dr jaideep malhotra talking on malaria in pregnancy at the MEDICAL DISORDERS WORKSHOP.....jam paccked halls at AICOG 2013 ................enjoy the presentation

1. JAIDEEP MALHOTRA
M.D., F.I.C.O.G., F.I.C.M.C.H.
• Secretary Elect ICOG
• Editor Journal SAFOMS
• Treasurer IMS (2011 -14)
• Executive member Asia Pacific Initiative in Reproductive endocrinology.
• Editor ICOG Evidence
• Sec UP Chapter ISAR
• VICE PRESIDENT FOGSI 2010
• Governing council member ISAR,ICOG ,IMS and IFUMB
• Chairperson International Academic Exchange Committee FOGSI 2004-2008
• Practicing I.V.F. specialist at Agra (Special Interest in Infertility, Laparoscopy, Ultrasound and Genetics)
• Member and Fellow of many Indian & International organization
• Indumati Zhaveri Award, Jagdeshwari Misra Award three times, Ethicon Fellowship, Outstanding Achievement Award
1999, Chorion Award
• Over 50 published and 100 presented papers
• Organised many workshops and travel seminars
• Co-editor of step by step series of books
• Co-editor of manual of operative Obs Gyn
• Editor of “Fetus Our Other Patient” and “Step by Step ART”
• Credited with producing firsts of U.P. : IVF birth, ICSI birth, IVF Twins, ICSI Twins, IVF Triplets,
TESA-ICSI Pregnancy etc.
• Credited for producing first Test Tube Baby of Nepal
• Awarded Corion Prize for best original research in “Improving endometrial receptivity and blood flows.”
• Technical Advisor to MAMC Delhi and SMS Medical college Jaipur ART Units
• Consultant IVF specialist at Ludhiana, Jalandhar, Ambala, Bhiwani, Gorakhpur, Gwalior, Allahabad ,Moga &
Kathmandu & Dhakka

2. Malaria and Pregnancy
Dr Jaideep Malhotra
Dr Narendra Malhotra

3. Malaria Menance
• World wide 107 countries with 2.5 billion people, developing
countries worst affected.
• 40 % of world’s population in shadow of Malaria.
• Of the 2.5 million reported cases in the South East Asia, India alone
contributes about 70% of the total cases.
• 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.

4. Malaria Life
Cycle Oocyst
Sporozoites
Mosquito Salivary
Zygote Gland
Gametocytes Liver stage
Plasmodium falciparum
Plasmodium vivax Red Blood Cell
Cycle
Plasmodium ovale
Plasmodium malariae

5. Why are Malaria and Pregnancy
mutually aggravating?
• 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.

6. Malaria in Pregnancy :
• More 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.

7. Malaria in Pregnancy :
• More fatal
– 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.

8. 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.

9. 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.

10. 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).

11. Placental Parasitemia by
Pregnancy Number
Parasite density/mm3
30
1-999 1000-9,999 >10,000
25
% parasitemic
20
15
10
5 772
402 479
0
First Pregnancies Second Pregnancies Three or more
pregnancies
Source: van Eijk AM et al 2001. Malaria During Pregnancy 11

12. 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.

13. 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
– anemia are more common in pregnancy.
– Jaundice, convulsions, altered sensorium, coma, vomiting
/ diarrhoea and other complications may be seen.

14. Effects on the Pregnant Woman
Primigravidae in All parities in
Effects Stable malaria Unstable malaria
areas areas
 High fever + +++
 Placental infection +++ +
 Puerperal sepsis ++ ++
 Complicated malaria
 Severe anemia +++ +++
 Cerebral malaria - ++
 Hypoglycemia - ++
 Pulmonary edema - ++
 Acute renal failure - ++
 Increased maternal mortality + ++
( +++ =Very Common, ++ =Common, + =Infrequent, -- =Rare)

15. 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.

16. Complications of Malaria in Pregnancy
Acute 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.

17. 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..

18. 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.

19. 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.

