Malaria In Pregnancy
PC Bhattacharyya, Manabendra Nayak
INTRODUCTION
Malaria in pregnancy is an obstetric, social and medical
problem of all over the world particularly in tropical and
sub-tropical countries. Pregnant women with no previous
immunity to malaria are two or three times more likely
to develop severe disease as result of malaria infection
than are non pregnant adults living in the same area1.
Pregnant women are especially prone to severe attacks of
malaria which may cause abortion, premature labour and
still birth2,3. In most endemic areas pregnant women are
the main adult risk group for malaria. The main burden of
malaria infection during pregnancy results from infection
with plasmodium falciparum . The impact of the other three
human malaria parasites (P.vivax, P.malarie and P. ovale) is
less clear.
PATHOPHYSIOLOGY
Malaria and pregnancy are mutually aggravating conditions.
The physiological and the pathological changes due to
malaria have a synergistic effect on the patient which
causes life difficult for the mother, the child and the treating
physician.
Pregnant women compared to non pregnant women are
at on increased risk of malaria and the severity of clinical
manifestation experienced by these women and their foeti
depend on the level of pre- pregnancy immunity4. Pregnant
women are more susceptible to plasmodium falciparum
infection with more frequent episode of clinical malaria,
increased prevalence and density of parasitaemia during
episode5,6. The effect of infection on the pregnancy is
dependent on pre-pregnancy immunity. This acquired anti -
malarial immunity depends on intensity of transmission and
the number of previous pregnancies among others. Studies
have shown that prevalence of infection is highest in second
gravida while others have reported a higher prevalence in
primigravida and the density of parasitaemia is reported to
be highest in the first trimester and primigravida could be
at maximum risk in highly endemic area 7,8.
Loss of anti-malarial immunity is consistent with the
pregnancy viz.-reduced lymphoproliferative response. What
is lost is cell mediated immunity, by which pregnant mother
suffers. In pregnant women a change of balance of the local
placental environment observed, which is consistent with
large number of monocytes in infected placenta. While
IFN-γ, IL-2 and TNF-α levels - hall marks of a type-1 cytokine
response. Inflammatory cytokine account for the pathology
of maternal malaria, associated with severe maternal
anaemia, symptomatology of malaria and contributes to
adverse pregnancy out comes 9.
Placenta in Pregnancy
Placental parasitaemia in pregnant women leads to
impairment of foetal nutrition and this contributes to low
birth weight, a leading cause of poor infant development
and survival10. P. falciparum has the unique ability of
cytoadhesion. Adhesion molecule - 1 may be involved in
the development of severe malaria in adults. Chondroitin
sulfate A and hyaluronic acid have been identified as
a parasite attachment to placental cells. The putative
ligand expressed by the malaria has been found to be
antigenically conserved among global cases of maternal
476 Medicine Update-2011
sub population of P. falciparum that do not bind to CD
36 10. The parasites sequentiate placental membrane,
specifically the trophoblastic villi. Intervillous spaces are
filled with parasites and macrophages which transport to
the foetus. Villous hyprtrophy and fibrinoid necrosis of villi
are also observed. All the placental tissues exhibit malarial
pigments, which impede oxygen nutrient transfer and can
cause general haemorrhge to the complications by both
mother and child9.
Manifestation of Malaria in Pregnancy
The symptoms of malaria during pregnancy differ with
the intensity of malaria transmission and with the level of
immunity acquired by the pregnant women11. Since malaria
transmission intensity may very within the same country
from areas of relatively stable transmission to areas of
unstable or epidemic transmission. The clinical picture of
malaria infection during pregnancy may like wise range from
asymptomatic to severe life threatening illness. Atypical
manifestation of malaria are more common in pregnancy
particularly in primigravida. Patient may have different
pattern of fever from afebrile to continuous pyrexia. In
the second half of pregnancy, there may be more frequent
paroxysm of fever. Patient living in hyperendemic area may
present with a severe anaemia without any definite pyrexia.
