Malaria In Pregnancy 4

Malaria During Pregnancy Dr. Emmanuel Oladipo Otolorin

Objectives • Describe the impact of malaria on pregnancy and the newborn • Discuss the impact of malaria on HIVinfected pregnant women • Discuss malaria control during pregnancy, including prevention and case management of malaria illness

Malaria During Pregnancy

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Why Is the Issue of Malaria During Pregnancy Important? • Each year, more than 30 million women in Africa become pregnant in malariaendemic areas. • Malaria during pregnancy in malariaendemic settings may account for: – 2-15% of maternal anemia – 5-14% of low birth weight newborns – 30% of “preventable” low birth weight newborns 3-5% deaths Source: – WHO 2002. of newborn Malaria During Pregnancy

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Primigravida

Multigravida

st

aU

i al aw M

Za ire

er ia N ig

G

am bi

aR am bi

G

C oa

a Iv or y

Ta nz an i

a

70 60 50 40 30 20 10 0 U ga nd

Prevalence %

Prevalence of Placental Malaria in African Women by Gravidity in Eight Studies

Malaria During Pregnancy

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Characteristics of Stable and Unstable Areas of Malaria Transmission • Stable Areas

• Unstable Areas

– People receive – People are frequent infective infrequently mosquito bites exposed to malaria each month – Levels of acquired – Levels of acquired immunity are low immunity are high (pregnant women (pregnant women are not immune) are semi-immune to malaria) – Heavy peripheral – Low peripheral parasitemia parasitemia Malaria During Pregnancy 5 – Low or

Effect of Malaria on Pregnancy in Stable Transmission Areas Plasmodium falciparum malaria Asymptomatic Infection Placental Sequestration Altered Placental Integrity Reduced Nutrient and Oxygen Transport Anemia

Low Birth Weight (IUGR) Risk of Newborn Mortality

Source: WHO 2002.

Malaria During Pregnancy

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Effect of Malaria on Pregnancy in Unstable Transmission Areas Acquired Immunity – Low

Clinical Illness

Severe Disease

Risk to Mother

Source: WHO 2002.

Risk to Fetus

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Effects on the Pregnant Woman

Effects

Primigravid All parities ae in in Unstable Stable malaria malaria areas areas + +++ +++ + ++ ++

• High fever • Placental infection • Puerperal sepsis ( +++ =Very Common, ++ =Common, + =Infrequent, -- =Rare) • Complicated +++ +++ Malaria During Pregnancy malaria

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Effects on the Fetus and Newborn

Effects

• Low birth weight

Primigravid All parities ae in in Stable Unstable malaria malaria areas areas +++

+

-

++

– IUGR ( +++=Very Common, ++=Common, + +=Infrequent, -- =Rare) ++ – Prematurity Malaria During Pregnancy

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Placental Parasitemia by Pregnancy Number Kenya, 1996-1998 Parasite density/mm3

% parasitemic

30

1-999

25

1000-9,999

>10,000

20 15 10 5

772

0 First Pregnancies

Source: van Eijk AM et al 2001.

402

479

Second Pregnancies

Three or more pregnancies

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Frequency of Low Birth Weight by Placental Malaria Infection Malawi 1988-1991

% Low Birth Weight

35 30 25 20 15

With placental parasites

10

Without placental parasites

5 0

First Pregnancy

Source: Steketee 2001.

Second Pregnancy

Three or more pregnancies

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% parasitemic

Placental Parasitemia by HIV Status and Pregnancy Number 40 35 30 25 20 15 10 5 0

Parasite density/mm3

Kenya, 1996-1998 1-999

231

G1

159

G2 HIV (+)

1000-9,999

>10,000

197

772

402

479

G3

G1 G2 HIV (-)

G3

Summary RR = 1.63 (1.41-1.89), p <0.001

Total n = 2263

Source: van Eijk AM et al 2001.