20. Complications of Malaria in Pregnancy
Immunosuppression
• 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.

21. Complications of Malaria in Pregnancy
Immunosuppression
• 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.

22. Cerebral malaria
Quite common
Diagnosis can be difficult
Coma scoring
Exclude other causes of coma
Needs Intensive care
1. ABC of coma care
2. Prompt institution of antimalarials
3. Treatment of hyperpyrexia
4. Management of other complications
5. Treatment of associated infections

23. Effects on the Fetus and Newborn
Primigravidae in All parities in
Effects Stable malaria Unstable malaria
areas areas
 Low birth weight
 IUGR +++ +
 Prematurity + ++
 Abortion - ++
 Stillbirth - ++
 Congenital malaria - +
 Fetal anemia ? +
 Infant mortality + ++
( +++=Very Common, ++=Common, +=Infrequent, -- =Rare)

24. 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.

25. Risks for the foetus
• The prenatal and neonatal mortality may vary from 15 to
70%.
– neonatal 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
– 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.

26. Frequency of Low Birth Weight by
Placental Malaria Infection
35
30
% Low Birth Weight
25
20
With placental
15 parasites
10 Without placental
parasites
5
0
First Second Three or more
Pregnancy Pregnancy pregnancies
Source: Steketee 2001.

27. Risks for the foetus
Congenital malaria
• It is very rare and occurs in < 5% of affected
pregnancies. Placental barrier and maternal 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.

28. Risks for the foetus
Congenital malaria
• All four species can cause 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.

29. Diagnosis
• High level of awareness
• Peripheral blood smear (Gold standard)
thick smear: rapid diagnosis
thin : species identification
• other advantages
- platelets, anaemia, toxic picture
If negative : repeat blood test 6 hourly for 6 times
• Antigen detection techniques : (PfHPR-2)
• Fluorescent staining
• PCR based assay
• Antibody test
• Placental blood smear

30. Why parasites are not detected at
times in peripheral smear ?
a. sequestration deep vascular bed
b. partially treated patients
c. prophylactic antimalarial Tt
d. inexperienced microscopist
e. poor quality staining

31. Antigen capture tests
* Pf-ICT test
* Parasight-F test/ Malacheck etc
Principle: dipstick antigen capture assay employs a monoclonal
antibody detecting the Pf.HRP-2 antigen in the blood
Rapid, simple, sensitive test
Species specificity
Antibody detection test
- RIA
- ELISA
antibodies persists for a long
time, so not helpful in
acute infection

32. PCR test
Sensitive can identify different species
Takes 48- 72 hours
Expensive
Available in selected places only
DNA Probes
QBC test
Spinning blood in a specialised capillary tubes in
which parasite DNA is stained with acridine orange.
Detected by ultraviolet microscope
Sensitive and specific (?) in Experienced hands

33. 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.

34. 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.
1. Treatment of malaria
2. Management of complications
3. Management of labour

35. 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.

36. 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.

37. 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.

38. 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

39. 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.
• Presently fixed dose combinations of
• Artesunate + amodiaquine
• Blister pack of artesunate +mefloquine

40. Treatment of Malaria in Pregnancy
Dose of Anti malarials
Artemisinin compounds(rapid Schizonticidal)
• Artesunate(Falcigo):
– 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.
• Artemether(Larither):
– Six amp (480mg) IM in 5 / 3 days. 1x2x1+1x1x4 OR 1x2x3.
– 80mg BD X3 days
• Arteether(Emal inj):
– One amp (150mg) IM / day for3 consecutive days.

41. Dose of Antimalarials
• 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.

42. NIMR guidelines 2010
• ACT should be given for treatment of P. falciparum
malaria in:
• second and third trimesters of pregnancy,
• while quinine is recommended in the first trimester.
• P. vivax malaria can be treated with chloroquine
• ACT containing mefloquine should be avoided in
cerebral malaria due to neuropsychiatric
complications.

