correction of electrolyte imbalance
Blood transfusion / EBT in acute and severe cases
Oxygen + Diuretics in pulmonary oedema
Anticonvulsants
ICU for CM
Dialysis for ARF
Monitoring of the fetal growth & health
Deceleration & death (Opare Addo)
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PREVENTION & CONTROL PROGRAMS
Available options are:
Vector control
Drug prophylaxis
Vaccination
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VECTOR CONTROL• Insecticide Treated Nets (ITNs)
- Promote growth and development of fetus and newborn
- Shulman et al(2000), Isah/Ekele’2006 (?enough)
• Residual house hold spraying
• Environmental management
- Cleanliness is next to Godliness
- Drainage and water flow control
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•All pregnant women should receive at least two doses of IPT after quickening at ANC visits (WHO recommends a schedule of four visits, three after quickening)
•Intermittent preventive treatment (IPT) given 3 times during pregnancy is effective for women with HIV/AIDS
•Presently, the most effective drug for IPT is sulfadoxine-pyrimethamine (SP) combination
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Conception
Birth20 3010
Weeks of gestation
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Fetal growth velocity
Quickening
Source: WHO 2002.
Last month
RxRx
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• A single dose is three tablets of sulfadoxine 500 mg + pyrimethamine 25 mg. (Daraprim, the ‘Sunday-Sunday tablet’ is no longer effective)
• Healthcare provider should dispense dose and directly observe client taking dose
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CANDIDATE VACCINEI. PRE- ERYTHROCYTIC VACCINE
(SPOROZOITE)
1. Irradiation Attenuated Sporozoite (IAS)
2. Circumsporozoite protein (CSP)
Escape of even a single sporozoite leads to
failure of anti-sporozoite vaccine
II. ASEXUAL BLOOD STAGE VACCINE
3. Merozoite specific antigen (MSA-1)
4. Erythrocyte binding antigen (EBA)
III INFECTED RED CELLSSchizont infected cell surface antigen (SICA)
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CANDIDATE VACCINE
IV TRNSMISSION-BLOCKING VACCINES1. Antigametocyte: Pfs 25; Pfs 230; Pfs 48/45
2. Antiookinete- Interferes with fertilization- Prevent maturation of gametocytes- Prevent mosquitoes from being infected- But no effect on those already infected- However even if infection occurs
transmission to another individual is prevented
- Hence: Reduce incidence of malaria & prevent transmission of resistant strains.
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CANDIDATE VACCINE
V. MULTIVALENT/MULTISTAGE VACCINE 1. SPf66
- Developed in Colombia- Made of synthetic peptide from 3 sexual
blood stage MSA- Highly immunogenic & probably
predominantly act by cellular mechanism - Clinical Trials:
Colombia (All age groups): 33.6% efficacyTanzania (Age 1-5 years): 31% efficacyGambia (Age 6-11 Months): 0%
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Conclusion
• Malaria during pregnancy has adverse
consequences for both mother and the baby
• Malaria preventive package includes:
– Intermittent preventive treatment with
SP during antenatal clinic visits
– Use of ITNs throughout pregnancy and in
the postpartum period
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Conclusion
• Prevention must be complemented by
effective case management of malaria for all
women of reproductive age
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THANK YOU!!!
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Thank you