Infection
International
MALARIA DALAM KEHAMILAN
Divisi Fetomaternal Departemen Obstetri dan Ginekologi FKUI/RSCM
Infection
International
Tujuan
• Penjelasan epidemi Malaria
• Penjelasan Komplikasi Ibu & Janin
• Prinsip Tatalaksana dan Strategi
pencegahan
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International
Data Tentang Malaria dan Kehamilan
• 25 Juta ibu hamil di Afrika tinggaldi daerah endemis
• Malaria sering terjadi dan merupakan komplikasi
hamil
• Di derah endemik malaria, saat hamil risiko terjadia:
– Sampai 15% of Anemia ibu
– 8–14% Bayi berat lahir rendah / PJT
– 30% of “preventable” Pertumbuhan janin
terhambat
– 3–8% of Kematian Bayi
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Data INDONESIA
• 46,2% populasi tinggal di daerah endemis
• P. vivax :predominan di Jawa Bali
• P. falciparum: di luar Jawa Bali
• 415.140 kasus malaria di Indonesia pada 2022.
• Meningkat 36,29% dibandingkan tahun 2021 ( 304.607
kasus
• Jumlah kasus (+) per 1000 penduduk atau annual paracite
incidence (API) : 1,51 (thn 2022) meningkat 1,12 (thn
2021)
• Re-emerging disease
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International
Infection
International
Infection
International
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.
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Siklus Hidup Malaria
Oocyst
Sporozoites
Mosquito Salivary Gland
Zygote
Exo-
erythrocytic Hypnozoites
(hepatic) cycle
Gametocytes
Erythrocytic
Cycle
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International
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
Infection
International Manifestasi Ekologi dan Hambatan Klinik Malaria
Hypoglycemia
Anemia
Acute Severe illness Respiratory Death
febrile distress
illness
Cerebral malaria
Infected
Mosquito
Anemia
Chronic Neurologic/ Impaired
Malnutrition
effects cognitive growth and
Infected development
Developmental
Human
Fetus Low birth weight Infant mortality
Pregnancy
Acute illness
Maternal Impaired
Anemia productivity
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International
Types of Malaria
• Uncomplicated:
– Most common
• Severe:
– Life-threatening, can affect brain
– Pregnant women more likely to get severe malaria
than non-pregnant women
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International
Recognizing Malaria in Pregnant Women
Uncomplicated Malaria Severe Malaria
Signs of uncomplicated malaria PLUS
• Fever one or more of the 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
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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
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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. 19
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Effect of Malaria on Pregnancy in
Unstable Transmission Areas
Acquired Immunity – Low
Clinical Illness
Severe Disease
Risk to Mother Risk to Fetus
20
Source: WHO 2002.
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Maternal complication
In non-Endemic areas
• Greater risk of severe
In Endemic areas disease
• Malaria related anaemia • Higher risk of death
• Febrile illness • Anaemia,
• Placental sequestration hypoglycemia,
pulmonary oedema,
renal failure
Infection
Effects on the Pregnant Woman
International
Primigravidae in
All parities in Unstable
Effects Stable malaria
malaria areas
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)
22
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Fetal Complications
International
In endemic areas In non-endemic areas
• Low birth weight • Abortions
• Intra-uterine growth • preterm delivery
retardation
• Congenital malaria
• Low birth weight
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Effects on the Fetus and Newborn
All parities in
Primigravidae in
Effects Unstable malaria
Stable malaria areas
areas
Low birth weight
IUGR +++ +
Prematurity + ++
Abortion - ++
Stillbirth - ++
Congenital malaria - +
Fetal anemia ? +
Infant mortality + ++
( +++ = Very Common, ++ = Common, + = Infrequent, -- = Rare)
Infection
Insecticide-Treated Nets
International
ITN tucked under a bed ITN tucked under a mat
Infection
Kelambu dengan insektisida
International
Kelambu tanpa insektisida Kelambu dengan insektisida
Memberikan proteksi terhadap Memberikan proteksi tinggi
malaria terhadap malaria
Tidak membunuh atau mengusir Membunuh dan mengusir
nyamuk yang menyentuh nyamuk yang menyentuh
kelambu kelambu
Tidak menurunkan jumlah Mengurangi jumlah nyamuk di
nyamuk dalam/di luar kelambu
Tidak membunuh serangga lain Membunuh serangga lain seperti
seperti kutu, roaches dan kutu kutu, roaches, dan kutu kasur
kasur Aman untuk ibu hamil, anak dan
Aman untuk ibu hamil, anak dan janin
bayi
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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
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International
Malaria Berat
• Cerebral malaria: Unrousable coma with
asexual peripheral parasitaemia or placental
infection.
