Malaria During

Pregnancy

Dr. Emmanuel Oladipo

Otolorin
 Objectives
• Describe the impact of malaria on
pregnancy and the newborn
• Discuss the impact of malaria on HIV-
infected pregnant women
• Discuss malaria control during pregnancy,
including prevention and case
management of malaria illness

Malaria During Pregnancy 2

 Why Is the Issue of Malaria
During Pregnancy Important?
• Each year, more than 30 million women in
Africa become pregnant in malaria-
endemic areas.
• Malaria during pregnancy in malaria-
endemic settings may account for:
– 2-15% of maternal anemia
– 5-14% of low birth weight newborns
– 30% of “preventable” low birth weight
newborns
Source: – 3-5%
WHO 2002. of newborn deaths
Malaria During Pregnancy 3
 Prevalence of Placental Malaria
in African Women by Gravidity in
Eight Studies Primigravida Multigravida
70
60
Prevalence %

50
40
30
20
10
0
a

ia

ire
st
a

i
aw
nd

a-

a-

er
an

oa

Za
bi

bi

al
ig
ga

nz

M
am

am

N
U

y
Ta

or

G
Iv

Malaria During Pregnancy 4

 Characteristics of Stable and
Unstable
Areas of Malaria Transmission
•Stable Areas • Unstable Areas
– People receive – People are
frequent infective infrequently
mosquito bites exposed to malaria
each month
– Levels of acquired – Levels of acquired
immunity are high immunity are low
(pregnant women (pregnant women
are semi-immune are not immune)
to malaria) – Heavy peripheral
– Low peripheral parasitemia
parasitemia – Low or
Malaria During Pregnancy 5
 Effect of Malaria on Pregnancy
in
Stable Transmission Areas
Plasmodium falciparum malaria

Asymptomatic Infection

Placental Sequestration
Altered Placental Integrity

Reduced Nutrient and Oxygen Transport

Anemia Low Birth Weight (IUGR)

Risk of Newborn Mortality

Source: WHO 2002. Malaria During Pregnancy 6

 Effect of Malaria on Pregnancy
in
Unstable Transmission Areas
Acquired Immunity – Low

Clinical Illness

Severe Disease

Risk to Mother Risk to Fetus

Source: WHO 2002. Malaria During Pregnancy 7

Effects on the Pregnant Woman

Primigravid
All parities
ae in
in Unstable
Effects Stable
malaria
malaria
areas
areas
• High fever + +++
• Placental +++ +
infection ++ ++
• Puerperal sepsis
• Complicated +++
( +++ =Very Common, ++ =Common, + =Infrequent, -- =Rare)

malaria Malaria During Pregnancy

+++ 8
 Effects on the Fetus and
Newborn
Primigravid All parities
ae in in
Effects Stable Unstable
malaria malaria
areas areas
• Low birth
weight +++ +
– IUGR
+ +=Infrequent, -- =Rare)
( +++=Very Common, ++=Common, ++
– Prematurity
-
Malaria During Pregnancy
++ 9
 Placental Parasitemia by
Pregnancy Number
Kenya, 1996-1998
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 10

 Frequency of Low Birth
Weight by Placental Malaria
Infection
35
Malawi 1988-1991
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. Malaria During Pregnancy 11

 Placental Parasitemia by HIV
Status
and Pregnancy Number
Parasite density/mm3
40 Kenya, 1996-1998
35 1-999 1000-9,999 >10,000
30
% parasitemic

25
20
15
10
231 159 197 772
5 402 479
0
G1 G2 G3 G1 G2 G3
HIV (+) HIV (-)
Summary RR = 1.63 (1.41-1.89), p <0.001
Total n = 2263
Source: van Eijk AM et al 2001. Malaria During Pregnancy 12
 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

Malaria During Pregnancy 13

 Proportion of Pregnant Women
Seeking Care at an Antenatal
Clinic at Least Once
100
Survey year ranges from 1988-1999

