Pregnant women are more susceptible than the general population to malaria: they are more likely to become infected, suffer a recurrence, develop severe complications and to die from the disease [1]. Malaria contributes very significantly to maternal and fetal mortality [2,3]. Sub- Saharan Africa has the largest burden of malarial disease, with over 90% of the world’s malaria-related deaths occurring in this region [1].

Malaria in pregnancy is different to the disease in the non-pregnant state. The severity of malaria in pregnancy is thought to be due to general impaired immunity plus a diminution of acquired immunity to malaria in endemic areas [4].

Regardless of symptoms, the presence of plasmodial parasites in a pregnant woman’s body will have a negative impact on her own health and that or her fetus [5]. Malaria in pregnancy also contributes to significant perinatal morbidity and mortality. Infection is known to cause higher rates of miscarriage, intrauterine demise, premature delivery, low-birth-weight neonates, and neonatal death [6].

Chad since 2008 imposed the politics of exemption from payment of emergencies cares fees and the distribution of malaria preventing drugs for pregnant women and child. Despite this decision, pregnant women and child infected by malaria are more and more recorded during consultation. Few prior studies focused on fetal and maternal complications of malaria in this country.

Our objective was to combat both malaria and foeto-maternal complications, to improve maternal and perinatal health and curb the spread of this preventable infectious disease.

This was a prospective and descriptive survey of six months (from April 15th 2014 to October 15th 2014) about epidemiological aspects and foeto-maternal complications of malaria at N’Djamena mother and child hospital.

N’Djamena mother and child hospital is a third level hospital in N’djamena city which helps to take care of referred patients coming from surrounding hospitals.

All women pregnant women admitted for symptomatic or asymptomatic malaria during this survey period were included. Symptomatic malarial cases were defined as the presence of asexual forms of Plasmodium species on a blood smear, associated with fever (axillary temperature, above 37.5°C) or history of fever with one or more of the following: headache, weakness, myalgia, chills, dizziness, abdominal pain, diarrhea, nausea, vomiting. Malarial cases were asymptomatic when none of the symptoms listed above was reported. Malaria diagnosis had involved identifying malaria parasites or antigens/products in patient blood. All pregnant women with a positive malarial diagnose were treated. Before including a patient in this survey her consent was obtained after explaining to her the need for the survey. Patients with absence of malaria parasite or antigens/ products in blood were not included.

We got the agreement of the Director of N’Djamena Mother and Child hospital and ethical committee. Data were analyzed using SPSS17.0. Chi-square (X2) test (p<0.05) was used to compare variables.

We recorded 155 patients admitted for malaria among 1065 patients, giving and incidence of 14.55%.

Parity

Primiparous represented 47.74% (n=74/155) followed by multiparious with18.72% (n=29/155). Khi²=8.79; p=0.03 (Table 1).

Table 1: Parity.

Antenatal consultation

The majority of pregnant women, 65% (101/155) hadn’t attended ante natal consultation. Nineteen patients (19/155) did more than four ante natal consultations as recommended WHO (p=0.00000).

Intermittent preventive treatment (ITP)

Three quarters (¾) of patients didn’t receive malaria ‘preventive treatment during pregnancy (khi²=103; p=0.01). Ten patients (6.45%) had correctly taken intermittent preventive treatment (Table 2).

Table 2: Intermittent preventive treatment (itp).

This preventive treatment composed of Sulfadoxine-Pyrimethamine must be given after the 16th gestation week.

Seventy-eight patients (50.3%) declared using insecticide-treated bed nets.

Diagnose and confirmation exams

Clinical diagnosis is based on the patients’ signs and symptoms, and on physical findings at examination. The earliest symptoms of malaria are very nonspecific and variable, and include fever, headache, weakness, myalgia, chills, dizziness, abdominal pain, diarrhea, nausea, vomiting, anorexia, and pruritus. We recorded respectively, 61.9% (n=96/155), 51.6% (n=80/155), 34.2%( n=53/155), 21.9% (n=34/155), 16.1% (n=25/155), and 18% (n=28/155) of fever, headache, myalgia, abdominal pain, diarrhea, and vomiting.

