Malaria in Pregnancy | How to Prevent it.
In my country, Kenya, policy on malaria prevention and control during pregnancy, especially in endemic areas has set guidelines. They include use of:
Facts about Malaria in Pregnancy
- Pregnant women get malaria easily than the ones who are not.
- Many pregnant women have malarial parasites but have no symptoms at all.
- Pregnant women lose some of the ability to fight malaria infection.
Often, when dealing with cases of malaria in pregnancy, blood test for peripheral parasitemia is negative despite malarial parasites in the placenta.
What happens when a pregnant woman has malaria?
Firstly, the mother may have no signs and symptoms of malaria in her pregnancy.
Secondly, malarial parasite hides in the placenta and so, may not be found when you do Finger-Blood sample.
Thirdly, malarial parasites in the placenta interfere with the passage of nutrients and oxygen to the unborn baby slowing down its normal growth.
Signs and Symptoms of Malaria
Let us focus on uncomplicated malaria in pregnancy first. They include:
- Fever with or without shivering.
- Loss of appetite
- Nausea and vomiting
- Joint pains
- Backache and muscle pain
- False labour -uterine contraction.
Effect of Malaria to Unborn Baby
According to research, malaria in pregnancy may cause upto 30% preventable low-birth rate and 3% – 5% of neonatal deaths.
Nevertheless, low birth-weight babies have a higher chance of dying than babies who are born with a good weight.
Therefore, malaria in pregnancy increases the risk of:
- Premature labours
- Spontaneous abortion
- Still birth (child born dead)
In addition, malaria in pregnancy can cause anaemia and fibril. Fibril (high fever), Afibril (low fever).
How to Prevent Malaria in Pregnancy.
Pregnant women are more at risk of malaria infection because pregnancy reduces degree of partial immunity.
Moreover, women in their first and second trimester/pregnancy are at a greater risk! WHY? Because of lack of exposure to placental infection than before.
Generally, all pregnant women at risk should be advised on malarial prevention measures.
RELATED ARTICLES: Dangers Signs in Pregnancy, Labour and Delivery, After.
IPT (Intermittent Preventive Therapy)
It is an effective approach of preventing malaria in pregnancy.
When we give antimalarial drugs or treatment in doses at defined interval after quickening, we aim to clear presumed burden of parasites that can interfere with the pregnancy.
By the way, quickening is the first movement of the baby the pregnant mother feels in the uterus which sometimes people refer it as flutters.
Meaning, others can feel their babies move as early as 13-16 weeks from the start of their last period.
However, the MOH (Ministry of Health) guidelines on malaria in pregnancy directs us to give IPTp to pregnant women in endemic areas.
The dosage is at least thrice a minimum of 4 (doses) at 4 weeks interval from the 16th week gestation, even if she has signs of malaria.
More so, even if the haemoglobin is at normal range!
Administer IPTp each scheduled visit after quickening from 16 weeks.
IPTp should be given under DOT (Daily Observe Treatment). DOT is done in 2 ways :-
- Aseptic – taken on the spot.
- Through a health worker.
It can be given on an empty stomach. Sp is a combination of two different drugs.
Results show that, use of IPTp-SP during pregnancy improves (pregnancy) outcomes. However, coverage rates of the malaria in pregnancy intervention have remained below the national target. Reason?
There are several influencing factors like the SP stock-out situation experienced in Kenya.
What is Sulphadoxine pyrimethamine?
A combination of 500mg – Sulphadoxine and 25mg – pyrimethamine. It is a single drug consisting 3 tablets taken at once.
Fansider is the most common brand/name but there are many other names that obtains the same drugs.
Facts about Sp and IPT.
It is based to clear the placenta of parasites during the period of maximum foetal growth.
It allows the mother to recover from anaemia by clearing the malaria parasites that infect the red blood cells (that then rupture!).
However, WHO recommends a pregnancy schedule of 4 antenatal visits with 3 visits after quickening.
The delivery of IPTp with each schedule visit will ensure that a high proportion of women receives at least 3 doses of the IPTp-Sp.
