Malaria in pregnancy

HNS 316
Objectives
• Introduction
• Definition of malaria
• Clinical features of malaria
• Effects of malaria in pregnancy
• Prevention of malaria in pregnancy
• Treatment of malaria in Pregnancy
Introduction

• Malaria is a disease caused by parasites of the genus Plasmodium.

• Nationally, Plasmodium falciparum is the predominant species
accounting for 98.2 per cent of all infections.
• Malaria is one of the major diseases of public health significance in
this country.
• It causes 5 times more illness than TB, AIDS, measles and leprosy
combined.
Introduction
• It is responsible for 20- 45% of hospital admissions and 25 -35% of
outpatient clinic visits.
• In Kenya alone, 96 children die daily from malaria.
• It is also a major cause of maternal morbidity and mortality,
accounting for 10% of maternal deaths.
• By preventing malaria during pregnancy an estimated 25,000 lives
could be saved each year.
 Epidemiology
• Kenya has four malaria epidemiological zones, with diversity in risk
determined largely by altitude, rainfall patterns and temperature.
• The zones are:
• Endemic: Areas of stable malaria have altitudes ranging from 0 to 1,300
meters around Lake Victoria in western Kenya and in the coastal regions.
• Transmission is intense throughout the year
• Seasonal transmission: Arid and semi-arid areas of northern and south-
eastern parts of the country experience short periods of intense malaria
transmission during the rainfall seasons.
• Epidemic prone areas of western highlands of Kenya: Malaria
transmission in the western highlands of Kenya is seasonal, with
considerable year-to-year variation.
• Epidemics are experienced when climatic conditions favor
sustainability of minimum temperatures around 18C.
• Low risk malaria areas: This zone covers the central highlands of
Kenya including Nairobi.
• The temperatures are usually too low to allow completion of the
sporogonic cycle of the malaria parasite in the vector.
• Approximately 1.5 million women become pregnant each year in Kenya,
majority live in areas of moderate to intense transmission of malaria.
• Pregnant women are especially vulnerable to malaria infection.
• Effects of MIP are greatest in primigravida, second pregnancy and HIV
positive pregnant women.
• Women without pre existing immunity (those living in a non endemic
malaria area) are susceptible to more severe complications of malaria;
• Women with acquired immunity to malaria (those living in Malaria
endemic areas) are at a higher risk for developing severe anaemia and its
consequences.
Life cycle of malaria parasite
Clinical features of malaria
• Uncomplicated Malaria:
• This is characterized by fever in the presence of peripheral
parasitaemia.
• Other features may include chills, profuse sweating, muscle pains,
joint pains, abdominal pain, diarrhea, nausea, vomiting, irritability
loss of appetite and splenomegaly.
• In pregnancy, false labour may occur.
• These features may occur singly or in combination.
 Clinical features of malaria
• Severe malaria
• This is a life threatening manifestation of malaria
• Defined as the detection of P. falciparum in the peripheral blood in the
presence of any of one or more of the clinical or laboratory features listed
below:
• Prostration (inability or difficulty to sit upright, stand or walk without
support in a person normally able to do so)
• Alteration in the level of consciousness (ranging from drowsiness to deep
coma)
• Cerebral malaria (unrousable coma not attributable to any other cause in a
patient with falciparum malaria)
• Respiratory distress (acidotic breathing) Multiple generalized convulsions (2 or
more episodes within a 24 hour period)
Clinical features of malaria
• Severe malaria
• Shock (circulatory collapse, septicemia)
• Pulmonary edema
• Abnormal bleeding (Disseminated Intravascular Coagulopathy -DIC)
• Jaundice
• Haemoglobinuria (black water fever)
• Acute renal failure - presenting as oliguria or anuria
• Severe anemia (Hemoglobin < 5g/dl or Haematocrit < 15%)
• Hypoglycemia (blood glucose level < 2.2.mmol/l)
• Hyperlactataemia
Investigations

