CHAPTER II
CONTENT
CONTENT
2.1 Effect of malaria during pregnancy
Malaria in pregnant women can cause many abnormalities. It depend on the severity of the disease. In endemic region, a pregnant woman with low antibody of malaria can get severe manifestation of malaria including death. The severity of malaria in pregnancy is affected by number of parity. The clinical manifestation
of malaria in pregnancy will be worse in primigravidae (first pregnancy) than multigravidae (next pregnancy).2 Primigravidae were infected more commonly (47.5%) than multigravidae (33.3%).4Malaria in pregnant women has clinical manifestations such as fever, anemia, hypoglycaemia, acute pulmonary oedema, and other severe malaria.2 The further explanation about the clinical manifestations of malaria in pregnant women will be discussed below :
1. Fever
It is commonly reported in a pregnant women who have low antibody to malaria or do not have antibody to malaria and suffer from malaria. Fever is often occured in primigravidae than multigravidae. The multigravidae seldom have fever although they live in endemic region and have high level of parasitemia.
It is commonly reported in a pregnant women who have low antibody to malaria or do not have antibody to malaria and suffer from malaria. Fever is often occured in primigravidae than multigravidae. The multigravidae seldom have fever although they live in endemic region and have high level of parasitemia.
2. Anemia
Gregor (1984) show that there is a correlation between reducing hemoglobin level with parasitemia, the most is happened in primigrivedae and reduce as the increasing of pregnant frequency.2 Anemia can be happened in malaria because the leakage of erythrosite that contain parasite. A study shows that anemia in first trimester determine wether the baby has low birth weight or not. Anemia in malaria during pregnancy can cause maternal death and increase the number of death caused by bleeding after giving birth.
Gregor (1984) show that there is a correlation between reducing hemoglobin level with parasitemia, the most is happened in primigrivedae and reduce as the increasing of pregnant frequency.2 Anemia can be happened in malaria because the leakage of erythrosite that contain parasite. A study shows that anemia in first trimester determine wether the baby has low birth weight or not. Anemia in malaria during pregnancy can cause maternal death and increase the number of death caused by bleeding after giving birth.
3. Hypoglycaemia
In pregnant women, there is a change in carbohydrat metabolism, particularly in last trimester of pregnancy.2 In pregnant women, there is also an increasing of activity of B cell pankreas that cause in increasing insulin and can cause hypoglycaemia. Pregnant women who suffer from malaria, the erythrosite has been injected by parasite of malaria and cause it needs glucose 75 times more than normal erythrosite. This condition make the pregnant women become hypoglicaemia. Hypoglycaemia may be asymptomatic or may present with sweating, abnormal behaviour, convulsions or a deteriorating level, or sudden loss of consciousness. The pregnant women can re aware if they are injected by glucose, but due to the hyperinsulin, the pregnant women can be back to unconciousness.
In pregnant women, there is a change in carbohydrat metabolism, particularly in last trimester of pregnancy.2 In pregnant women, there is also an increasing of activity of B cell pankreas that cause in increasing insulin and can cause hypoglycaemia. Pregnant women who suffer from malaria, the erythrosite has been injected by parasite of malaria and cause it needs glucose 75 times more than normal erythrosite. This condition make the pregnant women become hypoglicaemia. Hypoglycaemia may be asymptomatic or may present with sweating, abnormal behaviour, convulsions or a deteriorating level, or sudden loss of consciousness. The pregnant women can re aware if they are injected by glucose, but due to the hyperinsulin, the pregnant women can be back to unconciousness.
4. Acute pulmonary oedema
Acute pulmonary oedema is usually happened after giving birth. The pathogenesis of this manifestation is still unclear. It might be caused post-partum blood autotranfussion that is full of injected erythrosite. The symptoms are increase breath, dyspnea, and die in hours.
5. Other severe malaria
Clinical manifestations of severe malaria are hyperparasitemia, cerebral malaria, severe anemia, hyperpyrexia, pulmonary oedema, renal failure, hypoglycemia, and shock.2 If the pregnant woman has this symptoms, she need special treatment for her safety and her child.
