Kailash Chandra Nayak, Mahesh Pal Khatri, Bal Kishan Gupta, Parmendra Sirohi, Vinita Choudhary, Surendra Kumar Verma & Sanjay Beniwal

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J Vector Borne Dis 46, December 2009, pp. 299–302Spectrum of vivax malaria in pregnancy and its outcome: a hospital-based studyKailash Chandra Nayak, Mahesh Pal Khatri, Bal Kishan Gupta, Parmendra Sirohi,Vinita Choudhary, Surendra Kumar Verma & Sanjay BeniwalDepartment of Medicine, S.P. Medical College, Bikaner, IndiaKey words Malaria – Plasmodium vivax – pregnancyIt has been recognized for nearly a century that preg-nant women are especially prone to severe malaria.Studies from various countries of Asia regardingimpact of unstable malaria in pregnant women haveshown it to be an important cause of maternaldeath1,2, but in India only a limited number of hospi-tal-based studies have been carried out regarding theconsequences of malaria infection in pregnantwomen3–5. Considering the severity of the problem,we planned to undertake an in-depth prospectivestudy on impact of Plasmodium vivax malaria in preg-nancy and its outcome in comparison to non-preg-nant female patients residing in the same environ-ment and community. These observations are ofimmense clinical significance and are essential for thetheme presented in implementation of global malariacontrol programme.This study was conducted on pregnant and non-preg-nant female patients suffering from P. vivax malaria(confirmed by demonstration of asexual phase ofparasite in peripheral blood smear) admitted in clas-sified malaria wards of PBM Hospital, Bikaner(Rajasthan), India during 2006–08. Smear positivecases of only P. vivax infection were included in thestudy. Rapid card test for malaria (OptiMal test) wasalso performed in every case. Patients with P.falciparum infection were not included in the study.Thorough clinical and biochemical examinations weredone in all patients, which included complete bloodcounts, liver function tests, blood urea, serum crea-tinine and urine analysis. Other investigations likewidal test, blood culture, Australia Antigen (HBsAg)(Positive HBsAg cases were not included) and bru-cella antibody titre were performed to rule out othercauses of fever1. Fundus and CSF examinations weredone in patients of suspected cerebral malaria.All pregnant patients were subjected to regular ob-stetric checkup in antenatal clinic and cases werefollowed-up till delivery. Sonography of abdomenwas done in all the pregnant patients and weight ofthe fetus and placenta were recorded. Cord bloodsmear and fetal blood smear were also taken to seethe evidence of malaria parasite. The InstitutionalEthical Committee of S.P. Medical College, Bikanerapproved the study. All the patients with uncompli-cated malaria and pernicious syndromes were treatedaccording to WHO guidelines1. Mortality and morbid-ity trends were statistically compared in pregnant andnon-pregnant females by applying chi-square test.The study was conducted on 169 female patients ofP. vivax malaria, which included 25 pregnant femalesand 144 non-pregnant females. There was no historyof prior hospitalization and treatment in both thegroups. Duration of fever was 1 to 11 days in boththe groups with mean 5.3 days in pregnant and 5.76days in non-pregnant women and the difference wasnot statistically significant (p >0.05). The incidenceof malaria in pregnancy was found to be more inprimigravida and second gravida (18/25) as comparedto multigravida (7/25). Highest incidence of infec-tion was observed during 14–28 wk of gestation(13/25) followed by the period >28 wk (9/25) andleast in period of <14 wk (3/25) of gestation. We J  VECTOR  BORNE  DIS  46, DECEMBER 2009 300observed high incidence of all pernicious syndromesof malaria infection in pregnant females in compari-son to non-pregnant patients. The results of statisti-cal analysis are shown in Table 1. Out of 25 preg-nant females, severe anemia was found in 15, hepaticdysfunction in three, renal failure in two, hypoglyce-mia in one, acute respiratory distress syndrome(ARDS) in one, multiorgan dysfunction in one andthrombocytopenia in 14 cases and in comparison to144 non-pregnant females where severe anemia wasfound in 40 (27.77%), hepatic dysfunction