Int J Gynecol Obstet, 1992, 38: 231-233
231
International Federation of Gynecology and Obstetrics
Pregnancy complicated by malaria, precipitate labor and uterine rupture Y.N. Bakri, A. Martan
and A. Amri
Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Centre. Riyadh (Saudi Arabia)
(Received August 7th, 1991) (Revised and accepted December 20th, 1991)
Abstract A case of Plasmodium falciparum malaria is reported in a 25-year-old pregnant woman with a history of three previous cesarean sections. She developed premature precipitate labor which was complicated by stillbirth, uterine rupture, bladder and vaginal tears necessitating hysterectomy.
Keywords: Pregnancy; uterus; Labor.
Malaria;
Rupture
Introduction Malaria is a protozoan infection characterized by relapsing fever, rigors, splenomegaly and anemia caused by four plasmodium species transmitted from human to human by the bite of female anopheline mosquitoes. It has been and continues to be a worldwide health problem, endemic in Africa, Asia and Central and South America [3]. In pregnancy, malaria increases the incidence of abortion and premature labor [4] probably by stimulating prostaglandin metabolism [S]. We report a case of malaria in pregnancy associated with uterine rupture, which we speculate may have been related to 0020-7292l92/%05.00 0 1992 International Federation of Gynecology and Obstetrics Printed and Published in Ireland
malarial pyrexia initiating vigorous uterine contractions and precipitate labor. In this report we wish to emphasize the importance of malaria prophylaxis throughout pregnancy in endemic areas. Case report The patient, a 25year-old bedouin, gravida 4, para 4 with a history of 3 previous cesarean sections. She was well until week 34 of her last pregnancy, when she developed premature spontaneous precipitate labor which resulted in a stillbirth home delivery. Labor started by sudden onset of severe sharp lower abdominal pain which was accompanied with vaginal bleeding and followed by expulsion of the stillborn, 20 min later. There was no history of premature rupture of the membranes or heralding symptoms of an established labor pattern before. The placenta was delivered in the ambulance car, shortly before arrival to a local hospital, where upon arrival she manifested high fever, vaginal bleeding and frank hematuria. Emergency exploratory laparatomy revealed uterine atony with anterior longitudinal rupture which involved the upper uterine segment and extended into the bladder, cervix and vagina. The uterine tear location corresponded to a previous . classic Case Report
232
Bakri et al.
cesarean section scar. Inspection of the placental implantation site was without signs of placental accretism or previa location. A total abdominal hysterectomy with repair of bladder and vaginal tears was performed. On gross pathology, the placenta appeared dark coffee-colored and weighed 410 g. Histopathology revealed maternal intervillous plasmodial and macrophage infiltration without fetal side involvement. Fever workup revealed Plasmodium falciparum malaria for which chloroquine antimalarial therapy was started. Upon referral to the Ring Faisal Specialist Hospital, the patient appeared lethargic and pale. Her pulse was 130/min, temperature 4O.K, BP 90/70. Eyes showed bilateral corneal opacities. Abdomen was distended with active bleeding from penrose drains placed during hysterectomy. Laboratory investigations included Hb 5.5 g, hematocrit 23%, total bilirubin 4.3 mg/dl (normal 0.15- 1.O), alkaline phosphatase 636 units/l (normal 30-85), SGPT 62 units/l (normal 6-53), SGOT 85 units/l (normal 7-40), LDH 616 units/l (normal 100-225). A second laparotomy was performed which revealed a large right broad ligament hematoma, right ureteral partial obstruction, and active bleeding from a retracted right uterine artery. Evacuation of hematoma with bilateral hypogastric arterial ligation were performed and accomplished complete hemostasis. Right ureteral partial obstruction was judged to be related to tissue edema adjacent to the previously repaired bladder tear. Postoperative recovery was satisfactory, however, relapsing fever with chills and headache continued, repeated blood smear revealed persistent Plasmodium falciparum which required another course of chloroquine. The patient gradually improved and was discharged from hospital on day 25. Discussion The interaction of pregnancy and malaria is influenced by the nature of the organism and Int J Gynecol Obstet 38
