Malaria in Pregnancy

7/21/2019 Malaria in Pregnancy

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MALARIA in

PREGNANCY

Diadopsi dari ppt Prof.M.C.Bansal,dengan perubahan

Founder principal & Controller ; Jhalawar Medical college And ospital, Jhalawar.

!". Principal & collenter;Mahat#a $andhi Medical College And

ospital,%itapura, Jaipur



'MP!(!)%*

• Mhs #a#pu #ela+u+an #enelas+an#orfologi parasit pen-ebab infe+si#alaria pada +eha#ilan

• Mhs #a#pu #ela+u+an identi+asiparasit pen-ebab #alaria pada+eha#ilan



INTRODUCTION

• Malaria is a protozoal diseasetrans#itted b- bite of infectedfemale Anopheles #os/uito.

• *t is Most i#portant parasiticinfestation in hu#ans with atrans#ission in 012 countriescontaining 3 billion people andresponsible for 0 4 3 #illion deaths

per -ear.



EPIDEMIOLOGY

*nsiden #alaria #enunu++an penurunan.Berdasar+an hasil 5is+esdas 6103, insiden#alaria #enurun dari 6,2 persen 761189

#enadi 0,2 persen 761039. )a#un, apabiladibanding dengan hasil 5is+esdas 6118,pre:alensi #alaria #ening+at -aitu 6,<persen 761189 #enadi > persen 761039. al

ini #enunu++an +e#ung+inan adan-apengobatan terhadap #alaria -ang +urangefe+tif sehingga u#lah penderita #alariase#a+in berta#bah.



?i#a pro:insi tertinggi pre:alensi#alaria adalah Papua 76,> persen9,

)usa (enggara (i#ur 763,3 persen9,Papua Barat 702,@ persen9, %ulawesi

(engah 706,< persen9, dan Malu+u

701,8 persen9. 0223 -aitu 6@,8@persen serta telah #ela#paui targetMD$s bidang sanitasi tahun 610<

sebesar >6,38 persen.



MALARIA



Malaria in pregnant women

• <1 #illion pregnant wo#en e"posedto #alaria each -ear.

• 3.< #illion pregnant wo#en infected

Poor birth outco#esPoor #aternal outco#e.

• Pregnant wo#en constitute the #ain

adult ris+ group for #alaria.



Gravidity and malaria

• Pri#igra:ida ha:e no pree"istingi##unit- to placental parasites and arehighl- susceptible.

• *n high trans#ission areas, pri#igra:idade:elop i##unit- to placental parasitesand are protected in subse/uentpregnancies.

• *n low trans#ission areas, #ultigra:ida

are une"posed and unprotected





A)'P!?!%Mos/uito

MALARIA

THE VECTOR…

Anophles balabacensis



Life Cycle ofAnopeles



They choose their victim by odor. Males are more frequently bitten. Most common time of bite is late evening to early

morning with peak at midnight. Stylets cut & proboscis probe for tiny blood vessels

in the skin. If it does not strike blood proboscis iswithdrawn and struck again at different angle.

They can fly for few m. Their life span is !"# weeks.

$uman blood is needed to lay eggs and nourisheggs.

ME FACTS ABOUT ANAPHELES…



T!ansmission…

Bite of infected #os/uito.

Congenitall- ac/uired disease.

Blood transfusion.

%haring of conta#inatedneedles.

'rgan transplantation.



CAUSAT"VE OR#AN"SM…Plas!odi"!

Apico#ple"a group of protooa,ha:especialied co#ple" of apical

organellesin:ol:ed in host cell in:asion.

More than 061 species are presentbut onl- @ are capable of causingEMA) MA?A5*A.

p# $i%a&

p# falcipar"!

p# Malariae

p# o%al



LIFE CYCLE OFPLASMODIUM

• P5*MA5 G D!F*)*(*H! '%( 4

MOS$U"TO

• %!C')DA5 G *)(!5M!D*A(! '%(

HUMAN





Malaria in Pre'nancy ( Do")le Tro")le

• Malaria is #ore co##on inpregnanc- co#pared to the generalpopulation.

• Malaria in pregnanc- tends to be#ore at-pical in presentation. (hiscould be due to the hor#onal,i##unological and he#atological

changes of pregnanc-.

• (he parasitea#ia tends to be 01 ti#es higher.

• P. al!ipar"m #alaria in pregnanc- being#ore se:ere, the #ortalit- is also double 703I9 co#pared to the nonpregnant population

7>.<I9.