in 11(7.63%), renal failure in five (3.47%), hypoglycemiain four (2.77%), ARDS in four (2.77%), multiorgandysfunction in five (3.47%) and thrombocytopeniain 28 (19.44%) cases.The outcome of pregnancy was worse in primipa-rous women as compared to multiparous. Normalpregnancy continued in only two out of 10 primipa-rous and nine out of 15 multiparous pregnant women.Other complications of pregnancy, i.e. preterm livebirth  was reported in four, intrauterine death  in one,stillbirth in two and abortion in one case were re-ported in primiparous group and preterm live birthwas reported in four, intrauterine death  in one andabortion in one case was reported in multiparousgroup. Majority of fetus (20) were born with lowbirth weight of <2.5 kg.  Two fetus were abortedwhich were having birth weight <500 g. Out of 25placenta examined, 18 had weight between 200 and400 g, two patients who aborted had placental weight< 200 g and only five had weight >400 g6.Pregnant women are especially prone to develop se-vere and complicated malaria1,2. The incidence ofseverity of infection and pregnancy related compli-cations varies according to the level of acquired im-munity of pregnant women against the infections andthe parity7. In our study, the susceptibility to malariainfection was found to be high in first and secondpregnancies (18 cases). Similar results were reportedin India which indicate primigravida are associatedwith more clinical severity than multigravida in theareas where transmission rate of malaria is high3,4.In highly endemic areas the peak level of P. vivaxparasitaemia occurs between 9 and 16 wk of gesta-tion and then decreases progressively until delivery.In our study, 13 patients were having 14–28 wk ofgestation at the time of infection. This shows a greaterincidence of malaria infection during second trimes-ter and is in accordance with earlier studies3,4. Themechanism of increased susceptibility to malarial in-fection during pregnancy has not been elucidated butincreased cortisol level, depressed cell mediated im-munity, altered immune functions of spleen, immuneevasion by parasite and interactions between malariaparasite and human nutritional status are believed toplay an important role7,8.Pregnancy is associated with severe P. vivax malariaTable 1. Incidence of various pernicious syndromes observed among pregnant and non-pregnant groupsPernicious syndrome Pregnant Non-pregnant Odds ratio Risk ratio Chi-square p-valuen = 25 (%) n =144 (%)Severe anemia (Hb <5 g%) 15 (60) 40 (27.7) 3.9 2.16 8.66 0.002Hepatic failure 3 (12) 11 (7.6) 1.64 1.57 – 0.342  (S. bilirubin >3 mg%)Renal failure 2 (8) 5 (3.4) 2.41 2.3 – 0.276  (S. creat. >3 mg%)Hypoglycemia 1 (4) 4 (2.7) 1.45 1.44 – 0.556  (Blood glucose <40 mg%)Thrombocytopenia 14 (56) 28 (19.4) 8.9 4.48 – 0.000005  (Platelet count <100000)ARDS 1 (4) 4 (2.7) 1.45 1.44 – 0.556Multiorgan dysfunction 1 (4) 5 (3.4) 1.158 1.152 – 0.623 301 NAYAK ET AL: VIVAX MALARIA IN PREGNANCYand increased prevalence of various pernicious syn-dromes. Multiple organ failure was more commonin pregnant females and associated with grave prog-nosis. Severe anemia (Hb <5 g%) was more com-monly seen amongst pregnant group as compared tonon-pregnant females. The mechanism of anemia ismultifactorial and complex involving hemolysis andinappropriate bone-marrow response3.Thrombocytopenia (platelet <100,000/l) is animportant complication of P. vivax malaria which ismore pronounced during pregnancy. Severe throm-bocytopenia (platelets <50,000/l) may be associ-ated with bleeding tendency and it was observed infive pregnant patients as compared to only 10 non-pregnant patients in our study. Similar observationswere reported by other workers8.Various authors from India9,10 have describedhypoglycemia in severe malaria. The incidence ofhypoglycemia (blood glucose <40 mg%) is alsoincreased during pregnancy. The possible mechanismfor hypoglycemia in our patients included increasedglucose consumption by host and the parasite11, gly-cogen depletion and impaired gluconeogenesis12,13.Malaria leads to significant impact on developmentof fetus and placenta and outcome of pregnancy inareas of unstable transmission. In our study, pretermlive births were seen in eight patients while the inci-dence