Malaria infection during pregnancy is
a major public health problem in
tropical and subtropical regions
throughout the world. In most endemic
areas of the world, pregnant women are the main adult risk group for malaria.
Malaria during pregnancy has been most widely evaluated in Africa, south of the
sahara where 90% of the global
malaria burden occurs. The burden of
malaria infection during
pregnancy is caused chiefly by p falciparum,
the most common malaria species in
Africa and Nigeria. The impact of the
other three human malaria parasites (P. vivas,
p ovale and p malarial) is less clear. every year, at least 30
million pregnancies occur among women in malarious
area of Africa, most of whom reside in areas of relatively stable malaria
transmission (WHO 2009) malaria
in pregnancy are mutually
aggravation conditions. The
physiological changes of Pregnancy and the pathological changes due to malaria have synergistic effect on the course of each
other, thus making life difficult
for the
mother, the child and treating physician. P falciparium
malaria can run a turbulent and dramatic
course in pregnant women. The non immune primigravidae are usually the most affected (Kakkilaya
2009) pregnant women are more susceptible to malaria which causes serious adverse effects including abortion, low birth and
material anaemia (Adam, et al 2005)
READ PREVIOUS POSTS ON MALARIA
- PREVENTION OF MOSQUITO BITES AND BREEDING (MALARIA)
- GENERAL METHODS OF MALARIA CONTROL
- OBJECTIVES OF ANTI-MALARIA PROGRAM (W.H.O)
- MANAGEMENT OF MALARIA (PREVENTION AND CONTROL OF MALARIA)
- DIAGNOSIS OF MALARIA (WHO)
- CLASSIFICATION OF MALNUTRITION
- DIAGNOSIS OF MALNUTRITION
- WHAT IS MALNUTRITION? (DEFINITION)
- AIMS AND OBJECTIVES OF STUDYING THE EFFECTS OF MALNUTRITION ON CHILD MORTALITY IN DEVELOPING COUNTRIES
- THE EFFECTS OF MALNUTRITION ON CHILD MORTALITY IN DEVELOPING COUNTRIES
The prevalence of malaria during
pregnancy varies according to the pre –existing
immunity of the mother . Women
living in areas of low transmission have little immunity to malaria,
which can cause severe syndromes
such as cerebral malaria and pulmonary
oedema. In contrast, those who live in areas of stable malaria transmission
enjoy greater immunity and
experience fewer symptoms during episodes of malaria although they commonly develop severe anaemia
as a consequence of the infection (Brabin, el at, 1983)
PATHOPHYSIOLOGY
OF MALARIA IN PREGNANCY
The pathophysiology of
malaria in pregnancy is greatly
due to altered immunity and
availability of a dramatic break down
of acquired immunity (Paradoxically, jully effective antimalaria, immunity is transferred to the child). Various by hypothesis have been put forth to explain the
pathophysiology malaria in
pregnancy.
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Hypothesis 1 :
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Loss
of antimalaria immunity
consistent with the general immunosuppressant pregnancy. Reduced
lymphoproliferative response sustained by elevated levels of serum cortisol.
This is designed to prevent the total rejection but renders the pregnant
women susceptible to infection
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Hypothesis 2:
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What
is lost is cell mediated immunity, but what is transferred is the passive antibody
mediated immunity and therefore
the pregnant women suffers
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Hypothesis 3:
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Placenta
is a new organ in primigravidae and
allows the parasites to by pass
existing host immunity or allows placenta specific phenotypes of P.falciparum to multiply. Development
placenta specific immunity may thus explain the decreased
susceptibility in multigravidae.
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CLINICAL
FEATURES OF MALARIA IN PREGNANCY
The patient remains asymptomatic for a week or more from the time of original mosquitoe bite. The typical malaria symptoms (paroxysms or chills) appear when merozoites and the metabolic waste by products are
release into the blood
stream at the end of the first schizogony in red cell (Ochei, 2004)
Atypical manifestations of malaria are common in pregnancy, particularly in the 2nd pregnancy.
Common features include:
Fever – Patient may have different patterns
of fever from afebrile to continuous
fever low grade to hyperpyrexia. In
the 2nd half of
pregnancy there may be more frequent paroxysms due to immunosuppresion (Kakkilay, 2009)
RISK
FOR THEIR FOETUS
High grades of fever, placental insufficient
hypoglycemia, anaemia and other
complications can adversely affect the foetus. Both p .vivax
and p. falicparum malaria can pose problems for the foetus with
the latter being more serious. The
prenatal and neonatal mortality
may vary from 15-70%. In one study mortality
due to p vivax malaria during pregnancy was 15.7%
while that due to falciparum
was 33%
spontaneous abortion. Premature
birth, still birth, placental insufficiency and intrauterine growth retardation
(temporal/chronic), low birth weight,
foetal distress are the different problems observed in the growing foetus . transplacental spread of
the infection to the foetus can
result in congenital malaria
Congenital malaria is very rare and occurs in 45% of
affected pregnancies placental barrier and maternal IgG antibodies which cross the placenta may protect the foetus to some extent. It is much more common in non-immune
population and the incidence goes up
during epidemics of malaria.
