Malaria has no effect on birth weight in Rwanda

Cause of fetal growth restriction during high-altitude pregnancy

High-altitude pregnancy increases the incidence of fetal growth restriction and reduces birth weight. This poses a significant clinical challenge as both are linked to adverse health outcomes, including raised infant mortality and the development of the metabolic syndrome in later life. While this reduction in birth weight is mostly understood to be driven by the hypobaric hypoxia of high altitude, the causative mechanism is unclear. Moreover, it is now recognized that highland ancestry confers protection against this reduction in birth weight. Here, we analyze the evidence that pregnancy at high altitude reduces birth weight and that highland ancestry confers protection, discussing mechanisms contributing to both effects.

Assessment of perinatal outcomes of pregnant women with severe versus simple malaria

Objective

Malaria in pregnancy is associated with adverse perinatal outcomes. The objective was to compare outcomes of simple and severe malaria and to determine whether they vary by trimester or severity of infection.

Methods

Prospective cohort study performed in 3 hospitals in Rwanda. Both hospitalized and non-hospitalized pregnant patients with confirmed malaria were enrolled and followed until 7 days postpartum. Demographic, clinical manifestations and perinatal outcomes were recorded.

Results

There were 446 pregnant women with confirmed malaria and outcome data; 361 (80.9%) had simple malaria. Severe malaria was more common as pregnancy progressed; out of 85 with severe malaria, 12.9%, 29.4% and 57.6% were in the 1^st, 2^nd and 3^rd trimesters (p<0.0001). Overall, a normal term delivery occurred in 57.6%, with preterm delivery in 24.9% and abortion in 13.5%. Adverse perinatal outcomes increased with trimester of infection (p<0.0001). Eight of the 9 early neonatal deaths had 3^rd trimester infection (p<0.0001). There were 27 stillbirths; 63.7% were associated with 3^rd trimester infection. A significant difference in perinatal outcomes between simple and severe malaria was seen: 64% of women with simple malaria had a normal term delivery as compared to 30.6% with severe malaria (p<0.0001). All complications were significantly greater with severe malaria.

Conclusion

Overall poor outcomes are seen in malaria with significant differences in perinatal outcomes between simple and severe malaria and by trimester of infection. In addition to vector control and exposure prevention, efforts need to be made in screening, treatment education and monitoring pregnancies affected by malaria.

Adverse birth outcomes among mothers who received intermittent preventive treatment with Sulphadoxine-Pyrimethamine in the low malaria transmission region

BACKGROUND

Malaria in pregnancy increases the risk of adverse birth outcomes such as low birth weight (LBW), maternal and foetal anemia. In Tanzania, some areas have attained low malaria transmission. However, data on the burden of preterm delivery, LBW, maternal and foetal anemia following substantial reduction of malaria transmission in recent years is still scarce in these settings.

METHODS

A study involving 631 pregnant women was conducted at Mwananyamala referral hospital in Dar es Salaam from April to August, 2018. Study enrollment was done prior to delivery. Structured interview and antenatal clinic cards were used to obtain data including the use of intermittent preventive therapy in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP). Infants birth weights were recorded, maternal venous and cord blood were taken for testing of malaria and determination of haemoglobin (Hb) levels. Chi-square test and regression analysis were done to identify risk factors for preterm delivery, LBW, maternal and foetal anemia.

RESULTS

The prevalence of malaria among mothers who used at least one dose of IPTp-SP was 0.6% (4/631). Fourteen mothers (2.2%) did not use IPTp-SP and had no malaria infection. The prevalence of maternal anemia, LBW, foetal anemia and preterm delivery was 40.6, 6.5, 5.9 and 9.2% respectively. Participants who were malaria positive had 11 times more risk of LBW compared to those who were negative (AOR, 11; 95%, CI 1.07-132.2; p = 0.04). The risk of delivering babies with LBW was 1.12 times high among mothers who were ≤ 36 weeks of gestation (AOR, 1.12; 95% CI, 0.06-0.25; p = < 0.001). The use of ≥3 doses of IPTp-SP was associated with 83% decrease in risk of LBW compared to those who did not use any dose of IPTp-SP (AOR, 0.17; 95% CI, 0.03-0.88; p = 0.05). Severe anaemia at delivery was associated with seven times increased risk of preterm delivery compared to non-anemic participants (AOR, 6.5; 95% CI, 1.49-28.16; p = 0.013).

CONCLUSION

Despite the reduced malaria transmission and use of IPTp-SP, prevalence of preterm delivery, maternal anemia, LBW and foetal anemia is still high in Tanzania. The recommended ≥3 doses of IPTp-SP should continue be provided even in areas with substantial reduction of malaria.

The relationship between malaria parasitemia, malaria preventive measures and average birth weight of babies in a tertiary facility in Owerri, Nigeria

BACKGROUND

Despite the global efforts made to eradicate malaria, it continues to be a significant cause of morbidity and mortality in both neonates and the parturients. This study was done to determine the relationship between placental parasitemia, average neonatal birth weight and the relationship between the use of malaria preventive measures and the occurrence of placental parasitemia with the aim to improving maternal and neonatal outcome.

PATIENTS AND METHODS

This cross-sectional study was done at the labor ward unit of the Federal Medical Center, Owerri, from December 2013 to May 2014. It involved one hundred and eighty primigravidae and baby pairs recruited consecutively. Thick and thin blood films were made from maternal peripheral blood and placenta. The babies were examined and weighed immediately after delivery.

