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1.1 BACKGROUND OF STUDY
Malaria, a condition caused by infestation with Plasmodium parasite specie, is a major public health problem globally especially in developing countries causing considerable morbidity and mortality especially in sub Saharan Africa where it accounts for up to 1 million death per annum (Murray et al., 2012). Nigeria contributes the highest burden to global malaria morbidity and deaths, recording 25% of global malaria cases and about 30% of global malaria deaths (Tolu, 2016). Pregnant women are vulnerable to malaria infection. Malaria during pregnancy is a substantial public health problem in endemic tropical countries, especially sub Saharan Africa. It has been estimated that approximately 125 million pregnant women live in malaria endemic areas in sub Saharan Africa and 32 million of these pregnant women are at risk of malaria (Dellicour et al., 2010; Desai et al., 2007).
Pregnant women are at high risk of being infected with malaria owning to the ability of the parasite to adhere to trophoblastic villous epithelium and sequester in the placenta which could eventually lead to poor pregnancy outcome (Suguitan et al., 2003). it is estimated that over 200,000 infants die annually in sub-Saharan Africa as a result of their mother becoming infected with malaria during pregnancy (Steketee et al., 2001). Malaria during pregnancy can lead to maternal and foetal adverse effects, mainly anaemia, cerebral malaria, hemorrhage and low birth weight.
Cytokines are low molecularweight regulatory proteins that are secreted by many cells of the immune system in response to a number of stimuli. They are involved in virtually all physiological responses in the body and are key players in coordinating immune responses between cells, by binding to a variety of receptors and to induce cell-specific immune responses. They are secreted by many cells of the immune system in response to a number of stimuli. During successful pregnancies, fetal trophoblasts and maternal leukocytes secrete predominantly T-helper 2 type cytokines to prevent initiation of inflammatory and cytotoxic type responses that might damage the integrity of the materno-fetal placental barrier (Bennett et al., 1999). in response to invading malaria parasites, however it has been documented that Th-1 type cytokines are produce to reverse the Th-2 type bias within the placenta (Rogerson et al., 2003). Inconsistence reports on the response of some pro-inflammatory interleukins to peripheral and placental malaria have been documented (Diouf et al., 2007; Ismaili et al., 2003). Both pro and anti inflammatory cytokines are found at significantly increased levels in the peripheral blood and in the intervillous spaces of placentas of malaria infected woman. Productions of these cytokines is responsible for the resulting Th-1:Th-2 imbalance observed in Plasmodium falciparum infected placentas (Kabyemela et al., 2008; Suguitan et al., 2003).
Severe malaria has long been associated with high circulating levels of inflammatory cytokines such as tumour necrosis factor (TNF-a), IL-1, IL-6. Studies have demonstrated a link between TNF-a, IL-6, IL-10 and the severity of the disease in human malaria (Akanmori et al., 2000). Anti inflammatory cytokines has also been found to have important roles in the immune response against Plasmodium. IL-10 has an important role as an immunoregulator during plasmodium falciparum infection, neutralizing the effect of the other cytokines produced by Th-1 and CD8 cells (Couber et al., 2008; Langhorne et al., 2008). Additionally, IL-10 and granulocyte colony stimulating factor (G-CSF) have been found to be elevated and correlated with parasitemia in asymptomatic pregnant women in Ghana (Wilson et al., 2010), suggesting that these cytokines may act to reduce symptoms.
Haemostasis is the regulation of blood loss in the case of injury to the vain and artery and the dissolution of excessive blood clot in cases of thromboembolism. Previous studies indicate that Plasmodium falciparum malaria especially the severe form can lead to an impairment of the coagulation system which correlates with pro-inflammatory cytokines (Vogetseder et al., 2004). Fibrin deposition is an important feature of placental malaria infections (Bulmer et al., 1993). Furthermore, it has been shown that excessive fibrin deposition in the infected placenta occurs in association with dramatic upregulation of tissue factor, the initiator of the extrinsic pathway of coagulation on infiltrating monocytes (Imamura et al., 2002). malaria has been associated with changes in coagulation and fibrinolytic factors of blood.