the immune status of the host, with known higher incidence of premature labor and abortion in infected pregnant patients [3]. A large body of clinical observations indicates that pregnancy exerts a dampening effect on the immunity to malaria with marked tendency toward recrudescence of the disease during pregnancy and the puerperium just as after surgical procedures [4]. Malaria in general, and especially an infection with Plasmodium falciparum, is more hazardous and even life-threatening during pregnancy. Strang et al. [5], described a fatal case of Plasmodium falciparum malaria during pregnancy, and suggested that the increased incidence of abortion and premature labor may be related to a pyrexia-stimulated prostaglandin metabolism. In our case, who manifested severe pyrexia, it is probable that such a mechanism may have been responsible for initiating uterine contractions which led to rupture of a uterus scarred by 3 previous cesarean sections. This speculation is perhaps supported by the exclusion of other causes of premature labor in this case, and the absence of placental accretism and previa position on histopathological examination of the extirpated uterus. Acute malaria in a pregnant woman requires speedy and complete treatment by the most effective drugs available, with full supporting medications [ 1,2]. Congenital transmission of malaria may occur, though it is relatively rare. Since erythrocytes infected with P. falcifarum become sequestered in the placenta and can induce cellular hyperplasia in the intervellous space, it is perhaps not surprising that fetal health may also be compromised. Indeed, lower birthweight is characteristic of babies born to infected mothers [6]. Pregnant women from nonendemic regions should be discouraged from travelling to malarious areas. However, chemoprophylaxis of malaria throughout pregnancy, but particularly during its last third, is imperative for all nonimmune women visiting endemic malarious areas [ 11. Prophylaxis is also ad-
Pregnancy with malaria and ruptured uterus
visable for all women permanently resident in tropical countries where malaria occurs [I]. Chloroquine can be safely administered in standard prophylactic doses or in a therapeutic regimen in pregnancy, apparently without risk or teratogenic effects [6]. On the other hand, the antifolates and tetracyclines are potentially harmful to the fetus and should be avoided [6]. References 1 Bruce-Chwatt LJ: Malaria and pregnancy. Br Med J 286: 1457, 1983. 2 Gilles HM: The management and treatment of malaria. Am Sot Belg Med Trop 60: 129, 1980. 3 Lee RV: Protozoan infections in pregnancy. In: Principles
233
of Medical Therapy in Pregnancy (ed. N Gleicher) p 603. I st edn. Plenum Medical Book Co., New York, 1986. Pritchard JA, MacDonald PC, Gant NF: Williams Obstetrics. 17th edn, p 629. Appleton-Century Crofts, Norwalk, Connecticut, 1989. Strang A, Lachman E, Pitose SB, et al.: Malaria in pregnancy with fatal complications. Br J Obstet Gynaecol 91: 399, 1984. Wyler DJ: Malaria-resurgence, resistance, and research (first of two parts). New Engl J Med 308: 875, 1983.
Address for reprints: Y.N. Rakri Department of Obstetrics and Gynecology King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadb 11211 Saudi Arabia
Case Report
231
International Federation of Gynecology and Obstetrics
Pregnancy complicated by malaria, precipitate labor and uterine rupture Y.N. Bakri, A. Martan
and A. Amri
Department of Obstetrics and Gynecology, King Faisal Specialist Hospital and Research Centre. Riyadh (Saudi Arabia)
(Received August 7th, 1991) (Revised and accepted December 20th, 1991)
Abstract A case of Plasmodium falciparum malaria is reported in a 25-year-old pregnant woman with a history of three previous cesarean sections. She developed premature precipitate labor which was complicated by stillbirth, uterine rupture, bladder and vaginal tears necessitating hysterectomy.
Keywords: Pregnancy; uterus; Labor.
Malaria;
Rupture
Introduction Malaria is a protozoan infection characterized by relapsing fever, rigors, splenomegaly and anemia caused by four plasmodium species transmitted from human to human by the bite of female anopheline mosquitoes. It has been and continues to be a worldwide health problem, endemic in Africa, Asia and Central and South America [3]. In pregnancy, malaria increases the incidence of abortion and premature labor [4] probably by stimulating prostaglandin metabolism [S]. We report a case of malaria in pregnancy associated with uterine rupture, which we speculate may have been related to 0020-7292l92/%05.00 0 1992 International Federation of Gynecology and Obstetrics Printed and Published in Ireland
malarial pyrexia initiating vigorous uterine contractions and precipitate labor. In this report we wish to emphasize the importance of malaria prophylaxis throughout pregnancy in endemic areas. Case report The patient, a 25year-old bedouin, gravida 4, para 4 with a history of 3 previous cesarean sections. She was well until week 34 of her last pregnancy, when she developed premature spontaneous precipitate labor which resulted in a stillbirth home delivery. Labor started by sudden onset of severe sharp lower abdominal pain which was accompanied with vaginal bleeding and followed by expulsion of the stillborn, 20 min later. There was no history of premature rupture of the membranes or heralding symptoms of an established labor pattern before. The placenta was delivered in the ambulance car, shortly before arrival to a local hospital, where upon arrival she manifested high fever, vaginal bleeding and frank hematuria. Emergency exploratory laparatomy revealed uterine atony with anterior longitudinal rupture which involved the upper uterine segment and extended into the bladder, cervix and vagina. The uterine tear location corresponded to a previous . classic Case Report
232
Bakri et al.