Despite its use in dealing with malaria in pregnancy, there is no evidence that receiving 3 or more doses of Sp as IPTp will result in an increased risk of drug reaction.
WHO recommends that IPTp-Sp is safe up to 40 weeks gestation.
Studies have found that mothers who had taken IPTp-Sp in the second trimester had fewer malarial parasites in the placenta than women who had only taken malaria treatment when they are ill.
More so, field experiences on malaria in pregnancy have shown that, when a client does not take Sp at the clinic, she may not take it all.
Taking IPTp-Sp at the ANC, under supervision increases compliance.
Clean, safe drinking water and clean cups should be available. After use you wash, rinse with water for some patient to use.
Side effects of Sp
Ask her if she is allergic to sulphur. As a matter of fact, Sp can have side effects like mild headaches,nausea and occasional vomiting.
These are not serious and mothers can get a second dose to fight malaria in pregnancy.
Serious side effects are very rare but can still occur. They can be a skin and mucus membrane reaction. In essence, mouth and genital ulceration (STEVEN JOHNSON’S SYNDROME).
Each clinic should have a great system for keeping track of the number of clients under prevention of malaria in pregnancy, through reporting severe skin reactions.
Unfortunately, there is no alternative for Sp on the use of IPT for pregnant women that has been approved.
Therefore, if your client is allergic to Sp, counsel her carefully.
Counsel her on symptoms of early malaria and early seeking treatment.
Monitor her for anaemia and ensure that she knows she has to return to the clinic if she develops symptoms of anaemia or malaria in her pregnancy.
Advice her to sleep under ITN (Insecticide Treated Net).
Minimize a risk of anaemia or other cause such as iron deficiency, and hookworm by appropriate diet, medication and supplements.
If she becomes symptomatic of malaria, she can be treated safely with mefloquine or AL (First Line), Artemeter Lumefrantine (coartem).
How to provide Sp to a pregnant woman
Ask the client about her gestational age. Remember, prevention of malaria in pregnancy starts at 16 weeks. Therefore, if she is not certain or less ask her when she first felt the baby move.
Thickening is a rough estimate of the onset of the second trimester.
Ask about history of severe skin rash or mucus membrane ulceration with sulphur drugs. If she has had a severe reaction, do not give Sp and make sure allergy is marked.
Ask about use of Sp in the past months.
Give client 3 tablets of Sp as dose with clean and safe drinking water. Can be given on an empty stomach then ask your client to come for the second dose after 4 weeks.
She should also come back if she experiences any side effects.
Insecticide Treated Nets
Use of ITN is recommended for all pregnant women and children under 5 years of age. The only reason is because they are the most vulnerable group.
ITN use should be encouraged early and consistently throughout pregnancy and after delivery.
They are more effective in preventing malaria in pregnancy (or in general) than using untreated nets.
Signs and Symptoms of Severe Malaria
- Severe and persistent headache
- Loss of appetite
- High fever
- Breathing difficulties. They can be signs of cerebral malaria which occurs in pregnancy.
- Low blood sugar (hypoglycemia)
- Sweating, weakness and fold skin.
- Severe dehydration especially if the mother has been vomiting repeatedly.
- Spontaneous bleeding from the gums and skin.
- Severe jaundice (severe yellow discoloration of conjuctiva, skin).
- Extremely tired, change in behaviour, sleepiness/drowsiness, confusion, convulsions, inability to walk, sit, speak or recognize relatives.
- Fast bleeding due to pulmonary idioma or cardiac failure.
- Passage of a very dark-coloured urine (Coca-Cola like).
- Hb less than 7g/dl (anaemia).
Malaria is more likely to cause death in a pregnant woman. Antenatal visits are vital to any pregnant mother.
At least 3 visits from the 16th week gestation can benefit an ANC mother susceptible to get malaria. Receiving IPTp with Sp can prevent malaria in pregnancy.
Mmaka Abbas. (2020). Jamii-Health Blogger & Community Health Officer/Health Counselor. Mombasa County. Kenya. https://jamii-health.co.ke/