43. General recommendations for the management of
uncomplicated malaria
• Avoid starting treatment on an empty stomach.
• The first dose should be given under observation.
• Dose should be repeated if vomiting occurs within
30 minutes.
• The patient should be asked to report back, if there
is no improvement after 48 hours or if the situation
deteriorates.
• The patient should also be examined for
concomitant illnesses.

44. SEVERE MALARIA
• Impaired consciousness/coma
• Repeated generalized convulsions
• Renal failure (Serum Creatinine >3 mg/dl)
• Jaundice (Serum Bilirubin >3 mg/dl)
• Severe anaemia (Hb <5 g/dl)
• Pulmonary oedema/acute respiratory distress syndrome
• Hypoglycaemia (Plasma Glucose <40 mg/dl)
• Metabolic acidosis
• Circulatory collapse/shock (Systolic BP <80 mm Hg, <50 mmHg in children)
• Abnormal bleeding and Disseminated intravascular coagulation(DIC)
• Haemoglobinuria
• Hyperpyrexia (Temperature >106o F or >42o C)
• Hyperparasitaemia (>5% parasitized RBCs )

45. 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.

46. 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.
– It is especially useful in cases of very high parasitemia (helps in
clearing) and impending pulmonary oedema (helps to reduce fluid
load).

47. 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.

48. 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.

49. 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.

50. 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.

51. TREATMENT OF MIXED PLASMODIUM INFECTIONS
• In patients with confirmed or suspected mixed infections i.e. P. falciparum
with either P. vivax or P. ovale, the standard therapy for uncomplicated or
severe P. falciparum malaria (either quinine or artemether-lumefantrine) plus
a follow-up course of primaquine is recommended.
• A mixed infection of P. falciparum and P. malariae should be
managed as for P. falciparum malaria. The severity of the P. falciparum
infection should dictate choice of initial therapy. Doubt frequently exists
about the presence of P. falciparum in addition to other Plasmodium species.
• The patient should then be treated for P. falciparum, as this is the species
most frequently associated with severe infections and complications.

52. COMMON ERRORS IN MANAGEMENT OF
SEVERE MALARIA
1. Failure to diagnose associated complications such as bacterial
infections, eclampsia, Gram negative septicemia etc
2. Missed hypoglycaemia
3. Misjudgement of severity
4. Errors of fluid and electrolytic replacement
5. Errors in anti-malarial chemotherapy
6. Delay in starting treatment
Unjustified withholding of antimalarial drug for the fear of
toxicity e.g. Quinine in pregnant women, in hypoglycaemia
-Inadequate dosage administration
-Failure to control the rate of IV infusion
7. Delay in considering obstetrics intervention pregnant women
suffering from malaria
8. Missed / late diagnosis of ARDS, acute pulmonary oedema
9. Use of inappropriate ancillary therapies e.g. steroids
10. Delay in starting dialysis

53. Components of
Malaria Control During Pregnancy
1.Quality focused antenatal care and health
education
2.Intermittent preventive treatment (IPT)
3.Use of insecticide-treated nets (ITNs)
4.Case management of malaria disease

54. Health Education on Malaria During
Pregnancy: What To Tell Patients
• Pregnant women (especially primigravida,
secundigravida and HIV-infected women) are at higher
risk of malaria
• Malaria:
– Is transmitted through mosquito bites
– Can cause severe anemia, with adverse consequences for
mother and baby
– Can cause abortions, stillbirths and result in low birth
weight newborns
– Can be prevented through the use of IPT and ITNs during
pregnancy
– Can be easily treated if recognized early but complicated
malaria requires specialized treatment

56. Use of Insecticide-Treated Nets
(ITNs)
ITNs:
• Have been shown to result in reduction of
newborns born with low birth weight or
prematurely
• Reduce transmission by physically preventing
vector mosquitoes from landing on sleeping
persons
• Repel and kill mosquitoes that come in contact
with the net
• Kill other insects like cockroaches, lice, ticks and
bed bugs
• Should be used by pregnant women as early
during pregnancy as possible and use should be
encouraged throughout pregnancy and in the
postpartum period