Enlargement of the spleen may be variable in the course
of pregnancy 12,13.
Complication of malaria in Pregnancy
In comparison to general population, risk of development
of complications in pregnant women because of malaria is
more. Particularly complications of malaria in pregnancy in
women with low immunity are hyperpyrexia, hypoglycemia,
severe haemolytic anaemia, cerebral malaria and pulmonary
oedema.14
1. Anaemia:
Anaemia due to malaria is more common in between 16-29
weeks of gestation. The cause of anaemia particularly in
pregnant lady is because of haemolysis of parasitized blood
and increased demand of blood during pregnancy. Anaemia
increases perinatal mortality and morbidity and increased
risk of post-partum haemorrage11.
2. Acute pulmonary oedema:
Acute pulmonary oedema may be the presenting symptoms
of some cases of malaria in pregnancy in first trimester or it
can develop in the second and third trimesters of pregnancy.
It is aggravated by pre-existing anaemia and haemodynamic
changes of pregnancy12. Acute pulmonary oedema carries a
very high mortality13.
3. Hypoglycemia:
It is one of the complication of malaria more common
in pregnant women because of increased demand of
hypercatabolic state and infecting parasites. Increased
response of pancreatic islet a secretory stimuli is also
another cause. Hypoglycemia in these patients can remain
asymptomatic, but it can be recurrent and therefore
constant monitoring is needed 12,13.
4. Immuno suppression:
Hormonal changes of pregnancy reduce synthesis of
immunoglobulins and decrease endothelial system function
are the cause for immunosuppression in pregnancy. These
make the pregnant women more prone for malaria.
Risk for the foetus
Malaria in pregnancy is one of the dreaded cause of fetal
mortality and morbidity. Hypoglycemia, anaemia and other
complications can all adversely affect the foetus. Falciparum
malaria can cause problem for the foetus with mortality
up to 15% 11,12. Spontaneous abortion, still birth, placental
insufficiency and IUGR can also observed due to effect of
malaria in pregnancy. Transplacental spread of malarial
parasites result in congenital malaria13 in the first and second
pregnancies in highly endemic areas 15.
Prevention and Management of malaria during pregnancy
WHO recommends a three - pronged approach to the
prevention and Management of malaria during pregnancy15
 Insecticide - treated net (ITNs).
 Intermittent preventive treatment.
 Effective care management of malarial illness.
Insecticide - Treated Nets (ITNs)
ITNs kill and repel the mosquitoes that carry malaria,
providing protection for both mother and newborns. In areas
of stable transmission use of ITNs has been associated with
lower prevalence of malaria infection and fewer premature
death15. A trial in the Gambia found that, during the rainy
season in villages where ITNs were used, the prevalence
of malaria infection among pregnant women was lower
and fewer babies were classified as premature16. Further
evidence came from a recent study in a highly malarial
areas of Keneya. During the first four pregnancies women
who were protected by ITNs at night gave birth to 25% fewer
premature or small - for gestational - age babies than women

who did not sleep under ITNs 15.
Intermittent Preventive Treatment (IPT)
For many years WHO recommended that pregnant women
in malaria endemic areas should receive an initial anti
malarial treatment on their first contact with antenatal
check up , followed by weekly chemoprophylaxis (given at
less than therapeutic dose) with an effective and safe anti
malarial drug 16,17. In 2000 the WHO expert committee on
malaria recommended the intermittent treatment with an
effective, preferably one dose anti malarial drug , should
be made available as a routine part of antenatal care to
women in the first and second pregnancies in highly endemic
areas18. At present sulfadoxine - pyrimethamine (SP) given
at therapeutic dose is the single dose anti malarial with
the best over all effectiveness for prevention of malaria in
pregnancy in areas with high transmission and low resistance
to SP. Other anti malarial are being evaluated for potential
use in IPT18.
