Malaria in pregnancy

More than 45 million women (30 million in

Africa) become pregnant in malaria endemic areas
each year.
Common adverse effects of malaria in pregnancy include:
• Maternal anaemia
• Stillbirths
• Premature delivery and intrauterine growth retardation
result in the delivery of low birth weight infants

The WHO now recommends intermittent preventive

treatment (IPT): the administration of anti-malarial
drugs (e.g. sulphadoxine-pyrimethamine) during
antenatal care whether or not women show symptoms.
IPT has been shown to substantially reduce the risk of
maternal anaemia in the mother and low birth weight in
the newborn.
Previously, chemoprophylaxis (e.g. with chloroquine) was
recommended for all women living in malaria endemic Source:
areas. http://phil.cdc.gov/phil/quicksearch.asp
 Memilih “kurban” karena bau badan
 Waktu gigit : sore- pagi, peak midnite.
 Saliva : anti hemostatik dan anti inflamasi
 Jarak terbang : bbp kilometer
 Masa hidup : 2-3 minggu
 Darah manusia : tempat perkembangan telur
Gambaran Klinis dan
Diagnosis
 Simtom Awal :
1. Sakit kepala
2. Malaise, Kelemahan
3. Mual
4. Nyeri otot
5. Diare (ringan)
6. Demam (ringan), tdk intermitten
 Sering dianggap influensa atau GE
 Demam paroksismal setiap 48-72 jam,
dengan interval afebril
 Cenderung berulang
 Temuan Klinis :
 Gejala Paroksismal :
 Periodisitas :

- Hari 1 dan 3 : Pv, Po (dan Pf)

- Demam persisten, atau paroksismal harian
(Pf)
- Hari 1 dan 4 : Pm
 Sering sulit dibedakan dengan infeksi virus
 Demam dan Ikterik : heptitis, kolesistityis dan
abses hepar
 Pucat, Ikterik dan splenomegali :DHF/ DF,
Leptospirosis, anemia hemolitik.
 Klinis : sakit kepala, muntah, diplopia,
disorientasi, bingung, tingkah laku
abnotrmal. Sering : mengantuk dan kejang.

 Pemeriksaan : gangguan kesadaran, deviasi

mata, refleks patologis, hiper/hiporefleks,
hiper/hipotonia, kaku kuduk (iritasi selaput
otak)
 Malaria serebral (malaria otak)
 Anemia berat ( Hb < 5 gr% atau hematokrit< 15%)
 Gagal ginjal akut (vol. urin < 400 mg/24 j,
kreatinin >3 mg%).
 Edema paru atau Acute Respiratory Distress
Syndrome.
 Hipoglikemia: gula darah < 40 mg%.
 Gagal sirkulasi atau syok + keringat dingin.
 Perdarahan spontan
 Kejang berulang
 Asidemia (pH:< 7,25)
 Makroskopik hemoglobinuri karena infeksi malaria
akut
Clinical : gelisah, hiperventilasi, hipotermia, perdarahan,
koma, kejang berulang, anuria, syok
Laboratory :
 Biochemical :
◦ Hipoglikemia (<2.2 mmol/L),
◦ Hiperlaktat (>5 mmol/L)
◦ Asidosis (pH<7.3, HCO3<15)
◦ kreatinin > 265 umol/L)
◦ Bilirubin > 50 umol/L)
◦ Sgot/Sgpt: > 3 x N
◦ 5-nucleotidase
◦ CPK
◦ Myoglobin
◦ Urate > 600 umol/L
Hematology :
• Lekositosis > 12.000/uL
• Anemia ( PCV < 15% )
• Koagulopati:
• trombosit < 50.000
• Protrombin time > 3 s
• Prolong PTT
• Fibrinogen < 200 mg/dL
• Parasitology :
• Hyperparasitemia
• Mortality > 100.000/ uL
• Mortality > 500.000
• > 20 % Trophozoit & Schizont
• > 5% neutrophil + visible
pigment
 Pasien dari daerah endemis
 Serangan berulang saat anak anak
 Hepatosplenomegali
 Pemeriksaan apus darah NEGATIF
 Antibodi malaria : Positif
 Ditemukan parasit di sumsum tulang
 Hipersplenisme
 Splenomegali dengan/ tanpa hipersplenisme

 Komplikasi imunologis :
- Sindroma nefrotik
- Limfoma
Standar : mikroskopik
 85-95% sensitiv
 95-100% spesifik dibanding PCR
 Mendeteksi 0.001% parasitemia
 Dapat dikerjakan kapan saja
 Bila hasil negatif, diulang 12 jam selama 2
hari
 Negatif : hanya garis
kontrol (C) yang
muncul

 Positif P. Vivax / lain

 Positif P. Falcifarum,

 Tidak Benar
 Kasus suspek
(kriteria klinis)
Diagnosis
Alat Uji Malaria
/ Mikroskopik