57. Impact of ITNs on
Maternal and Newborn Health
Among Gravidae 1-4, ITNs were associated with:
• During pregnancy
– 38% reduction in peripheral parasitemia
– 21% reduction in all causes of anemia (Hb < 11 g/dl)
– 47% reduction in severe malarial anemia
• At delivery
– 23% reduction in placental malaria
– 28% reduction in LBW
– 25% reduction in any adverse birth outcome
• No trend towards decreasing efficacy with increasing
transmission rate
Source: Shulman 2001.
58

58. Intermittent Preventive Treatment
(IPT)
• An approach for effectively preventing and controlling malaria
during pregnancy
• Based on an assumption that every pregnant woman in a
malaria-endemic area is infected with malaria
• Recommends that every pregnant women receive at least
two treatment doses of an effective antimalarial drug
• Sulfadoxine-pyrimethamine (SP) currently considered the
most effective drug for IPT

59. 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.

60. Fetal Growth Velocity
Fetal growth velocity 
Last
month
10 16 20 30
Conception Weeks of gestation Birth
Source: WHO 2002.
61 Malaria During Pregnancy

61. Fetal Growth Velocity
Fetal growth velocity 
Quickening Last
month
10 16 20 30
Conception Weeks of gestation Birth
Source: WHO 2002.
62 Malaria During Pregnancy

62. Rationale for the Timing
of the Doses
Fetal growth velocity 
Rx Rx
Quickening Last
month
10 16 20 30
Conception Weeks of gestation Birth
Source: WHO 2002.
63 Malaria During Pregnancy

63. Key Issues About Timing of Doses
• SP should be avoided during the
first 16 weeks of pregnancy which
is the period of initial development
of the fetus
• It is best to clear the placenta of
parasites during the period of
maximum fetal growth
• IPT allows the mother to recover
from anemia by clearing peripheral
parasitaemia
64

64. 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.

65. Effect of Intermittent Preventive
Treatment with SP
Case Two-dose Monthly
management SP SP p
N=472 N=432 N=431
Mean Hb. 9.9 10.2 10.4 < 0.05
Maternal
27% 9% 7% 0.004
parasitemia
Placental
27% 12% 9% < 0.001
parasitemia
LBW 14% 8% 8% 0.01
Source: Steketee 2001.

66. Case Management: Drug Efficacy
• Effective drugs are needed for P. falciparum
malaria as it can be fatal to both mother and child
• Drug of choice depends on the geographic drug
resistance profile:
– Chloroquine is the drug of choice in few areas where it
is still effective
– SP often next choice
– Quinine is the drug of choice for complicated malaria

67. Resistance to Drugs
• Resistance of P. falciparum to antimalarial drugs is an ever
increasing problem
• To minimize the problem of drug resistance, encourage women to
complete their course of antimalarial drugs, even when they feel
better
• Drug resistance is inevitable;
• WHO recommends these combinations,incase of drug resistance.
• Artemether–lumefantrine,
• Artesunate– amodiaquine,
• Artesunate–mefloquine,
• Artesunate–sulfadoxine–pyrimethamine, area dependent
• Dihydroartemisinin–piperaquine.

68. Drugs That Should Not Be Used
During Pregnancy
• Tetracycline
– Cause abnormalities of skeletal and muscular growth, tooth
development, lens/cornea
• Doxycycline
– Risk of cosmetic staining of primary teeth is undetermined
– Excreted into breast milk
• Primaquine
– Harmful to newborns who are relatively Glucose-6-
Phosphatase-Dehydrogenase (G6PD) deficient
• Halofantrine
– No conclusive studies in pregnant women
– Has been shown to cause unwanted effects, including
death of the fetus, in animals

69. Conclusions
• Widely prevalent 36% population exposed
• Preventing mosquito bite
• Chemoprophylaxis
• Drug resistance is a problem.
• Energetic anticipatory management
• Maternal and neonatal morbidity and
mortality high.