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Gatoet Ismanoe

Division of Tropical Infectious


Diseases Department of
Medicine Brawijaya Medical
Faculty
Saiful Anwar General Hospital

Introduction (1)

Malaria is an infectious disease


caused by protozoan organisms of the
genus plasmodium (falciparum, ovale,
vivax, malariae)
It is characterized by high fever and
erythrocyte infection resulting anemia
In pregnant woman it causes a
placental infection that impacts the
fetus development

Introduction (2)

300 million cases each year world


wide
Malaria is more frequent and
complicated during pregnancy may
account for :
Up to 15% of maternal anemia
5-14% of low birth weight
30% of preventable low birth weight
3-8 % of infant death

Malaria endemic countries divided into 4


regions

In Africa , 95-100% caused by P.Falciparum.


America ,Middle East P.Vivax
Asia and Pacific Mixed Infection

EPIDEMIOLOGY OF MALARIA
35 countries in the
world reponsible for
98 %
of total malaria deaths

30 in Africa:
Nigeria,DRC,Uganda,Ethiopia,Tanzani
a,KenyaSudan.aniger,Burkinofaso,Gha
na,Mali,Cameroon,Angola,CotedIvoire
,Mozambique,Chand,Guinea
,Zambia,Malawi,Benin,Senegal,Sierra
Leone,Burundi,Togo,Liberia,Rwanda,C
ongo,Central African
Republic,Somalia,Guinea Bissau.

5 in Asia- Pacific:
India,Myanmar,Bangladesh,Indonesia,Pap
ua New Guinea

Africa-highest
mortality

Asia Pacific Mutilple


Resistance to Drugs

Malaria cases in Asia


-Pacific

India accounts for 45% of cases


P.Vivax & P.falciparum present
Indoot and out door vectors

Population Most Affected by


Malaria

Children under 5 years of age


Pregnant woman
Unborn babies
Immigrants from low-transmission
areas
HIV-infected persons

Malaria and Pregnancy


Related to level of transmission and immunity of
individual exposed

In areas of high transmission, endemic or stable


malaria area.
In areas of low transmission or non-endemic or
unstable areas

Effects of Malaria on
Pregnant Women

All pregnant women in malariaendemic areas are at risk


Parasites attack and destroy red blood
cells
Malaria causes up to 15% of anemia in
pregnancy
Can cause severe anemia
In Africa, anemia due to malaria causes
up to 10,000 maternal deaths per year

Maternal complications
In Endemic Areas
Malaria-related
anaemia
Febrile illness
Placental
sequestration

In Non-Endemic Areas
Greater risk of severe
disease
Higher risk of death
Anaemia,
hypoglycemia,
pulmonary oedema,
renal failure

Effects on Unborn Babies

Parasites hide in placenta


Interferes with transfer of oxygen
and nutrients to the baby,
increasing risk of:
Spontaneous abortion
Preterm birth
Low birthweightsingle greatest risk

factor for death during first month of life


Stillbirth

Fetal complications
In endemic areas
Low birth weight
Intra-uterine growth
retardation

In non-endemic areas
Abortions
Preterm delivery
Congenital malaria
Low birth weight

Effects on Communities

Causes missed work and wages


Results in frequent school absences
Uses scarce resources
Causes preventable deaths:
increases maternal, newborn, and
infant mortality rates

Recent findings pregnant women

Pregnancy phase of immunosuppression


P. falciparum affinity to
placenta
Immune responses specific
to placenta physiology
Primigravidae
Secundigravidae
Multigravidae

Recent findings pregnant women

P.falciparum
falciparum malaria
malaria
P.
Placental infection
infection
Placental
Lowbirth
birth weight
weight
Low
Maternal
Maternal
anemia
anemia

Riskof
of infant
infant mortality
mortality
Risk

STABLE TRANSMISSION
Acquired Immunity-high

Asymptomatic infection

Placenta sequestration
Altered placental Integrity

Less nutrient transport


Anemia

Maternal
Morbidity

Low Birth Weight

Higher infant
Mortality
WHO 2004

UNSTABLE TRANSMISSION
Acquired Immunity low or
none
Clinical Illness
Severe Disease

Risk to Mother

All pregnancies are at risk


Key intervention
strategies : disease
recognition and case
management

Risk to Fetus

WHO 2004

Management and Preventive


Strategies

Early diagnosis, effective treatment, manage


collateral effects
Use of chemo-prophylaxis or intermittent
preventive treatment (IPT)
Use of insecticide-treated bed nets
Regular antenatal care and health education
about malaria

Intermittent Preventive
Treatment
1.

