JURNAL ANALISIS

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PROGRAM STUDI SARJANA KEBIDANAN

POLITEKNIK BHAKTIASIH PURWAKARTA
2023

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 ORIGINAL ARTICLE

Placental Parasitic Infections and Pregnancy Outcomes Among

Women Delivering at a Tertiary Hospital in Northern Tanzania

Eustadius Kamugisha Feliciana,b, Octavian Aron Ngodaa,c*, Ola Farid Jahanpourd,

Jackson Kahimae, Sia Emmanuel Msuyaa,f, Abdul Hamid Lukambagiref,g
aDepartment of Epidemiology & Biostatistics, Institute ofPublic Health, KCMUCo, Moshi–Tanzania, bBukoba Regional Referral
Hospital, Bukoba– Tanzania, cTanzania Medicine and Medical Devices Authority-TMDA, dDepartment of Community Medicine,
Kilimanjaro Christian Medical Centre, Moshi–Tanzania, eBugando Medical Centre, Mwanza– Tanzania, fKilimanjaro Clinical
Research Institute, Moshi – Tanzania, gDepartment of Veterinary Medicine and Public Health, College of Veterinary Medicine and
Biomedical Sciences, Sokoine University of Agriculture, Morogoro – Tanzania
Correspondence to Octavian Aron Ngoda ([email protected])

ABSTRACT
Background: Placental parasitic infections continue to be a public health problem despite numerous interventions
put in place. Placental parasitic infections reported are Toxoplasma, Trypanosome, Borrelia, Schistosoma,
Hookworm and Plasmodia. The infections persist to cause poor pregnancy outcomes such as maternal anaemia, low
birth weight and stillbirth. This study aimed to determine the prevalence and pregnancy outcomes associated with
placental parasitic infections at a tertiary hospital in northern Tanzania.
Methods: A cross sectional study was conducted at Kilimanjaro Christian Medical Centre between June and July 2016.
Pregnant women were interviewed before delivery and additional information obtained from their medical files.
Blood samples as well as placental material were collected from each mother. Malaria was tested using a
malaria rapid diagnostic test (mRDT). A total of 80 placental slide sections were made following histological
protocols. After staining, slide sections were examined for the presence of parasites microscopically. Pearson’s Chi-square
and Fisher’s exact tests were used to test for differences between groups.
Results: Placental malaria parasites were found on histological examination of 8(10%) mothers’ placental sections, none
of whom had a positive mRDT. Education status was significantly associated with placental malaria (p=0.035). Stillbirth,
maternal anaemia and pre-eclampsia were significantly associated with placenta malaria (p<0.05).
Conclusion: Placental malaria was found to be prevalent in the studied population and was associated with
stillbirth, maternal anaemia and pre-eclampsia. Efforts for developing malaria tests that will detect subclinical
infections are needed in order to identify infections early and offer prompt treatment to prevent poor pregnant
outcomes.

BACKGROUND Borrelia, Schistosoma, Hookworm and Plasmodia.5

lacental parasites infect millions of pregnant
P
Placental infections have been associated with
women in the world each year, and either directly or maternal and neonatal mortality7–9 as well as
indirectly lead to fetal complications like intrauterine
growth retardation, congenital malformations
and fetal loss.1 There is a regional variability in the
prevalence of placental parasites affecting pregnant
women. In Latin America 1, 1250,000 women are
infected annually with Trypanosomacruzi.2 Each year,
25 million pregnant women in sub-Saharan countries
are at risk of placental infections, the majority reported
are from Plasmodium falciparum.3 In Tanzania, the
prevalence of placental parasitemia has been reported
to range from 8%4 to 63.5%.5 In Kilimanjaro,
the Malaria Survey conducted in 2017 reported the
maximum monthly prevalence of placental infection
in antenatal care to be ≥2% to <5%.6 The reported
placental infections include; Toxoplasma, Trypanosome,

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morbidity.7–11 It is estimated that up to 200,000 deaths
per year in sub-Saharan Africa result directly from
placental parasitic infections.7Maternal anemia,8–10
stillbirth,8,11 premature delivery, intrauterine growth
retardation and low birth weight 7,8,11are among the
outcomes of placental parasites.
Malaria incidence fell by 37% from 2000 to 2015
and one of the targets of the Sustainable Development
Goal (SDG) number 3.3 is to end the epidemics of
Acquired Immune Deficiency Syndrome (AIDS),
tuberculosis, malaria and neglected tropical diseases
by 2030.12 Successful control of placental parasites
especially malaria in pregnant women is a major
step towards reducing the disease burden in Africa.
Control of these parasites in pregnancy involves
preventing infection as well as clearing parasitemia
when it occurs.13 Preventive measures put in place
by the World Health Organization (WHO) include
keeping a clean environment, use of Insecticide
Treated Nets (ITN), intermittent preventive
treatment in pregnancy and effective case
management.14 The use of preventive