All four species can cause congenital malaria but
it is proportionately more with P malaria new born child can manifest with fever,
irritability, feeding problems hepatosplenomegaly manaemia, jaundice etc.
the diagnosis can be confirmed by smear for malaria parasite from cord blood (Kakkilaya, 2009)
MANAGEMENT
OF MALARIA IN PREGNANCY
The management of malaria in pregnancy involves the following three aspects and equal importance should be
attached to all the them
1.
Treatment of malaria
2.
Management
of complications
3.
Management
of labour
TREATMENT
OF MALARIA
The treatment of malaria should be
energetic, anticipatory and careful
Energetic:
i.
They
should be no waste of time
ii.
It
is better to admit all cases of p
falciparun malaria
iii.
Assess
severity – general condition, pallor, jaundice, blood pressure, temperature,
hemoglobin, parasite count, serum bilirubin, serum creatinine, blood sugar
ANTICIPATORY
Malaria in pregnancy can causes
sudden and dramatic complications. Therefore, one should always be looking for any
complications by regular monitoring .
i.
Monitor maternal and fetal vital
parameters 2 hourly
ii.
RBS
4-6 hourly, hemoglobin and parasite count
12 hourly serum creatinine, bilirubin and
intake / output chart daily.
Careful:
The physiologic changes of pregnancy pose special problems
in management of malaria. Certain drugs
are contra indicated in pregnancy and
may cause more severe adverse effects.
In the treatment of these patients these factor should be taken into
consideration
i.
Choose
drugs according to severity of
the disease /sensitivity pattern in the locality
ii.
Avoid
drugs that are contra indicated
iii.
Avoid
over /under dosing of drugs
iv.
Avoid
fluid overload / dehydration
v.
Maintain
adequate intake of calories
ANTI
MALARIALS IN PREGNANCY
All
Trimesters : Chloroquine,
quinine, artesumate/artemether /arteether
2nd Trimester : Mefloquine, pyrimethamine /sulfadoxine
3rd Trimester. Mefioquine, pyrimethamine /sulfadoxine
MANAGEMENT
OF COMPLICATIONS
Acute
pulmonary oedema: Careful
fluid management back-rest, oxygen, diuretics, ventilation if needed.
Hypoglycemia: 25-50%
dextrose, 50-100mi I.V
followed by 10%
dextrose continous infusion. If fluid over load is a problem then inject glucagon
0.5 -1mg can be given intra muscularly
. Blood sugar should be monitored every
4-6 hours for recurrent hypoglycemia
Anaemia: Packed cells should be transfused if
hemoglobin is < 5g%
Renal
failure: Renal
failure could be pre –renal due to unrecognized dehydration or ranal due to
server parastaemia. Treatment involves
careful fluid management, diuretics, and dialysis if needed.
Septicaemia
schock: Secondary bacterial
infections like urinary tract infection, pneumonia etc are more common in pregnancy
associated with malaria. Some of these patients may develop septicaemia shock,
known as Algid malaria. Treatment involves administration of 3rd generation
cephalosporins, fluid replacement, monitoring of vital, parameters and intake
and output.
Exchange
Transfusion: Exchange transfusion is indicated in cases of
severe falciparium malaria to reduce the parasite load. Patients blood is
removed and it is replaced with packed cells. Especially
useful in cases of very high
parasitaemia (helps in
clearing ) and impending
pulmonary oedema (helps in clearing
) (helps to reduce fluid
load).
MANAGEMENT
OF LABOUR
Severe falciparium malaria in full term
pregnancy carries a very high mortality
maternal and fetal distress may go unrecognized
in these patients. Therefore, careful monitoring of maternal and foetal
parameters is extremely important and pregnant
women with severe malaria are
better manages in an intensive
care unit.
Falciparum malaria induces uterine contractions
resulting in premature labour. (Bernard J Brabin 2008) the frequency and intensity of contractions
appear to be related to the height of the fever. Fetal distress is common and often unrecognized.
Therefore only monitoring of uterine contraction and fetal heart rate may
reveal asymptomatic labour and foetal tachycardia, bradycardia or late deceleration in relation to uterine
contractions, indicating fetal
distress. All efforts should be made to rapidly bring the temperature
under control, by cold sponging, anti
pyretics like paracetamol etc.
Careful fluid management is also very
important dehydration as well as fluid
overloud should be avoided, because both could be detrimental to the mother and the foetus . In cases of very
high prasitaemia, exchange transfusion may have to be carried out.
In
the situation demands, induction of
labour may have to be considered
once the patient is in labour, foetal or maternal distress may
indicate the need to shorten the
2nd stage by forceps or vacuum extraction . If needed,
even caesarian section must be considered.
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