Effects of malaria parasitaemia on some haemostatic parameters among pregnant women of African descent in Specialist Hospital Sokoto,Nigeria

Abstract

BACKGROUND:

Malaria in pregnancy is a major contributor to adverse maternal and prenatal outcome. In hyper endemic areas like ours, it is a common cause of anaemia in pregnancy and is aggravated by poor socioeconomic circumstance. This study evaluated the prothrombin time and activated partial thromboplastin time of malaria parasitized pregnant women.

METHOD:

A total of 90 pregnant women participated in the study, 60 of which were malaria positive and 30 of which were malaria negative. Participants were recruited from the antenatal Clinic of Specialist Hospital Sokoto, Nigeria. A structured interviewer-administered questionnaire was used to obtain some socio-demographic characteristics of subjects. Blood samples were collected in ethylene diamine tetra acetic acid and examined for malaria parasite and platelet count while citrated samples were used for the determination of some haemostatic parameters (prothrombin time and activated partial thromboplastin time). Data generated was analyzed using SPSS 25.0 statistical package. A $p$ -value $\leqslant$ 0.05 was considered significant in all statistical comparisons.

RESULT:

There was a statistically significant decrease ( $p=$ 0.000) in the platelet counts of the parasitized subjects compared to the non-parasitized controls. We observed a significant prolongation on both the prothrombin time and activated partial thromboplastin time among the parasitized subjects compared to the non-parasitized controls ( $p=$ 0.000).

CONCLUSION:

This study has shown that malaria in pregnancy causes a significant decrease in the platelet count and prolongation in the prothrombin (PT) and the activated partial thromboplastin time (APTT). There is need for the malaria and haemostatic parameters to be assayed routinely on pregnant women particularly those presenting to antenatal clinic with febrile illness.

Keywords

Malaria haemostatic parameters pregnant women African descent Specialist Hospital Sokoto Nigeria

1. Introduction

An estimated 30 million women living in malaria endemic areas of Africa become pregnant each year. Pregnant women are particularly vulnerable to malaria because pregnancy reduces immunity to malaria and increases susceptibility to malaria infection. Malaria is associated with severe anaemia, acute pulmonary oedema, renal failure, puerperal sepsis, postpartum haemorrhage and increased risk of death. Malaria in pregnancy is associated with adverse pregnancy outcomes, such as spontaneous abortion, neonatal death, and low birth weight. Chronic anaemia, due to malaria may also affect a child’s growth and intellectual development [1].

The two commonly used coagulation tests, the prothrombin time (PT) and activated partial thromboplastin time (APTT) have been used historically to define two pathways of coagulation activation: the extrinsic and intrinsic pathways respectively [2]. Depleted levels of various factors either in common pathway or both in intrinsic and extrinsic pathway leads to the prolonged PT and PTT. During normal pregnancy the haemostatic balance tends to change in the direction of hypercoagulability [3], thus decreasing bleeding complications in connection with delivery. Slightly decreased activated partial thromboplastin time (APTT) and increased prothrombin complex level (PT) measured as international normalized ratio (INR) of less than 0.9 have been reported previously among pregnant Caucasian women [4]. The haemostatic changes, noted during pregnancy, normalize after delivery within 4 to 6 weeks. Pregnancy has been shown to increase the susceptibility to malaria [5] and is often associated with profound alterations in the fibrinolytic and coagulation systems. While normal pregnancy produces physiological changes resulting in a procoagulant effect aimed at reducing the risk of intrapartum haemorrhage, malaria [6], in particular severe malaria caused by Plasmodium falciparum, can cause profound anaemia, thrombocytopaenia, activation of the coagulation cascade and rarely disseminated intravascular coagulopathy [7].

Reduced platelet counts during malaria infection result from platelet activation, splenic pooling, and a decreased platelet life-span to 2–3 days (from normal 7–10 days) [7, 8]. The role of immunological factors remains uncertain as the reduction in platelet count is directly proportional to disease severity, and recovers promptly with recovery from the infection [9]. Pregnancy itself can also cause thrombocytopaenia for reasons that are not fully understood [10]. The rate of platelet recovery following initiation of treatment for malaria is reported variably as between 4 to 10 days but differs with the severity of malaria and antimalarial treatment prescribed [11, 12, 13].

