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Severe Plasmodium falciparum malaria in a non-immune pregnant woman
International Journal of Gynecology & Obstetrics 59 Ž1997. 143]144
Brief communication
Severe Plasmodium falciparum malaria in a non-immune pregnant woman A. Bukman, M.J.N. WeinansU , A.J. van Loon Department of Obstetrics and Gynaecology, Uni®ersity Hospital Groningen, The Netherlands Received 20 March 1997; received in revised form 30 July 1997; accepted 12 August 1997
Keywords: Malaria tropica; Pregnancy; Fetal death
A Dutch primigravida was living in Uganda and used proguanil and chloroquine as malarial prophylaxis. At a gestational age of 29 and 31 weeks, she had periods of high fever and received a course of antimalarial treatment with chloroquine. She returned to the Netherlands and visited her gynecologist at a gestational age of 33 weeks because of high fever, vomiting, diarrhoea and general weakness. A serious malaria infection was suspected. A blood smear showed a parasitemia index Žpercentage of infected erythrocytes. of 10% Plasmodium falciparum, which confirmed the diagnosis of severe malaria tropica. She was referred to the University Hospital for intravenous treatment with quinine. On arrival, she was clearly in labor and fetal death was diagnosed. She gave birth to a stillborn boy of 2020 g. The repeated maternal blood smear showed 25]30% infection with P. falciparum. There was severe hemolysis U
Corresponding author. Tel.: q31 503 613020; fax: q31 503 611806
with anemia of 4.6 mmolrl, trombocytopenia of 9 = 10 9rl, coagulopathy and renal function disorder. She was admitted to the intensive care unit where she was treated with quinine and doxycycline intravenously. Complete recovery was achieved in two weeks. The histology of the placenta showed an impressive parasite invasion into the maternal erythrocytes without any fetal malaria ŽFig. 1.. Autopsy of the fetus showed signs of acute hypoxemia. Malaria caused by the parasite P. falciparum Žmalaria tropica. is the most dangerous form of malaria and it has a high mortality rate, caused by complications such as fatal anemia, coagulopathy, renal failure, cerebral and cardiovascular problems and liver function disorders. Malaria and pregnancy influence each other. Malaria can cause abortion, low birth weight, preterm delivery and stillbirth, but it can also cause very serious maternal morbidity and even mortality w1x. After the third month of pregnancy, the placenta is highly susceptible to malaria infection. The maternal
0020-7292r97r$17.00 Q 1997 International Federation of Gynecology and Obstetrics PII S0020-7292Ž97.00205-1
144
A. Bukman et al. r International Journal of Gynecology & Obstetrics 59 (1997) 143]144
Fig. 1. Histology of the placenta. Intervillous space with maternal erythrocytes affected with malaria parasites Ž¤.. Unaffected fetal erythrocytes Ž¤..
sinusoids allow parasites to develop in the sequestered erythrocytes. Congenital malaria is very rare since the parasite cannot pass through a normal placenta. Antimalarial chemoprophylaxis and treatment during pregnancy require special consideration. Chloroquine and proguanil can safely be administered during pregnancy in prophylactic doses, and are still the drugs of choice for prophylaxis. Resistance against these drugs, however, is widespread over the world. Anti-folates such as fansidar Žsulfadoxine and pyrimethamine. showed teratogenicity and fetotoxicity in animal experiments and are not recommended during pregnancy. Halofrantine and mefloquine in toxic doses showed teratogenic effects in animal experiments. Administration of mefloquine during a small number of human pregnancies showed no adverse effects. Quinine is still used in cases of acute malaria, when treatment can be life-saving and immediate therapy is obligate.
In conclusion, malaria in pregnancy is a very serious problem, especially for women from nonendemic areas. The incidence of malaria in Western countries is increasing owing to the frequent traveling to and from endemic countries. Nonimmune women should be advised to take regular chloroquine andror proguanil chemoprophylaxis and take all possible precautions to avoid being bitten by the carrier mosquito w2x. As prophylaxis may be inadequate in areas with drug resistance, we advice pregnant women to consider not to travel for pleasure to malaria infested areas. References w1x Nathwani D, Currie PF, Douglas JG, Green ST, Smith NC. Plasmodium falciparum malaria in pregnancy: a review. Br J Obstet Gynaecol 1992;99:118]121. w2x Dolan G, Kuile FO ter, Jacoutot V et al. Bed nets for the prevention of malaria and anaemia in pregnancy. Trans R Soc Trop Med Hyg 1993;87:620]626.