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treatment like Sulfadoxine Pyrimethamine (SP) has (BMC) pathology laboratory for External Quality Control
been shown to be effective in pregnancy.14 (EQC). Pre-tested questionnaires were used to collect
The Ministry of Health (MOH) of the Government socio demographic information where examination
of United Republic of Tanzania adopted SP as the record files and clinic card were used to collect clinical
preferred chemo preventive method in pregnancy with characteristics.
set guidelines for its use. Despite these interventions, Maternal anemia, stillbirth, low birth weight and
placental parasitic infections, especially malaria, may preeclampsia were the main outcomes assessed. Low
still occur. The presence of placental receptors for birth weight was defined as an infant born with a weight
parasites may enable their sequestration, which may of less than 2.5kg while maternal anemia as a pregnant
then cause re-infections or ultimately lead to maternal mother with hemoglobin level less than 11g/dl. This
and neonatal complications.15 However, there are was further categorized into mild anemia 10.0-10.9g/dl,
limited studies in Tanzania to quantify these infections moderate anemia 7.0-9.9 g/dl, and severe anemia <7.0
especially after the introduction of various g/dl as adapted from a study conducted in Jordan. 19 Pre-
interventions. The majority of researchers would use eclampsia was defined as a blood pressure of greater than
daily routine (eosin and hematoxylin) or Giemsa stain to 140/90 and protein in urine. Stillbirth, the death of an
investigate placental parasite infections.16 The use of infant before delivery in a term pregnancy, was based
both stains may provide more accurate findings, on the first day after the mother’s last menstrual period.
whereby Giemsa stain would reveal parasites like The exposures for placental parasitic infections included
Leishmania,17 while eosin and hematoxylin would reveal maternal age, maternal occupation, marital status,
malaria parasites. 18 This study was carried out to area of residence; types of diet often used (nutrition),
determine the prevalence, risk factors and peripartum consumption of soil, education status and gravidity.
maternal outcomes associated with placental parasitic Analysis was conducted using SPSS Inc. Released 2009.
infections among women who delivered at Kilimanjaro PASW Statistics for Windows, Version 18.0. Chicago:
Christian Medical Centre (KCMC). This information can SPSS Inc. Pearson’s Chi-square test was used to determine
be used to plan effective measures for reducing the association between the exposures and outcomes
maternal and fetal risk factors and outcomes resulting of interest. A p value of less than 0.05 was considered
from parasitic infections. statistically significant.
METHODS Ethics Approval and Consent to Participate
A hospital based cross sectional study recruited delivering Approval to conduct this study was obtained from
mothers from June to July 2016 at the KCMC referral the Kilimanjaro Christian Medical College Research
and consultant hospital serving the northern zone in and Ethical Review Committee (CRERC) with ethical
Tanzania. Pregnant women aged 18 to 40 years who clearance certificate code number 2103, an independent
delivered and were admitted to the labour ward were review board for the medical college. Pregnant women
invited to participate in this study after providing written, aged 18-40 years who were admitted to the labor ward
informed consent. Pregnant women who did not and delivered were invited to participate in this study
consent, had planned abortion and those that after providing written, informed consent. Individual
experienced miscarriage were excluded from this study. level medical information obtained from those mothers
A total of 80 pregnant women met the inclusion criteria before and after delivery was kept strictly confidential.
and consented to participate in this study. A non-
probability convenient sampling technique was used to RESULTS
select study participants. A hemoglobin test using The socio-demographic characteristics of the pregnant
Haemoglobinometer HemoCue 201+ machine and the mothers are summarized in Table 1. The median age
rapid malaria detection test (mRDT)using SD BIOLINE of the 80 participants was 32 years (IQR 24-36). Most
Malaria Antigen P.F HRP2/ PLDH, followed by mothers had secondary or higher education 53(66.2%)
microscopic examination of blood slides on positive and were multigravida 51(63.8%). Proportion of anemia
samples using Olympus CX31 Binocular Microscope, cases was 23(28.7%).
was done for each participant at enrollment.
Hemoglobin test, rapid malaria detection test and Histopathological examination revealed that 8(10%) of
microscopic examination of blood slides were placenta were infected with malaria parasites, despite the
performed the clinical laboratory. After delivery, the fact all mothers had negative mRDTs test results. Placental
maternal surface of the placenta was washed with malaria infection was significantly associated with level
normal saline and then incised with a scalpel and of education of the mother (Table 2).
specimens fixed in 10% neutral buffered formalin. One Prevalence of placental malaria infection was associated
full placental block with 4-5µm thickness was prepared with low hemoglobin levels (χ²=14.978, p<0.01), pre-
by dehydration using acetone for two hours using Semi- eclampsia (χ²=7.485, p=0.048), and stillbirth (χ²
Automated Rotary Microtome M-240, clearing by using =14.815, p=.006) (Table 3).
Xylene for two hours, and paraffin infiltration with
paraffin wax. Two slides’ sections were made and
stained differently; one slide stained with Hematoxylin
and Eosin (H&E) as the routine stain and other slide
stained with Giemsa stain as the special stain. The slides
were then examined by light microscopy. Placental
parasites were recorded during examination and all
diagnoses confirmed by an experienced pathologist at
Bugando Medical Centre

