4. Introduction
Malaria is more common in
pregnancy compared to the general
population.
The non- immune, primigravidae are
usually the most affected(prevalence & complications)
The increased risk of contracting
malaria may be due to
Decreased immunity
Hormonal changes
5. Introduction cont..
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 the life difficult for the
mother, the child and the treating
physician.
6. Introduction cont..
In pregnancy, malaria tends to be
more atypical in presentation.
This could be due to the hormonal,
immunological and hematological
changes of pregnancy
7. Introduction cont..
Some anti malarial drugs are
contraindicated in pregnancy and some
may cause severe adverse effects.
Therefore Choice of medication becomes difficult.
Management of complications of malaria
may be difficult
8. Pathophysiology
Pathogenesis of malaria relates to the various
host and parasite factors
Starts by inj of Plasmodium sporozoites via a
bite from an infected mosquito
The sporozoites travel through the
bloodstream of the host to the liver, where they
invade hepatocytes.
These cells divide many 1000-fold until mature
tissue schizonts are formed, each containing
thousands of daughter merozoites.
This exoerythrocytic stage is asymptomatic
9. Pathophysiology cont..
The liver schizonts rupture after a week or so
This event releases thousands of merozoites into
the bloodstream, where they invade red blood
cells (the erythrocytic stage)
At the completion of the schizogony within the red
cells,(48hrs for P. falciparum) newly developed merozoites are
released by the lysis of infected erythrocytes
Along with them, numerous waste substances are
also released into the blood.
These include red cell membrane products,
hemozoin pigment, and other toxic factors such as
glycosylphosphatidylinositol (GPI)
10. Pathophysiology cont..
These products, particularly the GPI, activate
macrophages and endothelial cells to secrete
cytokines and inflammatory mediators such as
TNF-alpha, IFN-γ, Il-1, IL-6, IL-8, MCSF, and
lymphotoxin, as well as superoxide and nitric oxide
(NO).
The systemic manifestations of malaria have been
largely attributed to these cytokines
12. Placental Malaria
Caused by P. falciparum–infected erythrocytes
that bind to placental tissue.
Binding is mediated by VAR2CSA, a parasite
antigen which interacts with chondroitin
sulfate A (CSA) on the syncytiotrophoblast
The VAR2CSA is coded by the var2csa gene
By this process, the parasites avoid being
filtered through the spleen
Also it impairs movements of nutrients across
the placenta
13. Placental Malaria cont..
Consequences include maternal
anemia and fetal growth retardation.
Antibodies against VAR2CSA occur
during pregnancy after exposure to
infected erythrocytes sequestering in
the placenta
Concentrations of these antibodies
increase with parity.
Placental changes due to malaria infxn (hemozoin deposition &
increased monocyte deposition) also contribute to placental
15. Clinical presentation cont…
Severe malaria
Presence of one or more of the following
Prostration (extreme weakness),
Impaired consciousness/coma
Change of behavior
Convulsions
Jaundice
Vomiting everything
Circulatory collapse/shock
Hyperparasitemia
Bleeding tendency (DIC)
Respiratory distress
16. Complications
Anemia
Abortion and its
complications
Premature labour
Cerebral malaria
AKI
Pulmonary edema
IUGR
Congenital infection
To the newborn
Premature delivery
Low birth weight
and its
complications
Congenital/neonat
al malaria
To the mother To the fetus
17. Management
Includes
Investigations
Treatment of malaria
Management of complications
Prevention
Treatment of malaria in pregnancy should be
Energetic :
Don't waste any time.
Careful
Choose drugs and dosage carefully
Anticipatory
One should always be looking for any complications by
regular monitoring
18. Investigations
Includes
Antigen detection techniques : - MRDT-(HRP-
2/pLDH(PfPAN))
Peripheral blood smear for MPs( thin & thick films)
PCR based assay
Antibody test
Placental blood smear(postpartum)
Others depending on the clinical presentation
20. Treatment cont…
A: Uncomplicated malaria
In the first trimester,
Pregnant women with uncomplicated
malaria should be treated with quinine
tablets for seven days
The dose is 10 mg/kg every 8 hours for
7days
Do not exceed a maximum dose of
600mg per dose
21. Treatment cont..
In the second and third trimester
Artemether-Lumefantrine should be used as
medicine of choice
The dose is 4 tabs stat then 8hours after the first
dose then 12hourly for 2days (a total of three
days)
Alternatively
Dihydoartemisinin-Piperaquine (DPQ)
Artesunate-Amodiaquine
22. Treatment cont..
B: Severe malaria
The primary objective of treatment in severe malaria is
to prevent death.
The secondary objective is to prevent disabilities and
to prevent recrudescent infection
In the first trimester
The medicine of choice for treatment of severe
malaria in the first trimester is IV Quinine(dose)
23. Severe malaria Rx cont..
In the second and third trimester
The medicine of choice for treatment of
severe malaria in 2nd and 3rd trimester of
pregnancy is Inj. Artesunate
The dose is dose 2.4 mg/kg given at time 0 hour,
then at 12 hours and 24 hours
Followed by ALu for 3days
The first oral dose should start 8hrs after the last injection
Quinine should be used only if Artesunate
injectable is not available.
