Malaria In Pregnancy

MALARIA IN PREGNANCY

BY

OMOGE ADEYEMI O.

DEPARTMENT OF PUBLIC HEALTH

FACULTY OF BASIC MEDICAL SCIENCES

ADELEKE UNIVERSITY, EDE, OSUN STATE

 OCTOBER, 2017

INTRODUCTION

Malaria infection in pregnant women is associated with high risks of both maternal and perinatal morbidity and mortality. Each year, more than 30 million African women in malaria-endemic areas become pregnant and are at risk of infection with Plasmodium falciparum. Prevention of malaria in pregnancy, which can have serious consequences for both the mother and her unborn child, is a major public health challenge. Pregnant women are more susceptible than non - pregnant women to malaria, and this susceptibility is greatest in first and second pregnancy. Although some other infectious diseases are also worse in pregnancy, malaria seems to be a special case. Susceptibility to pregnancy-associated malaria probably represents a combination of immunological and hormonal changes associated with pregnancy.

Human malaria is caused by the protozoan parasite of the genus Plasmodium. It lives in the red blood cells and is transmitted by the female anopheles mosquito. Malaria is a disease with major health problems that has attracted global concerns; hence it is regarded as the most important parasitic disease. In Africa, 30 million women living in malaria endemic areas become pregnant each year. For these women, malaria is a threat both to themselves and to their babies, with up to 2 million newborn deaths each year as a result of malaria in pregnancy. Pregnancy exacerbates malaria through a non-specific activity of the immune system. The protective anti - plasmodial activity is suppressed at pregnancy, which has clinical consequences with important public health implications on pregnant women. The symptoms and complications of malaria during pregnancy differ with the intensity of malaria transmission and the level of immunity the pregnant women has acquired. Malaria infection of the mother may result in a range of adverse pregnancy, outcomes, including spontaneous abortion, neonatal death, low birth weight and intrauterine growth retardation.

MALARIA WORLDWIDE

Malaria affects 3.3 billion people, or half of the world’s population, in106 countries and territories.  WHO estimates 216 million cases of malaria occurred in 2010, 81% in the African region.  WHO estimates there were 655,000 malaria deaths in 2010, 91% in the African Region, and 86% were children under 5 years of age. Malaria is the 3rd leading cause of death for children under five years worldwide, after pneumonia and diarrheal disease. 

MALARIA IN AFRICA

Thirty countries in Sub-Saharan Africa account for 90% of global malaria deaths. Nigeria, Democratic Republic of Congo (DRC), Ethiopia, and Uganda account for nearly 50% of the global malaria deaths.  Malaria is the 2nd leading cause of death from infectious diseases in Africa, after HIV/AIDS. Almost 1 out of 5 deaths of children under 5 in Africa is due to malaria.

MALARIA IN NIGERIA

Malaria is a major public health problem in Nigeria where it accounts for more cases and deaths than any other country in the world.  Malaria is a risk for 97% of Nigeria’s population. The remaining 3% of the population live in the malaria free highlands.  There are an estimated 100 million malaria cases with over 300,000 deaths per year in Nigeria. This compares with 215,000 deaths per year in Nigeria from HIV/AIDS. Malaria contributes to an estimated 11% of maternal mortality. Malaria accounts for 60% of outpatient visits and 30% of hospitalizations among children under five years of age in Nigeria.  Malaria has the greatest prevalence, close to 50%, in children age 6-59 months in the South West, North Central, and North West regions. Malaria has the least prevalence, 27.6 percent, in children age 6 to 59 months in the South East region. 

CAUSATIVE AGENT

Malaria is caused by the protozoan parasite Plasmodium. Human malaria is caused by four different species of Plasmodium: P.falciparum, P. malariae, P. ovale and P. vivax. Humans occasionally become infected with Plasmodium species that normally infect animals, such as P. knowlesi. As yet, there are no reports of human–mosquito–human transmission of such “zoonotic” forms of malaria.

MODE OF TRANSMISSION

The malaria parasite is transmitted by female Anopheles mosquitoes, which bite mainly between dusk and dawn. Malaria is mostly a disease of hot climate. The Anopheles mosquito, which transmits the malaria parasite from one human being to another, thrives in warm, humid climates where pools of water provide perfect breeding grounds. It proliferates in conditions where awareness is low and where health care systems are weak.

 In addition malaria, anophelines also transmit filariasis and some arboviral diseases, but other mosquitoes are more important as vectors of the latter infections. A typical attack comprises three distinct stages: Cold Stage, Hot Stage and Sweating Stage. The clinical features of malaria vary from mild to severe and complicated according to the species of parasite present, the patient’s state of immunity, the intensity of the infection and also the presence of concomitant conditions such as malnutrition or other diseases. 