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TABLE 2: Association Between Socio-demographic Characteristics and Parasitic Infections

Characteristics Number Parasitic Infections

Seen (%) Not seen (%) χ² (p-value)
Occupational 2.956 (0.135)
Employed 43 2 (4.7) 41 (95.3)
Self employed 37 6 (16.2) 31 (83.8)
Pica habit 1.455 (0.424)
Yes 55 7 (12.7) 48 (87.3)
No 25 1 (4.0) 24 (96.0)
Education 6.960 (0.035)
Primary education 27 6 (22.2) 21 (77.8)
Secondary education 43 2 (4.7) 41 (95.3)
Higher education 10 0 (0.0) 10 (100.0)
Gravidity 2.170 (0.247)
Primigravida 29 1 (3.4) 28 (96.6)
Multigravida 51 7 (13.7) 44 (86.3)
Gestation Age (Week) 1.437 (0.284)
28-36 36 2 (5.6) 34 (94.4)
37-43 44 6 (13.6) 38 (86.4)
Marital status 1.725 (0.341)
Union 67 8 (11.9) 59 (88.1)
Non union 13 0 (0.0) 13 (100.0)

TABLE 3: Association Between Placental Malaria Parasitic Infection and Pregnancy Outcomes

Adverse pregnancy outcomes Placenta malaria parasites

N YesNo
n (%)n(%) χ² (p-value)
14.815 (0.006)
Still birth
Yes 5 3(60.0) 2 (40.0)
No 75 5 (6.7) 70(93.3)
B irth weight (Kg) 0.969 (0.459)
< 2.5 47 6(12.8) 41(87.2)
≥ 2.5 33 2 (6.1) 31(93.9)
H emoglobin level (g/dl) 14.978(<0.0001)
Normal 57 1 (1.8) 56(98.2)
Anemia 23 7(30.4) 16(69.6)
P re-eclampsia 7.485 (0.048)
Yes 4 2(50.0) 2 (50.0)
No 76 6 (7.9) 70(92.1)

Key: Kg – Kilogram; g/dl – grams/deciliter; χ²– Chi-square

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in Dar es Salaam used immunosorbent agglutination