Pathogenesis of #alaria in

pregnanc-

• During nor#al pregnanc-, the cellulari##une response 7(h09 is suppressed topre:ent fetal reection.

• Malaria sti#ulates the (h0 response intrauterine growth retardation.

• Malaria sti#ulates e"pression of an *H coreceptor 7CC5<9 in the placenta.

• Harious h-potheses ha:e been put forth toe"plain the pathoph-siolog- of #alaria inpregnanc-.



(he general i##unosupression of pregnanc-

5educed l-#ph proliferati:e response

!le:ated le:els of seru# cortisol

(o pre:ent the fetal reection

5enders the pregnantwo#an susceptible toinfestations7(his does not e"plain the di#inished

susceptibilit- to #alaria e"perienced b-

#ultigra:id wo#en.9

H%POTHES"S &'



#YPO$#ESIS % &

• Placenta is a new organ in the pri#igra:ida andallows the parasites to b-pass the e"isting hosti##unit- or allows placenta specic phenot-pes of P.al!ipar"m to #ultipl-.

• De:elop#ent of placenta specic i##unit- #a- thuse"plain the decreased susceptibilit- in #ultigra:ida.

• *t has been disco:ered that #ultigra:ida wo#en canfor# strainindependent antibodies against C%Aspecic parasites, and the- de#onstrate greatl-di#inished parasite load.



H(po)hesis & *

• Pregnant wo#en displa- a bias towards t-pe 6 c-to+inesand are therefore susceptible to diseases re/uiring t-pe 0responses for protection li+e (B, #alaria, leish#aniasis etc.

• *n infected pregnant wo#en a change of balance of the localplacental en:iron#ent fro# (6 to (0 has been obser:ed,consistent with large nu#ber of #onoc-tes in infectedplacenta. *?01 le:els are decreased, while *F)g , *?6, and

()F le:elshall#ar+s of a t-pe0 c-to+ine responseareele:ated.

• (hese proinKa##ator- c-to+ines account for the patholog-

of #aternal #alariaL !le:ated le:els of ()F are associatedwith se:ere #aternal ane#ia; s-#pto#atolog- of #alariaand localied c-to+ine ele:ation contributes to ad:ersepregnanc- outco#es.



E'e!t( o malaria on pregnant

women

MA$E)*AL EFFEC$S+• #yperpyre,ia

• #emolyti! anemia

• La!ti! a!ido(i(

• Folate de-!ien!y

• leeding di(order( in!l"ding DIC• #ypogly!emia

• A!"te renal ail"re

• A!"te p"lmonary edema

• Cere/ral malaria+(ei0"re(1deliri"m

• 2a"ndi!e

• #epatiti(• #epati! ail"re

• Po(t part"m 3aemorr3age

• Cir!"latory !ollap(e

• Fl"id and ele!trolyte im/alan!e

• la!4water ever

• Yellow ever • Deat3



FE$AL A*D PE)I*A$AL EFFEC$S+

• #ig3 ri(4 o a/ortion

• #ig3er in!iden!e o preterm delivery

• Intra"terine growt3 retardation

• Low /irt3 weig3t

• Intra"terine etal demi(e

• Congenital malaria

• Fail"re to t3rive• #ig3 perinatal mor/idity and mortality



EFFEC$ OF P)EG*A*CY O*

MALA)IA

• Pregnanc- is ani##unoco#pro#ised state thereforethe haards of #alaria increases.

• Fre/uenc- of infection is high duringad:anced pregnanc-.

• %e:erit- of infection is higher in

pri#igra:ida.

• igher #orbidit- because ofco#plications following #alaria

during pregnanc-.



Role of Placen)a+ )he NE, OR#AN of p!e-nanc(.

• In!iden!e o pla!ental involvement d"ring pregnan!y in womenliving in endemi! area( varie( /etween 56 to 678.

• P. al!ipar"m has the uni/ue abilit- of c-toadhesion.

• Chondroitin sulfate A and h-aluronic acid ha:e been identied asthe adhesion #olecules for parasite attach#ent to placental cells.

• (he parasites se/uester along the surface of the placental#e#brane, specicall- the trophoblastic :illi, e"tra:illoustrophoblasts, and s-nc-tial bridges.

• *nter:illous spaces are lled with parasites and #acrophages,interfering with o"-gen and nutrient transport to the foetus.

