Written by Timothy Okooboh
Pregnancy is a gift; a period in which a woman nurtures, nourishes, and brings into being another life. However, as compared to nonpregnant women, pregnant women (including the foetus) are more severely affected by infections. This is mainly due to the altered state of immunity during pregnancy. One of such common infections that puts the life of a pregnant woman and her foetus/newborn at risk is malaria.
This article briefly explains the effects of malaria in pregnancy both on the woman and the baby, and how malaria in pregnancy can be prevented or treated based on WHO recommendations.
Why is malaria in pregnancy important ?
Some countries have successfully eradicated malaria. But in areas where there is a risk of malaria transmission, malaria in pregnancy can adversely affect both the health of the mother and the foetus if not properly controlled.
Effects on the mother include:
- Maternal anaemia
- Maternal deaths (causes up to 10,000 maternal deaths globally)
Effects on the baby includes:
- Preterm births
Preterm birth is the birth of a baby before 37th week of pregnancy.
- Newborn death ( causes up to 11% of newborn deaths in Sub Saharan Africa)
- Neonatal death
- Low birth weight
Birth weight is the weight of the newborn, usually measured within the first hour of life. Low birth weight is birth weight less than 2.5kg.
But how does malaria in pregnancy lead to low birth weight?
The presence of malaria parasites in the placenta causes a competition for nutrients and oxygen. Therefore, there will be reduced supply of nutrients and oxygen to the developing foetus, which impairs the growth of the foetus and leads to low birth weight. Also, malaria in pregnancy causes maternal anaemia which in turn leads to low birth weight.
Malaria in Pregnancy Control Strategies
Every pregnant woman should go to the health facility immediately she is pregnant to begin antenatal care.
There are 3 ways of controlling malaria in pregnancy in areas where malaria transmission is stable e.g Sub Saharan Africa like Nigeria.
By stable malaria transmission, it’s implied that people in that area are frequently exposed to mosquito bites each month.
1. Intermittent Preventive Treatment (IPT) with a type of antimalarial called Sulfadoxine/Pyrimethamine (IPT-SP).
What’s IPT-SP? When should a pregnant woman commence IPT-SP? What’s the minimum number of dose of SP a pregnant woman should take? All this will be addressed shortly.
2. Sleeping under long lasting insecticide treated nets.
3. Quick diagnosis and treatment with a safe and effective antimalarial if full blown malaria infection occurs.
NB: For areas with unstable malaria transmission, WHO recommended malaria control strategies are sleeping under long lasting insecticide treated nets and proper treatment with an antimalarial if malaria infection occurs. IPT-SP is not recommended for pregnant women in these areas.
By unstable malaria transmission, it’s implied that people in that area are not frequently exposed to mosquito bites. An example is Southern Africa. However, the effect of malaria in pregnancy is more severe in these areas because the women have low acquired immunity to malaria.
Intermittent Preventive Treatment and Antenatal Care
Intermittent preventive treatment in pregnancy is the administration of an antimalarial called Sulfadoxine/Pyrimethamine (Fansidar®) to pregnant women in areas of stable malaria transmission in order to reduce malaria in pregnancy, maternal anaemia, low birth weight, preterm birth and neonatal death. This is done effectively during antenatal care visits.
Important facts to note:
- WHO recommends a minimum of 8 antenatal care visits (formerly 4 visits) during pregnancy to the healthcare provider.
- A minimum of 3 doses (formerly 2 doses) of Sulfadoxine/Pyrimethamine for IPT is now recommended, with each dose separated by at least four weeks apart.
- A dose of Sulfadoxine/Pyrimethamine for IPT consists of 3 tablets swallowed at once.
- The first dose of Sulfadoxine/Pyrimethamine should be started at the beginning of the 2nd trimester, between 13-16 weeks, or after quickening.
Quickening refers to the first fetal movement. That is, when the foetus kicks for the first time in the womb.
- Sulfadoxine/Pyrimethamine should not be given at the first trimester of pregnancy.
- Pregnant women who are taking Cotrimoxazole (Septrin®) such as those with HIV, should not be given Sulfadoxine/Pyrimethamine, as co-administration of both drugs causes increased adverse effects.
- WHO recommends that IPT-SP be given as DOT (Directly Observed Therapy) at the health facility during antenatal care visit.
Directly Observed Therapy (DOT) implies that the healthcare provider directly watches the pregnant woman swallow the three tablets of Sulfadoxine/Pyrimethamine at the health facility. This is to ensure compliance.
Do you know of any disease treatment where DOT is carried out?
What’s the rational behind Intermittent Preventive Treatment with Sulfadoxine/Pyrimethamine?
IPT-SP is based on the assumption that every pregnant woman living in an area of stable malaria transmission has malaria parasites in her blood or placenta, and therefore, should be treated to reduce the effects of malaria in pregnancy both on the mother and the foetus/newborn.
People (including pregnant women) living in areas of stable malaria transmission have some level of acquired immunity. Why then should IPT-SP be given?
While it’s true that people (including pregnant women) living in areas of stable malaria transmission have some level of acquired immunity to malaria, IPT-SP should still be given because the placenta (especially in the first pregnancy) is a new tissue and has no acquired immunity to malaria. The effects of malaria in pregnancy is therefore worse during the first and second pregnancy. After then, the placenta accumulates substantial acquired immunity to malaria, but this does not rule out the need for IPT-SP in subsequent pregnancies.
What’s the recommended drug of choice for pregnant women who develop full blown malaria?
Artemisinin-based combination therapy (ACTs) such as Coartem® is recommended for the second and third trimesters of pregnancy. Quinine is recommended for the first trimester of pregnancy, but care should be taken not to give overdose of quinine as it’s potentially abortifacient.
Putting it all together
Just like many diseases, malaria can adversely affect the health of pregnant women and their foetus/newborn. Therefore, all pregnant women should commence antenatal care immediately they are pregnant (usually within the first 12 weeks).
In addition to sleeping under insecticide treated nets and proper treatment with an antimalarial if malaria infection occurs, pregnant women who live in areas where there is frequent mosquito bites every month, should receive at least 3 doses of Sulfadoxine/Pyrimethamine (starting from the beginning of the second trimester or at quickening), with each dose separated by at least four weeks apart.
If full blown malaria infection occurs, a pregnant woman should quickly visit the healthcare provider so that prompt diagnosis and effective antimalarial treatment will be administered with the safest drug possible.
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