Medical Disorders in Pregnancy: Malaria

Medical Disorders in Pregnancy

• Malaria is a significant cause of morbidity and mortality in developing countries.
• It's a protozoal disease caused by Plasmodium parasites transmitted by Anopheles mosquitoes.
• Blood transfusions and contaminated syringes can also spread the disease. Cross-placental transmission is possible.
• Plasmodium falciparum, Plasmodium vivax, and Plasmodium ovale are causative organisms.
• Pregnant women are particularly susceptible to malaria, and more susceptible to a recurrence of infection compared to non-pregnant women.
• Impaired placental and host defense contributes to higher parasitemia in pregnant women.
• Malaria is diagnosed by examining stained blood smears (thick and thin) under a microscope. This is the gold standard method. Parasite count and type are determined.
• Quantification can be done by examination of blood smears, fluorescent microscopy, and even PCR to detect plasmodium DNA.
• Management of Malaria in Pregnancy: Pregnant women require prompt treatment due to high risk of parasitemia affecting mother and fetus.
• Hydration status, hyperpyrexia, vomiting, and appetite loss are assessed to determine the best treatment approach.
• Oral medication is preferred but parental route is required if patient is vomiting.
• Fever management involves rest, removal of clothing, fanning, tepid sponging, and antipyretic medication like paracetamol.
• Anaemia frequently accompanies uncomplicated malaria. Packed cell transfusion may be necessary if PCV is <20%. Folic acid supplementation is also essential.
• Obtaining a history of prior antimalarial medication is crucial for proper treatment.

Management of Malaria in Pregnancy

• Prompt treatment of pregnant women with malaria is vital because of its higher severity and risk of transmission.
• General assessment of hydration, fever, appetite, and vomiting helps to determine the most effective treatment strategy.
• Administration of antimalarial drugs should preferably be via the parental route if vomiting is an issue.
• Physical measures like bed rest and antipyretics like paracetamol can help manage hyperthermia.
• Anaemia is common in malaria cases, and patients with PCV below 20% should receive packed cell transfusions, and folic acid supplementation.
• A detailed history of prior antimalarial drugs is important for successful treatment.

Management of Severe Malaria

• Patients with severe malaria should be admitted to intensive care units (ICUs).
• Fluid balance needs to be monitored closely.

Drug Treatment in Pregnancy

• Antimalaria chemoprophylaxis (preventative treatment) can reduce parasitaemia and anaemia. Folic acid supplementation is essential.
• Quinine is an effective drug, safe in pregnancy for the treatment of malaria and safe in the first trimester
• Other drugs like chloroquine can also be used for malaria prophylaxis or treatment in pregnancy.
• Dosage of various drugs and duration of treatment need to be taken into consideration in pregnancy
• Treatment should aim to reduce parasitemia, severe haemolytic and megaloblastic anaemia, and supplement folic acid.

Pregnancy Management

• Prompt treatment of pregnant women with malaria is necessary, as it is more severe.
• General assessments to determine the best approach to treatment, including hydration status, fever, appetite, and any vomiting, should be considered.
• Oral medication is usually the first choice, but the mother may need an intravenous route of administration if she is vomiting.
• Management of hyperpyrexia includes physical measures such as rest, removing clothing, fanning, tepid sponging, and appropriate antipyretic medications.
• Anaemia is common to malaria, and those with a PCV below 20% should receive packed cell transfusions, and folic acid supplementation.

Hypertension in Pregnancy

• Hypertension is defined as a blood pressure of 140/90mmHg or higher on at least two occasions taken at least 4 hours apart.
• Diastolic BP over 110mmHg is also considered hypertension.
• A rise of 20mmHg in MAP or greater than 105mmHg is suggestive for hypertension
• Pregnant women with hypertension need careful assessment as hypertension is a cause of maternal and perinatal morbidity and mortality.
• Hypertension complicates approximately 5 - 7% of pregnancies .
• Causes maternal morbidity and mortality in developing countries.
• Classification: It can be chronic (pre-existing) or gestational (developing during pregnancy).
• Management: Mild hypertension can sometimes be managed conservatively with antihypertensives but close monitoring is essential, whereas, severe hypertension may require hospitalization and potentially treatment to reduce risk of complications.

Diabetes in Pregnancy

• Introduction: With the advent of insulin, diabetes management has greatly improved pregnancy outcomes.
• Classification: Pregnancy-related diabetes (GDM or gestational diabetes mellitus) and pre-existing diabetes (predating pregnancy).
• Screening: GDM screening may be universal or selective, using glucose tolerance tests (e.g., 50g glucose challenge, OGTT).
• Management: Optimal management focuses on diabetic control for both mother and fetus, utilizing dietary adjustments, regular exercise, and potentially insulin therapy. This usually requires a combination of these methods or adjustments to the methods.
• Care After Delivery necessitates frequent monitoring for the first 6 weeks postpartum in order to check on the severity of any condition and risk of recurrence.

Anaemia in Pregnancy

• Anaemia is common in pregnancy—2–20% of women are affected.
• Causes: include nutritional deficiencies, infections, and haemorrhage.
• Complications: increase maternal and infant morbidity, premature labour, and intrauterine growth restriction (IUGR).
• Diagnosis: a combination of clinical evaluation (pale skin, nails, gums) and laboratory testing (Hb and PCV).
• Treatment: Addressing nutritional deficiencies (iron, folate) and treating any contributing causes like infections.
• Prevention: Optimizing dietary intake and addressing nutritional deficiencies early through supplements and lifestyle modifications to minimize the risk of pregnancy complications.

Care After Delivery

• Postpartum monitoring is important since many maternal deaths occur after delivery, most commonly due to pulmonary edema, and other factors.
• Follow-up: women with a history of hypertensive disorders or diabetes during pregnancy require screening, as they are often at high risk for recurrence during future pregnancies and for complications like connective tissue disorders and antiphospholipid syndrome