In an attempt to compensate for the low absolute platelet count, the bone marrow increases the formation of megakaryocytes, which usually escape from the bone marrow as mega platelets during an acute malaria infection. Evidence to support this hypothesis comes from a study by Kreil [12], that found a marked elevation in the level of thrombopoietin, a key platelet growth factor in patients with malaria. Because of an increase in the number of mega platelets, the mean platelet volume is increased during an acute malaria infection [15]. These findings may suggest that uncomplicated malaria is associated with mild or non-significant changes in the platelet profile.

The pathogenesis of thrombocytopenia is thought to involve a constellation of processes, some of which include splenic pooling of platelets, antibody (IgG) mediated platelet destruction, adenosine diphosphate (ADP) release following the haemolysis of parasitized RBCs, dysmegakaryopoiesis, platelet aggregation and activation, parasite invasion of platelets, platelet phagocytosis, platelet adhesion to erythrocytes, and oxidative stress [16]. The relatively diverse causative pathophysiological mechanisms could probably explain why changes in platelet homeostasis are more prominent than in other blood cell lines. Nevertheless, thrombocytopenia in malaria is observed to improve with disease resolution, and a normal platelet count is usually reported within 7 days after the initiation of antimalarial treatment [17].

There was no significant difference when the values of vivax, falciparum and the mixed infection groups were compared with each other which suggest rather uniform degree of activation of coagulation in all the species. PT and APTT was prolonged in 38% and 56% of the malaria patients respectively [18]. The derangements in values is comparable with those of Netha [18] who noted prolongation of PT in 22% of cases and deranged APTT in 11% of cases.

In Sokoto, there had been a number of researches on malaria [20, 21, 22] but there is probably no published information concerning the effect of malaria on the haemostatic parameter of pregnant women in the research study area. A comprehensive study on the effect of plasmodium infection among pregnant women in the locality is expected to provide baseline information, which will be useful in the effective formulation of adequate control measures, which could help move the locality towards achieving the Millennium Development Goals (MDGs). In addition, there is limited data on the result of prothrombin time, activated partial thromboplastin time and full blood count of pregnant women with malaria in Sokoto North Western Nigeria. The aim of this study is to determine the prothrombin time, activated partial thromboplastin time and full blood count parameters among pregnant women with malaria attending the antenatal clinic of Specialist Hospital Sokoto. The aim of this study was to determine the effect of malaria on some haemostatic parameters among pregnant women attending Specialist Hospital Sokoto in Sokoto Nigeria.

2. Materials and methods

2.1 Study area

This study was carried out in the Antenatal Clinic of Specialist Hospital, Sokoto, North-Western Nigeria. Specialist Hospital Sokoto is a tertiary institution located within the Sokoto metropolis. Sokoto is the capital city of Sokoto State of Nigeria. The State is located in the extreme Northwest of Nigeria, near to the confluence of the Sokoto River and the Rima River. The State is in the dry Sahel, surrounded by sandy savannah and isolated hills, with an annual average temperature of 28.3 ${}^{\circ}$ C (82.9 ${}^{\circ}$ F). Sokoto is, on the whole, a very hot area. However, maximum daytime temperatures are for most of the year generally under 40 ${}^{\circ}$ C (104.0 ${}^{\circ}$ F) and the dryness makes the heat bearable. The warmest months are February to April when day time temperature can exceed 45 ${}^{\circ}$ C (113.0 ${}^{\circ}$ F). The rainy season is from June to October during which shower are a daily occurrence. Sokoto city is a major commerce center in leather crafts and agricultural products. As at 2006, the state has a population of 3.6 million [23]. However, based on the population annual growth of 3%, the calculated projected population for Sokoto State now stands at around 4.9 million.

2.2 Study population

The study population for this study includes 60 malaria-infected pregnant women (subject) and 30 age-matched healthy non-parasitized pregnant women who were monitored as controls. Both subjects and controls ware recruited in the Antenatal Clinic of Specialist Hospital, Sokoto, Sokoto North-Western Nigeria.