• All the placental tissues e"hibit #alarial pig#ents 7with or e:en

without parasites9.• (hese changes i#pede o"-gennutrient transfer and can cause

general he#orrhaging.

• (hese changes contribute to the co#plications e"perienced b-both #other and child.



Pla!ental malaria



C?*)*CA?

M*C5'%C'P

*MME)'?'$M'?!CE?

A5%!5'?'

$

DIAGNO*

I* O+MALARIA



P)OG*OS$IC PA)AME$E)S

• Parasite#ia <I

• Pac+ed cell :olu#e 31I

• e#oglobin 8.0 g#I

• -pogl-ce#ia Lblood glucose @1 #gI

• ?ow le:els of glucose in cerebrospinal Kuid

• 5aised :enous lactic acid >1 #.#olG?

• ?ow le:el of antithro#bin 3

• Peripheral schionte#ia

• *ncreased plas#a %nucleotides

• %eru# creatinine 3.1#gI

• Blood urea >1.1#gI



CLI*ICAL FEA$U)E

• Atypi!al manie(tation( o malaria are more !ommonin pregnan!y1 parti!"larly in t3e &nd 3al o pregnan!y.

• %e:erit- of the disease depends on the species ofin:ading Plas#odiu# parasite ,the intensit- ofparasite#ia , the e"tent of host resistance & the speedof diagnosis and i#ple#ent of eNecti:e therap-.

• (he three stages.

(he cold stage

(he hot stage

(he sweating stage

*t is followed b- another si#ilar attac+ in 6@@ hours.



• +e%er( -Patient #a- ha:e diNerent patterns of fe:er fro# afebrile to continuous fe:er, low grade to h-per

p-re"ia. *n 6ndhalf of pregnanc-, there #a- be #orefre/uent paro"-s#s due to i##unosuppression.

• Ane!ia( Most co##on feature of #alaria in pregnanc-.

• *pleno!e'aly( !nlarge#ent of the spleen #a- be:ariable. *t #a- be absent or s#all in 6nd half ofpregnanc-.

• 'ther s-#pto#s besides fe:er with rigors includeheadache,#alaise,nausea and:o#iting,deliriu#,he#ol-tic aundice,cache"ia.



MICRO*COPIC DIAGNO*I*

?ight #icroscop- of thic+ and thin l#s b- a s+illed

#icroscopist 4 gold standered

(hic+ l# diagnosis of #alaria, #ore sensiti:e (hin l# species identication

%a#ple can be collected anti#e irrespecti:e offe:er but before ad#inistration of anti#alarials

For best results l# should be #ade soon aftercollection and in case of anticoagulant within 6 hrs

%#ear should be e"a#ined with 011" oil i##ersionobecti:e lense 3 ti#es before concluding it

negati:e



.ENE+IT* O+ MICRO*COPY

09 %+illed #icroscopist pic+ up <01

parasiteG#l of blood.

69 species identication along with stage ofparasite.

39 deter#ines parasite densit-.

@9 Malarial pig#ent in neutrophil &#onoc-tes 7in profound ane#ia9.



DI*AD$ANTAGE* O+MICRO*COPY

09 (i#e consu#ing .

69 %+illed technician & infrastructurere/uired.

39 Deep se/uestered parasite not deleted.

@9 *n #i"ed infection often one speciessuppresses.

other #a+ing detection of suppressed one



RAPID DIAGNO*TIC TE*T*/ RDTs 0

*##unochro#atographic tests to detectplas#odiu# specic antigens in blood

!#plo- #onoclonal antibodies directed againsttargeted parasite antigens

Currentl- a:ailable rapid Diagnostic (ests are asfollows 4

istidine rich protein ii 7 5P** 9 L ase"ual stagesand -oung ga#etoc-tes of p.Falciparu#

Parasite lactate deh-drogenase 7p?D9 L p.Hi:e" ,.Falci aru# , all @ las#odia



Perfor!ance caracteristic ofRDTs *ensiti%ity

' A M*)*MEM %(A)DA5D 'F 2<I%!)%*(*H*( F'5 P.FA?C*PA5EM D!)%*(*!% 'F

011 PA5A%*(!%G? 'F B?''D A)D A %P!C*F*C*('F 2<I

5P** with parasite densit- 011G#l of blood

21I with 01G#l 8<I

5P** re#ain positi:e for 03w+.

p ?D re#ain positi:e for < da-s.



