TREATMENT OF PREGNANT WOMEN Pregnant women with malaria should receive prompt and adequate treatment, since both the pregnant women and their babies are at high risk of
a fatal outcome. In pregnancy the disease is more severe, with higher parasitaemia, and is associated with abortion, premature labour, intra-uterine death, congenital malaria, low
birth weight, eclampsia, post-partum haemorrhage, severe haemolytic anaemia, cerebral malaria, hypoglycaemia and acute pulmonary oedema.20
The mortality rate from malaria is 2 to 10 times greater in pregnancy.6 QUININE
The treatment of choice in pregnancy is quinine. Quinine has proved to be safe when used in normal
therapeutic doses, and since the risks of malaria are great, there is no debate about using a less effective therapy.11
Quinine's main adverse effect in pregnancy is hypoglycaemia. Quinine may be oxytocic, but this effect may also be due to the malaria itself.22
The incidence of teratogenesis is unknown, although congenital abnormalities, notably eye and ear defects have been reported. With the doses used to treat malaria, the benefits of quinine therapy probably outweigh the risks.
23 CHLOROQUINE Chloroquine is considered to be safe during pregnancy, but the response should be monitored very closely due to resistance to the drug (see "
chloroquine" under uncomplicated malaria).
SULFADOXINE-PYRIMETHAMINE Because of the increasing anecdotal evidence of partial quinine resistance, it may
prove useful to combine quinine with sulfadoxine-pyrimethamine, particularly if the full course of quinine therapy cannot be supervised. As sulfadoxine-pyrimethamine is a slow acting
schizonticide, it cannot be recommended as monotherapy in pregnant non-immunes. There is a small potential risk of foetal malformation if sulfadoxine-pyrimethamine is given in the
first trimester. There is also a theoretical risk of the neonate developing kernicterus if sulfadoxine-pyrimethamine is given during late pregnancy11
because the sulfadoxine may displace bilirubin from albumin. This remains clinically unsubstantiated. MEFLOQUINE Mefloquine appears to be effective and safe to the foetus in
the treatment of uncomplicated malaria in pregnancy.24
Mefloquine in therapeutic doses has a significantly higher incidence of adverse effects than when used in prophylactic doses.11
It is not registered in South Africa for the treatment of malaria. As mefloquine is only available as an oral preparation, it may not be suitable for therapy of severe and complicated malaria.
The use of both doxycycline and primaquine is contraindicated in pregnancy. TREATMENT OF INFANTS AND YOUNG CHILDREN Infants and young
children (specially those under the age of 5 years) are particularly at risk since malaria symptoms can be severe and develop rapidly. The symptoms of malaria in children may differ
from those in adults, and therefore, malaria should be suspected if the child develops any febrile illness. Children with malaria may deteriorate rapidly, and are prone to
develop rapid increases in parasitaemia and severe and complicated malaria. This increased risk is believed to be due to their lower RBC mass and blood volume, and their
immunological immaturity.25 If confirmation of diagnosis is likely to take more than an hour, treatment should be started without waiting for confirmation.25
Cerebral malaria and other complications should be managed as medical emergencies.6
The use of a single intramuscular injection of phenobarbital sodium 10-15 mg/kg of body weight on admission may reduce the incidence of convulsions. Body weight is
probably the best and simplest guide to dosage in children, but it must be used with common sense and considering severity and complications. Fever, acidosis, malnutrition and
dehydration may affect metabolism of the drug.25 Serum quinine levels should be measured when quinine toxicity is suspected. Antimalarials in children
should be given orally where possible, as this route of administration is considered to be the safest. Parenteral administration is indicated in severe and complicated malaria.22
If vomiting occurs within half an hour of oral administration the same dose should be repeated.20 The bitter taste of antimalarials can be disguised in jam or
condensed milk. Fever can be reduced by tepid sponging and fanning, rehydration and paracetamol.20 Quinine is generally better tolerated in children than in
adults. Chloroquine calls for greater caution and parenteral chloroquine is contra-indicated as it may cause convulsions and cardiovascular collapse.22 In
addition to the specific treatment of malaria, general treatment and excellent nursing are of primary importance. Fluid balance and blood glucose should be monitored. Convulsions
should be aggressively treated. A lumbar puncture is indicated if a decreased level of consciousness or convulsions are present, to exclude secondary bacterial infections.6
A diet high in proteins and vitamins, with iron supplementation is recommended during convalescence.22 In Tables 1 , 2 and 3
are the drugs and dosages as recommended for infants and children.
The guidelines are endorsed by the Medical Association of South Africa. |