2.3 Study subjects/selection

2.3.1 Inclusion criteria

Women who meet the following inclusion criteria were recruited in the study;

a)
Adult Pregnant women ( $\geqslant$ 18 years) parasitized with plasmodium attending Antenatal Clinic Specialist Hospital, Sokoto, Nigeria.
b)
Women in (a) who gave written informed consent in their clinic and agreed to be included as participants in the study.

2.3.2 Exclusion criteria

The following were excluded from participating as subjects in the study.

a)
Non-adult pregnant women parasitized with plasmodium.
b)
Healthy pregnant women that are not parasitized with plasmodium.
c)
Plasmodium parasitized pregnant women who did not offer an informed consent to be included in the study.

2.4 Study design

The research was a case-control study and assessed the effect of malaria on some haematological and haemostatic parameters of 60 Plasmodium parasitized pregnant women and 30 age and gender-matched healthy non-parasitized pregnant women were monitored as controls visiting the Antenatal Clinic Specialist Hospital, Sokoto. Blood sample were collected (from both subjects and controls) and tested for malaria, platelet count, prothrombin time and activated partial thromboplastin time.

2.5 Sample size determination

The sample size was determined using the standard formula for calculation of minimum sample size:

$n=$ minimum sample size.

$z=$ standard normal deviation and probability.

$p=$ prevalence or proportion of value to be estimated from previous studies.

$q=$ Proportion of failure ( $=1-P$ ).

$d=$ precision, tolerance limit, the minimum is 0.05.

Therefore, $n=$ z ${}^{2}$ pq/d ${}^{2}$

Where $Z=$ 95% (1.96)

$P=$ 6.2% (0.062) [24]

$q=$ 1 $-$ 0.062 ( $=$ 0.938)

$d=$ 5% (0.05)

Therefore $n=$ (1.96) ${}^{2}$ (0.062) (0.938)/(0.05) ${}^{2}$

$n=$ 88

2.6 Sample collection

Whole blood was collected via venipuncture, using BD vacutainer system into K ${}_{3}$ EDTA anticoagulated and Tri-sodium citrate tube under strict aseptic techniques. The EDTA anticoagulated blood sample was used to analyze complete platelet count and malaria test while the sample from the tri-sodium citrate tubes was centrifuged at 3000 rpm for ten minutes on a bench-top centrifuge in order to get Platelet Poor Plasma (PPP). The PPP obtained was transferred into sterile tube and analyzed for PT and APTT. These samples were tested in the Haematology Laboratory of Usmanu Danfodiyo University Teaching Hospital (UDUTH) Nigeria. The following laboratory investigations were carried out on K ${}^{3}$ EDTA and Citrated anticoagulated blood.

3. Analytical method

3.1 Diagnosis of malaria

Giemsa stain being one of the Romanowsky stain contains both acidic and basic components and thus can stain both the acidic and basic structures of the cell. When blood films are stained using Giemsa stain, the nucleus and cytoplasm of white blood cells takes on characteristic blue or pink. The platelet count was carried out using the Genesis HA6000 Auto Haematology Analyzer (Perlong Medical Equipment Company, China).

Prothrombin time and activated partial thromboplastin time test was carried out using manual PT and APTT reagents (Diagen, United Kingdom). The principle of the PT reagent is based on the ability of tissue thromoplastin. In the presence of calcium ions to initiate the extrinsic coagulation pathway by the direct activation of factor VII to VIIa. This culminates in the conversion of soluble Fibrinogen in to insoluble Fibrin by the direct action of Thrombin. Reduction the concentration of clotting factors of the extrinsic or commo pathways will result in the prolongation of the PT, the degree of which is proportional to the level of concentration reduction. For oral anticoagulation therapy, the degree of prolongation is defined by the INR (International Normalize Ratio) ad forms the basis of therapeutic anticoagulant control. The activated partial thromoplastin time (APTT) or kaolin cephalin cloting time (KCCT) has developed from the partial thromoplastin time (PTT), the recalcification time and the whole blood clotting time.it is a measure of the combine effect of the clotting factors of the intrinsic and common coagulation pathways. It represents the ultimate refinement in which platelet activity is standardized by the use of platelet substitute and contact activation is standardized by pre-incubation of the plasma with the kaolin platelet substitute mixture of a standard time before re-calcification. At 2 minutes pre-incubation, for the manual method, the normal range for this test is 36–50 seconds (40–150% factor VIIIc) and at 5 minutes pre-incubation 32–45 seconds. Plasma sample completely deficient in factors VIII or IX give clotting times in the region of 120 seconds, and minor deficiencies of these factors should result in a clotting time prolonged beyond the normal range. Because of the “broad spectrum” nature of this test, it will reflect deficiencies of any of the factors of the intrinsic or common clotting pathways (Factors II, V, VIII, IX, X, XI, XII and fibrinogen) and is therefore a valuable ancillary screening test. The reagent is also sensitive to therapeutic levels of heparin and the lupus anticoagulant.