.ENE+IT* O+ RDTs

)'( MEC (5A*)*)$ 5!QE*5!D

!A% (' *)(!5P5*(

D'!% )'( )!!D !?!C(5*C*(

5AP*D 5!%E?(

$''D F'5 FA5 5!AC !A?( CA5! FAC*?*(*!%!5! M*C5'%C'P*C D*A$)'%*% *% )'( P'%%*B?!

*) %!H!5! C'MP?*CA(!D MA?A5*A *( )!$A(*H!P!5*P!5A? PA5A%*(A!M*A DE! (' %!QE!%(5A(*')



DI*AD$ANTAGE* O+ RDTs09Cannot distinguish new infection fro# old

69 Do not /uantif- parasite load .

39 Detection threshold @1>1 parasitesG#l.

@9 %torage proble#.

<9 cost.

6: Cro((%rea!tion( wit3 a"toanti/odie(

;: Fal(e po(itive < al(e *egative re("lt(





MOLECULAR MET1OD*

D)A P5'B!% .

D'( B?'( A%%A .

PC5 AMP?*F*CA(*').

MA%% %P!C(5'M!(5

F?' C('M!(5



*EROLOGICAL TE*T

*)D*5!C( *MME)'F?E5'%C!)C! 7using /uantitati:e buN- coat 4 QBC 9

Detect *R#, $ig, *gA.

*ndirect hae# agglutination .

!?*%A

5*A



Co!plications

•Ane!ia(-

• Malaria can cause or aggra:ate ane#ia. *t could be due to the following causesL

• e#ol-sis of parasitised red blood cells.

• *ncreased de#ands of pregnanc-.

• Profound he#ol-sis can aggra:ate folate decienc-.• *t is #ore co##on and se:ere between 0>62 wee+s. *t can de:elop suddenl-, in

case of se:ere #alaria with high grades of parasite#ia. Pre e"isting iron andfolate decienc- can e"acerbate the ane#ia of #alaria and :ice :ersa.

• Ane#ia increases perinatal #ortalit- and #aternal #orbidit- and #ortalit-. *talso increases the ris+ of pul#onar- oede#a.

• 5is+ of postpartu# hae#orrhage is also higher.

• %ignicant ane#ia 7e#oglobin 8 gI9 #a- ha:e to be treated with bloodtransfusion. *n :iew of the increased Kuid :olu#e in pregnanc-, it is better totransfuse pac+ed cells than whole blood. 5apid transfusion, particularl- wholeblood, #a- cause pul#onar- oede#a.

Ac"te p"l!onary oede!a(



Ac"te p"l!onary oede!a(-

• *t #a- be the presenting feature or can de:elopsuddenl- after se:eral da-s.

• More co##on in 6nd and 3rdtri#esters.• *t can de:elop suddenl- in i##ediate post

partu# period due to auto transfusion ofplacental blood with high proportion ofparasitised 5BCSs and sudden increase inperipheral :ascular resistance after deli:er-.

• Aggra:ated b- pre e"isting ane#ia andhe#od-na#ic changes of pregnanc-.

• *t carries a :er- high #ortalit-.

1ypo'lyce!ia(



1ypo'lyce!ia(

• *t is also #ore co##on in pregnanc-.

• Contributing factorsL

*ncreased de#ands of h-per catabolic state and infectingparasites. -pogl-ce#ic response to star:ation. *ncreased response of pancreatic islets to secretor- sti#uli 7li+e/uinine9 leads to h-per insuline#ia and h-pogl-ce#ia..% -pogl-ce#ia in these patients can re#ain as-#pto#atic and #a-

not be detected. (his is because, all the s-#pto#s ofh-pogl-ce#ia are also caused b- #alaria :i. tach-cardia,sweating, giddiness etc. %o#e patients #a- ha:e abnor#al

beha:iour, con:ulsions, altered sensoriu#, sudden loss ofconsciousness etc.

% (hese s-#pto#s of h-pogl-ce#ia #a- be easil- confused withcerebral #alaria. (herefore, in all pregnant wo#en with falciparu##alaria, particularl- those recei:ing /uinine, blood sugar should be

#onitored e:er- @> hours.%



I!!"no s"ppression(-• *t #a+es #alaria #ore co##on and #ore

se:ere.• #alaria itself suppresses *##une response.• or#onal changes of pregnanc-, reduced

s-nthesis of i##unoglobulins, reduced functionof reticulo endothelial s-ste# are the causes fori##unosuppression in pregnanc-.