cesarean section scar. Inspection of the placental implantation site was without signs of placental accretism or previa location. A total abdominal hysterectomy with repair of bladder and vaginal tears was performed. On gross pathology, the placenta appeared dark coffee-colored and weighed 410 g. Histopathology revealed maternal intervillous plasmodial and macrophage infiltration without fetal side involvement. Fever workup revealed Plasmodium falciparum malaria for which chloroquine antimalarial therapy was started. Upon referral to the Ring Faisal Specialist Hospital, the patient appeared lethargic and pale. Her pulse was 130/min, temperature 4O.K, BP 90/70. Eyes showed bilateral corneal opacities. Abdomen was distended with active bleeding from penrose drains placed during hysterectomy. Laboratory investigations included Hb 5.5 g, hematocrit 23%, total bilirubin 4.3 mg/dl (normal 0.15- 1.O), alkaline phosphatase 636 units/l (normal 30-85), SGPT 62 units/l (normal 6-53), SGOT 85 units/l (normal 7-40), LDH 616 units/l (normal 100-225). A second laparotomy was performed which revealed a large right broad ligament hematoma, right ureteral partial obstruction, and active bleeding from a retracted right uterine artery. Evacuation of hematoma with bilateral hypogastric arterial ligation were performed and accomplished complete hemostasis. Right ureteral partial obstruction was judged to be related to tissue edema adjacent to the previously repaired bladder tear. Postoperative recovery was satisfactory, however, relapsing fever with chills and headache continued, repeated blood smear revealed persistent Plasmodium falciparum which required another course of chloroquine. The patient gradually improved and was discharged from hospital on day 25. Discussion The interaction of pregnancy and malaria is influenced by the nature of the organism and Int J Gynecol Obstet 38
the immune status of the host, with known higher incidence of premature labor and abortion in infected pregnant patients [3]. A large body of clinical observations indicates that pregnancy exerts a dampening effect on the immunity to malaria with marked tendency toward recrudescence of the disease during pregnancy and the puerperium just as after surgical procedures [4]. Malaria in general, and especially an infection with Plasmodium falciparum, is more hazardous and even life-threatening during pregnancy. Strang et al. [5], described a fatal case of Plasmodium falciparum malaria during pregnancy, and suggested that the increased incidence of abortion and premature labor may be related to a pyrexia-stimulated prostaglandin metabolism. In our case, who manifested severe pyrexia, it is probable that such a mechanism may have been responsible for initiating uterine contractions which led to rupture of a uterus scarred by 3 previous cesarean sections. This speculation is perhaps supported by the exclusion of other causes of premature labor in this case, and the absence of placental accretism and previa position on histopathological examination of the extirpated uterus. Acute malaria in a pregnant woman requires speedy and complete treatment by the most effective drugs available, with full supporting medications [ 1,2]. Congenital transmission of malaria may occur, though it is relatively rare. Since erythrocytes infected with P. falcifarum become sequestered in the placenta and can induce cellular hyperplasia in the intervellous space, it is perhaps not surprising that fetal health may also be compromised. Indeed, lower birthweight is characteristic of babies born to infected mothers [6]. Pregnant women from nonendemic regions should be discouraged from travelling to malarious areas. However, chemoprophylaxis of malaria throughout pregnancy, but particularly during its last third, is imperative for all nonimmune women visiting endemic malarious areas [ 11. Prophylaxis is also ad-
Pregnancy with malaria and ruptured uterus
visable for all women permanently resident in tropical countries where malaria occurs [I]. Chloroquine can be safely administered in standard prophylactic doses or in a therapeutic regimen in pregnancy, apparently without risk or teratogenic effects [6]. On the other hand, the antifolates and tetracyclines are potentially harmful to the fetus and should be avoided [6]. References 1 Bruce-Chwatt LJ: Malaria and pregnancy. Br Med J 286: 1457, 1983. 2 Gilles HM: The management and treatment of malaria. Am Sot Belg Med Trop 60: 129, 1980. 3 Lee RV: Protozoan infections in pregnancy. In: Principles
233
of Medical Therapy in Pregnancy (ed. N Gleicher) p 603. I st edn. Plenum Medical Book Co., New York, 1986. Pritchard JA, MacDonald PC, Gant NF: Williams Obstetrics. 17th edn, p 629. Appleton-Century Crofts, Norwalk, Connecticut, 1989. Strang A, Lachman E, Pitose SB, et al.: Malaria in pregnancy with fatal complications. Br J Obstet Gynaecol 91: 399, 1984. Wyler DJ: Malaria-resurgence, resistance, and research (first of two parts). New Engl J Med 308: 875, 1983.
Address for reprints: Y.N. Rakri Department of Obstetrics and Gynecology King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadb 11211 Saudi Arabia
Case Report