In the laboratory, malaria is diagnosed using different techniques. In this survey, the rapid diagnostic tests were use first and the conventional microscopic diagnosis by staining thin and thick peripheral blood smears later. The majority (141/155 i.e. 90.97%) had had positive malaria rapid test. The microscopic examination of stained blood films using Giemsa showed Plasmodium falciparum malaria diagnosis in 80.64% (125/155).

Curative treatment

Quinine and artesunate were used for curative treatment. More than ¾ of patients (n=120/155 i.e. 77.4%) received quinine. All patients admitted during this survey were considered as severe malaria.

The maternal complications

Anaemia represented 18% (n=28/155), therefore 2.58% (n=4/155) were in a coma.

Iron and folic acid treatments were given to all women who developed anemia, defined as a hematocrit of less than 30 percent. Women with severe anemia (hematocrit of less than 20 percent) received a blood transfusion (n=7/155 i.e. 4.51%). Women were encouraged to deliver at a hospital.

The outcome of malaria infection was fatal for one patient giving a death rate of 0.65%. This death was due to neurologic complications of malaria.

Foetal complications

Table 3 shows that, low birth weight represented 15.48 %( n=24/155, p=0.0000) followed by premature delivery with 10.3 %( n=16/155, p=0.0000). Low birth weight was defined as a birth weight of less than 2,500 g, and premature birth was defined as gestational age of less than 37 weeks.

Table 3: Foetal complications.

Ninety one fetuses (58.72%) were normal (no complication).

The number of malaria cases worldwide seems to be increasing, due to increasing transmission risk in areas where malaria control has declined, the increasing prevalence of drug resistant strains of parasites, and in a relatively few cases, massive increases in international travel and migration [7]. Malaria during pregnancy is a major cause of maternal morbidity worldwide and leads to poor birth outcomes. 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% [8,9]. 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 [10]. According to earlier studies, Chad is an endemic area for malaria [11]. Our incidence of 14.55% is less than what was reported in some endemic areas [10]. Primiparous represented 47.74% that confirms the highest infection ‘risk and morbidity in primigravidas and primipara [10].

At least four antenatal consultations are recommended by WHO [12]. Antenatal consultations are moment to institute prevention of malarial disease. Ours findings showed that the majority of pregnant women (65%) hadn’t attended ante natal consultation, ¾ of patients didn’t receive intermittent preventive treatment and the half (50%) used insecticide-treated bed nets. Current prevention of malarial disease in pregnancy relies on 2 main strategies: providing pregnant women with insecticide-treated bed nets (ITN) and intermittent preventive treatment (IPT) with antimalarial medications. IPT refers to the administration of 2 or more doses of chemoprophylaxis after 16 weeks of gestation in an attempt to reduce subclinical malarial load [12,13]. In a Cochrane Review comparing malarial chemoprophylaxis with no prophylaxis during pregnancy [6], Garner and Gülmezoglu found a significant reduction in maternal anemia, parasitemia, and perinatal death, and a higher mean birth weight in the groups given IPT [14]. Sulfadoxine-pyrimethamine has been found safe in pregnancy when used intermittently as part of IPT [15]. Data from clinical trials and program evaluations in stable transmission areas indicate that intermittent preventive treatment is safe, efficacious, and effective in preventing maternal anemia, placental parasitemia, and low birth weight. Data also show that women using insecticide-treated bednets during pregnancy are also less likely to suffer these same adverse outcomes of malaria during pregnancy [15,16].

