Malaria in pregnant women

Treating and preventing malaria in pregnant women. Guidelines in Chaaria. Kenya Pregnant women and children less than 5 years old are at special risk of serious consequences of malaria.

Malaria infection can have very serious consequences for the mother (anaemia and febrile illness), the developing foetus and newborn infants (particularly low birth weight babies) and is associated with infant mortality.

Women in their first and second pregnancy and pregnant women who are also infected with HIV are at greatest risk from the effects of malaria. 

DIAGNOSIS AND TREATMENT OF SEVERE MALARIA IN PREGNANCY

Severe malaria in pregnancy is a medical emergency that puts both the lives of the mother and baby at high risk.

Aggressive management is essential.

Features of severe malaria in pregnant women are similar to non-pregnant population. However, pregnant women have an increased risk of hypoglycaemia and severe anaemia.

Eclampsia is a differential diagnosis in pregnant women presenting with convulsions or alteration in level of consciousness.

In all suspected cases of severe malaria, a parasitological confirmation of the diagnosis of malaria is recommended.

In the absence of or delay in obtaining a parasitological diagnosis, patients should be treated for severe malaria on clinical grounds.

TREATMENT OF SEVERE MALARIA

The recommended medicine of choice is parenteral quinine, and the preferred route of administration is the intravenous route.

However, the intramuscular route can be used as an alternative where intravenous route is not feasible.

Because of the increased risk of hypoglycaemia in pregnant women, 5% dextrose is the preferred infusion solution for quinine administration.

Note: pregnancy is not a contraindication for the use of a loading dose regimen of quinine.

DIAGNOSIS AND MANAGEMENT OF UNCOMPLICATED MALARIA IN PREGNANCY

Due to the increased risk of severe disease in pregnancy, uncomplicated malaria is an emergency and requires very effective treatment with lowest possible clinical failure.

Diagnosis of Uncomplicated Malaria: clinical symptoms are as in the non pregnant population. In ALL PREGNANT WOMEN with fever or history of fever, the use of parasitological diagnosis is RECOMMENDED.

At health facilities where malaria diagnostics (microscopy) are not available, patient with fever or history of fever in whom the health worker suspects malaria and has eliminated other possible causes of fever, should be presumptively classified and treated as malaria.

TREATMENT OF UNCOMPLICATED MALARIA IN PREGNANCY

The recommended treatment of uncomplicated malaria in all trimesters of pregnancy is a 7-day therapy of oral quinine.

However, artemether-lumefantrine (COARTEM) can also be used in the 2nd and 3rd trimesters.

Do not withhold artemether-lumefantrine in the 1st trimester if quinine is not available.

SUPPORTIVE CARE

Prevent hypoglycaemia

Monitor the foetus’ wellbeing

Treat anaemia

Give antipyretics

INTERMITTENT PREVENTIVE TREATMENT IN PREGNANCY(IPTP)

Intermittent preventive treatment for pregnant women (IPTP) is the use of antimalarial drugs given in treatment doses at defined intervals after quickening (start of fetus kicks), to clear a presumed burden of parasites.

The use of IPTP is based on the assumption that every pregnant woman living in an area of high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria.

Preventing parasites from attacking the placenta helps the foetus develop normally and avoids low birth weight.

IPTP is important because many pregnant women with malaria have no symptoms but still may have malaria parasites in their blood.

All pregnant women living in areas of high malaria transmission should receive IPTP.

Pregnant women who are HIV-positive and are also taking antiretroviral therapy for the prevention of mother-to-child transmission (PMTCT) should receive IPTP.

Pregnant women who are HIV-positive and are taking daily cotrimoxazole chemoprophylaxis should NOT be given IPTP.

The recommended medicine for IPTP is sulphadoxine (500mg) pyrimethamine (25mg) (SP or FANSIDAR) given as a dose of three tablets, under directly observed therapy (DOT) in the antenatal clinic. IPTP with SP can be given on an empty stomach.

While SP is no longer Kenya’s first-line drug due to resistance problems, it is still effective when used for IPTP and it is safe.

We are supposed to administer IPTP with each scheduled visit after quickening to ensure women receive at least 2 doses.

Women known to be HIV-infected or with unknown HIV status living in areas of high HIV prevalence (>10% among pregnant women) should receive at least 3 doses of IPTP.

IPTP should be given at an interval of at least 4 weeks (1 month).

INSECTICIDE-TREATED NETS (ITNs)

The use of ITNs is encouraged for everyone living in high transmission areas, but it is especially important to encourage those at highest risk (pregnant women and children under 5) to sleep under an ITN. ITN use should be encouraged throughout pregnancy and after delivery.

Bro Beppe