90
80
Percenta

70
60
50
40
ge

30
20
10
0

Burkina
Benin

ue

Niger
Togo

Faso

Mali
Cameroon
Guinea

Nigeria

Chad
CAR
Mozambiq

Eritrea
Senegal
Zimbabwe

Tanzania

Cote
d’Ivoire
Malawi
Zambia

Botswana
Kenya
Uganda

Ghana
Namibia

Source: WHO 2002. Malaria During Pregnancy 14

 1. Antenatal Care and Health
Education
• Antenatal visits provide a unique
opportunity for:
– Monitoring of maternal and fetal health during
pregnancy
– Provision of micronutrient supplementation
(e.g., iron folate)
– Health education and counseling about
malaria during pregnancy
– IPT with an effective antimalarial drug (e.g.,
sulfadoxine-pyrimethamine, SP)
Malaria During Pregnancy 15
– Prompt diagnosis and treatment of malaria
 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 and16
Malaria During Pregnancy
 2. 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
Malaria During Pregnancy 17
 IPT with Sulfadoxine-
•
Pyrimethamine (SP)
SP is a combination of two different drugs.
Each tablet of SP contains:
– 500 mg of sulfadoxine, and
– 25 mg of pyrimethamine
• A single dose consists of three tablets
taken at once, preferably under direct
observation of the healthcare provider
• Fansidar is the most common brand
name. Others include Falcidin, Laridox,
Maladox, Orodar Malaria During Pregnancy 18
 Effect of Intermittent
Preventive
Treatment
Case with SP
Two- Monthl
manage
Kenya dose
1998 y
ment SP SP p
N=472 N=432 N=431
Mean <
9.9 10.2 10.4
Hb. 0.05
Maternal
0.00
parasite 27% 9% 7%
4
mia
Source: Steketee 2001.
Placenta Malaria During Pregnancy 19
 Fetal Growth Velocity

Fetal growth velocity 

Last
month

10 16 20 30
Birth
Conception Weeks of gestation
Source: WHO 2002. Malaria During Pregnancy 20
 Fetal Growth Velocity

Fetal growth velocity 

Quickening Last
month

10 16 20 30
Birth
Conception Weeks of gestation
Source: WHO 2002. Malaria During Pregnancy 21
 Rationale for the Timing
of the SP Doses
Fetal growth velocity 

Rx Rx

Quickening Last
month

10 16 20 30
Birth
Conception Weeks of gestation
Source: WHO 2002. Malaria During Pregnancy 22
 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

Malaria During Pregnancy 23

Steps for Providing IPT with SP
• Determine quickening has occurred
• Inquire about history of severe skin rash
• Inquire about use of SP in last month
• Provide three tablets of SP with clean
water in a clean cup
• Observe the patient swallowing all three
tablets (Directly Observed Treatment or
DOT strategy)
Malaria During Pregnancy 24
Steps for Providing IPT with SP
continued
• Record SP on the antenatal card and the
clinic record
• Instruct patient to return at next scheduled
visit or earlier if she is feeling ill
• Ask about side effects from previous dose
before giving the next dose, which should
not be less than 4 weeks from the last
dose

Malaria During Pregnancy 25

 3. 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 Malaria During Pregnancy 26
 ITN: Impact on Fetal Growth and
Duration of Gestation
%
Premature SGA Premature
45
or SGA
40
35
Percentage

30 control
25 bednets
20
15
10
5
0
<3

>4

<3

>4

<3

>4
G

Gravidity G

Source: ter Kuile et al 1999. Malaria During Pregnancy 27

 Impact of ITNs on
Maternal and Newborn Health
Among Gravidae 1-4, ITNs were
Western Kenya 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
Source: –
28% reduction in
Shulman 2001.
LBW
Malaria During Pregnancy 28
 4. 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 Malaria During Pregnancy 29
 Treatment of Symptomatic
Patients
• Uncomplicated
malaria • Complicated malaria
– Provide first line
– Weigh patient
antimalarial drug
approved for use – Administer quinine as
during pregnancy soon as it is diluted
– Treat fever with – Manage fever
analgesics (analgesics, tepid
sponging)
– Diagnose and treat
anemia – Provide rehydration as
needed
– Provide fluids
– Monitor for severe
Malaria During Pregnancy anemia, 30
 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; therefore
healthcare providers must stay informed
about policy changes recommended by
their Ministry of Health
Malaria During Pregnancy 31
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
Malaria During Pregnancy 32
Glucose-6-Phosphatase-Dehydrogenase
 A Partnership for Malaria
Control
During Pregnancy
• WHO Programs
– Making Pregnancy Safer
– Roll Back Malaria
• Partnership between both
programs and national
reproductive health
programs essential
• Partnership of programs
and individual involvement
necessary to reach Abuja
Malaria During Pregnancy 33
 Country Activities at Different
Levels
District Teams
Program Leaders Operationalize
Develop policies, guidelines and
standards, and support
guidelines, advocacy, IEC, National Program Leadership Level supervision,
PST/IST, support drug supply
supervision, M&E logistics,
District Level and sensitization
of public,
Facility Level promotion of ITNs,
M&E
Community
Facilities Level
Integrated health ed.,
community mobilization,
promotion of ITNs, Communities
provision of IPT, CHWs and TBAs
treatment of complications sensitize about
such as anemia, data malaria control,
collection and feedback referrals, followup

Malaria During Pregnancy 34

 Summary

• Malaria during pregnancy has

adverse consequences for mothers
and their babies
• Malaria preventive package 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 During Pregnancy 35