MALARIA DALAM

KEHAMILAN

dr. Danny Taliak, SpOG

Bagian Obstetri & Ginekologi
RSU Dr. M. Haulussy - Ambon
 Data Tentang Malaria dan Kehamilan
• Malaria sering terjadi dan merupakan salah satu
komplikasi kehamilan di daerah endemik
• Di derah endemik malaria, saat hamil berisiko terjadi:
– Anemia ibu ( 15% )
– 8–14% Bayi berat lahir rendah / PJT
– 30% of “preventable” Pertumbuhan janin terhambat
– 3–8% of Kematian Bayi
 Data INDONESIA
• 46,2% populasi tinggal di daerah endemis
• 3,2 juta kasus kecurigaan malaria klinis
• 160.282 kasus konfirmasi laboratorium
• P. vivax :predominan di Jawa Bali
• P. falciparum: di luar Jawa Bali
• 1998-‐1999 : insidensi 
• 15 juta penduduk mengidap malaria
• 13 propinsi KLB (1998-‐2001)
• Indonesia (surkenas 2001) : 1.2 % dari total (23,483
deaths)
• Re-‐emerging disease
 ENDEMISITAS MALARIA, 2004
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se da n g
tinggi
 Kerjasama Roll Back
Malaria
• Kerja sama Dunia oleh WHO, UNICEF, UNDP in
1998 to provide a coordinated global approach
to fighting malaria
• Partners:Governments,Private groups,
Research Organizations, Civil society,Media
• Vision: By 2015 the malaria-related Millennium
Development Goals (MDGs) are achieved. Malaria
is no longer a major cause of mortality and no
longer a barrier to social and economic
development and growth anywhere in the world.
 Namuk Anopheles

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.
 Siklus Hidup Malaria
Oocyst

Sporozoites

Mosquito Salivary Gland

Zygote

Exo-
erythrocytic Hypnozoites
(hepatic) cycle
Gametocytes

Erythrocytic
Cycle
 Siklus Transmisi Cycle
Exo-erythrocytic (hepatic) Cycle:
Sporozoites injected Sporozoites infect liver cells and
into human host during develop into schizonts, which release
blood meal merozoites into the blood

Parasites
mature in
mosquito
midgut and Dormant liver stages
MOSQUITO HUMAN
migrate to (hypnozoites) of P.
salivary glands vivax and P. ovale

Erythrocytic Cycle:
Merozoites infect red
blood cells to form
Parasite undergoes sexual Some merozoites schizonts
reproduction in the mosquito differentiate into male or
female gametocyctes
 Manifestasi Ekologi dan Hambatan Klinik
Malaria
Hypoglycemia
Anemia
Acute Severe illness Respiratory Death
febrile distress
illness
Cerebral malaria
Infected
Mosquit
o

Anemia
Chronic Neurologic/ Impaired
Malnutrition
effects cognitive growth and
Infected development
Human Developmental

Low birth weight

Fetus
Infant
Pregnancy mortality
Acute illness
Maternal Impaired
Anemia productivity
 Types of Malaria

• Uncomplicated:
– Most common
• Severe:
– Life-threatening, can affect brain
– Pregnant women more likely to get severe
malaria than non-pregnant women
 Recognizing Malaria in Pregnant Women

Uncomplicated Malaria Severe Malaria

Signs of uncomplicated malaria
PLUS one or more of the
• Fever following:

• Shivering/chills/rigors • Confusion/drowsiness/coma
• Headaches • Fast breathing,breathlessness,
dyspnea
• Muscle/joint pains
• Vomiting every meal/unable to eat
• Nausea/vomiting • Pale inner eyelids, inside of
mouth, tongue, and palms
• False labor pains
• Jaundice
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
Effect of Malaria on Pregnancy in Stable Transmission
Areas

Plasmodium falciparum malaria

Asymptomatic Infection

Placental Sequestration
Altered Placental
Integrity

Reduced Nutrient and Oxygen

Transport
Anemia Low Birth Weight (IUGR)

Risk of Newborn
Mortality

Source: WHO 2002.

17
 Effect of Malaria on Pregnancy in Unstable
Transmission Areas
Acquired Immunity – Low

Clinical Illness

Severe Disease

Risk to Mother Risk to Fetus

Source: WHO 1
2002. 8
 Maternal Complication
 In non-Endemic areas
 Greater risk of severe
In Endemic areas disease
• Malaria related  Higher risk of death
anaemia
 Anaemia,
• Febrile illness hypoglycemia,
pulmonary oedema,
• Placental renal failure
sequestration
Effects on the Pregnant Woman
Primigravidae
in Stable All parities in
Effects
malaria areas Unstable
malaria areas
High fever + +++
Placental infection +++ +
Puerperal sepsis ++ ++
Complicated malaria
 Severe anemia +++ +++
 Cerebral malaria - ++
Hypoglycemia
 - ++
 Pulmonary edema - ++
Acute renal failure
 - ++
Increased maternal mortality + ++