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Components of Malaria Control During Pregnancy

1.Quality focused antenatal care and health education 2.Intermittent preventive treatment (IPT) 3.Use of insecticide-treated nets (ITNs) 4.Case management of malaria disease

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Proportion of Pregnant Women Seeking Care at an Antenatal Clinic at Least Once Survey year ranges from 1988-1999

100 90

Percenta ge

80 70 60 50 40 30 20 0

Zambia Zimbabwe Botswana Kenya Uganda Malawi Tanzania Ghana Namibia Cote d’Ivoire Togo Senegal Benin Cameroon Guinea Mozambiq ue CAR Burkina Faso Nigeria Eritrea Mali Niger Chad

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Source: WHO 2002.

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1. Antenatal Care and Health Education • Antenatal visits provide a unique opportunity for: – Monitoring of maternal and fetal health during pregnancy – Provision of micronutrient supplementation (e.g., iron folate) – Health education and counseling about malaria during pregnancy – IPT with an effective antimalarial drug (e.g., sulfadoxine-pyrimethamine, SP) Malaria During Pregnancy 15 – Prompt diagnosis and treatment of malaria

Health Education on Malaria During Pregnancy: What To Tell Patients

• Pregnant women (especially primigravida, secundigravida and HIV-infected women) are at higher risk of malaria • Malaria:

– Is transmitted through mosquito bites – Can cause severe anemia, with adverse consequences for mother and baby – Can cause abortions, stillbirths and result in low birth weight newborns – Can be prevented through the use of IPT and16 Malaria During Pregnancy

•

2. Intermittent Preventive Treatment (IPT) An approach for effectively preventing and

controlling malaria during pregnancy • Based on an assumption that every pregnant woman in a malaria-endemic area is infected with malaria • Recommends that every pregnant women receive at least two treatment doses of an effective antimalarial drug • Sulfadoxine-pyrimethamine (SP) currently considered the most effective drug for IPT Malaria During Pregnancy

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•

IPT with SulfadoxinePyrimethamine (SP) SP is a combination of two different drugs. Each tablet of SP contains: – 500 mg of sulfadoxine, and – 25 mg of pyrimethamine

• A single dose consists of three tablets taken at once, preferably under direct observation of the healthcare provider • Fansidar is the most common brand name. Others include Falcidin, Laridox, Maladox, Orodar Malaria During Pregnancy

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Effect of Intermittent Preventive Treatment Case Twowith SP Monthl manage Kenya dose 1998 ment SP N=472 N=432

Mean 9.9 Hb. Maternal parasite 27% mia Source: Steketee 2001. Placenta

10.2 9% Malaria During Pregnancy

y SP N=431

p

10.4

< 0.05

7%

0.00 4 19

Fetal Growth Velocity Fetal growth velocity 

Last month

10 Conception Source: WHO 2002.

16

20

Weeks of gestation Malaria During Pregnancy

30 Birth 20

Fetal Growth Velocity Fetal growth velocity 

Last month

Quickening

10 Conception Source: WHO 2002.

16

20

Weeks of gestation Malaria During Pregnancy

30 Birth 21

Rationale for the Timing of the SP Doses Fetal growth velocity  Rx

Rx

Last month

Quickening

10 Conception Source: WHO 2002.

16

20

Weeks of gestation Malaria During Pregnancy

30 Birth 22

Key Issues About Timing of Doses • SP should be avoided during the first 16 weeks of pregnancy which is the period of initial development of the fetus • It is best to clear the placenta of parasites during the period of maximum fetal growth • IPT allows the mother to recover from anemia by clearing peripheral parasitaemia Malaria During Pregnancy

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Steps for Providing IPT with SP • • • •

Determine quickening has occurred Inquire about history of severe skin rash Inquire about use of SP in last month Provide three tablets of SP with clean water in a clean cup • Observe the patient swallowing all three tablets (Directly Observed Treatment or DOT strategy) Malaria During Pregnancy