Brief communication
Severe Plasmodium falciparum malaria in a non-immune pregnant woman A. Bukman, M.J.N. WeinansU , A.J. van Loon Department of Obstetrics and Gynaecology, Uni®ersity Hospital Groningen, The Netherlands Received 20 March 1997; received in revised form 30 July 1997; accepted 12 August 1997
Keywords: Malaria tropica; Pregnancy; Fetal death
A Dutch primigravida was living in Uganda and used proguanil and chloroquine as malarial prophylaxis. At a gestational age of 29 and 31 weeks, she had periods of high fever and received a course of antimalarial treatment with chloroquine. She returned to the Netherlands and visited her gynecologist at a gestational age of 33 weeks because of high fever, vomiting, diarrhoea and general weakness. A serious malaria infection was suspected. A blood smear showed a parasitemia index Žpercentage of infected erythrocytes. of 10% Plasmodium falciparum, which confirmed the diagnosis of severe malaria tropica. She was referred to the University Hospital for intravenous treatment with quinine. On arrival, she was clearly in labor and fetal death was diagnosed. She gave birth to a stillborn boy of 2020 g. The repeated maternal blood smear showed 25]30% infection with P. falciparum. There was severe hemolysis U
Corresponding author. Tel.: q31 503 613020; fax: q31 503 611806
with anemia of 4.6 mmolrl, trombocytopenia of 9 = 10 9rl, coagulopathy and renal function disorder. She was admitted to the intensive care unit where she was treated with quinine and doxycycline intravenously. Complete recovery was achieved in two weeks. The histology of the placenta showed an impressive parasite invasion into the maternal erythrocytes without any fetal malaria ŽFig. 1.. Autopsy of the fetus showed signs of acute hypoxemia. Malaria caused by the parasite P. falciparum Žmalaria tropica. is the most dangerous form of malaria and it has a high mortality rate, caused by complications such as fatal anemia, coagulopathy, renal failure, cerebral and cardiovascular problems and liver function disorders. Malaria and pregnancy influence each other. Malaria can cause abortion, low birth weight, preterm delivery and stillbirth, but it can also cause very serious maternal morbidity and even mortality w1x. After the third month of pregnancy, the placenta is highly susceptible to malaria infection. The maternal
0020-7292r97r$17.00 Q 1997 International Federation of Gynecology and Obstetrics PII S0020-7292Ž97.00205-1
144
A. Bukman et al. r International Journal of Gynecology & Obstetrics 59 (1997) 143]144
Fig. 1. Histology of the placenta. Intervillous space with maternal erythrocytes affected with malaria parasites Ž¤.. Unaffected fetal erythrocytes Ž¤..
sinusoids allow parasites to develop in the sequestered erythrocytes. Congenital malaria is very rare since the parasite cannot pass through a normal placenta. Antimalarial chemoprophylaxis and treatment during pregnancy require special consideration. Chloroquine and proguanil can safely be administered during pregnancy in prophylactic doses, and are still the drugs of choice for prophylaxis. Resistance against these drugs, however, is widespread over the world. Anti-folates such as fansidar Žsulfadoxine and pyrimethamine. showed teratogenicity and fetotoxicity in animal experiments and are not recommended during pregnancy. Halofrantine and mefloquine in toxic doses showed teratogenic effects in animal experiments. Administration of mefloquine during a small number of human pregnancies showed no adverse effects. Quinine is still used in cases of acute malaria, when treatment can be life-saving and immediate therapy is obligate.
In conclusion, malaria in pregnancy is a very serious problem, especially for women from nonendemic areas. The incidence of malaria in Western countries is increasing owing to the frequent traveling to and from endemic countries. Nonimmune women should be advised to take regular chloroquine andror proguanil chemoprophylaxis and take all possible precautions to avoid being bitten by the carrier mosquito w2x. As prophylaxis may be inadequate in areas with drug resistance, we advice pregnant women to consider not to travel for pleasure to malaria infested areas. References w1x Nathwani D, Currie PF, Douglas JG, Green ST, Smith NC. Plasmodium falciparum malaria in pregnancy: a review. Br J Obstet Gynaecol 1992;99:118]121. w2x Dolan G, Kuile FO ter, Jacoutot V et al. Bed nets for the prevention of malaria and anaemia in pregnancy. Trans R Soc Trop Med Hyg 1993;87:620]626.