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Malaria in

Pregnancy

Prof.Surendra Nath Panda, M.S.


Department of Obstetrics & Gynaecology
M.K.C.G.MEDICAL COLLEGE
BERHAMPUR, ORISSA, INDIA
Malaria Menance
 World wide 103 countries with 2.5 billion people,
developing countries worst affected.
 40 % of world’s population in shadow of Malaria.
 Deaths- Under estimated/Unknown,1.1 to 2.7
million per year
 Gender related mortality - Females more
 Malaria in Pregnancy: -
 Mutually aggravating
 Mortality is double

 Primigravidae - 60-70%

 Highest prevalence in second half.

 Plasmodium Falciparum – More common.

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Malaria in Pregnancy :
Sinister
Coincidence
 Malaria and pregnancy are mutually aggravating conditions.
 The physiological changes of pregnancy and the
pathological changes due to malaria have a synergistic
effect on the course of each other, thus making life difficult
for the mother, the child and the treating physician.
 P. falciparum malaria can run a turbulent and dramatic
course in pregnant women.
 The non- immune, primigravidae are usually the most
affected.
 In areas where malaria is endemic, 20-40% of all babies
born may have a low birth weight.

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Malaria in Pregnancy :
Double
 More common. Trouble
 Malaria is more common in pregnancy compared to the
general population probably due to Immuno suppression
and loss of acquired immunity to malaria.
 More atypical.
 In pregnancy, malaria tends to be more atypical in
presentation probably due to the hormonal ,
immunological and haematological changes of
pregnancy.
 More severe.
 Probably for the same reason, the parasitemia tends to
be 10 times higher and as a result, all the complications
of falciparum malaria are more common in pregnancy
compared to the non-pregnant population.
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Malaria in Pregnancy :
Double
 More fatal Trouble
 P. falciparum malaria in pregnancy being more severe, the mortality
is also double (13 % ) compared to the non-pregnant population
(6.5%).
 Selective treatment
 Some anti malarials are contra indicated in pregnancy and some
may cause severe adverse effects.
 Therefore the treatment may become difficult, particularly in cases
of severe P. falciparum malaria.
 Other problems
 Management of complications of malaria may be difficult due to the
various physiological changes of pregnancy.
 Careful attention has to be paid towards fluid management,
temperature control, etc.
 Decisions regarding induction of labour may be difficult and
complex.
 Foetal loss, IUGR, and premature labour are common.

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Pathology of Malaria in
Pregnancy
 P. falciparum malaria can run a very turbulent
course in pregnancy, particularly the first and
second pregnancies.
 These complications are more common and
severe in hyperendemic areas for falciparum
malaria.
 Physiologic changes of pregnancy contribute to the
aggravation of malarial infection.
 Changes in the hormonal milieu,
 Increase in the body fluid volume,

 Decrease in haemoglobin level and other changes add


to the severity.

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Pathology of Malaria in
Pregnancy
 There is a generalised immunosuppression in
pregnancy with reduction in gamma globulin
synthesis and inhibition of reticulo endothelial
system, resulting in
 Decrease in the levels of anti malarial antibodies and
loss of acquired immunity to malaria.
 This makes the pregnant woman more prone for malarial

infection and the parasitemia tends to be much higher.

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Changes in Placenta
 Placenta is the preferred site of sequestration and
development of malarial parasite.
 Intervillous spaces are filled with parasites and
macrophages, interfering with oxygen and nutrient
transport to the foetus.
 Villous hypertrophy and fibrinoid necrosis of villi
(complete or partial) have been observed.
 All the placental tissues exhibit malarial pigments
(with or even without parasites).

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Clinical features
Atypical manifestations of malaria are more common in
pregnancy, particularly in the 2nd half of pregnancy.
 Fever :
 Patient may have different patterns of fever - from afebrile to
continuous fever, low grade to hyper pyrexia.
 In 2nd half of pregnancy, there may be more frequent paroxysms
due to Immunosuppression.
 Anemia :
 In developing countries, where malaria is most common, anemia is
a common feature of pregnancy.
 Malnutrition and helminthiasis are the commonest causes of
anemia.
 In such a situation, malaria will compound the problem.
 Anemia may even be the presenting feature of malaria and
therefore all cases of anemia should be tested for M.P.
 Anemia as a presenting feature is more common in partially
immune multigravidae living in hyper endemic areas.

