Malaria in pregnancy-Management

Malaria in pregnancy;ManagementMuriuki MariaraoutlineDisease burdenEndemicityApproachHealth EducationIPTITNTherapySummary

Patients with the highest risk;First or second pregnancies in malaria endemic areas.Immigrants or visitors from areas of low or no malaria transmission.HIV infected.

Malaria Epidemiology in KenyaPlasmodium falciparum is the predominant species (98.2 per cent) P. malariae, P.ovale is 1.8 per cent often occurring as mixed infections. P.vivax may account for up to 40-50 per cent of infections (often mixed with P.falciparum) in the Northern and North Eastern parts of Kenya.Kenya endemicity pattern

For clinical management purposes the above ecological zones are classified as follows:- High malaria risk areas: Lakeside, coastal, highland and arid areas.Low malaria risk areas: Highlands within central province.

ApproachQuality focused antenatal care and health educationIntermittent preventive treatment (IPT)Use of insecticide-treated nets (ITNs)Case management of malaria disease8So, what components should be included in a strategic framework for controlling malaria during pregnancy?

Malaria control during pregnancy should address four components. The first component is quality focused antenatal care that includes health education and counseling about malaria during pregnancy. The second is intermittent preventive treatment (or IPT for short) which is also sometimes referred to as intermittent presumptive treatment or intermittent protective treatment. For the purpose of this presentation, the World Health Organizations terminology intermittent preventive treatment will be used. The third component of malaria control is the use of insecticide-treated nets, and the fourth component is case management of malaria disease.

Health EducationMalaria:Is transmitted through mosquito bitesCan cause severe anemia, with adverse consequences for mother and babyCan cause abortions, stillbirths and result in low birth weight newbornsCan be prevented through the use of IPT and ITNs during pregnancyCan be easily treated if recognized early but complicated malaria requires specialized treatment

IPTp-SP in moderate to high malaria transmission areasStarting as early as possible in the second trimester, IPTp-SP is recommended for all pregnant women at each scheduled antenatal care (ANC) visit until the time of delivery, provided that the doses are given at least one month apart . SP should not be given during the first trimester of pregnancy; however, the last dose of IPTp-SP can be administered up to the time of delivery without safety concerns.IPTp-SP should ideally be administered as directly observed therapy (DOT) of three tablets sulfadoxine/pyrimethamine (each tablet containing 500mg/25mg SP) giving the total required dosage of 1500mg/75mg SP. SP can be given either on an empty stomach or with food. SP should not be administered to women receiving co-trimoxazole prophylaxis due to a higher risk of adverse events. WHO recommends the administration of folic acid at a dose of 0.4mg daily; this dose may be safely used in conjunction with SP. Folic acid at a daily dose equal or above 5mg should not be given together with SP as this counteracts its efficacy as an antimalarial. At a recent WHO evidence review,a meta-analysis of 7 trials evaluating IPTp-SP was undertaken. It showed that 3 or more doses of IPTp-SP were associated with higher mean birth weight and fewer low birth weight (LBW) births than 2 doses of IPTp-SP. The estimated relative risk reduction for LBW was 20% (95% CI 6-31). This effect was consistent across a wide range of SP resistance levels. The 3+ dose group also was found to have less placental malaria. There were no differences in serious adverse events between the two groups Kayentao K. et al. (2013). Intermittent preventive therapy for malaria during pregnancy using 2 vs 3 or more doses of sulfadoxine-pyrimethamine and risk of low birth weight in Africa: systematic review and meta-analysis. J o u r n a l o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n . 2013 Feb 13;309(6):594-604. doi: 10. 1001/jama.2012.216231.ITNsInsecticide-treated nets should be provided to pregnant women as early in pregnancy as possible. Women should be encouraged to use ITNs throughout the entire pregnancy, as well as during the postpartum period when the risk of malaria is also increased. IPTp-SP is not a replacement for ITN use; both interventions provide important benefits. Case management of malaria diseaseUncomplicated malaria is defined as symptomatic malaria without signs of severity or evidence (clinical or laboratory) of vital organ dysfunction. The signs and symptoms of uncomplicated malaria are nonspecific. Malaria is, therefore, suspected clinically mostly on the basis of fever or a history of fever.Severe malaria is a life threatening manifestation of malaria, and is defined as the detection of p. falciparum in the peripheral blood in the presence of any of the clinical or laboratory features (singly or in combination).Features and definitions of severe malaria Prostration (inability or difficulty to sit upright, stand or walk without support in a child normally able to do so, or inability to drink in children too young to sit) Alteration in the level of consciousness (ranging from drowsiness to deep coma) o Cerebral malaria (unrousable coma not attributable to any other cause in a patient with falciparum malaria) Respiratory distress (acidotic breathing) Multiple generalized convulsions (2 or more episodes within a 24 hour period) Circulatory collapse (shock, septicaemia) Pulmonary oedema Abnormal bleeding (Disseminated Intravascular Coagulopathy) Jaundice Haemoglobinuria (black water fever) Acute renal failure presenting as oliguria or anuria Severe anaemia (Hb 200,000/l - in high transmission area, or 100,000/l in low transmission area) HyperlactataemiaMicroscopyMicroscopy is the standard method for parasitological diagnosis of malaria. This is done by examining a stained thick or thin blood smear for the presence of malaria parasites.Thick films are recommended for parasite detection and quantification and can be used to monitor response to treatment. Thin films are recommended for species identification. sensitivity range of 86-98%.False neg?

RDTsRDTs are immunochromatographic tests based on detection of specific parasite antigens, either Plasmodium lactate dehydrogenase (pLDH) activity or the presence of Histidine- Rich Protein (HRP). RDTs are simple to use and are sensitive in detecting low parasitaemia. Use of RDTs is not recommended for follow-up as most of the tests remain positive for up to two weeks following effective antimalarial treatment and clearance of parasites. They also cannot be used to determine parasite density.

Case 125yrs Primigravida @ 12/40 presents with fever, malaise, myalgia,nausea and vomiting for 5days.Pregnancy was diagnosed when she presented at a facility in MSA during a 2 weeks seminar and was treated for hyperemesis gravidarum.Inv?RX?WHO guidelines

Case 235yrs para 1@28/40 gives a history of fever, chills, joint pains and recent travel to Kisumu. Has noticed yellowness of the eyes and is passing little urine. She was started on HAART for PMTCT 5 days ago.O/E Jaundice, pallor. VS Temp 37.7 RR 24P/A 24 week fundus, left hypochondrial tenderness.Inv?RX?

Supportive Care

chemoprophylaxisCausal or suppressive.Causal prophylaxis is directed against liver schizont stage, which takes approximately 7 days to develop so these drugs (for example, atovaquone-proguanil (Malarone) need to be continued for 7 days after leaving a malarious area.Suppressive prophylaxis (such as mefloquine) is directed against the red blood cell stages of the malaria parasite and so should be continued for 4 weeks after leaving a malarious area.

Mefloquine (5mg/kg once a week) is the recommended drug of choice for prophylaxis in the second and third trimesters for chloroquine-resistant areas

SummaryMalaria 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.Health Education on Malaria transmission.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.ReferencesGuidelines for the treatment of malaria Second edition-WHO 2010National guidelines for diagnosis, treatment and prevention of Malaria-Ministry of Health 2006WHO Policy Brief for the Implementation of Intermittent Preventive Treatment of Malaria in Pregnancy using Sulfadoxine-Pyrimethamine (IPTp-SP)-April 2013 RCOG Green-top Guideline No.54B.The diagnosis and treatment of malaria in pregnancy