Malaria: A Major Cause of Anaemia in Primigravidae

Department of Obstetrics and Gynaecology, SMS Medical College, Rajasthan, India

*Corresponding Author:

Manisha Gupta
Department of Obstetrics and Gynaecology
SMS Medical College, Rajasthan, India
Tel: 919530040645
E-mail: guptamanisha169@gmail.com

Received date: October 21, 2015; Accepted date: September 26, 2016; Published date: September 30, 2016

Citation: Gupta M, Garg P, Agrawal V, Pant R, Benarjee KP (2016) Malaria: A Major Cause of Anaemia in Primigravidae. J Preg Child Health 3:277. doi:10.4172/2376-127X.1000277

Copyright: ©2016 Gupta M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.

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Abstract

Anaemia; Malaria; Peripheral smear; Prevalence; Primigravidae; Multigravidae

Keywords

Anaemia; Malaria; Peripheral smear; Prevalence; Primigravidae; Multigravidae

Introduction

Anaemia is one of the major public health problems in developing world like India especially in pregnant and lactating women. According to WHO, globally anaemia affects 1.62 billion people and prevalence among pregnant women is 41.8% (95% CI 39.9–43.8) [1]. If left untreated anaemia lead to preterm delivery, low birth weight, maternal morbidity and if severe, higher risk of morbidities such as congestive heart failure, fetal demise and mortality.

According to WHO, haemoglobin level below 11 g/dl in pregnant women constitutes anaemia and haemoglobin below 7 g/dl is severe anaemia [2]. The Center for Disease Control and Prevention defines anaemia as less than 11 g/dl in the first and third trimester and less than 10.5 g/dl in second trimester [2].

The etiology of anaemia in pregnancy is often multifactorial with causes related to nutritional deficiency of iron, folate, vitamin A or other nutrients, parasitic diseases such as malaria, hookworm, schistosomiasis, haemoglobinopathies, HIV infection. In developing countries, like India, malaria in a major contributory cause of anaemia, especially in primigravidae. As per WHO estimates, each year 300 to 500 million people develop malaria and 1.5 to 3 million die [3]. It is estimated that 1.2 billion people, out of 1.4 billion people of South East Region live in malaria endemic areas [4]. Pregnant women are 3 times more likely to suffer from severe disease as a result of malarial infection compared with their non-pregnant counterparts, and have a mortality rate from severe disease that approaches 50% [5,6]. In areas endemic for malaria, it is estimated that at least 25% of pregnant women are infected with malaria, with the highest risk for infection and morbidity in primigravidas, adolescents, and those co-infected with HIV [7]. Primigravidae have greatly increased susceptibility to plasmodium falciparum malaria compared with multigravidae living under these malaria endemic conditions and this difference in susceptibility could be reflected in increased prevalence or excess anaemia risk in primigavidae compared with multigravidae.

It is hypothesized that the majority of sequelae in pregnancy results from 2 main factors: the immunocompromised state of pregnancy and placental sequestration of infected erythrocytes [8]. Splenic sequestration of malaria infected erythrocytes leads to folic acid deficiency and microcytic anaemia in adults. In pregnant women, additional sequestration of malaria infected erythrocytes occurs in the placenta. Pregnant women therefore suffer disproportionately from severe anaemia [8].

Therefore the present study was designed to determine the prevalence of malaria in anaemic primigravidae and compare it with multigravida and also it shows increased risk of primigravidae to falciparum malaria compared to multigravidae.

Materials and Methods

This prospective cross sectional comparative clinical trial was carried out in Kamla Raja hospital and outpatient department of Gajra Raja medical college, Gwalior from October 2008 to February 2010. This study included 100 anaemic (Hb<11 g%) pregnant women and divided them into 2 groups.

• Group A 50 were primigravidae

• Group B 50 were multigravidae

Selection criteria were informed written consent, no past history of any medical disorder like tuberculosis, bronchial asthma, hypertension, bleeding disorder, malabsorption syndrome or hemorrhoids, no surgical history of gut resection and anastomosis, no obstetric complication like multiple pregnancies or bleeding in I^st and II^nd trimester.

Detailed history, thorough general, systemic and antenatal examination was done. Peripheral smear examination was done for malaria positivity. Data collected, tabulated and statistical analysis was done.

Observations and Results

In present study of total 100 anaemic cases, 50 were primigravidae (group A) and 50 were multigravidae (group B).