Beside effect on the pregnant women, malaria also has effect on the fetus. Fetus has a placenta as its barrier from bacteria, parasites, and viruses, therefore parasites of malaria enter the placenta only when the placenta get damaged. Malaria can cause abortion, fetal death, death after delivery, and premature birth that the mechanism is still unclear.2 Malaria also can cause low birth weight. There were 14% cases of spontaneous abortion and 9% babies of infected mothers died in neonatal period.5
Malaria can cause fetal death. It can be caused by abnormal food transfer, hyperpyrexia, and/or hypoxia as result of anemia. Other study say that it is caused by Tumor Necrosis Factor (TNF) that is produced by macrofag. TNF cause the abnormalities in malaria patient, such as fever, fetal death, and abortion. Malaria often cause prematurity birth cases. In Tavoy Civil Hospital in 50 inpatient pregnant women with malaria, the case fatality rate was high (20%) and prematurity was as high as 86%. Prematurity of bith can be caused by the acute infection of malaria. Based on the datas above, we need to consider about malaria in pregnancy.
2.2 Control of malaria in pregnancy
Control of malaria that will be discussed below is about the prevention and management of malaria in pregnant women.
1. Chemotheraphy
Chemotherapy depends on the trimester of pregnancy. Early diagnosis and immediate treatment in pregnant women with low antibodies can not prevent the anemia and low birth weight.2
1. First trimester
The first trimester of pregnancy is organogenesis which is the time of greatest concern for potential teratogenicity, although development of the nervous system continues throughout pregnancy. The safety antimalarials for this first trimester are quinine, chloroquine, clindamycin and proguanil.6 The pregnant women who suffer from malaria in this period can be given quinine plus clindamycin for seven days or quinine monotheraphy if clindamycin is not available.
2. Second and third trimester
In this second and third trimester, artemisinin has no adverse effect to the mother and the child. Combination between quinine and clindamycin also can be used for seven days. Quinine is associated with an increased risk of hypoglycaemia in late pregnancy, and it should be used only if effective alternatives are not available.6 Other combination that can be used for second and third trimester of pregnancy is artesunate plus clindamycin for seven days.
2. Chemoprophylaxis
One of some strategic of prevention of getting malaria during pregnancy in endemic region that have been applied is using antimalarial chemoprophylaxis that is safe for pregnant women, chloroquine and proquanil. Mefloquine given from the second trimester onwards has proved safe and effective in areas where proquanil and chloroquine cannot be used. For semi-immunes and particularly primigravidae, chemoprophylaxis has been shown to be effective in several trials in Africa, in reducing the two most important clinical consequences of malaria in this group - low birth weight of infants and anaemia. Other chemoprophylaxis that can be used is sulfadoxine-pyrimethamine. The 2-dose IPT with sulfadoxine-pyrimethamine regimen resulted in greater reductions in malaria infection and low birth weight than weekly chloroquine but the difference was only statistically significant for low birth weight.1
One of some strategic of prevention of getting malaria during pregnancy in endemic region that have been applied is using antimalarial chemoprophylaxis that is safe for pregnant women, chloroquine and proquanil. Mefloquine given from the second trimester onwards has proved safe and effective in areas where proquanil and chloroquine cannot be used. For semi-immunes and particularly primigravidae, chemoprophylaxis has been shown to be effective in several trials in Africa, in reducing the two most important clinical consequences of malaria in this group - low birth weight of infants and anaemia. Other chemoprophylaxis that can be used is sulfadoxine-pyrimethamine. The 2-dose IPT with sulfadoxine-pyrimethamine regimen resulted in greater reductions in malaria infection and low birth weight than weekly chloroquine but the difference was only statistically significant for low birth weight.1
3. Reducing contact with vector
Reducing contact with vector can be applied by using insectiside on environment. A study shows insecticide-treated bed nets (ITNs) is effective to reduce maternal anaemia and parasitemia density in pregnant women in Thailand.
4. Vaccination
Application of vaccine in pregnant women is not safe and need complex consideration. There are 3 things those are needed to be considered :
1. Immunity level before pregnancy
2. Life cycle phase of parasites
3. Time of vaccination2
References :
2. Indra Chahaya S. Pengaruh Malaria Selama Kehamilan. USU : 1 – 7. 2003.
5. Naseem Saba, Anwar Sultana, Ihsanullah Mahsud. OUTCOME AND COMPLICATIONS OF MALARIA IN PREGNANCY. Gomal Journal of Medical Sciences : Volume 6 : 98 – 101. 2008
6. World Health Organization. Guidelines for the treatment of malaria - Second edition. 2010.
So, that's about malaria in pregnancy. For the simple one, just go to doctor if you get something abnormal when you pregnant, specially in first trimester. Why? Because the first trimester is the time when the fetus makes his organ such as eyes,heart,hand,etc. Last thing for you : Care for your child, care to your health.
(Regards)
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