OUTLINE

Objectives of lecture
Introduction
Epidemiology
Immunology
Effects of malaria on pregnancy
Effects of pregnancy on malaria
Diagnosis
Treatment
Strategies for prevention and challenges
Key points
Reflections
Objectives of lecture
Know the epidemiology of malaria in
pregnancy
Have an insight about the effects of
malaria in pregnancy and vice versa
Able to understand the principles of
management of malaria in pregnancy
Understand the preventive strategies
of malaria in pregnancy.
 Introduction-I
Malaria infection during pregnancy is a
major public health problem in tropical and
subtropical regions throughout the world.1
Africa alone has 90% of the world malaria. 2
In Africa, it is estimated that 30-50 million
women living in malaria endemic areas
become pregnant each year.
Introduction - II
For those women, malaria is a threat both
to themselves and to their babies, with
upto 200,000 newborn deaths each year
as a result of malaria in pregnancy
Although, considerable progress has been
made in the management and control of
malaria, these strategies such as Roll
back Malaria (RBM) are yet to achieve the
desirable impact in many areas of Africa.
 Epidemiology-I
Globally, malaria is transmitted in over 100
countries in the tropics and subtropics with
two billion people or ~ 40% of worlds pop at
risk of infection.
Africa accounted for 90% of malaria burden,
with ~ 50 million women getting pregnancy
each year and at risk of malaria in pregnancy.
Annually in Africa, malaria accounted for one
million deaths annually majority of which are
childhood death, follow by pregnant women.
Epidemiology-II
In Nigeria >100 million people are at risk.
It is estimated that 50% of adults have at
least one episode of malaria every year
while the under fives have 2-4 attacks per
annum.
Malaria accounted for 11% and 30% of
maternal and childhood mortality rates
respectively in Nigeria.
The economic burden of malaria in Nigeria
is estimated at 132 billion Naira annually.
 Epidemiology-III
Primigravida, secandigravida and young
women appeared to be more at risk.
Effects of malaria in pregnancy differ in
women with different level of endemicity
P. falcipanum is widely distributed and
most important
Less effects of malaria with pregnant
women on chemoprophylaxis.
 Immunology-I

Women in malaria stable malaria zones

Acquired Partial Immunity Pregnancy

induce
Placenta immunosuppressi
Age
barrier on
Parity
HB Genotype
Transfer of
Immunoglobin to G6PD
fetus Fetal haemoglobin

Protection of fetus (<6 months

extrauterine life)
Immunology-I

Women in areas of unstable

malaria
Little or no immunity

Recurrent malaria illness

Severe clinical disease
Less fetal protection
Increased risk of abortion,
 Effects of malaria on
Pregnancy-I
Effects more pronounced and intense in first
pregnancies
1) Maternal Anaemia
Most important consequence of P.falciparum
infection during pregnancy. Mechanism include:-
a) Haemolysis of parasitised non-parasitised red
blood cells
b) Sequestration of parasitised and non-parasitised
red blood cells into the spleen Hypersplenism.
c) Dyserythropoiesis from folate deficiency
d) Erythrophagocytosis
 Effects of malaria on
Pregnancy-II
2) Maternal illness
Most immune pregnant women remain
asymptomatic even in presence of parasitaemia
Mild febrile episodes may occur and infrequently
severe disease occurs.
3) Risk of abortion, preterm labour, IUGR,
IUFD,LBWt(150-200g lower)
4) Placentitis
Parasitisation of the placenta is common,
affecting upto 1/3 or more of all births in many
parts of Sub-Saharan Africa.
Effects of malaria on
Pregnancy-III
Congenital malaria
Asymptomatic congenital parasitaemia is
found in 8-15% of newborn infants (Recent
Nigeria study6 25% and 17% for congenital
malaria)
Infection occur during labour via braches in
the placenta.
All four species of plasmodium can produce
symptom in parasitaemia but this is more
in babies of partially immune mothers.
 Effects of Pregnancy on
Malaria-I
Intense evidence of inflammatory process in
almost all trophoblastic layers including the
basement membrane but not to the fetal stem
cells
Provides basis for the fetal effects of malaria.
With immunological adjustments of pregnancy,
risk of frequent attacks of malaria.
Risk of and course of malaria severe malaria,
cerebral malaria and complications including
cardiac failure, hypoglycemia, pulmonary
odema, DIC, and maternal death.
Effects of Pregnancy on
malaria-2
Worsening of Hyperimmune malaria
splenomegaly (HMS) characterized by
episode of haemolytic anaemia which can
be life threatening to mother and high
fetal morbidity /mortality
Bad prognostic factors include-