( +++ =Very Common, ++ =Common, + =Infrequent, -- =Rare)

20
 Fetal Complications

In endemic areas In non-endemic

areas
• Low birth weight
• Abortions
• Intra-uterine
growth • preterm delivery
retardation
• Congenital malaria

• Low birth weight

 Effects on the Fetus and Newborn
All parities in
Primigravidae in Unstable
Effects
Stable malaria malaria areas
areas
Low birth weight
 IUGR +++ +
 Prematurity + ++
Abortion - ++
Stillbirth - ++
Congenital malaria - +
Fetal anemia ? +
Infant mortality + ++

( +++ = Very Common, ++ = Common, + = Infrequent, -- =

Rare)
 Scope of Focused ANC
Core components of basic care:
to maintain normal pregnancy
Majority of pregnant
women need these
services only

Additional care:
to address common
Some pregnant women discomforts and special needs
require these services also

Initial specialized
Fewer pregnant women care: to address
require these services life-threatening
complications
 Insecticide-Treated Nets

ITN tucked under a ITN tucked under a

bed mat
 Kelambu dengan
insektisida
Kelambu tanpa insektisida Kelambu dengan insektisida
Memberikan Memberikan proteksi
proteksi terhadap tinggi terhadap malaria
malaria  Membunuh dan
Tidak membunuh atau mengusir nyamuk yang
mengusir nyamuk menyentuh kelambu
yang menyentuh Mengurangi jumlah
kelambu nyamuk di dalam/di luar
Tidak menurunkan kelambu
jumlah nyamuk  Membunuh serangga
Tidak membunuh lain seperti kutu,
serangga lain seperti roaches, dan kutu kasur
kutu, roaches dan kutu Aman untuk ibu hamil,
kasur anak dan janin
Aman untuk ibu hamil,
anak dan bayi
 Penyebab Anaemia
Multi Faktor:
• 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
 Malaria Berat
• Cerebral malaria: Unrousable coma with
asexual peripheral parasitaemia or
placental infection.
• Hypoglycemia
• Pulmonary edema (ARDS)
• Acute renal failure
 Diagnosis Malaria
• Biasanya berdasarkan Tanda dan Gejala
pasien, Riwayat Klinis, pemeriksaan fisik
dan/atau konfirmasi laboraturium jika
fasilitas tersedia.
• Prompt and accurate diagnosis leads to:
– Improved differential diagnosis of febrile illness
– Improved management of non-malarial illness
– Effective case management of malaria

2
8
 Methods of Diagnostic Testing
• 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).
 MICROSCOPY
• Species identification
• Quantitation (accurate parasite densi ty):
- drug efficacy
- monitoring other diagnostic tests
• Lower cost when high turn-over
• Reproducible
• Microscopy has other applications (TB, worms etc)
is already present in clinic
RAPID DIAGNOSTIC TEST
 Combination Therapy
• 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
 Types of Combination Therapy
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
 Selecting Treatment
• 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
 The Malaria Transmission Cycle
Sites of Action for Antimalarial Drugs
TISSUE SCHIZONTOCIDES:
primaquine
pyrimethamin
e proguanil
tetracyclines

MOSQUITO HUMAN
BLOOD
SCHIZONTOCIDES
:
Chloroquine mefloquine
quinine/quinidine
tetracyclines
SPORONTOCIDES: Halofantrine sulfadoxine
primaquine GAMETOCYTOCIDES: Pyrimethamine
pyrimethamin primaquine artemisinins
e proguanil
 PENANGANAN MALARIA DALAM KEHAMILAN
• Dibedakan berdasarkan usia kehamilan / trimester
kehamilan
• Untuk malaria tanpa komplikasi :
-‐Pada Trimester 1 : Kina
-‐Pada Trimester 2 -‐3 : ACT
• Primakuin tidak diberikan
• Dosis untuk pengobatan dengan ACT sama dengan orang
dewasa biasa
• Untuk malaria dengan komplikasi :
- Triester 1 : Kina injeksi
- Trimester 2 – 3 : Artemeter atau Artesunate injeksi
 Hari Jenis Obat Jumlah tablet per hari
H1 Kina 3x2
H2 Kina 3x2
H3 Kina 3x2
H4 Kina 3x2
H5 Kina 3x2
H6 Kina 3x2
H7 Kina 3x2

*) Dosis berdasarkan berat badan : Kina 30 mg/KgBB/hari (dibagi 3 dosis)

 Jumlah tablet per
hari
Hari Jenis Obat

40 – 60 kg > 60 kg
Artesunat 3 4
H1 Amodiakuin 3 4
Artesunat 3 4
H2 Amodiakuin 3 4
Artesunat 3 4
H3 Amodiakuin 3 4