Positif Negatif

Falsiparum Non Falsiparum Tetap curiga

malaria atau sakit
malaria berat
Terapi

Obati & Obati untuk sakit

Protokol Protokol perhatikan lain. Evaluasi,
Falsiparum Non Falsiparum mungkin sakit Rujuk
lain
  Cegah kematian
 Cegah kekambuhan, penularan, dan
kejadian resistensi obat
 Cegah kecacatan
1. Asesmen awal
2. Obat anti malaria
3. Pengelolaan suportif
4. Pengobatan tambahan
 Tentukan jenis plasmodium penyebab.
 Sensitivitas? Resistensi ?
 Gangguan liver? Ginjal?
 Gangguan elektrolit ?
 Hamil ?
 Berat badan ?
 Reaksi obat
 Mungkinkah diberikan per-oral ?
 Kloroquin, amiodaquine
 Quinine dan quinidine
 Mefloquine
 Lumefantrine
 Primakuin
 Artemisin
 Klindamisin
 Azitromisin
 Proguanil
 Dapsone
 Tetrasiklin, Doksisiklin
 Malaria Falsiparum
R/ ACT 4-4-4
Primakuin 3-0-0
Atau
R/ Kina 3x2 Tab (7 hari)
Primakuin 3 (1)
Doksisiklin 2x 100 mg (7 hari)
(Doksisiklin bisa diganti dengan :
Klindamisin 2x 300mg, atau
Tetrasiklin 4x 250 mg)
Malaria Vivax dan Ovale
R/ ACT 4-4-4
Primakuin 1 (14 hari)
Atau
R/ Kina 3 x 2 Tab ( 7 hari)
Primakuin 1 ( 14 hari)

 Malaria Campuran
R/ ACT 4-4-4
Primakuin 3 – 1 (13 hari)
 Tidak dapat minum obat
 Gangguan kesadaran
 Kejang kejang
 Pasien dengan Intubasi
 Pasien dengan ventilator
 Pasien pasien kritis
Artesunate/ ARTS ( i.v./ i.m / supp )
Artemether / ARTM (i.m.)
Arte-ether (i.m )
Artemisinin ( supp )
Dihydro-artemisinin ( supp )
Artelinate ( i.v)
(Quinine dan Quinidine)
(Klorokuin)
 Parenteral
 Mulai segera
 Dosis sesuai berat badan pasien
 Monitor respons
 Pindah ke oral bila memungkinkan
 Monitor efek samping
 Obat Dosis Efek Samping
Quinine
20 mg/kgkina-dihidroklorida Hipoglikemia,
Dihidro mendenging, rasa
klorida
Infus dalam 4 jam,
goyang, mual, muntah
Dilanjutkan
Bahaya !!

10 mg/kg 4 hr setiap 8 jam

Gangguan irama jantung,
hipotensi
Sampai bisa makan obat
 DRUGS Dosis SIDE EFFECTS

ARTESUNATE i.v. 2,4 mg/kg BB pada jam 0,

dan jam 12, kemudian
dilanjutkan jam 24, 48 dst
sampai 7 hari. Dosis total 17 –
18 mg/ 7 hari ( 1 Amp= 60
mg)
Artemeter Neurotoxicity in
3.2 mg/kg im pada hari I dibagi animal not human
2 dosis, dilanjutkan 1.6 mg/kg/
hari. TIDAK iv (1 amp = 80 mg)
Artemisinin
Suppositories, 10 mg/kg at 0 &
4 hr followed by 7 mg/kg at
24,36,48 & 60 hrs.