assay, in Mwanza ELISA 23 was used and in this study,
TABLE 1: Socio-Demographic Characteristics of Women whose
manual Placentastaining
histological were Examined
was used. for Parasitic Infections (
Furthermore, the presence of placental malaria infections
among participants was different based on their level
Characteristics Frequency Percentage of education while this difference was not seen with
Education other socio-demographic characteristics. This revealed
that pregnant women who are in the primary level of
Primary education 27 33.8 education were more likely than those with secondary
Secondary education 43 53.7 and higher education to have placental malaria
Higher education 10 12.5 infection.
Age(year) In this study, placental malaria was associated with
≤24 22 27.5 anemia. Anemia is the most common consequence
>24 58 72.5 of P. falciparum malaria infection. A study conducted in
Gravidity Tanzania found that malaria infection during pregnancy
Primigravida 29 6.2 contributed 15% of maternal anemia. 24 The result of this
Multigravida 51 63.8 outcome also corresponds with previous studies conducted
in Sub-Saharan Africa.25 The pathogenesis of anemia by
Birth weight (Kg) malaria parasites (P. falciparum) includes the hemolysis
<2.5 20 25.0 of the infected red blood cells. This is thought to be due
≥2.5 60 75.0 to the reduced production of red blood cells, rupture of
Gestation age infected red blood cells and the destruction of
(Week) 28-36 36 45.0 uninfected cells due to antibody sensitization and with
37-42 44 55.0 the resulting pathological effects. Marrow hypoplasia
Hemoglobin level/anemia (g/dl) occurs in acute infections of malaria which may reduce
Normal (> 11) 57 71.3 the production of red blood cells.21,26 The mentioned
Moderate (9.0 - 10.9) 9 11.2 processes may also explain how placenta malaria is
Mild (7.0 - < 9.0) 14 17.5 significantly associated with anemia in this study.
Severe (< 7.0) 0 0 The study also showed an association between
Occupation placental malaria and stillbirth. Eight (8) percent of
Employed 43 53.8 stillbirths worldwide (208,906) were estimated to be
Self-employed 37 46.2 contributed by malaria parasites especially P. falciparum
Soil Consumption in pregnancy.27 Most stillbirths, however, occur where
Yes 55 68.8 malaria transmission is low 3 and the effect of malaria on
No 25 31.2 stillbirth is likely to be greater in areas of low transmission
where there is little or no maternal immunity. 28 In Moshi,
Key: Kg – Kilogram; g/dl – grams/deciliter; χ²– Chi-square falciparum malaria detected at delivery, even at sub-
microscopic levels may increase the risk of stillbirth. These
findings suggest that even low-level, asymptomatic and/
or sub-microscopic infections that might easily be missed
DISCUSSION during routine antenatal care could be detrimental to the
Malaria was the only placental parasitic infection observed developing fetus.28
among delivering mothers in this study population. Placental malaria also was significantly associated with
Malaria positivity among women who delivered at pre-eclampsia. Seasonal changes in the incidence of pre-
KCMC referral hospital was significantly associated with eclampsia have been described in tropics, which are
level of education, stillbirth, anemia and pre-eclampsia. consistent with malaria transmission periods. Placental
The prevalence observed in this study is higher than the malaria is likely to impair placental development and
8% prevalence reported in the previous study 20 and lower cause maternal hypertension and placental vascular
than 16.4% reported in another study conducted in dysfunction.29–32
Tanzania.5 Variations in community acquired immunity,
sociodemographic characteristics of the study population, Strength and limitations of the study
as well as endemicity of parasitemia which can be This study used a standard histological examination,
attributed to behavioral and environmental exposure to where this method can diagnose parasites which could
malaria may explain the observed differences.21 not be detected by the rapid test (mRDT). Information
was collected with the help of midwives who
Additionally, geographical location, stage of pregnancy interviewed the women using a standardized
and the methods used to determine presence of questionnaire. To ensure data completeness and
parasites in the placenta may have also contribute to the accuracy, information obtained from clinic cards was
observed difference between the current and previous triangulated with responses from the questionnaire.
studies. Dar es Salaam and Mwanza (high endemic area)
are hotter than Kilimanjaro (low endemic area). Hotter This study also had some limitations which are important
weather has been found to favor the sporulation of to be taken into account while interpreting theresults.
Oocyst.22 A study Firstly, the sample size was small and therefore limits the
power of the inference being made. Secondly, the method

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used, although highly specific, can miss some other

parasite as compared with more sensitive techniques like 12. Nash R. Accelerating Progress. Interact Classr Pract
immunosorbent assay e.g. ELISA. Strateg Involv Students Learn Process. Published online
2020:107-118. doi:10.4135/9781544394183.n11
CONCLUSION 13. Falade CO, Yusuf BO, Fadero FF, Mokuolu OA,
These findings add to the evidence of adverse the Hamer DH, Salako LA. Intermittent preventive treatment
health outcomes of placental parasitic infections among with sulphadoxine-pyrimethamine is effective in
delivering mothers. Malaria in pregnancy was found to preventing maternal and placental malaria in Ibadan,
be significant associated with anemia, stillbirth as well south-western Nigeria. Malar J. 2007;6:1-8.
as contributing to increased risk of pre-eclampsia. There doi:10.1186/1475- 2875-6-88
is a need for more sensitive tests forearly diagnosis and
adequate treatment during pregnancy to prevent adverse 14. C.C. D, T. P, C. M, K.A. B. Perceptions of
pregnancy outcomes caused by submicroscopic malaria intermittent preventive treatment of malaria in
infection. pregnancy (IPTp) and barriers to adherence in Nasarawa
and Cross River States in Nigeria. Malar J.
2013;12(1):3-5.
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HASIL ANALISIS

