From the moment a woman conceives, what runs in the mind of the family is a bundle of joy. But what lurks in the shadows of her dream is a thing called malaria. The disease, deadliest in sub-Saharan Africa, takes the blame but at no time is its vicious felt so hard than in pregnant women or in children. 

Malaria is a tropical disease spread by infected female anopheles carrying a parasite called plasmodium that takes root mainly in the liver where it multiplies rapidly causing changes within the a normal body. 

A recent report by the World Health Organisation indicates that 627,000 people succumbed to death in 2013 resulting from malaria. 

The cold chills, high fever coupled with intervals of vomiting and general body weakness are nothing but not all to explain the end result of sleeping without a treated mosquito net. 

In about 10 to 15 days, symptoms begin to appear and parasite spreads into the entire body causing disruption in blood supply to body organs. 

Some parasites may however hibernate in the liver for up to four years but might regain activation afterwards. 

Malaria is more fatal during pregnancy since most adults who suffer from repetitive malaria throughout their lifetime may become partially immune to severe malaria. 

Particularly, the infection is more threating to women in their first or second pregnancies and those with other infections like HIV are at a high risk. Presence of a new organ (the placenta) provides a fresh site for malaria parasites to bind causing pregnant women to lose their immunity to the parasites.

The disease is more devastating, contributing negative effects to both the mother and the foetus. The effects include maternal anaemia, miscarriages, inhibited growth of the intrauterine tissue, premature babies, low birth weight and death. 

More than 10,000 maternal deaths and 20,000 neonatal deaths are realised annually, according to WHO report.The symptoms and complications of malaria during pregnancy differ with the intensity of malaria transmission and level of immunityacquired by the pregnant woman. 

Suppressing immunity

While these settings are presented as two distinct epidemiologic conditions, the intensity of transmission and immunity in pregnant women occurs on a scale, with potentially diverse condition.

HIV pregnant women with placental malaria are said to have a high risk of passing the infection to the foetus.

Dr Dan Jackson, a general practitioner from Rutongo Hospital, says the majority of shocking eventualities in pregnancy result from two main factors; the immune suppressed individual pregnancy and placental sequestration of infected erythrocytes.

In pregnant women, additional sequestration of malaria infected erythrocytes occurs in the placenta. Pregnant women, therefore, suffer disproportionately from severe anaemia as a result of infection, Dr Jackson says. 

In Africa, it has been estimated that malaria is responsible for 25 per cent of severe anaemia during pregnancy. Women with severe anaemia are at higher risk for morbidities such as congestive heart failure, fetal demise, and mortality associated with haemorrhage (blood loss) at the time of delivery.

Interestingly, the greatest degree of placental infestation is seen in women who have the highest level of immunity, leading to milder maternal symptoms and a disproportionate increase in fetal complications. 

Women with higher immunity may not demonstrate symptoms and not receive treatment which builds a higher placental parasite burden. 

"Foetal complications result from this placental inflammation, as well as maternal anaemia can manifest as stillbirth, intrauterine growth restriction, and low-birth-weight neonates,” says Dr Aliene Uwimana, a malaria specialist at Rwanda Biomedical Centre. 

Low-birth-weight neonates, in turn, are at higher risk for neonatal and new born death. 

Congenital malaria is a relatively rare complication in areas with endemic malaria, however, newborn parasitemia may present two to three months after delivery when maternal antibodies wear off.

It is also thought that infected erythrocytes collected in the placenta stimulate pancreatic cell production of insulin, leading to hyperinsulinism (excess levels of insulin in blood) and hypoglycaemia (low glucose levels in blood) during infection. 

This contributes to the severity of disease during pregnancy. Other maternal effects of malarial infection result from the stickiness of the infected erythrocytes that become trapped in small vessels, resulting in cerebral malaria, renal failure, and low levels of platelets.

HIV and malaria

In malaria endemic regions, some women are said to be infected with both malaria and HIV. The former is preventable and can be treated while a combination is responsible for significant maternal and neonatal morbidity. 

As a result of the impaired immune state, HIV infection increases the pregnant woman’s susceptibility to malaria and the morbidity associated with malaria, resulting in higher incidences of severe anaemia and low-birth-weight neonates in co-infected women.

Malarial infection in HIV-positive women is associated with higher levels of parasitemia, leading to a greater risk of severe anaemia. Equally, HIV viral load is increased, creating opportunity for infection and more severe diseases.

Prevention

Prevention of malaria is possible during pregnancy and two main strategies used to prevent malaria during pregnancy are sleeping under an insecticide treated mosquito net or presumptive treatment with malaria medications. 

Other common methods of prevention are vector control and elimination through indoor spraying using insecticides although after sometimethe vectors may gain resistance towards the insecticide.

For sever malaria during pregnancy, treatment involves intravenous subjection of quinine or artesunate in the second and third trimesters followed by proper medical care.

For travellers, shots of medication are usually administered which provides a form of immunity.

The severity of malaria can never be underestimated during pregnancy. Most mothers living in rural areas have limited access to medical facilities. Antenatal care itself is not a priority in the lives of some expectant mothers. 

Choice is to keep the tradition of home delivery and sometimes the medical facilities are inaccessible, distances are long and hard to cover while the only mode of survival is farm work which requires regular attention. 

Acquiring a mosquito net would be an immediate remedy to people living close to bushy areas as these provide habitat formosquitoes but the poverty may limit access to one or two. 

The disease is preventable and can be treated but there is a lot of negligence in the population making malaria the lead cause of deaths in Africa some of which are neonatal and maternal.