• (his results in loss of ac/uired i##unit- to#alaria, #a+ing the pregnant #ore prone for#an- infection and also #alaria.

• %econdar- infections 7E(* and pneu#onias9 andalgid #alaria 7septicae#ic shoc+9 are #oreco##on in pregnanc- due to

i##unosuppression.



Con'enital !alaria(

• *t is due to transplacental or peripartal infection of thefetus is being increasingl- reported in 433I of

pregnancies fro# both #alariaende#ic and nonende#ic areas.

• Most cases are following P. al!ipar"m or P.viva, #alaria.

• *nfants born to non i##une #others with #alaria atthe ti#e of labour #a- de:elop parasite#ia and illnessin the rst few wee+s of life.

• Congenital #alaria usuall- #anifests between thesecond and eighth wee+s of life 7as earl- as 0 da- ordela-ed b- wee+s or #onths9 with s-#pto#s such asfe:er, anore"ia, letharg-, ane#ia, andhepatospleno#egal- etc.

• Features suggesti:e of neonatal sepsis such as

irritabilit-, poor feeding, regurgitation, loose stools,

Mana'e!ent of Malaria in



Mana'e!ent of Malaria inPre'nancy(

Manage#ent of #alaria in pregnanc-in:ol:es the following three aspectsand e/ual i#portance should be

attached to all the three.• Treat!ent of !alaria• Mana'e!ent of co!plications

• Mana'e!ent of la)o"r

T!ea)men) of mala!ia.



T!ea)men) of mala!ia.$reatment o malaria in pregnan!y (3o"ld /e energeti!1anti!ipatory and !are"l.

• Ener'etic( DonRt waste anti#e. *t is better to ad#it all cases of P.al!ipar"m #alaria. Assess se:erit- $eneral condition, pallor,

aundice, BP, te#perature, he#oglobin, Parasite count,%$P(, %. bilirubin, %. creatinine, Blood sugar.• Anticipatory( one should alwa-s be loo+ing for an-

co#plications b- regular #onitoring. Monitor #aternal and fetal :ital para#eters 6hourl-. 5B% @> hourl-; he#oglobin and parasite count06 hourl-; %. creatinine; %. bilirubin and *nta+e G 'utputchart dail-.

Caref"l(



Caref"l(

• (he ph-siologic changes of pregnanc- posespecial proble#s in #anage#ent of #alaria.

• Certain drugs are contraindicated in pregnanc-or #a- cause #ore se:ere ad:erse eNects. Allthese factors should be ta+en into consideration

while treating these patients.• Choose drugs according to se:erit- of thediseaseG sensiti:it- pattern in the localit-.

• A:oid drugs that are contraindicated.

• A:oid o:er G under dosing of drugs• A:oid Kuid o:erload G deh-dration• Maintain ade/uate inta+e of calories.



ANT"MALAR"AL "N PRE#NANC%

• All tri#ester 4Chloro/uine,Quinine,Artesunate,Arte#ether,Artether.

• %econd tri#esterMeKo/uine,%ulfado"in.• (hird tri#esterMeKo/uine,%ulfado"in.

• Contraindication

Pri#a/uine,(etrac-cline,Do"-c-cline,Malopri#,Paludrin,MeKo/uine,alofentrin,Arte#esinine.



TREATMENT O+UNCOMPLICATED

MALARIA

*E$ERITY INDICATI DO*E*



*E$ERITY INDICATION

DO*E*

E)C'MP?*CA(!D MA?A5*A P.FA?C*PA5EM 'ral /uinine>11 #ghourl- andoralClinda#-cin@<1 #g hourl- for 8

da-s 7can begi:entogether9

'r



• Chloro/uine 01#g base G+g perorall-followed b- 01#gG+g at 6@ hours and

<.1 #g base G+g at @ hrs.• For radical care Pri#a/uine is

prescribed after deli:er- .

• Alternati:el-,Quinine 01 #gG+g poe:er- hours for 8 da-s.



TREATMENT O+COMPLICATED MALARIA

%!H!5! '5 A) P?A%M'D*EM A5(!%E)A(! i:



%!H!5! '5C'MP?*CA(!D MA?A5*A

A) P?A%M'D*EM A5(!%E)A(! i:6.@#gG+g at 1,06,6@ hrthan dail- artether whenpatient is well enough tota+e oral #edication.%he

can be switched to oralartesunate 6#gG+g oncea da- plus clinda#-cinor /uinine andclinda#-cin @<1 #g (D%for 8 da-s.

