7 April is World Health Day, and the World Health Organisation this year is running a campaign to raise awareness of vector-borne diseases with the slogan ‘Small bite, big threat’. One of the diseases included in this campaign is malaria, and here at the RCOG we have been involved in highlighting the dangers of this largely preventable disease to pregnant women. The guidelines issued in 2010 as part of the highly regarded Green-top Guidelines covered the prevention, diagnosis, and management of malaria in pregnancy and these can be found on the College website or from the College Library.
Going back a bit further in time, I have found a couple of references to malaria in the College Archive. The first is in a notebook kept by the physician Robert Barnes, who practised in London during the late nineteenth century and was affiliated to the Royal Maternity Charity. His notebook kept from1889 and entitled ‘Puerperal Fever’ contains hand-written notes and news cuttings about the nature and treatment of puerperal fever, and includes a curious article from the British Medical Journal, dated January 1890 in which the writer talks of puerperal fever and:
‘…expresses the opinion that the disease is of a malarial character, and that it’s endemic prevalence is favoured or determined by meteorological conditions…the sudden variations in temperature also predispose to the absorption of the malarial poison upon which he supposes influenza to depend.’
This definition of malaria is much at odds with our perception of insect-born disease, and a more modern description of managing malaria during pregnancy can be found in case notes compiled by College Member William Rotheram. Rotheram was stationed in the Middle East during the Second World War, and while there he gathered together notes to use on his case book for the MRCOG exam. He describes the management of a 20 year old housewife who came to him half-way through her first pregnancy in March 1944, suffering from high temperature, nausea and vomiting. She had been married for a year, during which time she had spent two months in Iraq. The symptoms together with her domicile in Iraq suggested to Rotheram a diagnosis of malaria, and this was proved by a blood smear. Treatment with quinine, atebrine and plasmoquine resulted in discharge of the patient within a month and a successful pregnancy and delivery.
The risks attached to malaria during pregnancy had been documented effectively by GAW Wickramasuriya, who won the Katherine Bishop Harman prize essay in 1936 for his work on malaria and ankylostomiasis in the pregnant woman, based on his experiences in Ceylon. During this period Ceylon had a high prevalence of malaria, which contributed to the high maternal and infantile mortality rates. Malaria was also recognised as a high factor in the production of toxaemia of pregnancy such as eclampsia.
Wickramasuriya concluded that malaria causes intra-uterine death of the foetus by one or more of three ways: massive infection of the placenta with parasites, persistently high temperature, and direct invasion of the foetus by parasites. In fact, the prognosis was and still is, definitely worse for the pregnant woman than the non-pregnant woman.
For information about World Health Day and the prevention of malaria, see the WHO website at http://www.who.int/campaigns/world-health-day/2014/en/.