WHO 2006 : AS is the recommended FIRST CHOICE in area

low transmission
0 JAM 12.J 24.J 48.J 72.J Max 7 hari

2.4 2.4 2.4 2.4 2.4

Mg/ Mg/ Mg/ Mg/ Mg/
KgBB KgBB KgBB KgBB KgBB

ARTESUNATE I.V/ I.M

* ARTEMETER , hanya I.M , dosis 1,6 mg/kg BB

 ARTESUNATE
I.V / I.M

ARTEMETHER I.M
1 Amp = 80mg
1 fl
= 60 mg
 Drugs Dosis Side effects

Quinine 20 mg / kg (dihidroklorida) dengan Hypoglycemia,

infus iv infusion dalam 4 jam.
Lanjutkan dengan 10 mg/kg dlm
infus selama 4jam setiap 8 jam.
(Pasien tidak boleh mendapatkan
kina /meflokin dalam 24 jam terakhir)
Cara lain
7 mg /kg di infuskan dalam 30 min,
lanjutkan 10 mg /kg dalam 4 jam.
Atau 10 mg /kg dalam infus selama 8
kontinu 3 x hari
chinchonism, tinnitus,
hearing impairment,
nausea, dysphoria,
vomiting, prolonged QT
interval, dysrhythmias,
hypotension
 Tidak perlu penyesuaian dosis obat derivat
artemisinin pada gangguan fungsi hati dan
atau ginjal
 Dosis kina parenteral diturunkan 1/3 setelah
48 jam pemberian pada :
Gagal ginjal akut
Gangguan fungsi hati
Tidak ada perbaikan klinis setelah 48 jam
Bila pasien sudah hemodialisis tidak perlu
pengurangan dosis kina
 Setelah pasien sadar/KU membaik, tx. Awal
parenteral dapat diubah dgn. Tx. Oral
 Diteruskan dengan :
 ACT dosis lengkap (selama 3 hari):
 Artesunate/artemether tab. (total 7 hari ) +
doksisiklin 3-5 Kg BB 1 kali sehari selama 7 hari
 Kina tab.(total 7 hari) + doksisiklin 7 hari
 Bagi bumil, anak-anak : doksisiklin diganti dengan
klindamisin 10 mg/Kg BB 2 kali sehari
 Dianjurkan sebelum merujuk setidaknya
dosis pertama obat antimalaria parenteral
sudah diberikan.
 Obat yang dipilih :
 Artemether i.m. atau Artesunate i.m.
 Artesunate atau artemisinin supositoria
 Kina i.m.
 Kina i.v. (didampingi petugas medis ) ??
 1. Cerebral malaria - clinical
 The most well-known severe
manifestation of malaria
 Defined as:
◦ unarousable coma persisting
for more than one hour
◦ with asexual forms of P.
falciparum in the peripheral
blood
◦ other common causes of
encephalopathy excluded*
 Occurs most commonly in young
children although non-immune
adults are also at risk
A 4 year old boy who was
 Cerebral malaria can rapidly
progress to death, even with deeply comatose and had
appropriate treatment. Case persistent deviation of the eyes
fatality is between 20-30%.
 In survivors, resolution of coma
usually occurs within 1-2 days in
children and within 2-4 days in
adults but may be complicated
by neurological sequelae in ~5%
adults and >10% of children.
 Cerebral malaria -
pathophysiology
A young girl with cerebral malaria. Note induce the release of nitrous oxide, a
the abnormal, decerebrate posturing
The exact pathogenesis of cerebral
malaria is not well understood. It is
believed to result from sequestration of
parasitised red cells in the small blood
vessels in the brain. The consequences
of this include:
• reduced cerebral blood flow
• cerebral hypoxia
• release of cytokines which in turn
known depressor of consciousness

Sequestration of parasitised
red cells in different tissues
probably underlies most
severe manifestations of
malaria

A 3 year old boy with impaired

consciousness, grimacing and
marked extensor posturing of the
arms
2. Severe malaria anaemia
Defined as a haematocrit of <15% or
haemoglobin concentration <5 g/dl.

Occurs commonly in young children and

pregnant women.

Anaemia in malaria results from a

combination of factors:
 Destruction of parasitised red blood
cells
 Destruction of unparasitised red cells
by complement-mediated lysis
 Bone marrow suppression by
cytokines produced by malaria
parasites
 Haemolysis induced by medications in
individuals with glucose-6-phosphate Marked pallor in an African
dehydrogenase deficiency child with severe anaemia due
to P. falciparum infection
Many patients require urgent
transfusion. The condition may be
rapidly fatal when blood transfusion is
delayed. Bac
3.Hypoglycaemia
 Blood sugar <2.5 mmol/L
 Increases the risk of mortality and
sequelae in children with cerebral malaria;
may present with convulsions or a
deterioration in level of consciousness.
 Results from a combination of factors:
◦ reduced glycogen stores because of
reduced food intake
◦ increased metabolism due to fever and
repeated convulsions
◦ glucose consumption by malaria
parasites
◦ cytokine or quinine-stimulated
hyperinsulinaemia Bac
k
4. Metabolic acidosis
 Lactic acidosis is a major contributor and
probably results from tissue anoxia and
anaerobic glycolysis

 Presents with deep, rapid respirations

(as in diabetic ketoacidosis)

Bac
5. Acute renal failure
 occurs almost exclusively in adults and
older children in areas of unstable malaria

 affected patients are usually oliguric

(urinary output <400 ml/day) or anuric
(<50 ml/day)

 serum creatinine levels are elevated

Bac
 6. Acute pulmonary oedema
This is a grave and usually fatal
manifestation of severe falciparum
malaria and occurs mainly in adults.
Hyperparasitaemia, renal failure
and pregnancy are recognised
predisposing factors and the
condition is commonly associated
with hypoglycaemia and metabolic
acidosis.

Acute pulmonary oedema, developing

shortly after delivery in a woman with
severe P. falciparum malaria

Bac
 7. Circulatory collapse, shock,
“algid malaria”

Features of circulatory collapse (cold/clammy skin, hypotension,

peripheral cyanosis, weak/thready pulses) may be seen in patients
with severe P. falciparum malaria.

“Algid malaria” is characterised by hypotension, vomiting, diarrhoea,

rapid respiration and oliguria. This condition is associated with a poor
prognosis.

Bac
 8. Haemoglobinuria or “Blackwater
Fever” Typical, dark urine of
haemoglobinuria on day 0 which has
This results from massive cleared by day 3
intravascular haemolysis. The
condition presents with severe
pallor, jaundice and passage of
dark urine due to haemoglobinuria.
It may be associated with acute
renal failure.

A 3 year old boy with severe

anaemia (Hb 3.3 g/dl) and dark
urine (shown in the container)