Malaria During Pregnancy

Malaria infection in pregnancy is a noticeable public health issue that requires multidimensional and multidisciplinary solutions. Pregnancy and malaria are both mutually aggravating situations. The physiological transformations during pregnancy and pathological transformations because of malaria have a combined effect onto the progression of each other, hence making life of the mother difficult and also of the child along with the physician who is treating. P. falciparum malaria may run a dramatic and turbulent course within pregnant ladies. The primi gravidae,  non- immune are generally the highest affected. In pregnant ladies the illness because of malaria involves anaemia, hypoglycaemia, fever illness, pulmonary edema, cerebral malaria, puerperal sepsis and also mortality may occur due to haemorrhage and severe malaria. The issues in new-borns comprise of lower birth weight, IUGR, malaria illness, prematurity and mortality.

Malaria during Pregnancy : How is it different  in comparison with general population

• More common – Because of  immunosuppression
• More atypicalin its presentation – This may be becayse of the hormonal, hematological and immunological changes during pregnancy.
• More fatal and more severe – Because of high prasitaemia
• Treatment can become tough – This is because few anti malarials are contra indicated during pregnancy and few may lead to highly adverse effects
• Management of complications posed by malaria may be tough– This is because of several physiological transformations during pregnancy. Careful observation has to be made into fluid management and temperature monitoring, etc. Decisions about induction of labour can be tough and complex also. Foetal loss, premature labour and IUGR are common.
• Atypical appearances of malaria– Symptoms like fever, anaemia, splenomegaly, acute pulmonary edema, etc, are seen.

Problems of Malaria during Pregnancy:

• Anaemia Anaemia because of  malaria is more severe and common from 16-29 weeks. Pre-existing iron along with folate deficiency can worsen the anaemia of malaria and vice versa. Anaemia raises perinatal mortality, maternal morbidity and also mortality. It also raises the danger of pulmonary oedema. Danger of post-partum haemorrhage is higher too.
• Acute pulmonary oedema:It is also a very common problem of malaria during pregnancy in comparison with non-pregnant populace. It is very common in 2^ndand in 3^rd It may develop unexpectedly in instant post-partum time because of auto transfusion of the placental blood with a high proportion of the parasitized RBC’s and also sudden rise in the  peripheral vascular conflict post delivery. It is worsened by pre-existing anaemia and also hemodynamic transformations in pregnancy. Acute pulmonary oedema comprises of a very high rate of mortality.
• Risks for foetus: Malaria during pregnancy is harmful to foetus. Both falciparum malaria and P. vivax  can cause issues to the foetus, especially the latter being comparatively more serious. Spontaneous abortion, still birth, pre mature birth, placental insufficiency & IUGR (chronic / temporary), low birth weight, foetal distress is different issues observed in a growing foetus. The Transplacental spread of infection into the foetus can lead to congenital malaria.

Malaria Management during Pregnancy:

It comprises the following 3 aspects:

• Treatment – treatment of malaria during pregnancy must be anticipatory, energetic, and very careful.

Anti malarials during pregnancy:

 All trimesters: Quinine; Chloroquine; Artesunate / Arteether /Artemether 2^nd trimester: Pyrimethamine; Mefloquine / sulfadoxine
3^rd trimester: Mefloquine; Pyrimethamine / sulfadoxine
Contra indicated: Tetracycline; Primaquine; Halofantrine; Doxycycline

 Malaria Prevention in pregnancy:

WHO recommends the below:

• Usage of LLINs or long-lasting insecticidal nets;
• In all regions with moderate or high malaria transmission within Africa, Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), as a part of the antenatal care services

 However, in India, LLIN is unavailable widely across public health system and SP-IPT is inappropriate as epidemiology is different within India. Also resistance is found to SP in north eastern provinces of India.

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