3.2 Study instrument

3.2.1 Questionnaire

A semi-structured interviewer-administered questionnaire was administered to all consenting participants in order to obtain information on their socio-demographic, nutritional and medical history. A sample of the questionnaire is shown in the appendix I.

3.2.2 Informed consent

Written informed consent was obtained from all the study participants (subjects and controls).

3.2.3 Statistical analysis

Data obtained was entered into a statistical package (such as SPSS version 25) on a computer to define the nature of the distribution of data for each group. Statistical differences of data were analyzed using series of statistical analysis such as mean, standard deviation, Chi-square, student’s $t$ -test, ANOVA depending on the nature (categorical or continuous) and distribution of data (normal or non-normal). Pearson’s correlation was used to determine the relationship between sets of data. Probability ( $p\leqslant$ 0.05) was used to determine the level of significant for all statistical analysis.

3.2.4 Ethical consideration

Ethical approval for this study was obtained from the Ethical Committee of Specialist Hospital Sokoto (Reference number: SHS/SUB133/VOL.1 25 ${}^{\text{th}}$ May, 2018).

Table 1
The socio-demographic characteristics of test and controls

Variables	Test		Control		$\chi^{2}$	$p$ -value
	( $n=$ 60)		( $n=$ 30)
Age group
15–20	8	(13.3%)	2	(6.67%)	2.500	0.645
21–25	22	(36.7%)	14	(46.67)
26–30	15	(25%)	8	(26.67)
31–35	11	(18.3%)	3	(10%)
36–40	4	(6.7%)	3	(10%)
Tribe
Hausa	57	(95%)	25	(83.3%)	5.370	0.068
Fulani	2	(3.3%)	5	(16.7%)
Yoruba	1	(1.7%)	0	(0%)
Place of residence
Urban	58	(96.7%)	25	(83.3%)	4.957	0.026 ${}^{*}$
Rural	2	(3.3%)	5	(16.7%)
Educational status
Non-formal education	29	(48.3%)	10	(33.3%)	9.040	0.029 ${}^{*}$
Primary	8	(13.3%)	3	(10%)
Secondary	18	(30%)	7	(23.3%)
Tertiary	5	(8.3%)	10	(33.3%)
Occupation
House wife	52	(86.7%)	22	(73.3%)	2.432	0.296
Business	6	(10%)	6	(20%)
Civil servant	2	(3.3%)	2	(6.7%)
Use of insecticide treated mosquito net
Yes	18	(30%)	28	(93.3%)	32.105	0.000 ${}^{*}$
No	42	(70%)	2	(6.7%)
On prophylactic medication
Yes	26	(43.3%)	0	(0%)	18.281	0.000 ${}^{*}$
No	34	(56.7%)	30	(100%)
Gravidity
Prim gravidae	14	(23.3%)	6	(20%)	2.057	0.357
Multigravida	29	(48.3%)	19	(63.3%)
Grand multipara	17	(28.3%)	5	(16.7%)

Data are presented as mean $\pm$ SEM for age and percentages for others. Figures in brackets are percentages of total. Key: $t=t$ -test, $\chi^{2}=$ chi-square, SEM $=$ standard error of mean, ${}^{*}=$ statistically significant.

