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The Malaria in Pregnancy (MiP) Library is a regularly updated, comprehensive bibliographic database of published and unpublished literature relating to malaria in pregnancy, including a trial registry of planned and ongoing trials. The MiP library is a product of the Malaria in Pregnancy Consortium and is available free of charge.

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 Article highlights from the update in January 2017

Article highlights from the update in January 2017

 

In January 2017, 157 new entries were added to the MiP library. New entries include peer reviewed journal articles, PhD and MSc theses, reports, and 63 abstracts related to malaria in pregnancy from the Annual Meeting of the American Society of Tropical Medicine & Hygiene. Here we highlight a few articles that may be of particular interest:

Phiri et al. reported on a pharmacokinetic and parasitological response study of a fixed combination of chloroquine-azithromycin (AZ-CQ: 155 participants), which was part of a large trial evaluating the combination as IPTp against IPTp with SP (Kimani et al. 2016). Although the main trial was terminated prematurely because of futility, this study showed a PCR-adjusted response of 99% on day 28 and 95% on day 42 for the AZ-CQ combination. 

A review on the safety, tolerability and efficacy of repeated doses of dihydroartemisinin-piperaquine (DP) identified 30 pregnant women with evaluation of cardiac parameters, and reported that all QTc intervals were within normal limits, with no significant increase in QTc prolongation with increasing courses of DP (Gutman et al. 2016). Treatment in the 2nd and 3rd trimester with artemisinin-derivatives was not associated with an increased risk of congenital malformations or miscarriage (Kovacs et al. 2016); artemisinins may actually be associated with a reduced risk of stillbirths compared to quinine. Clark et al.) conducted a series of rat and rabbit studies to generate information on the safety of artemether-lumefantrine in the first trimester. Lumefantrine was not teratogenic and was not a potent embryotoxin in rats and rabbits. The “developmental no-effects level dose” for artemether for rats was below the human therapeutic dose, whereas in rabbits it was about 2.5 times higher than the human therapeutic dose.

A study in Zambia examined the prevalence of curable sexually transmitted (STI) and reproductive tract infections (RTI) and co-occurrence with malaria among first antenatal care attendees (Chaponda et al. 2016). Overall, more than one third of women were co-infected with malaria and at least one STI/RTI; among women with malaria, 67% were co-infected with at least one STI/RTI indicating that an integrated approach to controlling infections among pregnant women attending antenatal care would be useful.

The effects of exposure to malaria in utero on the infant are not clear. (Prahl et al. 2016) reported that in utero exposure to malaria drives expansion of both regulatory and effector T cells in the foetus, and that the timing of this exposure has a pivotal role in determining the polarization of the foetal immune response. (Tran et al. 2016) suggest that in utero exposure to malaria in pregnancy may be a neglected risk factor for mental illness.

 

(Requena et al. 2016) report on immunological studies from the P. vivax in pregnancy study group, PREGVAX, and demonstrate that VIR antigens induce the natural acquisition of antibody and T cell memory responses that might be important in immunity to P. vivax during pregnancy in very diverse geographical settings (Brazil, Colombia, Guatemala, India and Papua New Guinea).

Using genotyping of malarial infections in the peripheral and placental blood of participants in a cohort study in Malawi by (Cohee et al. 2016) showed that 80% of peripheral infections persisted among women with more than one genotyped infection, and frequently did not respond to treatment with SP (33%) or artemether-lumefantrine (16%); placental infections could carry the same genotypes as in the peripheral blood prior to delivery (30%). Another study in Malawi examined the effect of the maternal malaria antibody response early in pregnancy (14-20 weeks) on outcomes later in pregnancy and detected that antibodies to placental-binding infected erythrocytes may be associated with higher haemoglobin levels in pregnancy but not with birth weight, whereas antibodies to other malaria antigens may be markers of malaria exposure (Chandrasiri et al. 2016).

As usual with these updates, there are plenty of articles highlighting one or more facets of prevention of malaria in pregnancy.  Krezanoski et al discussed attitudes of potential users to SmartNet®, an insecticide-treated net with inbuilt electric wiring and memory card to electronically record ITN usage longitudinally which can later be analysed, avoiding the issue of reporting bias.  Orobaton et al. (2016), described the efforts, effects, lessons learned, and costs to increase IPTp coverage in three local government areas in Nigeria. Rassi et al. (2016) evaluated barriers to higher IPTp coverage in Uganda in a qualitative study among stakeholders; they conclude that improvements will require consistent provision of ANC, implementation of current WHO IPTp policy recommendations, supply of SP to the private sector, availability of clear guidelines, as well as improved training and supervision for health workers, and improving facility and district-level recording. A similar study in Ghana identified shortage of SP, inadequate supply of potable water for administration of SP, unavailability of IPT during outreach services, lack of knowledge by ANC staff about the dropout rate in their area and poor attitudes of some health workers as barriers to achieving high IPT3 coverage (Doku et al. 2016).  A qualitative study from Benin described that the perceived need by policy makers for a user fee for antenatal care could contribute to deterring pregnant women in poverty from accessing preventive treatment, whereby health system dysfunctions including drug shortages and deficiencies in health care professionalism exacerbated the unintended effect (Danhoundo et al. 2016).  Stoner et al. examined the effect of three doses SP among HIV-positive women with unknown cotrimoxazole use in an

observational study in Zambia, and noted that the risk of low birth weight declined as the number of doses increased and appeared lowest among women who received three doses.

Lastly, Al Hammadi and colleagues (2017), reported on a woman from Ghana who developed P. falciparum malaria in pregnancy in the USA, more than 2 years after she left a malarious area. Just as a reminder.