Malaria in Pregnancy

Malaria is an endemic disease in many parts of Asia, Africa, Ocenia, Central and South America. Worldwide it is a maor health concern. About 300-500 million infections and approximately 1.1-2.7 million deaths in — each year are caused by malaria1,2 WHO. O Malaria has been eradicated from North America, Europe and Russia. Though resurgence is observed predomi- nantly in the tropical countries, it is persistent threat to the non-malarious countries, because of transmission across the international borders and travelers.

Malaria is a protozol disease caused by the bite of an infected female anopheles mosquito, four species of Plasmodium (P vivax, P falciparum, P malaria and P ovale) are the infective agents. Malaria through blood transfusion is not uncommon. Incubation period is usually short in that case.

Effects of pregnancy on malaria

• Risk of infection is high due to immunocompromised state.
• Frequency of infection is high specially in the second or third trimester.
• Severity of infection is high specially in primigravida
• Complications are high.

Management

Prevention is directed for improvement of sanitation and initiation of control programs with infrastructure.9 personal protection is obtained with the use of repellants and bed nets.10 Strategies have been adopted by WHO, UNICEF, UNDP, World Bank, Govt, of India—(1998) Mefloquine (15 mg/kg single dose) is being used in against malarial infection.11,12 These include: many countries as it is found effective against multidrug

1. To intensity malaria control activities in'high-risk areas'
2. Early case detection and treatment
3. Personal protection and community participation
4. Vector control.

1. Slide positively
2. Slide falciparum rate is 30% with SPR of 3%
3. Area with chloroquine resistant falciparum infection.

Revised strategy subsequently has been recom- mended by WHO (2000).13 These include:

1. Presumptive diagnosis of malaria and to institute treatmenti
2. Radical treatment of malaria
3. Mass chemoprophylaxis where annual parasite index (API) is more than 5,
4. To institute antenatal chemoprophylaxis
5. Consideration of multi-drug therapy for patients with HIV/AIDS and/or tuberculosis to minimize drug resistance.

Mass chemoprophylaxis in children and in pregnant g women is not recommended universally. There are several reasons from this. It is not possible to achieve C/9 complete suppression of infection. Secondly it interferes with the development of immunological defense of the individual. Lastly it causes development of drug resistance. Drug hazards are not uncommon when used on a long-term basis specially during pregnancy. These strengthen the importance of personal protection.14

Chemoprophylaxis: Pregnant women residing or traveling in endemic (malarious) areas should receive prophylaxis with chloroquine or proguanil. Chloroquine (300 mg base) is given orally once a week. This is considered safe and is well-tolerated in pregnancy. Proguanil 200 mg a day is also used as an alterative. Folic acid 5 mg/day should be given when proguanil is used.

Not all the antimalarial drugs are safe in pregnancy. Drug selection depends upon the severity of infection (parasite density) and the drugsensitivity of the parasite.16 Parenteral antimalarial therapy is needed in a case with severe and/or complicated malaria.17 Because of resistance, chloroquine may not be effective. Drugs and dosage of commonly used antimalarials in pregnancy are given in.

Drugs not used (contraindicated) or used with limited experience in pregnancy are: doxycycline, artemisinine (artemether, artesunate), pyrimethamine, halofantrine, atovaquone, maloprim and mefloquine.18,19

Proguanil with Atovaquone: Are recommended for treatment of falciparum malaria when other anti-malarial.