Maternal Malaria and Infant Mortality

Although malaria in pregnancy is often asymptomatic (the patient is infected but does not feel ill or has the typical symptoms of malaria), it nevertheless is the cause of unfavorable pregnancy outcomes both in the mother and in her child. The outcomes of the invasion of the placenta by the malaria parasites, even at low infection rates, leads to ill health for the mother, may cause abortion of the fetus, premature labour, small-for-date babies, low birth weight and post-neonatal infant mortality. The association between maternal malaria and neonatal or infant mortality is not completely clear, but it is evident that chronic malaria during pregnancy causes low birth weight.

Prevention or treatment of malaria in pregnancy are major public health challenges and essential components of the obstetrician and antenatal care in endemic areas, but these require special considerations during pregnancy. In particular, only few anti-malaria drugs can be used in this target group and there are some problems with the malaria parasite becoming resistant to these medicines.

Complications of malaria in pregnancy:

Anemia: Malaria can cause or aggravate anemia. It could be due to the following causes:
    Hemolysis of parasitised red blood cells.
    Increased demands of pregnancy.
    Profound hemolysis can aggravate folate deficiency.

Anemia due to malaria is more common and severe between 16-29 weeks. It can develop suddenly, in case of severe malaria with high grades of parasitemia. Pre existing iron and folate deficiency can exacerbate the anemia of malaria and vice versa.


Risks for the foetus:
Malaria in pregnancy is detrimental to the foetus. High grades of fever, placental insufficiency, hypoglycemia, anemia and other complications can all adversely affect the foetus. Both P. vivax and P. falciparum malaria can pose problems for the foetus, with the latter being more serious. The prenatal and neonatal mortality may vary from 15 to 70%. In one study, mortality due to P. vivax malaria during pregnancy was 15.7% while that due to P. falciparum was 33%. Spontaneous abortion, pre mature birth, still birth, placental insufficiency and IUGR (temporary / chronic), low birth weight, fetal distress are the different problems observed in the growing foetus. Transplacental spread of the infection to the foetus can result in congenital malaria.

P. vivax malaria in pregnancy:
There are very few documented studies on P. vivax malaria in pregnancy. It appears to be more common in primigravidae than multigravidae. Parasite densities are similar in pregnant and non-pregnant states. It may be associated with mild anaemia and increased risk of low birth weight and not associated with abortion, stillbirth or a reduction of the duration of pregnancy. Benefit of chemoprophylaxis has not been established.

Management of Malaria in Pregnancy:
Management of malaria in pregnancy involves the following three aspects and equal importance should be attached to all the three.

    Treatment of malaria
    Management of complications
    Management of labour

Treatment of malaria:
Treatment of malaria in pregnancy should be energetic, anticipatory and careful.

Careful: The physiologic changes of pregnancy pose special problems in management of malaria. In addition, certain drugs are contra indicated in pregnancy or may cause more severe adverse effects. All these factors should be taken into consideration while treating these patients.

    Choose drugs according to severity of the disease/ sensitivity pattern in the locality.
    Avoid drugs that are contra indicated
    Avoid over / under dosing of drugs
    Avoid fluid overload / dehydration
    Maintain adequate intake of calories.
    Anti malarials in pregnancy:
    All trimesters: Chloroquine; Quinine; Artesunate / Artemether / Arteether
   2nd trimester: Mefloquine; Pyrimethamine / sulfadoxine

Treatment of vivax malaria in pregnancy:
In pregnancy, use of primaquine is contraindicated. Therefore to prevent the relapse of vivax malaria from reactivation of hypnozoites in the liver, suppressive chemoprophylaxis with chloroquine is recommended. Tablet Chloroquine 500 mg weekly should be administered to all such patients until delivery. At that point, a complete treatment with full therapeutic dose of chloroquine and primaquine should be administered.

Vaccine against malaria in pregnancy: Although a general malaria vaccine appears to be a distant possibility, there is much hope for a vaccine against placental malaria. The administration of excessive soluble CSA to pregnant women has proven to drastically reduce parasite adhesion; however, in excess levels, this soluble protein is severely nephrotoxic. Studies have demonstrated that the administration of chondroitinase AC can effectively reduce parasite adhesion by 95%. This preliminary data is being further tested in combination with therapeutic use of monoclonal antibodies to CSA