his protozoan infection remains a global health crisis and causes 2000 deaths per day worldwide (White, 2015). Malaria has been efectively eradicated in Europe and in most of North America, and worldwide mortality rates have fallen more than 25 percent. In the United States, most cases of malaria are imported-some in returning military personnel (Mace, 2017). Transmitted by infected Anopheles mosquitoes, six species of Plasmodium cause human disease-alciparum, vivax, two species of ovale, malariae, and knowlesi.
Pregnant women have increased susceptibility to malarial infections (Kourtis, 2014). Antibodies to the parasite surface antigen VAR2CSA mediate placental accumulation of infected erythrocytes and lead to the harmful efects of malaria (Mayor, 2015). hrough this mechanism, some immunity accrues with parity and is called pregnancy-specic antimalarial immuniy. Ironically, malaria treatment dampens this immunity, and resurgence in pregnancy has been documented in Mozambique (Mayor, 2015).
Clinical findings are fever, chills, and flulike symptoms including headaches, myalgia, and malaise, which may occur at intervals. Symptoms are less severe with recurrences. Malaria may be associated with anemia and jaundice, and aciparum infections may cause kidney failure, coma, and death. That said, many otherwise healthy but infected adults in endemic areas are asymptomatic because of partial immunity. Pregnant women, although often asymptomatic, are said to be more likely to develop traditional symptoms (Desai, 2007) .
infections during pregnancy-whether symptomatic or asymptomatic-are associated with higher rates of perinatal morbidity and mortality (Menendez, 2007; Nosten, 2007). Adverse outcomes include stillbirth, preterm birth, low birthweight, and maternal anemia. The latter two are documented most frequently (Machado Filho, 2014; McClure, 2013). Maternal infection is associated with a 14-percent rate of low-birthweight newborns worldwide (Eisele, 2012). These
FIGURE 64-10 Photomicrograph of placental malaria. A.Multiple infected red blood cells (long black arrow) are seen in the intervillous space of this placenta. Multiple villi cut in cross section are shown, and three are highlighted (short arrows). B. Increased magnification of image (A). Multiple infected erythrocytes are seen, and two are identified (arrows).
adverse perinatal outcomes correlate with high levels of placental parasitemia (Rogerson, 2007). The latter occurs when parasitized erythrocytes, monocytes, and macrophages accumulate in the vascular areas of the placenta (Fig. 64-10). Infections with P aciparum are the worst, and early infection raises the risk for abortion. The incidence of malaria increases signiicantly in the latter two trimesters and postpartum (Diagne, 2000). Despite this, congenital malaria occurs in <5 percent of neonates born to infected mothers.
Identiication of parasites by microscopical evaluation of a thick and thin blood smear remains the gold standard for diagnosis. In women with low parasite densities, however, the sensitivity of microscopy is poor. Malaria-speciic antigens are now being used for rapid diagnostic testing. Not only is their sensitivity still an issue in pregnancy, but these tests are not routinely available (Kashif, 2013; White, 2015).