of low birth weight babies was seen in 20 cases.Placental malaria is a significant cause of pregnancyrelated complications in the form of abortions, still-births, premature deliveries and low birth weightbabies. Several investigators have demonstrated anassociation between placental infection and low birthweight. The biologic mechanism by which placentalmalaria infection leads to low birth weight is not fullyestablished5,8.Limited data are available regarding spontaneousabortion as a complication of malaria infection. Inour study, two patients had abortion, although vari-ous authors from other parts of the world have re-ported that malaria is not an important cause of spon-taneous abortion in highly endemic areas8. As mostof the reports are from highly endemic areas and havefailed to document a direct association between ma-ternal malaria and abortions, it seems that the evi-dence of abortions varies inversely with immunity ofmother9.Malaria during pregnancy results in increased peri-natal wastage in the form of maternal deaths and fe-tal wastage. Pregnant women are likely to have 2–10 fold higher mortality than non-pregnant womenand few studies in India have also shown high inci-dence of maternal deaths in cases of malaria3,4 butwe have not observed any maternal death in our studywhich may be because of small number of cases, earlyrecognition and management of the disease.Thus, our study shows that P. vivax malaria infec-tion has an adverse effect on progress and outcomeof pregnancy. Therefore, early diagnosis and properinitiation of therapy can reduce the risk of seriousmaternal and fetal complications. As the chances ofacquiring malaria infection are increased during preg-nancy, measures should be taken to protect preg-nant women from hazards of malaria infection.AcknowledgementThe authors are highly thankful to hospital adminis-tration for providing all the investigative facilities anddrugs, free of cost to all the patients.References1. World Malaria Report. Global burden of malaria . Geneva:World Health Organization 2006; p. 126–7.2. Menon R. Pregnancy and malaria. Med J Malaya 1972;27 (2): 115–9.3. Nair LS, Nair AS. Effects of malaria infection on preg-nancy. Indian J Malariol 1993; 30(4): 207–14.4. Singh N, Shukla MM, Srivastava R, Sharma VP. Preva-lence of malaria among pregnant and non-pregnantwomen of District Jabalpur, Madhya Pradesh. Indian JMalariol 1995; 32(1): 6–13.5. Kaushik A, Sharma VK, Sadhana, Kumar R. Malarial J  VECTOR  BORNE  DIS  46, DECEMBER 2009 302placental infection and low birth weight babies. J CommunDis 1992; 24(2): 65–9.6. Tako EA, Zhou A, Lohoue J, Leke R, Taylor DW, LekeRF. Risk factors for placental malaria and its effect onpregnancy outcome in Yaounde, Cameroon. Am J TropMed Hyg 2005; 72(3): 236–42.7. Rasheed FN, Bulmer JN, Dunn DT, Menendez C, JawlaMF, Jepson A, Jakobsen PH, Greenwood BM. Suppressedperipheral and placental blood lymphoproliferative re-sponses in first pregnancies: relevance to malaria. Am JTrop Med Hyg 1993; 48(2): 154–60.8. Sholapurkar SL, Gupta AN, Mahajan RC. Clinical courseof malaria in pregnancy: a prospective controlled studyfrom India. Trans R Soc Trop Med Hyg 1988; 82: 376–9.9. Annual Report 2003–04, New Delhi: Ministry of Healthand Family Welfare,  Govt. of India 2004; p. 88.10. Molyneux ME, Taylor TE, Wirima JJ, Borgstein A. Clini-cal features and prognostic indicators in paediatric cere-bral malaria: a study of 131 comatose Malawian children.Qtl J Med 1989; 71(265): 441–59.11. Looareesuwan S, Phillips RE, White NJ. Quinine and se-vere falciparum malaria in late pregnancy. Lancet 1985;2: 4–8.12. McGregor IA. Epidemiology, malaria and pregnancy. AmJ Trop Med Hyg 1984; 33: 517–25.13. Alfonso J, Rodriguez M, Sanchez E, Vargas M, PiccoloC, Colina R, Arria M, Franco-Parades. Pregnancy out-comes associated with Plasmodium vivax malaria inNortheastern Venezuela. Am J Trop Med Hyg 2006; 74(5):755–7.Corresponding author: Dr B.K. Gupta, Prem Kutir, Opp. DRM Office, Hospital Road, Bikaner–334 003, India.E-mail: bkgbkn@rediffmail.comReceived: 11 July 2009 Accepted in revised form: 29 September 2009

Spectrum of vivax malaria in pregnancy and its outcome: a hospital- based study

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