Malaria in pregnancy and management; mosquito has been a dangerous insect long before zika virus

Emobileclinic Patient’s corner

Emobileclinic Specialist

Malaria remains a major health problem in Nigeria. More than 60% outpatient visits in Nigeria are due to malaria. Malaria is an important cause of death and illness in children and adults in tropical countries. It is very important cause of maternal and perinatal morbidity and mortality; women are being susceptible to malaria during pregnancy and in the puerperium.There are over 300-500 million infections and 1.1-2.7 million death each year.
In a stable malaria region (holo-endemic), immunity to malaria is made up of genetic, racial, passive immunity at birth and active immunity developed due to exposure. This immunity is depressed in pregnancy, but most profound in primigravida ( First time pregnancy) The consequence of this altered immunity to malaria in pregnancy results in many complications to both the mother and foetus. There is increase frequency and severity of malaria attacks. This was demonstrated in the story earlier presented with repeated malaria attacks in pregnancy leading to anaemia as shown by low packed cell volume of 27% at presentation. Several studies have suggested that the difference in susceptibility to falciparum between women who are pregnant and those who are not stems from the difference in cytoadherence properties of the infecting parasite.
There is high incidence of anaemia in pregnancy, malaria being second only to iron deficiency as the main cause of anaemia in pregnancy, having been implicated in the most cases. The patient earlier discussed had mild anaemia and was febrile at presentation.

Other effects of malaria in pregnancy include;

• Abortion

•  Preterm labour

•  Low birth weight

•  Intra-uterine foetal death from hypoxia in extreme cases( especially in non immune woman)

The diagnosis in the case presented was based on periodicity of the fever chills and rigor ,absence of any focus of bacterial infections and high index of suspicion. This was also confirmed by positive results of malaria parasite on the thick blood film. However non – identification of malaria parasite from the blood film does not exclude the diagnosis of malaria in malaria endemic region, as the incidence of false negative results may be as high as 15%. This observation led to the recommendation that any pregnant woman with anaemia in the malaria endemic areas should be treated for malaria regardless of the blood film report. Recent efforts have yielded more tools to diagnose reliably and accurately malaria attacks other than the old reliable but cumbersome microscopic examination of blood. Rapid diagnostic test is a device which detects specific antigens (proteins) produced by malaria parasite. The RDT signifies presence of antigens by colour change on nitrocellulose strip (test strip). They provide a useful guide to the presence of clinically significant malaria infection, complementing microscopy based diagnosis where such services are not available. The availability of rapid diagnostic test has made it possible to improve and expand diagnostic testing for malaria. The rate of testing-in the public sector in Africa – rose from less than 5% in 2000 to 45% in 2010.
Treatment of acute malaria include;

•  Bed rest

•  Administration of intravenous fluid for rehydration

•  Correction of electrolyte and acid/base imbalance

•  Reduction of pyrexia by tepid- sponging

•  Anti-pyretic analgesia such as paracetamol

•  However the main stay of treatment is administration of effective anti- malaria agents in use in the locality. Arteminisimine -based combination therapy are now generally considered as the best current treatment for uncomplicated malaria. Our patient was treated along this line with artenether and lunefantrine combination, other ACT is Artesunate- Amodiaquine combination. The use of monotherapy is not recommended. The antimalaria medicine recommended for treatment in Nigeria is intravenous or intramuscular Artesunate (2.4mg/kg body weight IV/IM start, repeat after 12 hours and 24 hours ,then once daily for 6 days) . Where this is not available, intravenous or intramuscular quinine and intramuscular artemether can be used as alternative.

  Our patient responded promptly and was placed on haematinics,as the level of anaemia was mild and gestation was 28 weeks , which means she had enough time to build up her heamogram. She was also started on malaria chemoprophylaxis in pregnancy by given intermittent Sulphadoxine-pyrimethamine . Other agents that can be used include daily Proguanil after clearing parasitaemia especially in the sickle cell disease patients. The current trend however is to give intermittent preventive therapy with Pyrimethamine/Sulphadoxine twice in pregnancy. It is best given when the foetal growth velocity is at its highest in order to reduce placental parasitaemia and resultant foetal retardation. IPT is given as a one-dose of a full course treatment after quickening as Direct Observed Therapy (DOT) and the second dose is given not earlier than one month after the first dose ,up to 36 weeks. Pregnant women who are HIV positive and on co- trimoxazole chemoprophylaxis ,should not receive IPT. This is because of their increased risk to the adverse effects of the Sulphonamides. They are encouraged to use other preventive measures such as regular use of Long Lasting Insecticide Nets (LLINs).

 Malaria can be prevented by vector control measures such as Inside Residual Spraying ( IRS) method and common environmental hygiene such as clearing the bush and stagnant pools of water surrounding the houses. All these measures were explaned to our patient and she did not have another attack during the rest of the pregnancy. She had a live birth of an average weight infant .