hyperparasitaemia(>5% of red cells

parasitised)peripheral leucocytosis >12 x
109), low CSF glucose, urea level >
11mmol/l and PCV <20%.
Diagnosis
High index of suspicion desirable
Diagnostic dilemma between cerebral
malaria and Eclampsia
Thin & thick films
Rapid tests
Treatment
Dictated by local sensitivity pattern because of
problem of multi drug resistance
CQ resistance pattern in Africa & Nigeria.
FMOH guidelines on malaria-2005(Revised in
2011)
Simple malaria Severe malaria
ACT Supportive therapy
A-L OR A-A IM/IV Artesunate(2.4mg/kg)
IV Quinine infusion
 Strategies for
Prevention-I
Developed by WHO Regional office for
Africa as part of RBM initiatives 3
pronged approach
i. Insecticide Treated Nets (ITN)
ii. Intermittent preventive Treatment (IPT)
iii. Effective case Mx of malaria illness
Vector control Integrated vector
management (IVM)
Strategies for Prevention-II
Challenges of strategies
Availability and distribution of ITN:

Health system respond

Issue of cost

Dynamism of multidrug resistance

Putting in place very effective and

efficient IVM.
Concurrent Mx of malaria & HIV in

pregnancy
 Conclusion
Since Africa carries 90% of global malaria burden and
Nigeria being the most populous country in Africa, the
impact of malaria (including its effects in pregnancy)
in Nigeria is probably higher than any other country in
the world.
The strategies for control of malaria poses

considerable challenges to most countries in sub-

Saharan Africa.
Renewed commitment and concerted efforts are

needed to reduced the burden of malaria particularly

in the most vulnerable groups of the population i.e.
pregnant women and children.
Key points
Immunological changes in pregnancy makes
a pregnant woman susceptible to malaria
Primigravida more at risk
Maternal anemia is via multiple mechanisms
For diagnosis, HDS and laboratory
confirmation recommeded
Treatment of severe malaria with parenteral
artesunate or quinine
Prevention with IPT and use of ITN
 References
1. Harrison KA. Malaria in Pregnancy. In
Lawson JB, Harrison KA, Bergsttom S (eds)
Maternity care in Developing Countries,
London. RCOG Press 2001: 99-11.
2. WHO. Lives at risk: Malaria in pregnancy
WHO Geneva: April 2003.
3. WHO/UNICEF. The Africa Malaria Report
2003. WHO/UNICEF. Geneva.2003: 38-43.
4. FMOH. National Antimalaria Treatment
Guidelines. FMOH Abuja 2005: 1-20.
 References-II
5. Yartey JE. Malaria in Pregnancy: Access to
effective interventions in Africa. Int J
Gynaecol Obstet 2006; 94(3): 364-73.
6. Runsewe Abiodun IT, Oguntowora OB,
Fesugu BM, Neonatal Malaria in Nigeria-a
two year review. BMC Pediatr 2006; 6: 19.
7. Gamble C, Ekwani JP, Terkenle FO.
Insecticide treated nets for preventing
malaria in pregnancy. Cochrame Database
Syst Dev. 2006; (2): CD 003755
 References-III
8. Hill J, Kazembe P. Reaching the Abuja target
for intermittent preventive treatment of
malaria in pregnancy in African women. A
review of progress and operational challenges.
Trop Med Int Health 2006; 11(4): 409-18.
9. Breatlinger PE,Behrens CB, Micek MA.
Challenges in the concurrent Management of
malaria and HIV in pregnancy in Sub-Saharan
Africa. Lancet Infect Dis 2006; 6(2): 100-11.
Reflections and Questions