RESULTS

Most of the participants had only one dose of intermittent preventive therapy (75%) with statistically significant higher level of fever episodes (P < 0.0001). Forty participants (58.0%) did not use any form of malaria preventive measure in pregnancy (P < 0.0001) and had a significantly higher placental parasitemia when compared with their counterparts. Average birth weight of neonates with placental parasitemia in mothers who used intermittent presumptive therapy (IPT) only (t = 2.22, P = 0.005), and IPT + insecticide-treated net (ITN) (t = 7.91, P ≤ 0.000) was significantly higher than those who did not use any form of malaria prevention in pregnancy (t = 4.69, P ≤ 0.0001).

CONCLUSION

Primigravidae with placental or maternal peripheral parasitemia who failed to use malaria preventive measures delivered babies with reduced average birth weight. A scheme aimed at making ITN readily available, and improving the girl child education is highly recommended.

Fetal and maternal hemodynamics in acute malaria during pregnancy

OBJECTIVE

To measure maternal and fetal hemodynamics during acute malaria in pregnancy.

METHODS

Time courses of maternal heart rate (MHR), maternal blood pressure (BP), and fetal heart rate (FHR) were performed until 56 days after initiation of anti-malarial treatment with artemether-lumefantrine. Women with malaria were hospitalized for at least 3 days until recovery.

RESULTS

Mean baseline characteristics of pregnant women with malaria (n=38) versus pregnant women without malaria (n=39) were as follows: gestational age (28.8 vs 24.6 weeks; P=0.006); maximum FHR (165.3 vs 158.3 beats per minute [bpm]; P=0.054); minimum FHR (137.6 vs 128.7 bpm; P=0.016); mean BP (74.7 vs 80.9 mm Hg; P=0.001); pulse pressure (40.3 vs 42.1mm Hg; P=0.300); and MHR (107.4 vs 81.3 bpm; P<0.001). The geometric mean parasite count was 13 795 per μL. Complete time courses were collected from a subgroup of participants. For women with malaria, maternal body temperature and BP normalized within 24 hours and after 72 hours, respectively. The MHR among pregnant women without malaria showed a physiologic increase during pregnancy of approximately 7 bpm between days 0 and 56. The mean FHR among women with malaria normalized after 72 hours.

CONCLUSION

Acute malaria induces maternal and fetal hemodynamic changes.

Prevalence of classic erythrocyte polymorphisms among 749 children in southern highland Rwanda

Classic erythrocyte polymorphisms were assessed by PCR-based methods among 749 children in southern highland Rwanda. Sickle cell trait, glucose-6-phosphate dehydrogenase (G6PD) deficiency, and α(+)-thalassaemia were observed in 2.8%, 9.6%, and 15.1%, respectively. Malariologic parameters did not correlate with these traits. Haemoglobin concentrations were significantly reduced in α(+)-thalassaemia but only homozygosity (0.8%) was a rare cause of anaemia in this population. The frequencies of malaria-protective polymorphisms reflect the high altitude (1700-1800 metres) of the study area. α(+)-thalassaemia and G6PD deficiency have previously been underestimated in Rwanda which may be of importance in the diagnosis and treatment of common childhood diseases.

Prevalence and risk factors of malaria among children in southern highland Rwanda

Background

Increased control has produced remarkable reductions of malaria in some parts of sub-Saharan Africa, including Rwanda. In the southern highlands, near the district capital of Butare (altitude, 1,768 m), a combined community-and facility-based survey on Plasmodium infection was conducted early in 2010.

Methods

A total of 749 children below five years of age were examined including 545 randomly selected from 24 villages, 103 attending the health centre in charge, and 101 at the referral district hospital. Clinical, parasitological, haematological, and socio-economic data were collected.

Results

Plasmodium falciparum infection (mean multiplicity, 2.08) was identified by microscopy and PCR in 11.7% and 16.7%, respectively; 5.5% of the children had malaria. PCR-based P. falciparum prevalence ranged between 0 and 38.5% in the villages, and was 21.4% in the health centre, and 14.9% in the hospital. Independent predictors of infection included increasing age, low mid-upper arm circumference, absence of several household assets, reported recent intake of artemether-lumefantrine, and chloroquine in plasma, measured by ELISA. Self-reported bed net use (58%) reduced infection only in univariate analysis. In the communities, most infections were seemingly asymptomatic but anaemia was observed in 82% and 28% of children with and without parasitaemia, respectively, the effect increasing with parasite density, and significant also for submicroscopic infections.

Conclusions

Plasmodium falciparum infection in the highlands surrounding Butare, Rwanda, is seen in one out of six children under five years of age. The abundance of seemingly asymptomatic infections in the community forms a reservoir for transmission in this epidemic-prone area. Risk factors suggestive of low socio-economic status and insufficient effectiveness of self-reported bed net use refer to areas of improvable intervention.

Malaria in pregnancy: the difficulties in measuring birthweight

Recommendations for interventions to control malaria in pregnancy are often based on studies using birthweight as the primary endpoint. Differences in birthweight may be attributable partly to methodological difficulties. We performed a structured search of the literature using ‘malaria’, ‘pregnancy’ and ‘birth weight’ as search terms. Of the clinical trials reporting birthweight, only 33% (14/43) gave information about the timing of the measurement and details on the scales used. Seventy seven per cent explained how gestational age was estimated. We propose a standardised method for the measurement and reporting of birthweight in future studies.