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Clinical features
Atypical manifestations of malaria are more common in
pregnancy, particularly in the 2nd half of pregnancy.
 Splenomegaly :
 Enlargement of the spleen may be variable. It may be absent or
small in 2nd half of pregnancy.
 A pre-existing enlarged spleen may regress in size in pregnancy.
 Complications :
 Complications tend to be more common and more severe in
pregnancy.
 A patient may present with complications of malaria or they may
develop suddenly.
 Acute pulmonary edema, hypoglycemia and anemia are more
common in pregnancy.
 Jaundice, convulsions, altered sensorium, coma, vomiting /
diarrhoea and other complications may be seen.
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Complications of Malaria in
Pregnancy
Anemia:
 Malaria can cause or aggravate anaemia due to:
 Hemolysis of parasitised red blood cells.
 Increased demands of pregnancy.

 Profound hemolysis can aggravate folate deficiency.

 Anemia due to malaria is more common and


severe between 16-29 weeks.
 It can develop suddenly, in case of severe malaria
with high grades of parasitemia.
 Pre existing iron and folate deficiency can exacerbate the
anemia of malaria and vice versa.

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Complications of Malaria in
Pregnancy
Anemia:
 Anaemia increases perinatal mortality and
maternal morbidity and mortality.
 It also increases the risk of pulmonary oedema.
Risk of post-partum haemorrhage is also higher.
 Significant anemia (Haemoglobin < 7-8 g%) may
have to be treated with blood transfusion.
 In view of the increased fluid volume in pregnancy,
it is better to transfuse packed cells than whole
blood.
 Rapid transfusion, particularly whole blood, may
cause pulmonary oedema.

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Complications of Malaria in
Pregnancy
cute pulmonary oedema:
 Acute pulmonary oedema is also a more common
complication of malaria in pregnancy compared to the non-
pregnant population.
 It may be the presenting feature or can develop suddenly
after several days. It is more common in 2nd and 3rd
trimesters.
 It can develop suddenly in immediate post-partum period.
This is due to
 Auto transfusion of placental blood with high proportion of
parasitised RBC’s
 Sudden increase in peripheral vascular resistance after delivery.
 It is aggravated by pre existing anaemia and hemodynamic
changes of pregnancy.
 Acute pulmonary oedema carries a very high mortality.
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Complications of Malaria in
Pregnancy
Hypoglycaemia:
 This is another complication of malaria that is
peculiarly more common in pregnancy.
 The following factors contribute to hypoglycemia:
 Increased demands of hypercatabolic state and infecting
parasites.
 Hypoglycaemic response to starvation.
 Increased response of pancreatic islets to secretory
stimuli (like quinine) leads to hyperinsulinemia and
hypoglycemia..

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Complications of Malaria in
Pregnancy
Hypoglycaemia:
 Hypoglycaemia in these patients can remain
asymptomatic and may not be detected, because:
 all the symptoms of hypoglycemia are also caused by
malaria viz. tachycardia, sweating, giddiness etc.
 Some patients may have abnormal behaviour,
convulsions, altered sensorium, sudden loss of
consciousness etc.
 These symptoms of hypoglycemia may be easily
confused with cerebral malaria.
 Therefore, in all pregnant women with falciparum
malaria, particularly those receiving quinine, blood sugar
should be monitored every 4-6 hours.

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Complications of Malaria in
Pregnancy
Hypoglycaemia:

Hypoglycaemia can be recurrent and


therefore constant monitoring is needed.
In some, it can be associated with lactic
acidosis and in such cases mortality is very
high.
Maternal hypoglycemia can cause foetal
distress without any signs.

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Complications of Malaria in
Pregnancy
mmunosuppression:
 Immunosuppression in pregnancy poses special
problems.
 It makes malaria more common and more severe.
And to add to the woes, malaria itself suppresses
immune response.
 Hormonal changes of pregnancy, reduced
synthesis of immunoglobulins, reduced function of
reticulo endothelial system are the causes for
Immunosuppression in pregnancy.

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Complications of Malaria in
Pregnancy
mmunosuppression:
 This results in loss of acquired immunity to
malaria, making the pregnant more prone for
malaria.
 Malaria becomes more severe with higher
parasitemia.
 Patient may have more frequent paroxysms of
fever and frequent relapses.
 Secondary infections (U.T.I. and pneumonias) and
algid malaria (septicaemic shock) are more
common in pregnancy due to Immunosuppression.

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Risks for the foetus
 Malaria in pregnancy is detrimental to the foetus
due to: -
 high grades of fever,
 placental insufficiency,

 hypoglycaemia,

 anaemia and other complications.

 Both P. vivax and P. falciparum malaria can pose


problems for the foetus, with the latter being more
serious.

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Risks for the foetus
 The prenatal and neonatal mortality may vary from
15 to 70%.
 In one study, mortality due to P. vivax malaria during
pregnancy was 15.7% while that due to P. falciparum
was 33%.
 Spontaneous abortion, pre mature birth, still birth,

placental insufficiency and I.U.G.R. (temporary /


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.