24. Treatment cont…
According to WHO recommendation,
Treatment of severe malaria is with Inj Artesunate for
both children and adults including infants, pregnant
women in all trimesters and lactating women.
Inj Artesunate should be given for at least 24hrs and
until patient can tolerate oral medication, then they
should complete treatment with 3days of ACT
If Artesunate is unavailable, Inj Artemether (IM) should
be given
If Artemether is unavailable, Inj Quinine should be
given(loading dose 1st)
25. Artesunate for injection
Descpription
Artesunate is a water-soluble derivative of
Artemisinin.
The only Artemisinin analogue that can be
given intravenously
It produces rapid parasite clearance in
falciparum malaria.
Superior to Quinine in preventing death
26. Artesunate for injection cont..
Three formulations are available:
30mg,
60mg and
120mg of Artesunate for injection.
27. Table 14: Artesunate for injection
package by strength
Strength 30mg 60mg 120mg
Artesunate for
injection
1 vial of 30mg 1 vial of 60mg 1 vial of
120mg
5% Sodium
bicarbonate
1 Ampoule of
0.5mls
1 Ampoule of
1ml
1 Ampoule of
2.5mls
Sodium
chloride
1 Ampoule of
2.5mls
1 Ampoule of
5mls
1 Ampoule of
10 mls
28. Administration and dosage (60 mg
strength)
Injectable Artesunate has 2-steps dilutions.
Step 1:
The powder for injection should be diluted with 1ml of 5%
sodium bicarbonate solution (provided in each box) and
shaken vigorously 2-3 minutes for better dissolving till the
solution becomes clear.
Step 2:
For slow intravenous infusion (3-4 minutes): Add 5 ml of
5% dextrose or normal saline, to obtain a Artesunate
concentration of 10 mg/ml
For deep intra-muscular injection: Add 2 ml of 5%
dextrose or normal saline to obtain a Artesunate
concentration of 20 mg/ml
29. Quantity for dilution of Artesunate for
injection
ROUTE IV INJECTION IM INJECTION
STRENG
TH
30mg 60mg 120mg 30mg 60mg 120mg
5%
NaCO3
0.5mls 1ml 2mls 0.5mls 1ml 2mls
NS/5%
dextrose
2.5mls 5mls 10mls 1ml 2mls 4mls
TOTAL
(mls)
3mls 6mls 12mls 1.5mls 3mls 6mls
Artesunate
concentrati
on (Mg/ml)
10 10 10 20 20 20
30. Caution;
The powder form for injection is difficult to
dissolve, care should be taken to ensure that it
is completely dissolved before parenteral
administration.
If the solution is cloudy or a precipitate is
present, the parenteral preparation should be
discarded.
Dissolved artesunate should always be used
immediately after 2nd dilution
Never store diluted Artesunate for further use
31. Supportive treatment in the
Management of malaria in
pregnancy
Treatment of anemia (BT, FA)
Correction of electrolyte imbalance
Oxygen + Diuretics in pulmonary oedema
Dialysis for ARF
Anticonvulsants
ICU care for CM
Monitoring of the fetal growth & health
32. Prevention
Available options are:-
Vector control
Insecticide Treated Nets (ITNs)
Residual house hold spraying
Environmental management
Drug prophylaxis
Intermittent preventive treatment (IPTp)
Alternative- DPQ (not yet adopted)
Vaccine?? –Still under development
33. Intermittent preventive treatment (IPTp)
The medicine of choice for IPTp is
Sulfadoxine/Pyrimethamine (SP)
Reduses the risk of
Placental malaria
Low birth weight and
Maternal illness
Dosing should start as early as possible in the sec
trimester
Should be given at least 1 month apart, at least
3doses
SP can be administered up to the time of delivery
34. Conclusion
Diagnosis and Management of malaria during pregnancy
can be challenging
The primary objective in the management of severe malaria
is to prevent death
Malaria preventive package during pregnancy includes:
Intermittent preventive treatment with SP during antenatal clinic
visits
Use of ITNs throughout pregnancy and in the postpartum period
Prevention must be complemented by effective case
management of malaria for all women of reproductive age
35. References
National Guidelines for Diagnosis and Treatment of Malaria-December
2014
The diagnosis and treatment of malaria in pregnancy-Royal College of
Obstetricians and Gynecologists-April 2010
A Review of Malaria Diagnostic Tools: Microscopy and Rapid Diagnostic
Test (RDT)-American journal of tropical medicine and hygiene
http://www.uptodate.com/contents/pathogenesis-of-malaria
http://www.malariasite.com/pathophysiology/
https://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-7-
133
https://en.wikipedia.org/wiki/Pregnancy-associated_malaria
https://malariajournal.biomedcentral.com/articles/10.1186/s12936-015-
0576-8