Pregnancy is an immunosuppressive stage; this makes them more susceptible to malaria-causing parasites than the general population. They are more likely to become infected, have a recurrence, or develop severe complications that may lead to death

Malaria is a parasitic disease caused by the protozoon of the genus Plasmodium. Four species of the genus Plasmodium; 

Plasmodium vivax, P. Ovale, P. Falciparum, P. Malaria First two pieces are prevalent in India. Parts of India where malaria is endemic include north-eastern states, Bihar, Orissa, Andhra Pradesh, Karnataka coastal region, and Chhattisgarh.

How does Malaria affect pregnancy?

According to the Centers for Disease Control and Prevention, pregnant women lose some protection from malaria infection due to changes in their immune systems and the existence of a new organ (the placenta) with new locations for parasites to adhere. This altered immune response in pregnancy makes them more vulnerable to its consequences. It can harm both mother and baby. 

Signs of Malaria in Pregnant Women

Pregnant women who contract malaria may experience these symptoms:

• Fever with chills

• Rigor

• Headache

• Pain in muscles

• Pain in joints

• Feeling of discomfort

• Nausea

• Vomiting

• Abdominal pain

• Dehydration

• Anemia

If a pregnant woman notices these symptoms, she must consult her doctor immediately to avoid complications

what are the Effects of Malaria on pregnancy?

A woman pregnant for the first time is at the maximal risk, as there is an increase in immunity status with rising parity. And the passive transfer of IgG antibodies across the placenta helps protect the foetus and newborn for the first 3-6 months during infancy. 

What is an Uncomplicated Malaria?

Uncomplicated malaria is defined as Symptomatic infection with malaria parasitemia without signs of severity and/or evidence of vital organ dysfunction.

What is Complicated or Severe Malaria?

Complicated or severe malaria is defined as symptomatic malaria in a patient with P. falciparum with one or more of the following life-threatening complications:

• Cerebral malaria (unarousable coma not attributable to other causes).

• Generalised convulsions (> 2 episodes within 24 hours) 

• Severe normocytic Anaemia (Ht<15% or Hb < 5 g/dl) – The malaria parasite is capable of rupturing and destroying the red blood cells. When this happens in a pregnant woman, it could result in severe anemia, such that she won’t have any capacity to cope with hemorrhage (bleeding) during childbirth, making the pregnant woman more likely to die during delivery

• Hypoglycaemia (blood glucose <40 mg/dl ) 

• Metabolic acidosis with respiratory distress (arterial pH < 7.35 or bicarbonate < 15 mmol/l) 

• Fluid and electrolyte disturbances – 

• Acute renal failure (urine <400 ml/24 h in adults; 12 ml/kg/24 h in children) 

• Acute pulmonary edema and adult respiratory distress syndrome Abnormal bleeding 

• Jaundice 

• Haemoglobinuria 

• Circulatory collapse, shock, 

• Septicaema (algid malaria) 

• Hyperparasitaemia (>10% in non-immune; >20% in semi-immune

How to Make a Diagnosis?

1. Light microscopy 2. Rapid diagnostic tests (RDTs).       

Common methods for parasitological diagnosis of malaria

Microscopy is the gold standard for the diagnosis of malaria for

• Parasite density 

• Species diagnosis 

• Monitoring response to treatment.

If you are pregnant and ill, see your doctor for prompt diagnosis and effective treatment.

What is the treatment of Malaria in Pregnancy?

The antimalarial considered safe in the first trimester of pregnancy is quinine, chloroquine, proguanil, pyrimethamine, and sulfadoxine-pyrimethamine. Of these, quinine remains the most effective and can be used in all trimesters of pregnancy including the first trimester.

There is increasing experience with artemisinin derivatives in the second and third trimesters and there have been no adverse effects on the mother foetus. Therefore, artemisinin derivatives can be used to treat uncomplicated falciparum malaria in the second and third trimesters of pregnancy, but should not be the first choice in the first trimester. 

What is the treatment for complicated malaria?

Parental therapy with quinine 20mg/kg over 4hours IV followed by 10mg/kg 8th hourly, until patient tolerated orally. 

Lactating women: Tetracyclines are contraindicated because of their effect on the infant’s bones and teeth.

For infants and young children, ACTs should be the first-line treatment.

Patients with HIV infection who develop malaria: should receive standard antimalarial treatment regimens.

Radical Cure: after pregnancy, primaquine can be used after ruling out G6PD deficiency. 15mg/kg for 14days. 

Prophylaxis: Chloroquine 300mg once weekly start 1-2 weeks before travel to the endemic area until 4weeks, after return

Chloroquine-resistant area Proguanil 100mg tab daily start 1-2 days before travel to the endemic area until 1 week after return 

What is Resistant Malaria?

WHO has defined“Resistance as the ability of the parasite strain to survive and/or to multiply despite administration and absorption of a drug in doses equal to or even higher than those recommended but within the limits of tolerance of subject. 

Treatment of resistant malaria in pregnancy: 

Pyrimethamine + Sulfonamide combination with folinic acid supplementation best available choice for the treatment and prophylaxis of chloroquine-resistant P falciparum infection in pregnancy.

The author is Founder, and Urology Laboratory Laparoscopic Surgeon, Altius Hospital, Bengaluru