Symptomatic maleria in pregnancy

Dear Sir,

The profound consequences of malaria in pregnancy, maternal and neonatal morbidity and mortality, are highlighted in the first three paragraphs of the manuscript by Nnaji and Ikechebele (2007). They report on 420 consecutively recruited pregnant women attending antenatal clinics in Nauth, Nnewi, Nigeria in 2001. The prevalence of peripheral blood parasitaemia was reported as 80.6% in those who reported febrile illness <1 month before booking; 77.7% in those who reported fever >1 month before booking and 78% in those who reported no fever at all. The mean parasite density, even in the women who reported no fever (mean ± SD) 1,686 ± 1,284/ml, was significant and well within the range of standard microscopy. Fever had a sensitivity and specificity in predicting malaria of 57.4% and 46%. These results highlight two very important features about our understanding of malaria.

First, that peripheral parasitaemia matters since it coincides with symptoms and correlates with poor pregnancy outcomes. Routine peripheral blood smear in pregnancy was not recognised (or even commented upon) as one of the most important findings of the study. Publications describing the association between parasitaemia in pregnancy, even asymptomatic, and harm to the mother and baby are numerous (Desai et al. 2007). Prompt and effective treatment has also been shown to reduce these harmful effects and the parasitisation of the placenta. To enrol pregnant women in a study and not to treat positive parasitaemia is clearly unethical. The manuscript makes no mention of treatment of these women.

Second, these results contradict the adage that pregnant women in Africa have asymptomatic parasitaemia. In this reportedly holoendemic area, most pregnant women have symptoms and most have parasites. Why not use this to their advantage? Offer peripheral blood smears (early detection) and effective treatment to all pregnant women who come to the ANC and to pregnant women with a history of fever who attend as out-patients.

As concluded by the authors, adequate prevention in pregnancy is a must but failing that, treatment is essential.