In the laboratory, malaria is diagnosed using different techniques: conventional microscopic diagnosis by staining thin and thick peripheral blood smears, rapid diagnostic tests, serological test, and molecular diagnostic methods, such as polymerase chain reaction [17- 21]. Some advantages and shortcomings of these methods have also been described, related to sensitivity, specificity, accuracy, precision, time consumed, cost-effectiveness, labor intensiveness, the need for skilled microscopists, and the problem of inexperienced technicians [22]. Since the World Health Organization (WHO) recognized the urgent need for new, simple, quick, accurate, and cost-effective diagnostic tests for determining the presence of malaria parasites, to overcome the deficiencies of light microscopy, numerous new malariadiagnostic techniques have been developed [23]. This, in turn, has led to an increase in the use of Rapid diagnostic tests (RDT) for malaria, which are fast and easy to perform, and do not require electricity or specific equipment [23]. Overall, RDTs appears a highly valuable, rapid malaria-diagnostic tool for healthcare workers; however it must currently be used in conjunction with other methods to confirm the results, characterize infection, and monitor treatment [24]. Our attitude joints this strategy above with 90.97% positive malaria rapid test and identification of Plasmodium falciparum malaria diagnosis in 80.64% (125/155). Microscopic detection and identification of Plasmodium species in Giemsa-stained thick blood films (for screening the presenting malaria parasite), and thin blood films (for species’ confirmation) remains the gold standard for laboratory diagnosis [25]. Malaria is diagnosed microscopically by staining thick and thin blood films on a glass slide, to visualize malaria parasites [22].

Treatment of uncomplicated malaria in pregnancy is a balance between potential fetal adverse effects from drug toxicity and improved clinical status with clearance of the parasite. In 2006, earlier studies recommended a combination of quinine and clindamycin for treatment of uncomplicated malaria in pregnancy [12,13]. For severe malaria in pregnancy, the WHO currently recommends treatment with either intravenous (IV) quinine or artesunate, or IV artesunate in the second and third trimesters [12]. Not only should IV quinine be avoided in the second and third trimesters as it is associated with recurrent hypoglycemia, but evidence supports the superiority of artesunate over quinine in the non-pregnant patient. All patients admitted during this survey were considered as severe malaria, our attitude aimed to reduce complications.

Malaria during pregnancy poses substantial risk to the mother, her fetus, and the neonate; the infection contributes to as much as 15% of maternal anemia, 14% of low birth weight infants, 30% of preventable low birth weight, 70% of intrauterine growth retardation, 36% of premature deliveries, and 8% of infant mortality. In areas of stable transmission where adult women have considerable acquired immunity, Plasmodium falciparum infection during pregnancy typically does not cause symptomatic malaria but may lead to maternal anemia and placental malaria, especially among women having their first and second children [26]. This placental malaria contributes to low birth weight, the single greatest risk factor for neonatal death, and a major contributor to infant deaths. In areas of unstable transmission, women do not acquire substantial antimalarial immunity; infection with P. falciparum can cause severe clinical illness and has also been linked to poor birth outcomes, including stillbirth and premature delivery [26]. Our findings confirm this with a high rate of maternal anemia and low birth weight infants respectively 18% and 15.48%. Anemia is due to haemolysis of parasitized cells and increased demands of pregnancy ± folate/iron deficiency [10]. Malaria and anemia are likely to act together to reduce birth weight. Their independent effects are difficult to distinguish. A study conducted in area of Papua New Guinea, which attempted to quantitate the separate effects of anemiaand malaria-attributable low birth weight, concluded that, in malarious areas, malaria was a more important risk factor for low birth weight than was anemia [27].

Malaria remains a frequent infectious disease during pregnancy. Current prevention of malarial disease in pregnancy relies on providing pregnant women with insecticide-treated bed nets and intermittent presumptive treatment. Sensitizations for antenatal consultations are useful to improve malaria ‘management.

All authors have declared that there is no conflict of interest.

No financial assistance or grants were solicited or obtained during the course of preparing this article.

For this survey we got the consent of patients and the agreement of the Director of N’Djamena Mother and Child hospital and ethical committee.