• Hypoglycemia
• Pulmonary edema (ARDS)
• Acute renal failure
Infection
Diagnosis Malaria
International
• 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
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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).
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MICROSCOPY
• Species identification
• Quantitation (accurate parasite density):
- 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
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International
RAPID DIAGNOSTIC TEST
Infection
Combination Therapy
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
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International
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
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International
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
Infection
International
The Malaria Transmission Cycle
Sites of Action for Antimalarial Drugs
TISSUE SCHIZONTOCIDES:
primaquine
pyrimethamine
proguanil
tetracyclines
MOSQUITO HUMAN
BLOOD
SCHIZONTOCIDES:
Chloroquine mefloquine
quinine/quinidine
tetracyclines
Halofantrine sulfadoxine
SPORONTOCIDES: Pyrimethamine
primaquine GAMETOCYTOCIDES: artemisinins
pyrimethamine primaquine
proguanil
Infection
International
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 :
- Pada Trimester 1 : Kina injeksi
- Pada Trimester 2-3 : Artemeter atau Artesunate
injeksi
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Rekomendasi PANLI Terakhir
1. Pengobatan Malaria pada Ibu Hamil Trimester I - III
Hari Jenis Obat Jumlah tablet per hari
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/DALAM
*) PPQ adalah 16 - 32 mg/KgBB/dosis per hari (320 mg/tablet) SATU DOSIS
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2. Pengobatan Malaria pada Ibu Hamil Trimester II - III
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
Infection
International
3. Pengobatan Malaria pada Ibu Hamil Trimester II - III
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/DALAM
*) PPQ adalah 16 - 32 mg/KgBB/dosis per hari (320 mg/tablet)
SATU DOSIS
Infection
IBU HAMIL KUNJUNGAN PERTAMA dan
International Kunjungan berikutnya dengan gejala
Tatalaksana malaria
Malaria Pada PEMERIKSAAN ANC, KONSELING &
Ibu Hamil SKRINING MALARIA
Dengan RDT atau MIKROSKOP
POSITIF P.falcifarum atau P.vivax atau NEGATIF
Mix (P.falcifarum dan P.vivax)
TRIMESTER 1 TRIMESTER 2-3
DENGAN GEJALA TANPA GEJALA
ACT (3 hari) ACT (3 hari)
PERIKSA ULANG • LANJUTKAN ANC
SEDIAAN DARAH • LLIN
• ZAT BESI/FOLAT
TEBAL
• NUTRISI
TAK ADA MEMBAIK
PERBAIKAN
POSITIF NEGATIF
RUJUK SEGERA
• LANJUTKAN ANC
• LLIN
• ZAT BESI/FOLAT
• NUTRISI
PENATALAKSANAAN MALARIA DENGAN KOMPLIKASI
Infection
Pasien datang dengan gejala malaria berat:
- Demam tinggi - Pucat/anemia
International berat, Hb<7gr% - Jaundice (kuning) -
Kesadaran menurun - Sesak nafas
- Hemoglobinuria
- Keadaan Umum (KU) : 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 Artesunate injeksi
ARTEMETER INJEKSI ARTESUNATE INJEKSI
Artemeter injeksi 80 mg/ampul Intramuscular(IM) Artesunate injeksi 60 mg/ vial , Intravena (IV)/ Intramuscular(IM)
Hari Pertama : 3,2 mg/kgBB atau 2 ampul untuk orang Hari Pertama : 2,4 mg/kg bb diulang setelah , 12 jam
dewasa ; intramuskular (IM) dengan dosis yang sama
Hari Berikutnya : 1,6mg/kgBB atau 1 ampul untuk orang Hari Berikutnya : 2,4mg/kgbb setiap hari sampai pasien sadar
dewasa; intramuskular (IM) 1xsehari sampai pasien sadar
Bila sudah dapat makan-minum : ganti dengan Bila KU memburuk rujuk ke RS
tablet ACTselama 3 hari + Primakuin pada hari I
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.
Infection
International
Third Edition (April 2015)
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http://www.who.int/malaria/publications/atoz/9789241549127/en/
Infection
Simpulan
International
• 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
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Terima Kasih