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Risks for the foetus Congenital
 It is very rare and occurs inmalaria:
< 5% of affected
pregnancies. Placental barrier and matenal Ig G
antibodies which cross the placenta may protect
the foetus to some extent.
 However, it is much more common in non-immune
population and the incidence goes up during
epidemics of malaria.
 Fetal plasma Quinine and Chloroquine levels are
about one third of simultaneous maternal levels
and this subtherapeutic drug level does not cure
the infection in the foetus.
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Risks for the foetus Congenital
 All four species can cause malaria:
congenital malaria, but
it is proportionately more with P. malariae.
 The new born child can manifest with fever,
irritability, feeding problems, hepato splenomegaly,
anaemia, jaundice etc.
 The diagnosis can be confirmed by a smear for
M.P. from cord blood or heel prick, anytime within
a week after birth (or even later if post-partum,
mosquito-borne infection is not likely).
 Differential diagnoses include Rh. incompatibility,
infections with C.M.V., Herpes, Rubella,
Toxoplasmosis, and syphilis.
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Diagnosis
 High level of awareness
 Peripheral blood smear

 Antigen detection techniques : (PfHPR-2)


 Fluorescent staining
 PCR based assay
 Antibody test
 Placental blood smear
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Indicators of Poor Prognosis
 Hyper parasitemia: - >5% erythrocytes infested.
 Peripheral schizotaemia.
 Leucocytosis >12,000/ cmm.
 Hb< 7.1 gm%.
 PCV <20 %.
 Blood urea >60 mg / dL
 Creatinine >3 mg / dL.,
 Blood glucose <40 mg / dL.
 High lactate and low sugar in CSF.
 Low antithrombin III level.
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Management of Malaria in
Pregnancy
 Management of malaria in pregnancy
involves the following three aspects and
equal importance should be attached to
all the three.
 Treatment of malaria
 Management of complications
 Management of labour

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Treatment of Malaria in
Pregnancy
Should Be Energetic, Anticipatory and Careful.
Energetic:
 Don't waste any time.
 It is better to admit all cases of P.
falciparum malaria.
 Assess severity-
 General condition, pallor, jaundice, B.P.,
temperature, haemoglobin, Parasite count,
S.G.P.T., S .bilirubin, S.creatinine, Blood sugar.

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Treatment of Malaria in
Pregnancy
Should Be Energetic, Anticipatory and Careful.
Anticipatory:
 Malaria in pregnancy can cause sudden and
dramatic complications. Therefore, one should
always be looking for any complications by regular
monitoring.
 Monitor maternal and foetal vital parameters 2
hourly.
 R.B.S. 4-6 hourly; haemoglobin and parasite
count 12 hourly; S. creatinine; S. bilirubin and
Intake / Output chart daily.

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Treatment of Malaria in
Pregnancy
Should Be Energetic, Anticipatory and Careful.
Careful:
 The physiologic changes of pregnancy pose special
problems in management of malaria.
 In addition, certain drugs are contra indicated in pregnancy
or may cause more severe adverse effects. All these
factors should be taken into consideration while treating
these patients.
 Choose drugs according to severity of the disease/
sensitivity pattern in the locality.
 Avoid drugs that are contra indicated
 Avoid over / under dosing of drugs
 Avoid fluid overload / dehydration
 Maintain adequate intake of calories.
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Treatment of Malaria in
Pregnancy
Choice of Anti malarials in pregnancy

 All trimesters:
First line - Chloroquine; Quinine;
Second line - Artesunate / Artemether / Arteether
 2nd / 3rd trimester: with caution
Pyrimethamine + sulphadoxine; Mefloquine
 Contra indicated:
Primaquine; Tetracycline; Doxycycline; Halofantrine

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Treatment of Malaria in
Pregnancy
Dose of Anti malarials

 Chloroquine:
 600mg (base) start, 300mg after 6 hours, 24 hours & 48 hours
 Quinine:
 IV - 20mg/kg infusion over 4 hours, repeat 8 hourly. Maintenance:
10mg over 4 hours, 8 hourly. Follow with oral medication after
clinically stable.
 Oral – 600mg 8hourly ( maximum 2 gm / day) for 7 days.
 Artesunate:
 Oral-100mg BD on day 1, then 50mg BD for 4-6 days (Total dose
10mg/kg).
 IM / IV-120mg on Day 1 followed by 60mg daily for 4 days. In
severe cases an additional dose of 60mg after 6 hours on Day 1.

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Treatment of Malaria in
Pregnancy
Dose of Anti malarials

 Artemether:
 Six amp (480mg) IM in 5 / 3 days. 1x2x1+1x1x4 OR 1x2x3.
 Arteether:
 One amp (150mg) IM / day for3 consecutive days.
 Pyrimethamine 25mg+sulphadoxine 500mg tablets:
 Three tablets single dose.
 Mefloquine:
 15mg / kg body wt., up to 1 Gm in a single dose. OR
 Tablets of 250mg, 3 tab start, then 2 tab after 6-8 hours. With body
wt >60kg, a third dose of 1 tab after 6-8 hours.