Management of Malarial Illness
Appropriate management should be available to all women
with clinical cases of malaria. Diagnosis of malaria is
typically based on the presence or recent history of a fever
and whether the women lives in an area of stable or unstable
transmission. Parasitological diagnosis of malaria is ideal
if reliable light microscopy or rapid diagnostic tests are
available. If this is not possible, the decision about whether
to start treatment must be based on clinical picture (WHO
2006)19,20,21.
Management of malaria in pregnancy involves the three
aspects, these are -
I) Treatment of malaria
II) Management of complications
III) Management of labour.
1. Treatment of Malaria:
 Treatment should be initiated as early as possible.
 Assess severity - general condition, temperature, BP,
pulse, LFT, blood sugar, Hb%, S. creatinine, Serum
sodium, Serum potassium, Parasite count, urine out put
chart.
 Monitor maternal and fetal, vital parameters 2 hourly.
Malaria in pregnancy can cause sudden and dramatic
complications. There fore it is very much essential to look
for any complications by regular monitoring of the patients-
Medicine Update-2011 477
 Choose drugs according to severity of the disease /
Sensitivity Pattern of the parasities.
 Avoid over / under dosing of drugs.
 Avoid drugs that are contraindicated.
 Maintain adequate intake of calories.
 Avoid fluid over load / dehydration.
Anti malarials:
The recommended treatment in the first trimester of
pregnancy is quinine. Chloroquine can be considered in mild
form of the disease. According to current WHO guidelines
Artemisinin Combination Therapy (ACT) can be given in
second and third trimester of pregnancy. Quinine and
Chloroquine can use in all trimester of pregnancy. It does
not cause abortion in therapeutic dose. Uterine contraction
is related to pyrexia and parasitemia. Mefloquine was
used in some studies where its shows to be safe during
pregnancy19,20.
Contraindicated - D o x y c y c l i n e , Pr i m a q u i n e ,
Tetracycline, Halofantrine.
2. Management of complications:
Hypoglycemia - 25% - 50% Dextrose 50-100 ml i.v. followed
by 10% dextrose infusion can be considered. But fluid
overload to be assessed and monitoring is essential. Blood
sugar to be monitored every 4-6 hours in case of recurrent
hypoglycemia.
Anaemia - Packed cell should be transfused if haemoglobin
is < 7gm%.
Septicamic shock - Secondary bacterial infections is
common in pregnancy associated with malaria. 3rd
generation cephalosporine is useful in this situation.
ARDS - Monitoring of vital parameters, careful fluid
management, oxygen supply, diuretics and ventilatory
support if needed are essential according to patients clinical
and laboratory parameters.
Renal failure - Renal failure could be pre-renal due to
unrecognised dehydration, heavy parasitemia. Diuretics,
careful fluid management and dialysis is the main treatment
for this complication.
Exchange transfusion - Exchange transfusion is indicated
in case of severe parasitemia.
478 Medicine Update-2011
3. Management of labour :
Severe malaria carries a very high mortality. Maternal and
fetal distress may go unrecognized. Careful monitoring of
maternal and fetal parameters is extremely important.
Falciparum malaria induces uterine contractions, resulting
in premature labour. Uterine contractions appear to be
related to the height of the fever. Therefore all efforts
should be made to rapidly control the body temperature
by cold sponging, antipyretics like paracetamol. Careful
fluid management is also very important. If the situation
demands induction of labour may have to be considered.
Fetal or maternal distress may indicate the need to shorten
the second stage of labour. If need even caesarian section
must be considered 20,21.
P. Vivax in pregnancy
There are very few documented studies on P. vivax malaria in
pregnancy. It affects more in primigravida than multigravida.
Parasite densities may be associated with mild aneamia and
increased risk of low birth weight baby, abortion, still birth
or a reduction of the duration of pregnancy19,20,21. Recently it
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