Table Of Contents
Malaria in Pregnancy
Malaria in pregnancy is a significant public health concer, particularly in Sub-saharan Africa and Southeast Asia. It is caused by Plasmodium falciparum (mainly in Africa) and Plasmodium vivax (mainly in Asia). Pregnant women are more succeptible to malaria due to immunologic changes and placental sequestration of Plasmodium falciparum parasites. Primigravidas have a higher prevalence of placental malaria, especially in areas with stable transmission i.e. endemic regions.
Malaria during pregnancy accounts for 15% of severe anaemia in pregnant women, 30% of preventable low birth weight and 5% of infant ortality. Each year, more than 30 million women in Africa become pregnant in malaria-endemic areas.
Population and the effects on malaria in pregnancy
| Population | Malaria in pregnancy |
|---|---|
| Primigravida | Higher prevalence of placental malaria than multigravidas since the placenta is immunologically naive. Local immunity develops with subsequent pregnancies |
| Stable (endemic) transmission areas | Pregnant women are semi-immune and have a low prevalence of peripheral parasitaemia but a high prevalence of placental malaria. Women are often asymptomatic due to low peripheral parasitaemia hence the need for intermittent-preventive treatment |
| Unstable tranmission areas | Pregnant women have low-acquired immunity and are more likely to be symptomatic, and develop severe malaria and anaemia |
| HIV-positive | More likely to have malaria parasitaemia than HIV-negative women. May also have decreased efficacy of antimalarials in controlling the infection |
- Pathophysiology of malaria in pregnancy
- Immunosuppression
- Hormonal changes e.g. increased progesterone and cortisol suppress maternal immune response. Primigravidas have a higher cortisol levels than multigravidas.
- Placental malaria
- The placenta is immunologically privileged making it easier for Plasmodium falciparum to evade clearance
- Plasmodium falciparum infected erythrocytes express variable surface antigens (VSAs) that bind to chondroitin sulfate A (CSA) on the syncytiotrophoblasts lining the intervillous space in the placenta
- Parasites are sequestrated in the intervillous space causing altered placental integrity → reduced nutrient and oxygen transport → low-birth weight and fetal growth restriction
- Severe anaemia also contributes towards low birth weight and fetal growth restriction
- Immunosuppression
- Signs and symptoms
- Fever and chills
- Headache
- Malaise
- Jaundice
- Seizures
- Respiratory distress
- Investigations
- Peripheral blood smear for microscopy: for parasitaemia
- Placental blood smear or biopsy postpartum: to confirm placental malaria
- Rapid diagnostic tests (RDTs): to detect histidine-rich proteins (HRP-2) for Plasmodim falciparum
- Supportive treatment of malaria in pregnancy
- Foetal monitoring
- Prevent hypoglycaemia particularly if taking quining
- Correct anaemia
- Antipyretics
- Treatment of uncomplicated malaria
- First trimester: PO quinine for 7 days
- Second and third trimester: PO artemether-lumefantrine or quinine
- Treatment of severe malaria
- IV quinine or artesunate
- Prevention of malaria in pregnancy
- Intermittent preventive treatment for malaria in pregnancy (IPTp) using 3 tablets of sulphadoxine-pyrimethamine (SP)
- Administer at each visit after quickening and ensure a minimum of 2 doses with an interval of at least 4 weeks
- Taken at quickening since fetal growth velocity is highest after this period
- Withold high-dose folic acid tablets when taking SP and resume 14 days after IPTp if needed
- HIV+ women on daily corimoxazole chemoprophylaxis do not need SP for IPTp
- Long-lasting insecticidal nets (LLINs)
- Intermittent preventive treatment for malaria in pregnancy (IPTp) using 3 tablets of sulphadoxine-pyrimethamine (SP)
- Maternal complications of malaria
- Severe anaemia (2 – 15%)
- Cerebral malaria
- Hypoglycaemia
- Pulmonary oedema
- Acute renal failure
- Maternal death
- Hypertension*
- Placental infection
- Puerperal sepsis
- Fetal complications of malaria
- Intrauterine growth restriction (13 – 70%)
- Low birth weight (20%)
- Preterm birth (8 – 36%)
- Congenital malaria (5%)
- Neonatal and infant death
- Miscarriage
- Stillbirth
- Fetal anaemia
