Download Malaria in Pregnancy

Prevention and Control of
Malaria during Pregnancy
Dr.M.Davarpanah
Facts about Malaria
 300 million cases each year worldwide
 9 of 10 cases occur in Africa
 A person in Africa dies of malaria every 10 seconds
 Women and young children are most at risk
 Affects five times as many people as AIDS, leprosy,
measles, and tuberculosis combined
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Populations Most Affected by Malaria
 Children under 5 years of age
 Pregnant women
 Unborn babies
 Immigrants from low-transmission areas
 HIV-infected persons
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Effects of Malaria on Pregnant
Women
 All pregnant women in malaria-endemic areas are at
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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
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Malaria in pregnant women
 >50 million pregnant women exposed to malaria
each year
 ~3.5 million pregnant women infected
Poor birth outcomes
Poor maternal outcomes
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Placental malaria
 Parasites accumulate and
thrive in the placenta
 Only affects
primigravidae in areas of
high transmission
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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 birthweight—single greatest risk factor for death
during first month of life
 Stillbirth
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Pathologenesis of malaria in
pregnancy
 During normal pregnancy, the cellular immune response
(Th1) is suppressed to prevent fetal rejection
 Malaria stimulates the Th1 response  intrauterine growth
retardation
 Malaria stimulates expression of an HIV co-receptor (CCR5) in
the placenta
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Gravidity and malaria
 Primigravidae have no pre-existing immunity to
placental parasites and are highly susceptible
 In high transmission areas, primigravidae
develop immunity to placental parasites and are
protected in subsequent pregnancies
 In low transmission areas, multigravidae are
unexposed and unprotected
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Effects of malaria on pregnant
women
 Poor birth outcomes
 Low birth weight due to preterm delivery (PTD) and
intrauterine growth retardation (IUGR)
 abortions, stillbirths
 Maternal outcomes
 Anemia, maternal mortality
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Maternal mortality
 Responsible for 0.5 – 23% of maternal
deaths in Africa
 Malaria causes severe anemia and  platelets
can predispose to death from hemorrhage
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HIV/AIDS and Malaria during
Pregnancy
 HIV/AIDS reduces a woman’s resistance to malaria
 Intermittent preventive treatment (IPT) given 3
times during pregnancy is effective for women with
HIV/AIDS
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Malaria Prevention and Treatment
during Pregnancy
 Focused antenatal care (ANC) with health education
about malaria
 Use of insecticide-treated nets (ITNs)
 Intermittent preventive treatment (IPT)
 Case management of women with symptoms and
signs of malaria
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Intermittent Preventive Treatment
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
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Intermittent Preventive Treatment
Although a pregnant woman with malaria may have
no symptoms, malaria can still affect her and her
unborn child
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Intermittent Preventive Therapy
(IPT)
 Areas of high transmission
 Therapeutic doses of SP given periodically to all
pregnant women or infants at risk
 Takes advantage of
 High
utilization by pregnant women of antenatal
clinics
 High coverage of infants for EPI vaccination visits (2,
3, 9 mos)
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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
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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 sulfacontaining 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
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Chemoprophylaxis with Chloroquine:
For Women Allergic to Sulfa Drugs*
Dose
1
Chloroquine
150 mg
4 tablets
Timing
2
4 tablets
Second day after first dose
3
2 tablets
Third day after first dose
Weekly
2 tablets
Every week during pregnancy
First ANC visit after 16 weeks
*If chloroquine resistance rates in the country are high,
chemoprophylaxis with chloroquine is not recommended.
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Detecting Malaria
 Symptoms
 Fever
 Chills
 Headaches
 Muscle/joint pains
 Lab exam of blood from a finger prick
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Types of Malaria
 Uncomplicated
 Most common
 Complicated
 Life threatening, can affect brain
 Pregnant women more likely to get complicated
malaria than non-pregnant women
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Recognizing Malaria in Pregnant
Women
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Uncomplicated Malaria
Fever
Shivering/chills/rigors
Headaches
Muscle/joint pains
Nausea/vomiting
False labor pains
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Complicated Malaria
Signs of uncomplicated
malaria PLUS one or more
of the following:
Dizziness
Breathlessness/difficulty
breathing
Sleepy/drowsy
Confusion/coma
Sometimes fits, jaundice,
severe dehydration
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Drugs Used to Treat Malaria
 Chloroquine (Aralen, Dawaquine)
 Amodiaquine (Camoquine)
 Quinine and Quinidine
 Sulfa combination drugs (Fansidar, Metakelfin)
 Mefloquine (Lariam)
 Halofantrine (Halfan)
 Atovaquone-proguanil (Malarone)
 Atemisinin derivatives (Paluther)
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Case Management: Drugs
 First-line drug therapy is indicated for
uncomplicated malaria
 Second-line drug therapy is indicated for
uncomplicated malaria that has failed to respond to
first-line drug
 In almost all countries, quinine is the drug of choice
for complicated malaria
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Malaria Treatment
non-falciparum infections
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Chloroquine (CQ) is the drug of choice
Some CQ-resistant P. vivax has been reported from
Oceania and South America
Mefloquine or quinine for proven resistant cases
Primaquine to eradicate liver phase in P. vivax and P.
ovale infections
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CQ-resistant P. vivax
 Emerged in Southeast Asia
 Indonesia, Papua New Guinea, Birma
 Also documented in Latin America
 Guyana
 Also documented in South Asia
 India
 CQ therapy still recommended
 Quinine after documented treatment failure
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Primaquine (PQ) use in P. vivax and
P. ovale infections
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Use to achieve radical cure and prevent relapses
Check glucose-6-phosphate dehydrogenase (G6PD) level first
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PQ can cause hemolysis in G6PD-deficient patients
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If mildly deficient, consider weekly PQ dosing instead of daily
Partial resistance in Oceania and Southeast Asia
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Double usual dose if exposed in these areas
Contraindicated in pregnancy
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Pregnant women and newborns use prophylactic CQ weekly until
delivery or until end of breast-feeding
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Then use primaquine
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Primaquine
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8-aminoquinoline
acts on gametocytes, hypnozoites; weak against asexual
blood stage parasites
primarily used as post-exposure prophylaxis and radical
cure for P. vivax and P. ovale
contraindicated in G6PD deficiency and pregnancy
decreased activity against some P. vivax
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Second-Line Drug
 Most clients will respond to malaria treatment and
begin to feel better within 48 hours
 However, if the client’s condition does not improve
or worsens, give second-line treatment for
uncomplicated malaria
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Malaria Treatment
Plasmodium falciparum infections
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Acquired in CQ-sensitive areas
 Chloroquine alone
Acquired in CQ-resistant areas
 Quinine + tetracycline
 Quinine + sulfadoxine/pyrimethamine
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Multidrug-resistant P. falciparum
 Focus in Southeast Asia
 Border areas, forest transmission
 Recommendations
Prophylaxis: Doxycycline
 Treatment:
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• Quinine combinations, longer duration of therapy
• High-dose MQ,artemisinin combinations
 Identifying and documenting treatment failure
is critical
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