• In all pregnant women with fever or history of fever the use of

parasitological diagnosis is recommended.
• At health facilities where malaria diagnostics (microscopy or RDT) are
not available, patients with fever or history of fever in whom the
health worker suspects malaria and has eliminated other possible
causes of fever, should be presumptively classified and treated as
malaria.
 Effects of malaria in pregnancy
• Mother:
• Pregnant women are at higher risk from malaria infection and its harmful
effects.
• During pregnancy a woman also loses some of the ability to fight the
infection thus exercabating her risk of morbidity and mortality.
• The malaria parasite in the blood of the mother hides in the placenta and
hence malaria parasites may not be detected when you take a finger blood
sample.
• The parasites may however still be present and cause damage to the
placenta.
• The major health effect of malaria on the mother is the development of
anaemia. (2 – 15% of severe maternal anaemia is attributable to malaria).
 Effects of malaria in pregnancy
• Mother:
• Malaria causes anaemia by destroying the red blood cells of the mother.
• This augments maternal ill health and increases her risk of dying.
• Severe anaemia manifests in approximately 6,000 primigravida in Kenya
(MOH, GOK 1998: A situation analysis for Kenya).
• Haemorrhage complicating malaria-related anaemia during pregnancy
contributes significantly to maternal mortality.
• Malaria-related anaemia is estimated to cause as many as 10,000 maternal
deaths in Africa each year.
• Malaria also increases the risk of premature labour (8 – 36% of preterm
delivery is attributable to malaria
Effects of malaria in pregnancy
• Baby:
• Malaria infection poses a risk to the unborn child leading to:
• Spontaneous abortion
• Stillbirth
• Congenital infection
• Low birth weight (up to 30% of preventable low birth weight is
attributable to malaria)
• Prematurity
• Intrauterine growth retardation (13 – 70% of intrauterine growth
retardation is attributable to malaria).
• It causes 3-5 % of neonatal deaths.
Prevention of malaria in pregnancy
• The goal of prevention of malaria in pregnancy is to reduce maternal
and perinatal morbidity and mortality associated with malaria.
• The strategies in prevention of malaria in pregnancy are integrated in
the overall antenatal care (ANC) package for maternal health.
• They include the provision of:
• Intermittent preventive treatment for malaria in pregnancy (IPTp)
• Long lasting Insecticidal Nets
• Provision of prompt diagnosis and treatment of fever due to
malaria
• Health education
 Intermittent Preventive Treatment
for Malaria in Pregnancy
• IPTp is the presumptive provision of a full treatment course of an
efficacious antimalarial at specific intervals during pregnancy (regardless
of whether the woman is infected or not).
• IPTp has been shown to reduce the risk of placental infection and the
associated risk of maternal anemia, miscarriage, premature deliveries and
low birth weight.
• The current recommended medicine for IPTp is 3 tablets of sulphadoxine/
sulphalene 500mg and pyrimethamine 25mg
• IPTp is recommended in areas of high malaria transmission
• Administer IPTp with each scheduled visit after quickening to ensure
women receive a minimum of 2 doses
Intermittent Preventive Treatment
for Malaria in Pregnancy
• IPTp should be given at an interval of at least 4 weeks (1 month)
• IPTp should be given under directly observed therapy (DOT) in the
antenatal clinic and can be given on an empty stomach.
• SP as IPTp is safe up to 40 weeks pregnancy and late dosing is
beneficial for women presenting late in pregnancy
• Folic acid tablets should NOT be administered with SP given for IPTp
and if need be, may be taken 14 days following administration of IPTp
• Before SP is given:
• Ask if the woman has had any allergic reaction e.g. a severe skin rash
or mucous membrane reaction to a sulpha drug
• If the client does not know whether she has had a reaction to sulpha
drugs it is safe to presume that they have not had a serious reaction
• If the woman has had a serious skin or mucous membrane reaction,
do not give SP
• If a patient is allergic to SP
• Unfortunately, no alternative to SP for use as IPT for pregnant women has
been approved.
• If your client is allergic to SP:
• Carefully counsel her about symptoms of malaria and early seeking of
treatment
• Monitor her for anaemia and ensure that she knows that she has to
promptly return to the clinic if she develops symptoms of anaemia or
malaria
• Minimize her risk for anaemia from other causes such as iron deficiency,
hookworm, etc. by appropriate diet, supplements and medication.
• Advice her to sleep under an Insecticide-treated net (ITN).
• If she becomes symptomatic for malaria treat her appropriately
 IPT in HIV positive Women
• HIV infection during pregnancy increases the risk of the complications of
malaria in pregnancy.
• Malaria infection during pregnancy particularly placental malaria increases
the risk of mother to child transmission of HIV.
• Women known to be HIV infected or with unknown HIV status living in
areas of high HIV prevalence (>10% among pregnant women) should
receive at least 3 doses of IPTp.
• Pregnant women who are HIV positive and are on daily cotrimoxazole
chemoprophylaxis should not be given SP for IPTp
• Pregnant women who are HIV positive and are also taking antiretroviral
therapy for PMTCT who are not receiving cotrimoxazole should receive IPTp
with SP.
Long Lasting Insecticidal Nets
• A study in an area of high malaria transmission in Kenya has shown
that women protected by ITNs every night during their first four
pregnancies produce 25% fewer underweight or premature babies.
• In addition, ITN use benefits the infant who sleeps under the net with
the mother by decreasing exposure to malaria infection.
• Therefore the service provider should ensure that:
• Each pregnant woman living in a malaria risk area receives a free LLIN
at the first contact visit to the ANC
• Each pregnant woman is shown how to hang the LLIN and encouraged
to use the net each and every night during her pregnancy and
thereafter.
Long Lasting Insecticidal Nets