A. JURNAL IDENTITAS
Judul Jurnal : Infeksi Parasit Plasenta dan Hasil Kehamilan Diantaranya Wanita Melahirkan
di Rumah Sakit Tersier di Tanzania Utara
Penulis : Eustadius Kamugisha Feliciana,b, Oktavianus Aron Ngodaa,c*, Ola Farid
Jahanpourd , Jackson Kahimae , Sia Emmanuel Msuyaa,f, Abdul Hamid
Lukambagiref,g
Tahun Terbit : 2022
Halaman :6
Negara : Tanzania Utara
Nama Jurnal : Jurnal Penelitian Kesehatan Afrika Timur 2022
Link Jurnal : https://www.ajol.info/index.php/eahrj/article/view/240067

B. ISI JURNAL
1. Pendahuluan

Malaria selama kehamilan merupakan masalah kesehatan masyarakat yang utama. Selain menyebabkan
sakit atau kematian ibu, malaria selama kehamilan juga bertanggung jawab atas seringnya aborsi, lahir
mati, kelahiran prematur, dan berat badan lahir rendah. Malaria selama kehamilan memiliki ciri utama
akumulasi plasenta eritrosit yang terinfeksi, yang merupakan cara parasit menghindari kekebalan inang.
Dalam ulasan ini, kami telah membahas secara singkat imunopatogenesis malaria pada wanita tidak
hamil, menjelaskan perkembangan normal penyakit pada wanita tidak hamil. Selanjutnya, kami telah
menjelaskan dalam ulasan bagaimana pengendaliannya, membahas respon imun seluler dan humoral pada
malaria. Selanjutnya, kami telah memfokuskan secara rinci pada imunopatogenesis malaria pada
kehamilan, bagaimana perbedaannya dengan malaria pada wanita tidak hamil, dan risiko khusus malaria
pada kehamilan. Tantangan endemisitas dan respons imun yang dimediasi sel [sel pembunuh alami (NK),
makrofag, sel dendritik (DC), sel T, dan sel B] terhadap malaria pada kehamilan.

2. Metode Penelitian

Metode penelitian yang digunakan dalam penelitian ini menggunakan Teknik sampling nyaman non-
probabilitas digunakan untuk memilih peserta studi. Tes hemoglobin menggunakan mesin
Haemoglobinometer HemoCue 201+ dan tes deteksi malaria cepat (mRDT) menggunakan SD BIOLINE
Malaria Antigen PF HRP2/ PLDH, dilanjutkan dengan pemeriksaan mikroskopis slide darah pada sampel
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 Placental Parasitic Infections and Pregnancy Outcomes www.eahealth.org
positif menggunakan Olympus CX31 Binocular Microscope, dilakukan untuk setiap peserta di
pendaftaran.

3. Hasil Penelitian

Malaria adalah satu-satunya infeksi parasit plasenta yang diamati di antara ibu bersalin dalam
populasi penelitian ini. Positif malaria pada wanita yang melahirkan di rumah sakit rujukan KCMC secara
signifikan terkait dengan tingkat pendidikan, lahir mati, anemia dan pre-eklampsia. Prevalensi yang
diamati dalam penelitian ini lebih tinggi dari prevalensi 8% yang dilaporkan dalam penelitian
sebelumnya20 dan lebih rendah dari 16,4% yang dilaporkan dalam penelitian lain yang dilakukan di
Tanzania.5 Variasi imunitas yang didapat masyarakat, karakteristik sosiodemografi populasi penelitian,
serta endemisitas parasitemia yang dapat dikaitkan dengan pajanan perilaku dan lingkungan terhadap
malaria dapat menjelaskan perbedaan yang diamati.21 Selain itu, lokasi geografis, tahap kehamilan dan
metode yang digunakan untuk menentukan keberadaan parasit di plasenta mungkin juga berkontribusi
pada perbedaan yang diamati antara malaria saat ini. dan studi sebelumnya. Dar es Salaam dan Mwanza
(daerah endemik tinggi) lebih panas daripada Kilimanjaro (daerah endemik rendah). Cuaca yang lebih
panas diketahui mendukung sporulasi Oocyst.22 Sebuah penelitian

C. KESIMPULAN
Temuan ini menambah bukti merugikan hasil kesehatan infeksi parasit plasenta antara ibu melahirkan.
Malaria dalam kehamilan ditemukan secara signifikan terkait dengan anemia, lahir mati serta berkontribusi
terhadap peningkatan risiko pre-eklampsia. Diperlukan tes yang lebih sensitif untuk diagnosis dini dan
pengobatan yang memadai selama kehamilan untuk mencegah hasil kehamilan yang merugikan yang
disebabkan oleh infeksi malaria submikroskopik.

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