Table 2

Mean comparison of platelet count and some haemostatic parameters for the test and controls

Parameter	Test ( $n=$ 60)		Control ( $n=$ 30)		$t$ -test	$p$ -value
PLT ( $\times$ 10 ${}^{9}$ /l)	198.6333	$\pm$ 1.6521	273.7667	$\pm$ 6.6752	$-$ 14.323	0.000 ${}^{*}$
PT (Sec)	20.8833	$\pm$ 0.2583	14.1667	$\pm$ 0.2253	16.829	0.000
INR	1.501	$\pm$ 0.0235	0.946	$\pm$ 0.0165	15.719	0.000
APTT (Sec)	48.8333	$\pm$ 0.18128	40.0667	$\pm$ 0.4958	20.240	0.000

Data are presented as mean $\pm$ SEM. Key: Platelet, PT $=$ prothrombin time, APTT $=$ activated partial thromboplastin time, INR $=$ international normalize ratio, SEM $=$ standard error of mean, ${}^{*}=$ statistically significant.

4. Results

The platelet count, Prothrombin Time (PT) and Activated Partial Thromboplastin Time (APTT) was determined among the 60-malaria parasitized pregnant women (subjects) recruited from the Antenatal Unit of Specialist Hospital Sokoto and 30 apparently healthy pregnant women (controls). A structured interviewer administered questionnaire was used to obtain information of the subjects.

Table 1 presents the socio-demographic characteristics of the Malaria parasitized pregnant subjects and controls. The prevalence of malaria was significantly higher in pregnant women resident in Urban area, those that do not use mosquito net, those that have no non-formal education and those that are not on prophylaxis medication ( $p<$ 0.05). Age, tribe, occupation, and gravidity had no significant effect of the prevalence of malaria among pregnant women ( $p>$ 0.05).

Table 2 shows the platelet count PT and APTT among the plasmodium parasitized subjects and controls. The Platelet Count was significantly lower ( $p=$ 0.000) among malaria-parasitized pregnant subjects as compared to controls ( $p=$ 0.000). The Prothrombin Time and Activated Partial Thromboplastin Time was significantly prolonged among malaria parasitized pregnant women subjects as compared to controls ( $p=$ 0.000).

5. Discussion

Malaria is a major public health problem in sub-Sahara Africa including Nigeria, where it accounts for more cases of infection and death than other countries in the world and the extent of utilization of malaria preventive measures may impact on the burden of malaria in pregnancy [25]. The aim of this study was to investigate the effect of malaria on some Haematological and Haemostatic parameters in pregnant women attending antenatal clinic in Specialist Hospital Sokoto. A total of 90 pregnant women participated in this study. The subjects were aged 15–40 years. Our finding is consistent with a previous report [26] in Sokoto which indicated that, young maternal age contributed to the seroprevalence of malaria parasitaemia among pregnant women. We observed that younger women in the age group 21–25 years constituted a significant number of the subjects (36.7%) compared to older age group 36–40 (6.7%). This finding is consistent with a previous report of Panti and Colleagues [27] who reported that majority of the asymptomatic malaria positive pregnant women (84%) were aged between 20 and 34 years. Uneke and Colleagues [28] in Southern Nigeria also reported that individuals of age group 20–24 years had the highest prevalence of maternal malaria (52%) while the least was recorded among those $>$ 40 years.

This study has also found that use of insecticide-treated mosquito net has great influence in preventing malaria. Malaria prevalence was significantly higher among women who do not use insecticide treated mosquito nets ( $p<$ 0.05). This confirms previous report [29] that reported the potential role of insecticide treated mosquito nets as a means to reduce the lethal impact of malaria.

In this study, the level of education was found to have influence on prevention of malaria in pregnancy. Majority of the malaria parasitized subjects had no formal education (48.3%), this is followed by those who attained secondary level education (30%) then followed by women educated to primary education (13%) and tertiary level education (8.3%) of the subjects. This finding is consistent with previous reports [30, 31] in Karachi, India and Maiduguri Nigeria respectively. This is suggestive that the level of education can play a role in preventing malaria infection.

This study indicated that the Platelet count was significantly lower ( $p=$ 0.000) in malaria parasitized pregnant women compared to non-parasitized controls. This finding is consistent with previous reports [24] which indicated that infected patients tended to have significantly lower platelets, haemoglobin and red blood cell count. The reduced platelet count in malaria may be due to platelet activation, splenic pooling and decrease platelet life span as previously reported [32].

