Hadiza M., 20

About emergency care

Severe malaria in pregnancy, especially when complicated by anemia, is a life-threatening condition for both the mother and the fetus. Prompt and aggressive treatment is crucial. Here's a breakdown of the key considerations and management strategies: Understanding the Problem: * Malaria in Pregnancy: Pregnant women are more susceptible to malaria infections, have higher parasite densities, and are at increased risk of severe malaria and its complications, even if they have some pre-existing immunity. This is particularly true for primigravidae (women in their first pregnancy). * Complications of Malaria in Pregnancy: These can include: * Maternal Anemia: Malaria is a significant cause of anemia in pregnancy, which can be severe and contribute to maternal mortality. Anemia is defined by the WHO as hemoglobin levels less than 11.0 g/dL in the first and third trimesters, and less than 10.5 g/dL in the second trimester. * Hypoglycemia: More frequent in pregnant women with severe malaria. * Pulmonary Edema: Also more frequent. * Acute Kidney Injury * Cerebral Malaria * Obstetric Complications: Premature labor, spontaneous abortion, stillbirth, low birth weight, and intrauterine growth retardation. * Maternal Death. * Complicated Anemia: Anemia in pregnancy is often multifactorial (nutritional deficiencies like iron and folate, other infections like hookworm), and malaria significantly exacerbates it due to hemolysis and impaired erythropoiesis. Severe anemia is typically defined as a hemoglobin level of less than 7 g/dL. Diagnosis: * Diagnosis relies on microscopic examination of thick and thin blood films to identify malaria parasites, quantify parasitemia, and confirm the species. Rapid diagnostic tests (RDTs) can also be used but should be followed by microscopy. Treatment of Severe Malaria in Pregnancy: Immediate and aggressive treatment with parenteral antimalarials is essential. * First-Line Treatment: Parenteral Artesunate * Injectable artesunate is the preferred treatment for severe malaria at any stage of pregnancy. It has been shown to be superior to quinine. * Dosing: Artesunate 2.4 mg/kg body weight (BW) administered intravenously (IV) or intramuscular (IM) at admission (time=0), then at 12 hours and 24 hours, then once a day until the patient can tolerate oral medication. * Even if the patient improves and can take oral medication, parenteral antimalarials should be continued for a minimum of 24 hours. * Alternative Parenteral Treatments (if artesunate is unavailable): * Injectable Artemether: 3.2 mg/kg BW IM given on admission, then 1.6 mg/kg BW per day. * Injectable Quinine: 20 mg salt/kg BW (loading dose) on admission, then 10 mg/kg BW every 8 hours. Quinine should be administered as a slow, rate-controlled IV infusion (usually diluted in 5% dextrose over 4 hours) to avoid dangerous rapid administration and reduce the risk of hypoglycemia. Quinine is associated with a 50% risk of hypoglycemia, necessitating frequent blood glucose monitoring. * Follow-on Treatment: * Once the patient is able to tolerate oral medication (after a minimum of 24 hours of parenteral treatment), complete the treatment with a full course of an effective WHO-recommended artemisinin-based combination therapy (ACT). * Examples of ACTs suitable for the second and third trimesters include: * Artemether-lumefantrine (AL) * Artesunate-amodiaquine (ASAQ) * Artesunate-mefloquine (ASMQ) * Dihydroartemisinin-piperaquine (DHA-PPQ) * For first-trimester uncomplicated P. falciparum malaria, the WHO currently recommends quinine with clindamycin for 7 days. If clindamycin is unavailable or treatment fails, an ACT may be considered if it's the only option. Recent meta-analyses suggest ACTs are not associated with increased risk of miscarriage, stillbirth, or embryotoxicity, and the WHO's Malaria Policy Advisory Committee (MPAC) has endorsed their use in the first trimester, although this may not yet be reflected in all official guidelines. Management of Complicated Anemia: * Blood Transfusion: For severe anemia (Hb < 7 g/dL or lower depending on clinical stability and presence of severe malaria symptoms), blood transfusion is often necessary. * Iron and Folic Acid Supplementation: * Routine iron and folic acid (IFA) supplementation is recommended for all pregnant women in malaria-endemic areas to prevent and control anemia. * The standard dose is 30-60 mg of elemental iron and 0.4 mg of folic acid daily. * For women with existing anemia, a double dose of iron may be considered. * Important Note: High doses of folic acid (5 mg or more daily) should not be given concurrently with sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment in pregnancy (IPTp), as it can counteract the efficacy of SP as an antimalarial. The 0.4 mg daily dose is generally safe.

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