Malaria Dalam Kehamilan

Erni Juwita Nelwan

Divisi Tropik dan Penyakit Infeksi
FKUI - RSCM
 MATERNAL EFFECTS OF MALARIA

Anaemia in pregnancy
More common and severe young primigravidae
Starts in mid trimester btn 16 24 th weeks of GA

Mechanisms:
a. Haemolysis and sequestration of infected
RBCs into the RES.
b. Haemolysis of non-parasitized RBCs
Non-parasitized RBCs may be may be opsonized
and develop auto-antibodies that make them prone
to haemolysis. Such opsonized RBCs are
sequestrated into the spleen and removed
from circulation by lympho-macrophages
 Malarial anaemia in pregnancy cont

c. Bone marrow suppression and

dyserythropoiesis (ineffective
erythropoiesis):
Tumor necrosis factor (TNF) is thought to
mediate bone marrow suppression by inducing
dyserythropoiesis and reducing erythroid
proliferation.
d. Loss of appetite
FETAL EFFECTS OF MALARIA
1. Pyrexia is associated with
Induction of uterine contractions leading to
Abortions, preterm labour
IUFD and fetal distress.

2. Placental Parasitization:
Presents with clogging of the intervillous spaces
with macrophages (placental reaction), which is
most marked during the second half of pregnancy:
Ultimate effect of placental parasitization:
IUGR, LBW, IUFD
 IMMUNITY IN ENDEMIC AREAS

1. Maternal immunity
Generally, immunity declines in pregnancy
Probably due to increased levels of cortisol, hence
increased susceptibility to falciparum malaria in
pregnancy

Immunity for malaria decrease is more

marked in primes and younger women
particularly in the third trimester, than in
multips and older women.
Fetal immunity in endemic areas

Protective mechanisms of the fetus in utero

a. Immune mother transmit passive immunity
(antimalarial IgG) to the fetus.
The few parasites that succeed are destroyed by
the antimalarial IgG
b. The placenta greatly limits the number of
parasites gaining access into the fetal
circulation.
c. Falciparum parasites do not grow well in fetal
RBC containing Hb F.
Fetal immunity in endemic areas cont

IMPORTANT NOTE:

1. These protective mechanisms wane after

birth

2. In non endemic areas usually there is low

maternal immunity, hence no protection
against development of congenital
anaemia.
 DIAGNOSIS OF MALARIA

1. Importance
Help to reduce unnecessary use of antimalarials.
High specificity can reduce unnecessary
treatment with antimalarials and improve
differential diagnosis of febrile illness.
2. Methods
The diagnosis of malaria is based on:
Clinical diagnosis - has very low specificity
Detection of parasites in the blood.
 DIAGNOSIS OF MALARIA cont

If blood results are not readily available,

Weigh the risk of withholding antimalarial treatment
against the risk associated with antimalarial
treatment when given to a patient who does not
have malaria
Methods in use for parasitological diagnosis
i. Light microscopy
Low cost, high sensitivity and specificity when
used by well-trained staff.
ii. Rapid diagnostic tests (RDTs)
Used to detection of parasite antigen
 DIAGNOSIS OF MALARIA cont

In areas of high stable malaria transmission,

Under fives should be treated on the basis of a
clinical diagnosis.
A parasitological diagnosis is recommended before
treatment is started in:
Older children and adults
Pregnancy
All suspected cases of severe malaria
 RESISTANCE TO ANTIMALARIAL DRUGS

Resistance has arisen to all classes of

antimalarials except, as yet, to the artemisinin
derivatives.
Resistance can be prevented, or its onset
slowed considerably,
By combining antimalarials with different mechanisms
of action and ensuring very high cure rates through
full adherence to correct dose regimens
Potential resistance to antimalarials has been
documented for P. falciparum, P. vivax
 RESISTANCE TO ANTIMALARIALS cont

In P. falciparum, resistance has been observed

to almost all currently used antimalarials
(amodiaquine, chloroquine, mefloquine, quinine
and sulfadoxinepyrimethamine) except for
artemisinin and its derivatives.

The geographical distributions and rates of

spread have varied considerably

Impact of resistance
Increased the global malaria burden and is a major
threat to malaria control.
 ANTIMALARIALS IN PREGNANCY

No sufficient information on the safety and

efficacy of most antimalarials in pregnancy,
particularly for exposure in the first trimester, and
so treatment recommendations are different to
those for non-pregnant adults.
 ANTIMALARIALS IN PREGNANCY cont

The antimalarials considered safe in the first

trimester of pregnancy are
Quinine, chloroquine, proguanil, pyrimethamine and
sulfadoxinepyrimethamine.
Of these, quinine remains the most effective and
can be used in all trimesters of pregnancy
including the first trimester.

Amodiaquine, chlorproguanil- dapsone, halofantrine,

lumefantrine and piperaquine
Have not been evaluated sufficiently to permit
positive recommendations.
 ANTIMALARIALS IN PREGNANCY cont

Sulfadoxinepyrimethamine
Is safe but may be ineffective in many areas
because of increasing resistance.

Primaquine and tetracyclines

Should not be used in pregnancy.

NOTE:
Despite these many uncertainties, effective treatment
must not be delayed in pregnant women.
 TREATMENT OF MALARIA IN PREGNANCY

I. UNCOMPLICATED MALARIA
First trimester:
Quinine (orally) for 7 days.
ACT should be used if it is the only effective
treatment available.

Second and third trimesters:

ALL effective drug can be used
 TREATMENT OF MALARIA IN PREGNANCY cont

SEVERE MALARIA
Quinine 10 mg/kg body weight
Dilute in 5 10 ml/kg body weight of 5% Dextrose or
dextrose saline
Infused over 4 hours and repeated every 8 hours

Drop rate per minute = amount of fluid to be infused x 20 (drop factor)

Time period to be infused (in minutes)

Discontinue infusions once the patient is able to take oral

medication. alternatively a full course of ACT should be
used for 7 days
 TREATMENT OF MALARIA IN PREGNANCY cont

Dilution of quinine for i.m

Dose: 10 mg/kg

Dilute four times in water for injection or

normal saline to a concentration of 60 mg/ml.

This dilution minimizes the risk of abscess

formation
 WHO package of interventions for the prevention
and control of malaria during pregnancy

1. Use of insecticide treated nets (ITNs) to

prevent infection
2. Intermittent Preventive Treatment (IPT)
To prevent asymptomatic infections among
pregnant women living in areas of moderate or high
transmission of P. falciparum
3. Effective management and prevention of
malaria illness and anaemia.
Prevalence of parasitemia 16.8% (432 / 2570)
P. falsiparum infection 250 (57.9%)
P. vivax 146 (33.8%)
Mixed infection 36 (8.3%)

P. falsiparum infection:
-Severe anemia 2.8 (95% CI 2.0 4.0)
-Lower birth weight 192g (119 265g)
P. vivax infection:
-Moderate anemia 1.8 (95%CI 1.2 2.9)
-Lower birth weight 108 (17.5 199)
Parasitemia associated preterm delivery 1.5 (95% CI 1.1 2.0)
Still birth 2.3 (95% CI 1.3 4.1)