Detection and clinical manifestation of placental malaria in southern Ghana.
BACKGROUND
Plasmodium falciparum can be detected by microscopy, histidine-rich-protein-2 (HRP2) capture test or PCR but the respective clinical relevance of the thereby diagnosed infections in pregnant women is not well established.


METHODS
In a cross-sectional, year-round study among 839 delivering women in Agogo, Ghana, P. falciparum was screened for in both, peripheral and placental blood samples, and associations with maternal anaemia, low birth weight (LBW) and preterm delivery (PD) were analysed.


RESULTS
In peripheral blood, P. falciparum was observed in 19%, 34%, and 53% by microscopy, HRP2 test, and PCR, respectively. For placental samples, these figures were 35%, 41%, and 59%. Irrespective of diagnostic tool, P. falciparum infection increased the risk of anaemia. Positive peripheral blood results of microscopy and PCR were not associated with LBW or PD. In contrast, the HRP2 test performed well in identifying women at increased risk of poor pregnancy outcome, particularly in case of a negative peripheral blood film. Adjusting for age, parity, and antenatal visits, placental HRP2 was the only marker of infection associated with LBW (adjusted odds ratio (aOR), 1.5 (95%CI, 1.0-2.2)) and, at borderline statistical significance, PD (aOR, 1.4 (1.0-2.1)) in addition to anaemia (aOR, 2.3 (1.7-3.2)). Likewise, HRP2 in peripheral blood of seemingly aparasitaemic women was associated with PD (aOR, 1.7 (1.0-2.7)) and anaemia (aOR, 2.1 (1.4-3.2)).


CONCLUSIONS
Peripheral blood film microscopy not only underestimates placental malaria. In this highly endemic setting, it also fails to identify malaria as a cause of foetal impairment. Sub-microscopic infections detected by a HRP2 test in seemingly aparasitaemic women increase the risks of anaemia and PD. These findings indicate that the burden of malaria in pregnancy may be even larger than thought and accentuate the need for effective anti-malarial interventions in pregnancy.
Mockenhaupt
Frank P
FP
Institute of Tropical Medicine and International Health, Charité--University Medicine, Berlin, Germany. frank.mockenhaupt@charite.de
Bedu-Addo
George
G
von Gaertner
Christiane
C
Boyé
Renate
R
Fricke
Katrin
K
Hannibal
Iris
I
Karakaya
Filiz
F
Schaller
Marieke
M
Ulmen
Ulrike
U
Acquah
Patrick A
PA
Dietz
Ekkehart
E
Eggelte
Teunis A
TA
Bienzle
Ulrich
U
D000818:Animals; D000953:Antigens, Protozoan / Q000032:analysis; D000962:Antimalarials / Q000627:therapeutic use; D005260:Female; D005869:Ghana / Q000453:epidemiology; D006801:Humans; D016778:Malaria, Falciparum / Q000175:diagnosis* / Q000453:epidemiology / Q000469:parasitology / Q000517:prevention & control; D008859:Microscopy, Polarization / Q000379:methods*; D010922:Placenta Diseases / Q000453:epidemiology / Q000469:parasitology* / Q000517:prevention & control; D010963:Plasmodium falciparum / Q000302:isolation & purification* / Q000378:metabolism; D016133:Polymerase Chain Reaction / Q000379:methods; D011247:Pregnancy; D015597:Pregnancy Complications, Parasitic / Q000453:epidemiology / Q000469:parasitology* / Q000517:prevention & control; D015800:Protozoan Proteins / Q000032:analysis; D011739:Pyrimethamine / Q000627:therapeutic use
D000953:Antigens, Protozoan; D000962:Antimalarials; C514457:HRP-2 antigen, Plasmodium falciparum; D015800:Protozoan Proteins; D011739:Pyrimethamine