Cerebral Malaria in Pregnancy

At our panel on malaria in pregnancy during the Women Deliver conference, a participant asked about the importance of cerebral malaria (CM) in pregnancy. Below is a brief review of recent available literature, which does indeed highlight CM as an important danger to pregnant women in certain settings.

reducing-material-deaths.jpgFor the most part the literature mentions the problem of CM in the form of review without presenting original data. For example, malaria is cited as one of the most frequent parasitic diseases in pregnancy in tropical countries, with CM as an important complication. [1] Such reviews distinguish that CM is more common and dangerous in low or seasonal transmission areas where the population has not built some natural immunity. CM has a wide geographic scope according to Karnad and Guntupalli who said that, “Infections such as cerebral malaria and acute viral hepatitis with fulminant hepatic failure are common causes of coma and seizures during pregnancy in tropical regions of Asia, Africa, and Latin America. [2]

As noted by Duffy and Fried, “In low transmission areas, women of all parities are at risk for severe syndromes like cerebral malaria, and maternal and fetal mortality are high. In high transmission areas, where women are most susceptible during their first pregnancies, severe syndromes like cerebral malaria are uncommon.” [3] Likewise, “Acute and severe consequences of pregnancy-associated malaria (PAM), such as materno-fetal death or cerebral malaria, seem limited to unstable malaria areas.” [4]

An example of a specific study came from Ethiopia where Mengistu et al., observed that, “Out of 204 reproductive age women admitted with severe malaria 57.8% were pregnant. Signs of severity occurred more frequently in the pregnant women and rural dwellers. The several neurological manifestations were most common complications for more than 70.0% of the pregnant women and in 60.0% of the non-pregnant women, namely cerebral malaria, convulsions, altered mental state and prostration. The case fatality rate 33.1% among the pregnant women was found to he significantly higher than the non pregnant (p = 0.03, OR 2.2. 95% confidence interval 1.1-4.2).” [5] Much of malaria in Ethiopia is of the highland and seasonal variety.

In addition a 10-year review of malaria in pregnancy cases in Karnataka, India, which had risen to an incidence1.3% in 1998, found that, “Complications noted in our study were haemolysis, renal failure, hepatopathy and cerebral malaria.” [6] In the Arusha highlands a study of maternal death documented, “cerebral malaria [as a cause] of indirect death, accounting for 20 cases, with most of them occurring during an epidemic season.” [7]

Although at present the biggest attention to malaria in pregnancy is focused on stable transmission areas of the African region, this brief review suggests that vigilance to protect pregnant women from CM in all malaria zones is required. Not only are preventive interventions needed early in antenatal care, but staff involved in emergency obstetric care need to be trained to manage CM.

References.

1. Bourée P, Bisaro F. Parasitic diseases and pregnancy [Article in French] Rev Prat. 2007; 57(2):137-47

2. Karnad DR, Guntupalli KK.Neurologic disorders in pregnancy. Crit Care Med. 2005 Oct;33(10 Suppl):S362-71.

3. Duffy PE, Fried M. Malaria in the pregnant woman. Curr Top Microbiol Immunol. 2005; 295:169-200.

4. Cot M, Deloron P.Malaria prevention strategies. Br Med Bull. 2003;67:137-48.

5. Mengistu G, Diro E, Kassu A. Outcomes of pregnancy in severe malaria with emphasis on neurological manifestations in Gondar Hospital northwest Ethiopia. Ethiop Med J. 2006; 44(4):321-30.

6. Sitalakshmi S, Srikrishna A, Devi S, Damodar P, Mathew T, Varghese J. Changing trends in malaria–a decade’s experience at a referral hospital. Indian J Pathol Microbiol. 2003 Jul;46(3):399-401.

7. Olsen BE, Hinderaker SG, Bergsjø P, Lie RT, Olsen OH, Gasheka P, Kvåle G.Causes and characteristics of maternal deaths in rural northern Tanzania. Acta Obstet Gynecol Scand. 2002; 81(12): 1101-9.

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