A) %P!C*!% QE*)*)! i: 61#gG+gloading dose7no loadingdose if patient too+ oral/uinine or #eKo/uine9in<IDe"trose o:er @hours than 01 #gG+g i:o:er @ hours in e:er- hours and Clinda#-cin@<1 #g in e:er- hours7#a" dose of/uinine is 0.@ g#s9.hen the patient is wellenough to ta+e orall-

$)EA$ME*$ OF COMPLICA$ED



$)EA$ME*$ OF COMPLICA$EDMALA)IA

• Chloro/uine 01#g baseG+g i: o:erhrs,followed b- 0< #g baseG+g o:er 6@hours.

• Alternati:el- consider Quinine salt 61#gG+g i: infusion o:er @ hrs e:er- hrl-until oral inta+e beco#e per#issible.

• Co#plete 8 da-s treat#ent in all.

• Patient with se:ere anae#ia7ct619re/uire pac+ed cell transfusions.



MANA#EMENT OF

COMPL"CAT"ON

P l O d C f l K id



P"l!onary Oede!a( Careful Kuid#anage#ent; bac+ rest; o"-gen; diuretics;:entilation if needed.1ypo'lyce!ia( 6<<1I De"trose, <1011 #l*.H., followed b- 01I de"trose continuousinfusion. *f Kuid o:erload is a proble#, then

*n. $lucagon 1.<0 #g can be gi:en intra#uscularl-. Blood sugar should be #onitorede:er- @> hours for recurrent h-pogl-ce#ia.Ane!ia( Pac+ed cells should be transfused if

he#oglobin is <gI.Renal fail"re( 5enal failure could be prerenal due to unrecognised deh-dration orrenal due to se:ere parasite#ia. (reat#ent

in:ol:es careful Kuid #anage#ent, diuretics,

*epticae!ic soc2( %econdar- bacterial



infections li+e urinar- tract infection, pneu#oniaetc. are #ore co##on in pregnanc- associated

with #alaria. %o#e of these patients #a-de:elop septicae#ic shoc+, the so called Ralgid#alariaR. (reat#ent in:ol:es ad#inistration of3rd generation cephalosporins, Kuid replace#ent,

#onitoring of :ital para#eters and inta+e andoutput.E&can'e transf"sion( !"change transfusion isindicated in cases of se:ere falciparu# #alaria to

reduce the parasite load. PatientSs blood isre#o:ed and it is replaced with pac+ed cells. *t isespeciall- useful in cases of :er- highparasite#ia 7helps in clearing9 and i#pending

ul#onar oede#a 7hel s to reduce Kuid load9.

M ) f l b



Mana-emen) of labo/!

• Pregnant wo#en with se:ere #alaria are better#anaged in an intensi:e care unit.

• Falciparu# #alaria induces uterinecontractions, resulting in pre#ature labour. (he

fre/uenc- and intensit- of contractions appearto be related to the height of the fe:er.• Fetal distress is co##on and often

unrecognised.

• 'nl- #onitoring of uterine contractions andfetal heart rate #a- re:eal as-#pto#aticlabour and foetal tach-cardia, brad-cardia orlate deceleration in relation to uterine

contractions, indicating fetal distress.

• All eNorts should be #ade to rapidl- bring the



te#perature under control, b- cold sponging,anti p-retics li+e paraceta#ol etc.

• Careful Kuid #anage#ent is also :er-i#portant. Deh-dration as well as Kuid o:erloadshould be a:oided, because both could bedetri#ental to the #other andGor the foetus.

• *n cases of :er- high parasite#ia, e"changetransfusion #a- ha:e to be carried out.

• *f the situation de#ands, induction of labour#a- ha:e to be considered. 'nce the patient is

in labour, foetal or #aternal distress #a-indicate the need to shorten the 6nd stage b-forceps or :acuu# e"traction.

• *f needed, e:en caesarian section #ust be

considered



*UPPORTI$E MANAGEMENT



ousehold spra-ing

• Anophelies rest onwalls and ceiling afterblood #eal

• 5e/uires too #uchinfrastructure for poorcountries



*nsecticide (reated )ets

• Bednets i#pregnatedwith per#ethrininsecticide. " )eed retreat#ent e:er-

> #onths " )ew Tper#anetsU do

not need retreat#ent

• Act as hu#anbaited

#os/uito traps andare better with highco:erage



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Malaria in Pregnancy