Based on the assumption that every


pregnant woman living in an area of high
malaria transmission has malaria
parasites in her blood or placenta,
whether or not she has symptoms of
malaria
Although a pregnant woman with
malaria may have no symptoms, malaria
can still affect her and her unborn child

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

Chloroquine: - 300mg base,


administered once every week.
Pyrimethamine-25mg + Sulphadoxine500mg: - 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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Intermittent Preventive
Treatment: WHO
Recommendation
All pregnant women should receive at least
two doses of IPT after quickening, during
routinely scheduled ANC visits (WHO
recommends a schedule of four visits, three
after quickening)
Presently, the most effective drug for IPT is
sulfadoxine-pyrimethamine (SP)
Women should receive at least two doses of
IPT with SP at ANC visits after quickening,
but no more frequently than monthly

IPTp can be given during regularly scheduled antenatal


care visits

Intermittent Preventive
Treatment: Dose and Timing

A single dose is three tablets of


sulfadoxine 500 mg +
pyrimethamine 25 mg
Healthcare provider should
dispense dose and directly observe
client taking dose

Instructions for Giving


Intermittent Preventive
Treatment
Ensure woman is at least 16 weeks

pregnant and that quickening has


occurred
Inquire about use of SP in last 4 weeks
Inquire about allergies to SP or other
sulfa drugs (especially severe rashes)
Explain what you will do; address the
womans questions
Provide cup and clean water

Instructions for Giving


Intermittent Preventive
Treatment
(contd.)
Directly observe
woman swallow three

tablets of SP
Record SP dose on ANC and clinic card
Advise the woman when to return:
For her next scheduled visit
If she has signs of malaria
If she has other danger signs

Reinforce the importance of using ITNs

Intermittent Preventive
Treatment: Contraindications to
Using
SP
Do NOT
give during first trimester: Be sure

quickening has occurred and woman is at least


16 weeks pregnant
Do NOT give to women with reported allergy to
SP or other sulfa drugs: Ask about sulfa drug
allergies before giving SP
Do NOT give to women taking co-trimoxazole, or
other sulfa-containing drugs: Ask about use of
these medicines before giving SP
Do not give SP more frequently than monthly: Be
sure at least 1 month has passed since the last
dose of SP

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 Falciparum Malaria in


pregnancy without complications

1st trimester
Quinine + Clindamycine
Failure :
- Quinine + Clindamycine
- ACT
- Artesunate + Clindamycine
2nd / 3rd trimester
ACT
Artesunate + Clindamycine
Failure :
Artesunate + Clindamycine
Quinine + Clindamycine

Treatment of Severe
Falciparum Malaria in
Initial : Artesunate
Pregnancy
2,4 mg/kg BW hour 0,12,24-every 24hour

Followed : Artesunate + Clindamycine


Alternative
Initial : Quinine

20mg/kgBW loading dose 4-hour


10mg/kgBW/8-hour
Followed : Quinine + Clindamycine

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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Treatment of Vivax Malaria


in Pregnancy
Radical
Use of Primaquine & Proguanil are
cure

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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Conclusion

Malaria is more common in pregnancy


compared to the general population probably
due to immuno supression and loss of acquired
immunity to malaria
Intermittent preventive treatment of pregnant
women has a benefecial impact on maternal
and infant health
Choice of antimalarials in pregnancy especially
falciparum malaria : all trimesters first line :
chloroquine, quinine. Second line : artesunate /
artemether / arteether. 2nd / 3rd trimester :
pyrimetamine + sulphadoxine, mefloquine.