The demographic characteristics of both groups were compared as shown in Table 1 and we observed that the two groups were comparable except that primigravidae were younger than multigravidae.

In present study, Peripheral smear for malaria positivity was done in both groups. We found that in group A 62% of anaemic primigravidae were malaria positive while only 30% of anaemic multigravidae were positive for malaria in group B and the odd ratio found to be 3.807 (95% CI 1.657, 8.74) for primigravidae as compared to multigravidae Table 2. It shows high susceptibility and association of primigravidae to anaemia due to malaria.

We also found that primigravidae are more susceptible to plasmodium falciparum infection compared to muligravidae. 20% of primigravidae were positive for plasmodium falciparum infection while only 6% muligravidae found to be positive. P value is 0.03 that shows increased risk of Plasmodium falciparum infection to primigravidae as compare to multigravidae Table 3.

Table 1: Comparison of demographic characteristics of both groups.

Table 2: Malaria positivity in both groups.

Table 3: Number of vivax and falciparum positive cases in both groups.

Discussion

Malaria is a major contributory cause of anaemia especially in primigravidae. It is well documented that primigravidae have greatly increased susceptibility to Plasmodium falciparum malaria compared with multigravidae living under these malaria endemic conditions and this difference in susceptibility could be reflected in increased prevalence or excess anaemia risk in primigravidae compared with multigravidae.

In our study, 62% of primigravidae were malaria positive as compared to only 30% of multigravidae. The odd ratio found to be 3.807 (95% CI 1.657, 8.74) for primigarvidae as compared to multigravidae. Also primigravidae were found to be more susceptible to Plasmodium falciparum infection compared to multigravidae as 20% of primigravidae were positive to falciparum infection and only 6% muligravidae were positive. (P-value 0.03) This shows that primigravidae have greatly increased susceptibility to plasmodium falciparum malaria compared with multigravidae living under these malaria endemic conditions and this difference in susceptibility is reflected by increased prevalence or excess anaemia risk in primigravidae compared with multigravidae.

Ofori et al. [9] in 2005 assess the prevalence, incidence and clinical markers of pregnancy associated malaria (PAM) in rural district of Ghana. Haemoglobin levels were significantly related to parity (1-way ANOVA, p=0.02), being lowest in primigravidae (9.7 [9.3 to 10.1] g/ dl), and highest in multigravidae (10.5 [9.7 to 10.9] g/dl). Prevalence of peripheral P. falciparum parasitaemia was also related to parity, the highest among primigravidae (30/116), followed by secundigravidae (16/93) and lowest in multigravidae (12/85) (P (χ²)=0.09).

Savagae [10] in Sub Sarahan Africa in 2007 also showed that malarial anaemia is more frequent in first pregnancy as primigravidae and more susceptible to P. falciparum and are at excess risk of malarial anaemia. They found the weighted odds ratio for excess anaemia in primigravidae compared to multigravidae was 1.34% (95% CI 1.14, 1.58).

Matteelli [11] in 1994 also found that severe anaemia in pregnancy is a major obstetric problem in malaria-endemic areas. When primigravidae were considered, malaria infection was significantly more frequent among anaemic women (65.2%) than in those with normal Hb values (40.0%). Malaria was significantly associated with anaemia in the primigravidae, with an OR of 3.2 (95% confidence interval: 1.1-9.6; P<0.05). In conclusion, this cross-sectional investigation indicated that malaria plays a significant role in the determination of anaemia in primigravidae, but not in multiparae, in the urban study area.

Desai reviewed evidence of the clinical implications and burden of malaria in pregnancy. They suggest that successful prevention of these infections reduces the risk of severe maternal anaemia by 38%. Low birth weight by 43% and perinatal mortality by 27% among paucigravidae.

Shulman also showed that malaria is more common in primigravidae than multigravidae.

All above studies also shows that there is higher susceptibility of primigravidae as compared to multigravidae for malaria among anaemic pregnant women and primigravidae are more susceptible to falciparum malaria as compared to multigravidae.

Conclusion

Malaria in a major contributory cause of anaemia, especially in primigravidae and primigravidae have greatly increased susceptibility to plasmodium falciparum malaria compared with multigravidae living under malaria endemic conditions and this difference in susceptibility could be reflected in increased prevalence or excess anaemia risk in primigavidae compared with multigravidae. So early detection of anaemia due to malaria routinely at first antenatal visit or at delivery could potentially prevent the complications due to malaria and anaemia by timely interventions.

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