• LLIN also kill lice, ticks, and pests such as bedbugs and cockroaches
• LLIN are not a substitute for IPTp and vice versa.
• Both must be used in order to achieve maximal benefits in the
reduction of both maternal and perinatal morbidity and mortality
Health education
• Continuous maternal health education should be provided at the ANC
• It should encourage use of all interventions and services
• It should also encourage the pregnant woman to attend all ANC visits
as scheduled.
Treatment of Malaria in pregnancy
• First trimester
• The recommended treatment for uncomplicated malaria in the first
trimester is a 7-day therapy of oral quinine.
• Do not withhold artemether-lumefantrine or any other treatment in
1st trimester if quinine is not available.
• Malaria if untreated can be fatal to the pregnant woman.
 Treatment of Malaria in pregnancy
• Second and third trimesters
• Artemether-lumefantrine is the recommended treatment in the 2nd and
3rd trimesters.
• Oral quinine may also be used but compliance must be ensured.
• Artemether-lumefantrine (AL) currently available as a co-formulated
dispersible tablet containing 20 mg of artemether and 120 mg of
lumefantrine.
• This is administered as a 6-dose regimen given over three days (that is 4
tablets stat, repeat after 8 hours, 24hrs, 36hrs, 48hrs and 60hrs).
• HIV/AIDS patients with Malaria should be managed according to the
same regimen.
 Treatment of Malaria in pregnancy
• Second line treatment in all age groups
• The recommended second line treatment for uncomplicated malaria in
Kenya is dihydroartemisininpiperaquine (DHA-PPQ).
• This is currently available as a fixed-dose combination with adult tablets
containing 40 mg of dihydroartemisinin and 320 mg of piperaquine.
• These are administered as three (3) tablets once daily for three days.
Treatment of Malaria in pregnancy
• Treatment of Severe MIP
• The recommended medicine for severe malaria in pregnancy is
parenteral quinine or parenteral artemisinins (artemether or
artesunate).
• The preferred route of administration is the intravenous route for
quinine and artesunate.
• However the intramuscular route can be used as an alternative where
intravenous route is not feasible.
• Administration of quinine to pregnant women should be closely
observed as it can induce premature labour.
 Treatment of Malaria in pregnancy
• Quinine administration in adults
• Quinine should only be given as an intravenous infusion and NEVER given as
an intravenous (bolus) injection.
• The Loading dose should be omitted if patient has received quinine in the last
24 hours or has received mefloquine in the last 7 days
• Quinine is not contraindicated in severe anemia
• In renal insufficiency the dose of quinine remains unchanged
• In hepatic insufficiency, the dose of quinine should be reduced by 25%
• Hypoglycemia is a potential side effect of quinine administration particularly
in pregnant women and therefore quinine should be administered in a
glucose containing infusion.
 Treatment of Malaria in pregnancy
• Administer quinine as follows:
• A loading dose of quinine 20mg/kg (maximum 1200mg) diluted in 15mls/kg
(maximum 500ml) of isotonic solution (5% dextrose or normal saline) is given
intravenously to run over 4 hours.
• 8 hours from commencement of the initial dose of quinine, give 10mg/kg
(maximum 600mg) diluted in 10mls/kg (maximum 500ml) of isotonic solution
(5% dextrose or normal saline) to run over 4 hours.
• Repeat l0mg/kg quinine infusion every 8 hours until the patient can take
medication orally.
• Thereafter a complete course of artemether-lumefantrine (AL) is given
• Alternatively oral quinine is continued at 10mg/kg (maximum 600mg) every 8
hours to complete a total of 7 days treatment, in combination with
clindamycin or doxycycline also for 7 days.