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Steps for Providing IPT with SP continued • Record SP on the antenatal card and the clinic record • Instruct patient to return at next scheduled visit or earlier if she is feeling ill • Ask about side effects from previous dose before giving the next dose, which should not be less than 4 weeks from the last dose Malaria During Pregnancy

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3. Use of Insecticide-Treated Nets (ITNs) ITNs: • Have been shown to result in reduction of newborns born with low birth weight or prematurely • Reduce transmission by physically preventing vector mosquitoes from landing on sleeping Malaria During Pregnancy persons

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ITN: Impact on Fetal Growth and Duration of Gestation % 45

Premature

SGA

Percentage

40

Premature or SGA

35 30

control

25

bednets

20 15 10 5

>4 G

<3 G

>4 G

<3 G

>4 G

G

<3

0

Gravidity Source: ter Kuile et al 1999.

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Impact of ITNs on Maternal and Newborn Health

Among Gravidae 1-4, ITNs were associated Western Kenya with: • During pregnancy – 38% reduction in peripheral parasitemia – 21% reduction in all causes of anemia (Hb < 11 g/dl) – 47% reduction in severe malarial anemia

• At delivery – 23% reduction in placental malaria Source: – Shulman 2001. Malaria During Pregnancy 28% reduction in LBW

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4. Case Management: Drug Efficacy • Effective drugs are needed for P. falciparum malaria as it can be fatal to both mother and child • Drug of choice depends on the geographic drug resistance profile: – Chloroquine is the drug of choice in few areas where it is still effective – SP often next choice – Quinine is the drug of choice for complicated malaria Malaria During Pregnancy 29

Treatment of Symptomatic Patients • Uncomplicated malaria – Provide first line antimalarial drug approved for use during pregnancy – Treat fever with analgesics – Diagnose and treat anemia – Provide fluids

• Complicated malaria

– Weigh patient – Administer quinine as soon as it is diluted – Manage fever (analgesics, tepid sponging) – Provide rehydration as needed – Monitor for severe Malaria During Pregnancy anemia, 30

Resistance to Drugs • Resistance of P. falciparum to antimalarial drugs is an ever increasing problem • To minimize the problem of drug resistance, encourage women to complete their course of antimalarial drugs, even when they feel better • Drug resistance is inevitable; therefore healthcare providers must stay informed about policy changes recommended by their Ministry of Health Malaria During Pregnancy

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Drugs That Should Not Be Used During Pregnancy • Tetracycline – Cause abnormalities of skeletal and muscular growth, tooth development, lens/cornea

• Doxycycline – Risk of cosmetic staining of primary teeth is undetermined – Excreted into breast milk

• Primaquine – Harmful to newborns who are relatively Malaria During Pregnancy Glucose-6-Phosphatase-Dehydrogenase

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A Partnership for Malaria Control During Pregnancy

• WHO Programs

– Making Pregnancy Safer – Roll Back Malaria

• Partnership between both programs and national reproductive health programs essential • Partnership of programs and individual involvement necessary to reach Abuja Malaria During Pregnancy

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Country Activities at Different Levels Program Leaders Develop policies, standards, and guidelines, advocacy, IEC, PST/IST, support supervision, M&E

National Program Leadership Level District Level Facility Level

Facilities Integrated health ed., community mobilization, promotion of ITNs, provision of IPT, treatment of complications such as anemia, data collection and feedback

Community Level

District Teams Operationalize guidelines and support supervision, drug supply logistics, and sensitization of public, promotion of ITNs, M&E

Communities CHWs and TBAs sensitize about malaria control, referrals, followup Malaria During Pregnancy

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Summary • Malaria during pregnancy has adverse consequences for mothers and their babies • Malaria preventive package includes: – Intermittent preventive treatment with SP during antenatal clinic visits – Use of ITNs throughout pregnancy and in the postpartum period

• Prevention must be complemented by effective case management of Malaria During Pregnancy

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