Management of Malaria in Special Groups

The  effects  of  malaria  in  pregnancy  are  related  to  the  malaria  endemicity,  with  abortion  more  common in areas of low endemicity and intrauterine growth retardation more common in areas of  high endemicity.  

Uncomplicated Malaria in Pregnancy  

In  high-transmission  areas  (moderate  to  high  immunity);  malaria  is  usually  asymptomatic  in  pregnancy or is associated with only mild, non-specific symptoms (See section on Asymptomatic Malaria Case) 

Pharmacological Treatment  

Artemether/Lumefantrine (ALu) is the recommended treatment of choice of a confirmed uncomplicated malaria to pregnant women in all trimesters. 

Severe Malaria in Pregnancy 

In  low-transmission  areas  (low  malaria  immunity);  women  in  the  second  and  third  trimesters  of  pregnancy  are  more  likely  to  develop  severe  malaria  than  other  adults,  often  complicated  by  pulmonary oedema and hypoglycaemia.  

The following are common features of severe malaria during pregnancy:  

• High fever
• Hyperparasitemia
• Low Blood Sugar
• Severe Hemolytic Anaemia
• Cerebral malaria
• Pulmonary oedema

Pharmacological Treatment Intramuscular/intravenous Artesunate is the drug of choice for treatment of severe malaria in all trimesters

Intermittent Preventive Treatment in Pregnancy (IPTp) 

Malaria  parasites  can  easily  accumulate  and  multiply  in  the  placenta  leading  to  placenta  malaria  infections,  resulting  to  complications  such  as  maternal  anaemia,  low  birth  weight,  premature  delivery, congenital infection and/or perinatal death. 

Note: 

• IPTp is an administration of antimalarial in full therapeutic doses at predetermined intervals during pregnancy individuals  with  no  signs/symptoms  of  malaria.  The  aim  is  to  prevent  above  mentioned complications with adverse  effects to both mother and fetus³ 

The medicine of choice for IPTp 

A: sulphadoxine+pyrimethamine (FDC) (PO) 500mg +25mg 

• The dose is 3 tablets once
• A minimum of 3 doses in entire pregnancy period
• The first dose should be administered from 14 weeks of pregnancy onwards
• Each dose should be given at least 4 weeks apart
• The last dose can be administered up to the time of delivery, without safety concerns

Note: 

• SP should not be administered to women receiving cotrimoxazole prophylaxis or pregnant women who are taking folic acid at a daily dose equal or above 5 mg, as it counteracts its efficacy
• SP can be administered safely with combined ferrous sulphate 200mg + folic acid 0.25mg
• If malaria is diagnosed to a scheduled pregnant woman for IPT with SP; SP should not be given, instead a full treatment with antimalarial should be given

Neonatal  malaria  is  defined  as  symptoms  attributable  to  malaria  with  evidence  of  ring  forms  of  malaria  parasite  in  the  blood  of  an  infant  within  the  first  twenty-eight  days  (4  weeks)  of  life.  Congenital  malaria  is  defined  as  symptoms  attributable  to  malaria  with  evidence  of  ring  forms  of  malaria parasite in the blood of an infant within the first seven days (1 week) of life. The signs and  symptoms resemble those seen in the new-born with septicemia. 

Clinical presentation 

• Fever
• Lethargy
• Unable to breastfeed
• Vomiting
• Irritability
• Respiratory distress
• Seizures
• Jaundice
• Pallor
• Hepatosplenomegaly
• Laboratory findings will include the presence of malaria parasites.

Investigations 

• Full blood picture
• Blood sugar
• Blood culture and sensitivity, blood smear for malaria parasite, serum electrolytes
• CSF for analysis

Management of neonatal malaria 

• Neonatal malaria should always be considered as severe malaria
• Neonates  with  suspected  malaria  should  be  admitted  to  hospital  immediately  as  they  can deteriorate quickly and die at home
• Parental Artesunate is recommended treatment of choice for neonates. Injectable Artemether can be used as an alternative if Artesunate is not available
• Broad spectrum antibiotic as majority of severe malaria accompanied with septicemia. Refer septicemia treatment section.

Nursing care and monitoring 

• Monitor vital signs (PR, RR & Temperature)
• Monitor input/output
• Check BS for malaria parasite daily
• Ensure feeding
• Advise on use of LLINs

If malaria is diagnosed, depending on classification of the malaria diagnosis, a full treatment with  antimalarial should be given according to the malaria classification. 

However, it should be noted that, clearance of parasitaemia may not necessarily be accompanied by  clearance of symptoms (fever) due to the presence of other underlying opportunistic infections. HIV  and AIDS infected adults with low CD4 cell counts may be more susceptible to treatment failure of  anti-malaria drugs. 

Note: In suspected  cerebral  malaria  in  a  HIV  and  AIDS  patient,  cerebrospinal  fluid  (CSF) examination to rule out other life-threatening conditions such as bacterial and cryptococcal meningitis