Background
Malaria infection during pregnancy is a major public health problem, with substantial risks for the mother, her foetus and the newborn. Each year, Malaria in Pregnancy (MiP) is responsible for 20% of stillbirths in sub-Saharan Africa, 11% of all newborn deaths in sub-Saharan Africa, and 10,000 maternal deaths globally. In areas with moderate to high transmission of Plasmodium falciparum, the World Health Organization (WHO) recommends a package of interventions for controlling malaria and its effects during pregnancy, which includes the promotion and use of insecticide-treated nets (ITNs), the administration during pregnancy of intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP), and appropriate case management through prompt and effective treatment of malaria in pregnant women. During the last few years, WHO has observed a slowing of efforts to scale-up IPTp-SP in a number of countries in Africa. Although there may be several reasons for this, an important factor is confusion among health workers about sulfadoxine-pyrimethamine administration for intermittent preventive treatment in pregnancy. At a recent WHO evidence review, a meta-analysis of seven trials evaluating IPTp-SP was undertaken. It showed that three or more doses of IPTp-SP were associated with higher mean birth weight and fewer low birth weight (LBW) births than two doses of IPTp-SP. The estimated relative risk reduction for LBW was 20% (95% CI 6-31). This effect was consistent across a wide range of SP resistance levels. The 3+ dose group also was found to have less placental malaria. There were no differences in serious adverse events between the two groups.
Based on this evidence review, in October 2012, WHO updated the recommendations on IPTp-SP as outlined below, and urges national health authorities to disseminate this update widely and ensure its correct application. IPTp-SP is an integral part of WHO’s three-pronged approach to the prevention and treatment of malaria in pregnancy, which also includes the use of insecticide treated nets and prompt and effective case management.
Timing of IPTp-SP
Complementing the use of an ITN, and prompt and effective case management, the Antenatal Care (ANC) contact schedule for MiP should be applied flexiblyso that pregnant women always receive IPTp-SP when eligible, starting as early as possible during the second trimester of pregnancy. It is important to keep in mind that:
Determining gestational age by clinical examination, especially early in pregnancy, can be challenging. WHO recommends that countries continue to use what is currently practiced for dating—either abdominal palpation or symphysis-fundal height. Doing one ultrasound scan, ideally during the first trimester, where available, is another opportunity to determine early gestational age, among other potential benefits for the pregnancy.
The period between 13 and 20 weeks is critical for irreversible negative consequences of MiP, when parasite densities are highest,11,12 and major benefit can be achieved from malaria prevention. For effective MiP programming, contact with a health provider early in the second trimester (between 13 and 16 weeks) is critical to ensuring timely access to the first dose of IPTp-SP for maximal impact.
Frequency of IPTp-SP
Following administration of the first dose of IPTp as early as possible in the second trimester (i.e., 13 to 16 weeks), pregnant women should receive an additional dose of IPTp-SP at each contact with a health care worker trained to deliver IPTp-SP until the time of delivery, ensuring that doses of IPTp-SP are administered at least one month apart. WHO does not recommend a maximum number of doses of IPTp-SP. SP can be safely administered from the beginning of the second trimester until delivery.
ITN use
All pregnant women should sleep under an ITN as early as possible in pregnancy, though ideally before becoming pregnant. Providing an ITN at the first contact will help to keep the pregnant woman and her foetus safe from malaria. Additionally, all efforts should be made to ensure women of reproductive age have access to and sleep under an ITN so that they are protected against malaria if they become pregnant.
Key points regarding ITN use include:
Free delivery of an ITN at the first ANC visit is an incentive to attend antenatal care and provides the pregnant woman with a lifesaving tool for herself and her baby. Sleeping under the ITN will also protect her baby during the first year of life.
Countries need to plan and budget for continuous ITN distribution to pregnant women at the first ANC contact, in addition to forecasting, procuring, and distributing ITNs for campaigns targeting the whole population.
Women living with HIV
Women living with HIV are at increased risk of all adverse consequences of malaria infections due to their compromised immune responses. All pregnant women should be screened for HIV at first ANC contact. Pregnant women living with HIV and taking co-trimoxazole prophylaxis should not receive SP, as concomitant administration of SP and co-trimoxazole could increase adverse drug reactions. When taken daily, co-trimoxazole provides protection against MiP. Despite this, it is especially important that pregnant women living with HIV sleep under an ITN, and seek prompt diagnosis and receive effective treatment if they experience symptoms of malaria.
Role of Pharmacists in IPTP
Pharmacists are medicines expert and as such have a large role to play in IPTP. Some include:
Monitoring for drug therapy problems. High doses of folic acid (i.e. daily dose equal to 5 mg or above) have been shown to
counteract the efficacy of SP as an antimalarial, and thus only the low dose (i.e. 0.4 mg daily) should be co-administered with SP. SP should not be administered concurrently with co-trimoxazole prophylaxis due to their redundant mechanisms of action and synergistic worsening of adverse drug reactions. Therefore, HIV-infected pregnant women who are already receiving co-trimoxazole prophylaxis should not receive IPTp-SP.
Increasing availability of SP, Folic Acid and other necessary medications via outsourcing, public-private partnership and collaborations with relevant government agencies.
Constant education of patients about drug dosage, side effects and basic info about medications being consumed.
Undertaking continuous research about this key subject.
Liaising with other healthcare workers on how to optimize drug therapy.