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Management of complications
 Acute Pulmonary Oedema:
 Careful fluid management; back rest; oxygen; diuretics; ventilation if
needed.
 Hypoglycaemia:
 25-50% Dextrose, 50-100 ml I.V., followed by 10% dextrose
continuous infusion.
 If fluid overload is a problem, then Inj. Glucagon 0.5-1 mg can be
given intra muscularly.
 Blood sugar should be monitored every 4-6 hours for recurrent
hypoglycemia.
 Anemia:
 Packed cells should be transfused if haemoglobin is <5 g%.
 Renal failure:
 Renal failure could be pre-renal due to unrecognised dehydration or
renal due to severe parasitemia.
 Treatment involves careful fluid management, diuretics, and dialysis
if needed.

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Management of complications
 Septicaemic shock:
 Secondary bacterial infections like urinary tract infection, pneumonia
etc. are more common in pregnancy associated with malaria.
 Some of these patients may develop septicaemic shock, the so
called '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 falciparum
malaria to reduce the parasite load. Patient’s blood is removed and
it is replaced with packed cells.
 It is especially useful in cases of very high parasitemia (helps in
clearing) and impending pulmonary oedema (helps to reduce fluid
load).
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Management of Labour
 Anaemia, hypoglycaemia, pulmonary oedema, and
secondary infections due to malaria in pregnancy
lead to problems for both the mother and the
foetus.
 Severe falciparum malaria in term pregnancy
carries a very high mortality.
 Maternal and foetal distress may go unrecognised
in these patients.
 Therefore, careful monitoring of maternal and
foetal parameters is extremely important.
 Pregnant women with severe malaria are better
managed in an intensive care unit.
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Management of Labour
 Falciparum malaria induces uterine contractions,
resulting in premature labour. The frequency and
intensity of contractions appear to be related to the
height of the fever.
 Fetal distress is common and often unrecognised.
Therefore only monitoring of uterine contractions
and fetal heart rate may reveal asymptomatic
labour and foetal distress.
 All efforts should be made to rapidly bring the
temperature under control,
 By tepid sponging (cold sponging causes cutaneous
vasoconstriction and can result in core hyperpyrexia).
 Anti pyretics like paracetamol etc.

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Management of Labour
 Careful fluid management is also very important.
Dehydration as well as fluid overload should be avoided,
because both could be detrimental to the mother and/or the
foetus.
 In cases of very high parasitemia, exchange transfusion
may have to be carried out.
 If the situation demands, induction of labour may have to be
considered.
 Once the patient is in labour, foetal or matenal distress may
indicate the need to shorten the 2nd stage by forceps or
vacuum extraction.
 If needed, even caesarean section must be considered.

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Treatment of Vivax Malaria in
Pregnancy
Radical
cure
 Use of Primaquine & Proguanil are not safe in pregnancy
and also in lactating mothers.
 Therefore to prevent the relapse of vivax malaria,
suppressive chemoprophylaxis with Chloroquine is
recommended.
 Tablet Chloroquine 300 mg (base) weekly should be
administered to all such patients until stoppage of lactation.
 At that point, a complete treatment with full therapeutic
dose of Chloroquine and Primaquine (7.5mg b.I.d. or 15mg
daily, for 14 days) should be administered.
 However in case of resistance, Primaquine or Proguanil
may be given with caution in 2nd half of pregnancy.
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Chemoprophylaxis in Pregnancy
 Malaria being potentially fatal to both the mother and the
foetus, this should be an important part of antenatal care in
areas of high transmission.
 All pregnant women, who remain in the malarious area during their
pregnancy, should be protected with chemoprophylaxis.
 Choice of anti malarials for chemo prophylaxis:
 Chloroquine being the safest drug in pregnancy, should be the first
choice.
 However, its use may be restricted due to the wide spread
resistance to this drug.
 In areas with known resistance to Chloroquine
 Pyrimethamine + Sulpha, Mefloquine or Proguanil can be used.
 But these drugs should be started only after 1st trimester only.

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Chemoprophylaxis in Pregnancy
DOSAGE –

 Chloroquine: - 300mg base, administered once


every week.
 Pyrimethamine-25mg + Sulphadoxine-500mg: -
One tablet once weekly.
 Mefloquine: -250mg weekly.
 Dose may have to be increased in the last trimester, in
view of the accelerated clearance of the drug.
 Proguanil: - 150-200mg / day.

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FOR A HEALTHY MOTHER
AND A HEALTHY BABY

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