GENERAL BACKGROUND HISTORY OF MALARIA

Malaria and mosquitoes - this association between insects and human disease is familiar to most of us. Indeed, to many the mere mention of mosquitoes is enough to suggest malaria. It is, however, a sobering thought to recollect that it is not so long since medical dictionaries defined “malaria” as a fever contracted from the miasma rising form swamps and prevented by sleeping with the windows closed. Malaria is one of the oldest recorded diseases in the world. In the 18th century, Italy people associated malaria with “bad air”- Mal’ aria- from which the name malaria is derived. In 1880, Laveran, a French Army Surgeon discovered the malaria parasite in Algeria, North Africa. Throughout the ages, suspicion fell on the part played by insects, and the mosquito incriminated in to folklore in Africa, Asia and Europe. The main credit goes to Ronald Ross, who discovered the transmission of malaria by Anopheline mosquitoes in 1897. Ross found malarial parasite growing as cysts (oocysts) on the stomach wall of an Anopheline mosquito (Anopheline stephensi) which had previously fed on malaria patient. Discovery of transmission human parasites plasmodium in 1898-1899. Chloroquine (Resochin) was discovered by German in 1934. Finally recognized and establish as effective and save anti malaria in 1946 by British and use scientists. Discovery of transmission of human malaria plasmodium (1889-1899) the presence of malaria in the blood of monkey was observed as early as (1893) and one of these parasite found in East African monkey received name plasmodia Kochi (later renamed Hepato cystis kochi by Garnham).

WHO IS AT RISK?

Most cases and deaths are in sub-Saharan Africa. However, Asia, Latin America, the Middle East and parts of Europe are also affected. In 2006, malaria was present in 109 countries and territories.

SPECIFIC RISKS FOLLOW

Travelers from malaria-free regions, with little or no immunity, who go to areas with high disease rates are very vulnerable.

Non-immune pregnant women are at high risk of malaria. The illness can result in high rates of miscarriage and cause over 10% of maternal deaths (soaring to a 50% death rate in cases of severe disease) annually.

Semi-immune pregnant women risk severe anemia and impaired fetal growth even if they show no signs of acute disease. An estimated 200,000 of their infants die annually as a result of malaria infection during pregnancy.

HIV-infected pregnant women are also at increased risk.

CLINICAL SIGNS AND SYMPTOMS OF MALARIA

The following are the clinical signs and symptoms of malaria

Fever 

Malaise 

Headache 

Abdominal discomfort 

Muscle and joint aches 

Chills, sweats, rigors 

May present as a respiratory or gastrointestinal illness

SEVERE MALARIA IN PREGNANCY

The following are the severe signs and symptoms of malaria in pregnancy

Altered mental state

Jaundice 

Prostration (inability or difficulty to sit upright, stand or walk without support) 

Acidosis 

Alteration in the level of consciousness (ranging from drowsiness to deep coma)

Fast breathing/breathlessness/difficulty breathing

Multiple generalized convulsions (2 or more episodes within a 24 hour period)

Shock (circulatory collapse, septicemia)

Pulmonary edema

Abnormal bleeding (Disseminated Intravascular coagulopathy)

Haemoglobinuria (black water fever)

Acute renal failure - presenting as oliguria or anuria

Severe anemia (Haemoglobin < 5g/dl or Hematocrit < 15%)

Hypoglycemia (blood glucose level < 2.2.mmol/l)

Hyperlactataemia

EFFECTS OF MALARIA ON FETUS AND MOTHER

Malaria in pregnancy adversely affects the mother and fetus. The main complications are: 

Increased mortality rate

Miscarriage/Spontaneous abortion

Stillbirth 

Preterm/Premature birth 

Low infant birth weight

Severe maternal and neonatal anemia

Intrauterine growth retardation

Congenital infection

Placental malaria infection

PREVENTIVE, CONTROL AND TREATMENT MEASURES

PREVENTIVE MEASURES

Environmental sanitation to prevent the breeding spaces for mosquitoes

Minimize exposure to mosquitoes in malarial risk areas 

Avoid outdoor night time activities

Use of insecticidal treated nets (ITN)

Wear clothing that covers the arms and legs 

Use of mosquito repellent

Indoor Residual Spraying (IRS) involves the coordinated, timely spraying of the interior walls of homes with insecticides that kill mosquitoes. 

Health communication/education programs on the mode of malaria transmission and the importance of sleeping under insecticide treated nets (ITNs). 

CONTROL AND TREATMENT MEASURES

Early diagnosis and prompt treatment

Intermittent preventive treatment for pregnant women (IPT) is an effective means of reducing the effects of malaria in both the pregnant woman and her unborn child by giving at least two doses of the drug sulfadoxine-pyrimethamine (SP). 

Prompt parasitological confirmation by microscopy or Rapid Diagnostic Test (RDT) is recommended for all patients with suspected malaria before treatment begins. 

Artemisinin-based combination therapy (ACT) has become the standard treatment of uncomplicated malaria. 

CONCLUSION

Research has clearly revealed that malaria in pregnancy is very devastating and pose a public health importance. It is one of the factors that contribute to the high mortality and morbidity in the tropics and sub tropics regions. All necessary measures must be set in place in the prevention, treatment and control of this menace in our country to avert complication that may result from this infectious disease. Appropriate health policies that will facilitate the speedily eradication of this disease must be set in place by the government, health practitioners in the country at large.

RECOMMENDATION

ENVIRONMENTAL SANITATION: Cutting down bushes around residents, burying of receptacles, avoidance of stagnation of water to prevent and control the breeding place for mosquitoes.

EARLY DIAGNOSIS AND TREATMENT: This involves laboratory tests, medical checkup, intermitted presumptive treatments (IPT) and antenatal care to promptly detect early so as to avoid complications

MOSQUITO NETS: Sleeping under insecticide treated mosquito nets to prevent the bite of mosquito

HEALTH EDUCATION: Health educating of the pregnant women on the malaria disease, transmission and complications.

REFERENCES

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