The results of this study indicated a significant prolongation in both the Prothrombin Time and Activated Partial Thromboplastin Time of malaria parasitized pregnant women when compared to controls ( $p<$ 0.05). This is in consonance with the finding of Rojanasthein et al. [33] who reported that there is prolongation in the PT and APTT of P. falciparum parasitized subjects. Our finding is an affirmation that plasmodium parasitaemia is associated with activation of coagulation system. Coagulation factors once activated are used up resulting in depleted levels of various factors either in the common pathway or both intrinsic and extrinsic pathways leading to prolonged PT and APTT. Our finding is consistent with previous studies which indicate that there is increased coagulation activity associated with both uncomplicated (mild) and complicated (severe) cases of malaria [34, 35, 36, 37]. Previous report indicates that the degree of coagulation derangement in malaria infection is often associated with disease severity [37, 38]. Coagulation disorder is a common finding in severe malaria (about 1% of all cases). Between 5% to 10% of these cases are associated with bleeding [39, 40]. Our finding is also in agreement with a previous report which indicated alterations in APTT, PT and platelet count with prolongation of APTT, PT and lower platelet counts in HIV and malaria co-infection [41].

6. Conclusion and recommendations

6.1 Conclusion

Findings from this study have shown that there is a significant decrease in Platelet count of malaria-parasitized pregnant women subjects. The subjects tended to have prolonged PT, APTT compared to the controls. We recommend that platelet count, PT and APTT should be assayed routinely among antenatal women particularly those presenting with febrile illness or infected with malaria. Those presenting to antenatal clinic with febrile illness should be tested for malaria.

6.2 Recommendations

This study recommends that:

More effort should be invested to ensure the implementation of malaria prevention and control strategies, especially among high-risk pregnant women.

PT and APTT should be assayed along with full blood count routinely for pregnant women visiting antenatal clinics.

There should be adequate and regular sanitation to avoid stagnant pools and poor environmental condition which encourage the breeding of mosquito vector.

There should be routine malaria investigation in the antenatal care for pregnant women.

Efforts should be made to supply all pregnant women with long-lasting insecticide-treated mosquito nets, and there should be a detail explanation of the risk of malaria in pregnancy in antenatal clinics.

There should be an increase in enrolment of females in school, so as to improve access to formal education.

More studies should be carried out to describe the trend in the haematological system and coagulation system of malaria parasitized pregnant women.

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Effects of malaria parasitaemia on some haemostatic parameters among pregnant women of African descent in Specialist Hospital Sokoto,Nigeria

Abstract

BACKGROUND:

METHOD:

RESULT:

CONCLUSION:

Keywords

1. Introduction

2. Materials and methods

2.1 Study area

2.2 Study population

2.3 Study subjects/selection

2.3.1 Inclusion criteria

a) Adult Pregnant women ( ⩾ 18 years) parasitized with plasmodium attending Antenatal Clinic Specialist Hospital, Sokoto, Nigeria. b) Women in (a) who gave written informed consent in their clinic and agreed to be included as participants in the study. 2.3.2 Exclusion criteria

a) Non-adult pregnant women parasitized with plasmodium. b) Healthy pregnant women that are not parasitized with plasmodium. c) Plasmodium parasitized pregnant women who did not offer an informed consent to be included in the study. 2.4 Study design

2.5 Sample size determination

2.6 Sample collection

3. Analytical method

3.1 Diagnosis of malaria

3.2 Study instrument

3.2.1 Questionnaire

3.2.2 Informed consent

3.2.3 Statistical analysis

3.2.4 Ethical consideration

Table 1 The socio-demographic characteristics of test and controls

5. Discussion

6. Conclusion and recommendations

6.1 Conclusion

6.2 Recommendations

References

a)
Adult Pregnant women ( $\geqslant$ 18 years) parasitized with plasmodium attending Antenatal Clinic Specialist Hospital, Sokoto, Nigeria.
b)
Women in (a) who gave written informed consent in their clinic and agreed to be included as participants in the study.

2.3.2 Exclusion criteria

a)
Non-adult pregnant women parasitized with plasmodium.
b)
Healthy pregnant women that are not parasitized with plasmodium.
c)
Plasmodium parasitized pregnant women who did not offer an informed consent to be included in the study.

2.4 Study design

Table 1
The socio-demographic characteristics of test and controls