Beruflich Dokumente
Kultur Dokumente
Pregnancy
Immunologic Perspective,
Implications to Treatment &
Impact to Public Health
Objectives
Describe the immune response of pregnant
women
Determine the effects of helminthiasis to the
health of a pregnant woman and her fetus
Identify the current strategies of treatment of
helminthiasis and the outcomes in pregnancy
Gestational Immunity
Gestation is a unique physiologic state that
carries with it several immunologic
consequences and results in changing
susceptibility to various diseases.
Adegnika, 2007
Gestational Immunology
Paradox of
Pregnancy
a lack of antigen
stimulation of maternal
lymphocytes, since the
fetal trophoblast cells
do not express major
histocompatibility
complex (MHC) Ia
antigens
Medawar, 1953; Veenstra van Nieuwenhoven
T cells in pregnancy
the numbers of Tc lymphocytes and Th
lymphocytes may or may not differ in pregnant
women versus non-pregnant women
pregnancy is a Th2 phenomenon probably due
to hormonal influences and placental
interference
Matthiesen et al., 1996; Luppi et al., 2002; Coulam et al., 1983;Veenstra van Nieuwenhoven et
al., 2002; Wegmann et al., 1993
Watanabe et al., 1997; Kuhnert et al., 1998; Veenstra van Nieuwenhoven et al., 2002; Sacks et
al., 1998; Germain et al., 2002; Williams et al., 2002
The Bottomline
cell-mediated immune response of the
maternal specific immune system is relatively
suppressed
the CMI suppression seems to be
compensated for by an activation of the
innate immune response
Cooper et al., 2000; Bentwich et al., 1996; Kalinkovich et al., 1998; Borkow et al., 2000; Borkow
et al., 2004; Bentwich et al., 1995; Bentwich et al., 1995
Steketee, 2003
Adegnika, 2007
Adegnika, 2007
Parasitic Burden
Anemia
Nutrient deficiency
Low pregnancy weight gain
Intrauterine growth retardation
Low birth weight
Pregnancy loss
Effects in lactation
Impact with co-parasitism
Anemia
intestinal helminthiasis is associated with blood
loss and decreased supply of nutrients for
erythropoiesis, resulting in iron deficiency
anaemia
over 50% of the pregnant women in low- and
middle-income countries suffer from iron
deficiency anaemia
though iron deficiency anaemia is multifactorial,
hook worm infestation is a major contributory
cause in women of reproductive age in endemic
areas
Haider et al., 2009
Anemia
impact of intestinal helminth infections on
anaemia during pregnancy is aggravated by
low nutritional status of subjects whose
staple foods, such as rice, cassava and maize
are poor sources of folate and iron
Ayoya et al., 2006; Pasricha et al., 2008; Brooker et al., 2008; Fleming, 1982
Anemia
data on the epidemiology of iron deficiency
anaemia in East Africa and elsewhere point to
the important contribution of hookworms to
this condition
in Kathmandu, Nepal, hookworm infection
was associated with severe but not moderate
anaemia among women receiving antenatal
care
Ayoya et al., 2006; Stoltzfus et al., 1997; Bondevik et al., 2000; Ayoya et al., 2006; Stoltzfus et al.,
1997; WHO, 1993
Anemia
hookworm infection causes mechanical
laceration and enzymatic damage to the
mucosa of the small intestine leading to
approximately 0.05 mL/d of blood loss per
adult Necator americanus and approximately
0.25 mL/d per adult Ancyclostoma duodenale
The hypochromic microcytic anemia follows
chronic infection within 35 months after
exposure
Torlesse et al., 2001; Macleod, 1988
Nutrient Deficiency
The gastrointestinal blood loss, malabsorption
and appetite inhibition (Cline et al., 1984) may
further aggravate the iron, zinc and proteinenergy deficiencies and the anemia of
pregnancy
Effects in Lactation
Lactating rats experience a breakdown of
immunity to parasites, i.e. they carry larger worm
burdens after re-infection compared to their nonlactating
counterparts. Feeding high-protein foods to
lactating rats results in reduced worm burdens.
This could be attributed to changes in
gastrointestinal
environment or to overcoming effects of nutrient
scarcity on host immunity.
Pharmacologic Therapy
Albendazole
Inhibits microtubule synthesis
Larvicidal and ovicidal
Safety in pregnancy has not been established
Mebendazole
Inhibits micrtubule synthesis
Teratogenic
Pharmacologic Therapy
Pyrantel pamoate
Not effective against migratory stages in the
tissues or against ova
Neuromuscular blocking agent
experience in pregnant is limited
Pharmacologic Therapy
Ivermectin
Intensifying GABA (-aminobutyric acid)-mediated
transmission of signals in peripheral nerves
contraindicated in pregnancy
Piperazine
Blocking acetylcholine at the myoneural junction
Not to be given to women during pregnancy
Pharmacologic Therapy
The specific and very effective treatment with
albendazole, mebendazole, ivermectin and
praziquantel has embryo-, fetotoxic, mutagenic
and teratogenic potential. Therefore, it should
be delayed until after delivery.
Larocque, 2006
Future Directions
further knowledge is required to identify the
components that are needed to establish a full
program effort;
evaluate new and alternative antimalarial drugs;
evaluate the combined benefit of a package of
interventions addressing malaria (with
intermittent preventive treatment and
insecticide-treated bed nets), anemia (with iron
and folate supplements) and intestinal helminths
(with an antihelminth drug)
Future Directions
identify when and where vitamin A and zinc
supplements should be part of this package so
that public health officials can provide clear,
implementable recommendations addressing
safety, efficacy and cost-effectiveness of these
interventions
determine the link between infection and
poor nutritional and pregnancy outcomes and
the public health extent of the problem;
Future Directions
establish the appropriate public health
interventions if these studies demonstrate
that the disease extent and burden merit a
public health approach
evaluate and update case diagnosis and
management options so that individuals can
be well managed for their specific infection
and disease