*) Artesunate adalah 4 mg/KgBB per hari (50 mg/tablet)

*) Amodiakuine adalah 10 mg/KgBB per hari (200 mg/tablet ~ 153 mg amodiakuin basa)
 Jumlah tablet per hari
Hari Jenis Obat
40 – 60 kg > 60 kg

H1
DHP 3 4

H2 DHP 3 4
H3 DHP 3 4
*) DHA adalah 2-4 mg/KgBB/dosis per hari (40mg/tablet) FIXED DOSE/
*) PPQ adalah 16 - 32 mg/KgBB/dosis per hari (320 mg/tablet) DALAM SATU
DOSIS
 PENATALAKSANAAN MALARIA DENGAN
KOMPLIKASI Pasien datang dengan gejala malaria berat:
-Demam tinggi - Pucat/anemia berat, Hb<7gr%
- Jaundice (kuning) - Kesadaran menurun
- Sesak nafas - Hemoglobinuria
- Keadaan Umum : Lemah - Gejala syok
- Kejang-kejang - Muntah terus menerus

Periksa Sediaan Darah dengan Mikroskop / Rapid Diagnostik Test

Hasil :Plasmodium Falsiparum (+) atau Mix (P. falciparum +
P.vivax)

Artemeter injeksi atau Artesunateinjeksi

ARTESUNATE
ARTEMETER INJEKSI
INJEKSI
Artesunate injeksi 60 mg/ vial , Intravena (IV)/ Intramuscular (IM)
Artemeter injeksi 80 mg/ampul Intramuscular(IM) Hari Pertama :
3,2 mg/kgBB atau 2 ampul untuk orang dewasa; intramuskular (IM) Hari Pertama : 2,4 mg/kg bb diulang setelah , 12 jam
dengan dosis yang sama
Hari Berikutnya : 1,6mg/kgBB atau 1 ampul untuk orang dewasa;
intramuskular (IM) 1xsehari sampai pasien sadar Hari Berikutnya : 2,4mg/kgbb setiap hari sampai pasien sadar

Bila sudah dapat makan-minum : ganti dengan tablet Bila KU memburuk rujuk ke
ACT selama 3 hari RS
(Primakuin hanya boleh diberikan jika bayi sudah lahir)

Lini 2 menggunakan Kina HCl 25 % : Pemberian I Loading dose 20 mg/kgbb/4jam, selanjutnya diberikan 10 mg/kgBB/4 jam
setiap 8 jam sampai pasien sadar, kemudian minum obat oral. Pada kasus malaria berat dapat terjadi hasil mikroskop
/RDT negatif (-), hal ini disebabkan oleh : Parasit pada saat itu tidak ada di darah perifer tapi ada di kapiler atau di jaringan,
maka dianjurkan pemeriksaan laboratorium/RDT diulang setiap 1- 6 jam.
 IBU HAMIL KUNJUNGAN PERTAMA dan
Kunjungan berikutnya dengan
gejala malaria

PEMERIKSAAN ANC, KONSELING

& SKRINING MALARIA
Dengan RDT atau MIKROSKOP

POSITIF P.falcifarum atau P.vivax NEGATIF

atau Mix (P.falcifarum dan P.vivax)

TRIMESTER 1 TRIMESTER 2-3

DENGAN GEJALA TANPA GEJALA
Kina 3x2 (7 hari) ACT* (3 hari)

PERIKSA ULANG • LANJUTKAN ANC

SEDIAAN • LLIN
DARAH TEBAL • ZAT BESI/FOLAT
• NUTRISI

TAK ADA MEMBAIK

PERBAIKAN

POSITI NEGATI
F F
RUJUK SEGERA

*Artesunate (4 – 4 -4) +Amodiaquin (4-4-4) atau • LANJUTKAN ANC

Dihydroartemisinin + Piperaquin (DHP) 3-3-3 • LLIN
• ZAT BESI/FOLAT
• NUTRISI
 Pengobatan Malaria
tanpa Komplikasi
• Pastikan penderita meminum Obat Anti Malaria
• Sarankan Penderita untuk:
– Menyelesaikan pengobatan.
– Kembali Jika tidak ada perbaikan dalam 48 jam
– Konsumsi suplemen besi atau makanan mengandung
Besi
– Gunakan ITN dan pencegahan gigitan nyamuk
 Simpulan
• Perlu sosialisasi Protokol pengobatan OAM
• Perlu ditingkatkan kerjasama dan
pendekatan team dalam pemberantasan
malaria antara kesehatan dengan sektor
terkait serta mengembangkan strategi baru
• Meningkatkan Pendidikan kesehatan pada
komunitas akan bahaya malaria dan
pemeriksaan antenatal dini dan teratur
Terima Kasih