Thrombocytopenia is a common finding in patients with Plasmodium falciparum malaria (Rodrigo et al., 2014). Some studies with human indicate that there is undoubtedly increased coagulation activity in malaria (Grubusch and Kremsner, 2005; Ansey et al., 2002). Significant elevations in plasma levels of thrombin, antithrombin complexes, fibrin degradation products and D-dimers have been reported (Holst et al., 1999; Moxon, 2015). Although mild prolongation in both the prothrombin time and activated thromboplastin have been noted; plasma fibrinogen level typically remain with normal range (Amged et al., 2015). Finally in keeping with this state of coagulation activity, significant reductions in plasma anticoagulant factor (including antithrombin, protein-C and protein-S) have also been observed in patient with malaria (Amged et al., 2015).
Pregnancy is associated with changes in haemostasis, including an increase in the majority of clotting factor, a decrease in the quantity of natural anticoagulants, and a reduction in fibrinolytic activity (Bremme, 2003).The platelet count decreases in normal pregnancy, possibly due to increased destruction and hemodilution, with a maximal decrease in the third trimester (O’Riordan and Higgins, 2003; McCrae, 2003).As most coagulation factors increase in normal pregnancy, the prothrombin time (PT) and the activated partial thromboplastin time (APTT) may be shortened. Laboratory-based screening is used routinely to assess coagulation status in obstetric patients. The tests consist of platelet count; PT, APTT, D-Dimer, and plasma fibrinogen levels (Orlikowski and Rocke, 1994).
1.2 STATEMENT OF THE PROBLEM
Malaria and its complications in pregnancy still remains a major challenge to pregnant women in malaria endemic regions like Nigeria.
There is scarcity information on the use of haemostatic parameters as a possible surrogate diagnostic tool in malaria and pregnancy in Nigeria.
Secretion of pro and anti-inflammatory cytokines in pregnancy associated with malaria is a threat to pregnant women.
Malaria remains today one of the major public health problem globally especially in sub-Saharan Africa like Nigeria. Plasmodium falciparum being the major specie that causes this disorder. It accounts for more than 1 million death per annum. It affects majorly young children and pregnant women and its effects to pregnant women and their foetus remains a trait to the society. Malaria complications in pregnant women includes haemorrhage, venous thrombosis, miscarriage. Pregnancy also elicit pre and post inflammatory cytokines which may cause problem to the foetus or mother. There has been scarcity of information on the diagnosis of this cytokines and haemostatic parameters in this part of the country. Therefore, this study will be carried out to assess some cytokines and haemostatic parameters in pregnant women infected with Plasmodium falciparum malaria in three senatorial zone in Imo State of Nigeria.
1.4 AIM OF STUDY
The study is aimed at assessing the interactions of some cytokines and haemostatic parameters in pregnant women infected with Plasmodium falciparum malaria in Imo State of Nigeria.
1.5 SPECIFIC OBJECTIVES
1) To assess the level of cytokines (IL-1, TNF-a, IL-6, IL-10 and IL-4) in pregnant women infected with Plasmodium falciparum malaria in Imo State of Nigeria.
2) To estimate the level of haemostatic parameters (prothrombin time, activated partial thromboplastin time, fibrinogen, protein-C and protein-S), in pregnant women infected with Plasmodium falciparum malaria in Imo State of Nigeria.
3) To assess the level of hematological parameters in pregnant women infected with Plasmodium falciparum malaria in Imo State of Nigeria.
4) To compare the difference between the cytokine parameters (IL-1, TNF-a, IL-6, IL-10 and IL-4) in malaria infected pregnant women, non infected pregnant women, non infected non pregnant women and infected pregnant women in Imo State of Nigeria.
5) To compare the difference between the haematological parameters in malaria infected pregnant women, non infected pregnant women, non infected non pregnant women and infected pregnant women in Imo State of Nigeria.
6) To compare the difference between the haemostatic parameters (prothrombin time, activated partial thromboplastin time, fibrinogen, protein-C and protein-S), in malaria infected pregnant women, non infected pregnant women, infected non pregnant women and non infected non pregnant women in Imo State of Nigeria.
7) To correlate cytokine parameters with haemostatic parameters in malaria infected pregnant women.
8) To correlate fibrinolytic factors (protein-C and protein-S) with coagulation factors (PT,APTT and Fibrinogen) in malaria infected pregnant women.
9) To compare the haemostatic and cytokine levels of malaria infected pregnant women according to parity.
10) To compare the haemostatic and cytokine levels of malaria infected pregnant women according to trimester.
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