Malaria in pregnancy lec

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MALARIA IN PREGNANCY

BY

Dr Swati SinghDept. Of Obs & Gyn

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Malaria Facts

• 300 million malaria cases each year worldwide

• 9 out of 10 cases occur in Africa

• An African dies of malaria every 10 seconds

• Affects 5 times as many as TB, AIDS, measles and leprosy combined

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Malaria and the Obstetric patient• Every minute

– About 12 Nigerian women become

pregnant (WHO)

• All are predisposed to dangers of Mal in Preg

– Asymptomatic / Undetected / Untreated * Agboghoroma (31%), Isah (3.1%)

• 11% of Maternal death is due to Malaria (NPC/UNICEF - Nigeria)

• There are also untoward effects on the unborn child

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Malaria is caused by one of 4 protozoan parasites:

Plasmodium falciparum

Plasmodium vivax

Plasmodium ovale

Plasmodium malariae

Malaria is transmitted through the bite of an infectedfemale Anopheles mosquito

MALARIA

5Source: http://encarta.msn.com/media_461541582/Life_Cycle_of_the_Malaria_Parasite.html Accessed on 31 March 2008Source: http://encarta.msn.com/media_461541582/Life_Cycle_of_the_Malaria_Parasite.html Accessed on 31 March 2008

ParasiteParasiteHostHost

Infected vectorInfected vector

Infecting vectorInfecting vector

Malaria Parasite Life Cycle

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Effects of Pregnancy on MalariaMore common.

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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Effects of Pregnancy on MalariaMore fatal

P. falciparum malaria in pregnancy is more severe, the mortality is also double (13 % ) compared to the non-pregnant population (6.5%).

Selective treatmentSome anti malarials are contra indicated

in pregnancy and therefore the treatment may become difficult, particularly in cases of severe P. falciparum malaria.

Other problemsManagement of complications of malaria

may be difficult due to the various physiological changes of pregnancy.

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Question

•What are the effects of malaria on the mother and unborn baby?

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EFFECTS OF MALARIA ON PREGNANCY [Species, Transmission pattern, Parity & Others]

Abortion – placental sequestration (pl sq)

Anemia

Cerebral malaria

Low birth weight (Prematurity, IUGR) – pl sq

Stillbirth

Congenital infection

Puerperal sepsis

Maternal Mortality

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Management of malaria in pregnancy involves three aspects that are of equal importance

1. Treatment of the malaria 2. Management of complications 3. Prevention of recurrence

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TREATMENT OF MALARIA IN PREGNANCY

• Depends on severity of the disease- Simple / Uncomplicated- Complicated

• Gestational age- First trimester- Second trimester - Third trimester

• Aims at bringing attack/pyrexia to an end.

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QUESTIONQUESTION

•How do you differentiate simple malaria from severe malaria in a pregnant woman?

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Recognizing malaria in pregnant women

Uncomplicated malaria

• Fever• Shivering/chills• Headaches• Muscle/joint pains• Nausea/vomiting (Can

tolerate per os)• False labor pains• + / ++

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Recognizing malaria in pregnant women

Complicated• Signs of

uncomplicated malaria, plus:

• Dizziness• Breathlessness• Sleepy/drowsy• Confusion/coma• Sometimes fits,

jaundice, severe dehydration

• ++ / +++

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Simple / Uncomplicated Malaria

1st trimester = Quinine ( safe and evidence-based)

2nd and 3rd trimesters

1st Line = Arthemeter/Lumefantrine(Coartem)2nd Line = Artesunate + Amodiquine

Artesunate + fansider

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Complicated MalariaAll trimesters!

Quinine Parenteral, then Orals Loading / maintenance Hypoglycaemia Absolutely safe!

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Supportive Treatment in Managementof Malaria in Pregnancy Adequate calories

Correction of electrolyte imbalance

Blood transfusion / EBT in acute and severe cases

Oxygen + Diuretics in pulmonary oedema

Anticonvulsants

ICU for CM

Dialysis for ARF

Monitoring of the fetal growth & health

Deceleration & death (Opare Addo)

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PREVENTION & CONTROL PROGRAMS

Available options are:

Vector control

Drug prophylaxis

Vaccination

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VECTOR CONTROL• Insecticide Treated Nets (ITNs)

- Promote growth and development of fetus and newborn

- Shulman et al(2000), Isah/Ekele’2006 (?enough)

• Residual house hold spraying

• Environmental management

- Cleanliness is next to Godliness

- Drainage and water flow control

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•All pregnant women should receive at least two doses of IPT after quickening at ANC visits (WHO recommends a schedule of four visits, three after quickening)

•Intermittent preventive treatment (IPT) given 3 times during pregnancy is effective for women with HIV/AIDS

•Presently, the most effective drug for IPT is sulfadoxine-pyrimethamine (SP) combination

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Conception

Birth20 3010

Weeks of gestation

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Fetal growth velocity

Quickening

Source: WHO 2002.

Last month

RxRx

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• A single dose is three tablets of sulfadoxine 500 mg + pyrimethamine 25 mg. (Daraprim, the ‘Sunday-Sunday tablet’ is no longer effective)

• Healthcare provider should dispense dose and directly observe client taking dose

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CANDIDATE VACCINEI. PRE- ERYTHROCYTIC VACCINE

(SPOROZOITE)

1. Irradiation Attenuated Sporozoite (IAS)

2. Circumsporozoite protein (CSP)

Escape of even a single sporozoite leads to

failure of anti-sporozoite vaccine

II. ASEXUAL BLOOD STAGE VACCINE

3. Merozoite specific antigen (MSA-1)

4. Erythrocyte binding antigen (EBA)

III INFECTED RED CELLSSchizont infected cell surface antigen (SICA)

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CANDIDATE VACCINE

IV TRNSMISSION-BLOCKING VACCINES1. Antigametocyte: Pfs 25; Pfs 230; Pfs 48/45

2. Antiookinete- Interferes with fertilization- Prevent maturation of gametocytes- Prevent mosquitoes from being infected- But no effect on those already infected- However even if infection occurs

transmission to another individual is prevented

- Hence: Reduce incidence of malaria & prevent transmission of resistant strains.

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CANDIDATE VACCINE

V. MULTIVALENT/MULTISTAGE VACCINE 1. SPf66

- Developed in Colombia- Made of synthetic peptide from 3 sexual

blood stage MSA- Highly immunogenic & probably

predominantly act by cellular mechanism - Clinical Trials:

Colombia (All age groups): 33.6% efficacyTanzania (Age 1-5 years): 31% efficacyGambia (Age 6-11 Months): 0%

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Conclusion

• Malaria during pregnancy has adverse

consequences for both mother and the baby

• Malaria preventive package includes:

– Intermittent preventive treatment with

SP during antenatal clinic visits

– Use of ITNs throughout pregnancy and in

the postpartum period

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Conclusion

• Prevention must be complemented by

effective case management of malaria for all

women of reproductive age

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THANK YOU!!!

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Thank you