Some initial symptoms of malaria include feeling unwell, experiencing headaches and fatigue, and having muscle aches and abdominal pain. This can eventually progress to a fever. Other common symptoms consist of nausea, vomiting, and orthostatic hypertension. Malaria can also lead to seizures which may precede going into a comatose state.
In regions of high transmission, such as Africa, women experiencing PAM may exhibit normal symptoms of malaria, but may also be asymptomatic or present with more mild symptoms, including a lack of the characteristic fever. This is due to the fact that these women most likely have partial immunity, which may prevent a woman from seeking treatment despite the danger to herself and her unborn child. Conversely, in regions of low malaria transmission, PAM is associated with a higher likelihood of symptoms as these women most likely did not acquire immunity.
Maternal and fetal outcomes
In general, women with PAM have a higher likelihood of premature birth and their infants having a low birthweight. In examination of possible malarial immunity, some studies have shown that the presence of P. falciparum antibodies (specifically CSA adhesion inhibitory antibodies or IgG antibodies) may decrease the likelihood of low birthweight in the infants of women who have had pregnancy-associated malaria, but these findings do not specifically correlate to malarial immunity during pregnancy. However, the relationship between many P. falciparum antibodies during pregnancy and maternal and birth outcomes remains variable.
Lower birthweight of infants born from mothers with PAM can be attributed to placental infection, as well as other complications such as anemia and malnutrition, since the malarial parasite can be passed vertically from mother to the infant via infected red blood cells. Children who are born with a below-average birthweight are at risk for other health problems, including increased risk of mortality.
Anemia is a great concern as an adverse effect of pregnancy-associated malaria, since it can be life-threatening to the mother. Its cause is often compounded with other factors, such as nutrition and genetics. Some studies have suggested that iron supplementation can help with maternal anemia, but more research on malaria-endemic regions is required to make a better recommendation for mothers with PAM.
One systematic review showed that children of women with PAM are also more likely to contract clinical malaria and P. falciparum parasitaemia, although the reasoning for this is uncertain.
Maternal death is one of the biggest complications of malaria in some areas during epidemics. Furthermore, its cause is compounded with other malarial complications, such as anemia.
Prevention and treatment
Prevention of pregnancy-associated malaria can be done with the use of various antimalarial drugs that are given before or during pregnancy to susceptible populations. Some of the antimalarial drugs used include Chloroquine, Mefloquine, and Sulfadoxine/pyrimethamine since they are safe for use during pregnancy. For regions of moderate or high malaria risk, preventative measures include insecticide-treated nets (ITNs) and intermittent preventive treatment in pregnancy (IPTp). ITNs act as two layers of protection, one from the physical net and another from the chemical nature and effects of the insecticide. Because IPTp plays a role in altering the immune response that the infant can display, the World Health Organization recommends starting IPTp as soon as possible during the 2nd trimester. These treatments are with doses of Sulfadoxine/pyrimethamine and are given at each antenatal visit, as long as the visits are one month apart. One concern with the use of Sulfadoxine/pyrimethamine along with other antimalarial drugs is P. falciparum developing resistance. In areas that have higher rates of resistance to the antimalarial Sulfadoxine/pyrimethamine, two doses of the drug is effective in reducing maternal parasitemia in women that do not have HIV while more doses are needed to reduce maternal parasitemia in HIV positive women.
Non-pharmacological treatment of PAM consists of utilizing the Artemisia annua plant as an herbal remedy. The basis for this reasoning is because A. annua acts as the plant source for Artemisinin-based combination therapy (ACT), a commonly used pharmacological treatment of PAM. However, the WHO currently does not support the use of A. annua as there are no standardization guidelines for plant harvest and preparation. Additionally, its clinical safety and efficacy have not yet been proven.
Treatment of PAM is highly dependent on the mother's current pregnancy stage (i.e. trimester) and the species responsible for the disease transmission.
For infection caused by P. falciparum, the WHO recommends during the first trimester a treatment consisting of both Quinine and Clindamycin for a duration of 7 days. During the second and third trimester, the WHO recommendations of ACT, are the same as ones for non-pregnant individuals.
For infection caused by the other species, which include Plasmodium malariae, Plasmodium vivax, and Plasmodium ovale, the WHO recommends Chloroquine or Quinine during the first trimester. Quinine is used as an alternative if chloroquine-resistance is detected. During the second and third trimester, the WHO recommends either ACT or Chloroquine. If chloroquine-resistance is detected, ACT is the treatment of choice. The Centers for Disease Control and Prevention (CDC) has similar recommendations to the WHO.
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