Malaria in Pregnancy

Malaria is a disease caused by a parasite of plasmodium genus.Anopheles mosquito which serves as a vector.

Its transmission in Kenya varies with regions;

• Endemic-all year.eg coast and around L. Victoria.
• Seasonal-during rainfall. North and S.E Kenya
• Low risk-central Kenya
• Epidemic-outbreaks in Western highlands

Risk factors for severe disease.

• Women in their first and second pregnancy
• HIV/AIDS
• Visitors from areas of no or low malaria transmission

Clinical presentation

• Uncomplicated malaria
  • Fever
  • Chills and rigors
  • Headache
  • Muscle or joint pain
  • Nausea and vomiting
  • Preterm labour

• Complicated malaria
  • Symptoms and signs of uncomplicated malaria plus :
  • Confusion
  • Drowsiness
  • Coma
  • Difficulty in breathing
  • Pallor
  • Jaundice
  • Convulsions
  • Dehydration
  • Spontaneous bleeding

Investigations

• Bloodslide for malaria parasites
• Full hemogram- Anaemia
• Random blood sugar-low blood sugar
• Arterial blood gases-Metabollic acidosis
• Urea electrolytes and creatinine-acute renal failure
• Coagulation profile if coagulopathy.

Differential diagnosis

• Eclampsia
• Bacteremia
• Meningitis
• Viral illnesses

Management

If parasitological diagnosis delays or is absent, start treatment.

1. Uncomplicated malaria
2. First trimester – 7 days of oral quinine. Give AL if quinine not available.
3. Second trimester and third – AL. quinine is an alternative

• Complicated malaria

The recommended medicine is parenteral artesunate. Artemether or quinine can be used if no artesunate.

• Artesunate is best given IV. However it can be given IM if no IV access. Loading dose = 2.4 mg/kg, followed by 1.2mg/kg at 12 and 24^th hour then once daily till patient can feed.
• For quinine, give a loading dose of 20mg/kg diluted in 15ml/kg of 5% dextrose (max 500ml) to run over 4 hours. Give 10mg/kg diluted in 10ml/kg of 5% dextrose at hour 8 then 8 hourly till the patient can feed orally.
•  Once oral feeds are tolerated give AL orally for 3 days.

 If the level of consciousness is altered, administer antibiotics such as ceftriaxone.

• Supportive management
• Antipyretics
• Monitor and control blood sugar especially if on quinine
• Fetal monitoring
• Treat

Prevention

• Patient education encouraging the use of the preventive services.
• Intermittent preventive treatment for malaria in pregnancy (IPTp). Sulphadoxine 500mg and Pyrimethamine 25mg (SP) at an interval of at least a month and at least 3 doses during the pregnancy. Don’t give it to women already on cotrimoxazole
• Long lasting Insecticidal Nets.
• Prompt diagnosis and treatment of fever

Complications

• Anemia
• Increased risk of maternal illness and death
• Miscarriage,
• Stillbirth
• Low birth weight
• Neonatal death           
• Complications of severe malaria –hypoglycaemia, acute renal failure, acute pulmonary edema, metabolic acidosis, shock, coagulopathy.