Malaria During Pregnancy

1
Malaria During Pregnancy

• Dr. Emmanuel Oladipo Otolorin

2
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

3
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
• 3-5 of newborn deaths

Source WHO 2002.
4
Prevalence of Placental Malaria in African Women
by Gravidity in Eight Studies
5
Characteristics of Stable and Unstable Areas of
Malaria Transmission

• Stable Areas
• People receive frequent infective mosquito bites
  each month
• Levels of acquired immunity are high (pregnant
  women are semi-immune to malaria)
• Low peripheral parasitemia
• Heavy placental infection

• Unstable Areas
• People are infrequently exposed to malaria
• Levels of acquired immunity are low (pregnant
  women are not immune)
• Heavy peripheral parasitemia
• Low or undetectable placental infection

6
Effect of Malaria on Pregnancy inStable
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.
7
Effect of Malaria on Pregnancy inUnstable
Transmission Areas
Source WHO 2002.
8
Effects on the Pregnant Woman
( Very Common, Common, Infrequent, --
Rare)
9
Effects on the Fetus and Newborn
( Very Common, Common, Infrequent, --
Rare)
10
Placental Parasitemia by Pregnancy
NumberKenya, 1996-1998
Parasite density/mm3
772
402
479
Source van Eijk AM et al 2001.
11
Frequency of Low Birth Weight by Placental
Malaria InfectionMalawi 1988-1991
Low Birth Weight
First Pregnancy
Second Pregnancy
Three or more pregnancies
Source Steketee 2001.
12
Placental Parasitemia by HIV Status and
Pregnancy Number Kenya, 1996-1998
Parasite density/mm3
parasitemic
231
159
197
772
402
479
HIV ()
HIV (-)
Summary RR 1.63 (1.41-1.89), p Total n 2263
Source van Eijk AM et al 2001.
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Components of Malaria Control During Pregnancy

• Quality focused antenatal care and health
  education
• Intermittent preventive treatment (IPT)
• Use of insecticide-treated nets (ITNs)
• Case management of malaria disease

14
Proportion of Pregnant Women Seeking Care at an
Antenatal Clinic at Least Once
Survey year ranges from 1988-1999
Percentage
Togo Benin Cameroon Guinea Mozambique CAR Burkina
Faso Nigeria Eritrea Mali Niger Chad
Zambia Zimbabwe Botswana Kenya Uganda Malawi Tanza
nia Ghana Namibia Cote dIvoire Senegal
Source WHO 2002.
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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)
• Prompt diagnosis and treatment of malaria

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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

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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

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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
• SP is generally more effective than chloroquine
  because of increasing prevalence of chloroquine
  resistance and the need for less frequent dosing
  when compared with chloroquine

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Effect of Intermittent Preventive Treatment with
SPKenya 1998
Source Steketee 2001.
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Fetal Growth Velocity
Fetal growth velocity ?
Last month
20
30
10
16
Birth
Weeks of gestation
Conception
Source WHO 2002.
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Fetal Growth Velocity
Fetal growth velocity ?
Last month
Quickening
20
30
10
16
Birth
Weeks of gestation
Conception
Source WHO 2002.
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Rationale for the Timing of the SP Doses
Fetal growth velocity ?
Rx
Rx
Last month
Quickening
20
30
10
16
Birth
Weeks of gestation
Conception
Source WHO 2002.
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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

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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)

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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

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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
• 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

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ITN Impact on Fetal Growth and Duration of
Gestation

Premature
SGA
Premature or SGA
45
40
35
control
30
Percentage
bednets
25
20
15
10
5
0
GG4
GG4
GG4
Gravidity
Source ter Kuile et al 1999.
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Impact of ITNs on Maternal and Newborn Health
Western Kenya

• Among Gravidae 1-4, ITNs were associated with
• During pregnancy
• 38 reduction in peripheral parasitemia
• 21 reduction in all causes of anemia (Hb 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.
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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

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Treatment of Symptomatic Patients

• Uncomplicated malaria
• Provide first line antimalarial drug approved for
  use during pregnancy
• Treat fever with analgesics
• Diagnose and treat anemia
• Provide fluids

• Complicated malaria
• Weigh patient
• Administer quinine as soon as it is diluted
• Manage fever (analgesics, tepid sponging)
• Provide rehydration as needed
• Monitor for severe anemia, hypoglycemia, acute
  renal failure and treat as needed
• Refer, if not skilled in managing complicated
  malaria

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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

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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

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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 Declaration
  goal of 60 coverage of pregnant women by 2005

34
Country Activities at Different Levels
National Program Leadership Level
District Level
Facility Level
Community Level
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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 illness for all women of
  reproductive age
• Case management must emphasize screening and
  prompt treatment for anemia