Case Report: Birth Outcome and Neurodevelopment in Placental Malaria Discordant Twins

Abstract

Maternal infection during pregnancy can have lasting effects on neurodevelopment, but the impact of malaria in pregnancy on child neurodevelopment is unknown. We present a case of a 24-year-old gravida three woman enrolled at 14 weeks 6 days of gestation in a clinical trial evaluating malaria prevention strategies in pregnancy. She had two blood samples test positive for Plasmodium falciparum using loop-mediated isothermal amplification before 20 weeks of gestation. At 31 weeks 4 days of gestation, the woman presented with preterm premature rupture of membranes, and the twins were delivered by cesarean section. Twin A was 1,920 g and Twin B was 1,320 g. Both placentas tested negative for malaria by microscopy, but the placenta of Twin B had evidence of past malaria by histology. The twins' development was assessed using the Bayley Scales of Infant and Toddler Development-Third Edition. At 1 year chronologic age, Twin B had lower scores across all domains (composite scores: cognitive, Twin A [100], Twin B [70]; motor, Twin A [88], Twin B [73]; language, Twin A [109], Twin B [86]). This effect persisted at 2 years chronologic age (composite scores: cognitive, Twin A [80], Twin B [60]; motor, Twin A [76], Twin B [67]; language, Twin A [77], Twin B [59]). Infant health was similar over the first 2 years of life. We report differences in neurodevelopmental outcomes in placental malaria-discordant dizygotic twins. Additional research is needed to evaluate the impact of placental malaria on neurodevelopmental complications. Trial registration number: ClinicalTrials.gov number, NCT02163447. Registered: June 2014, https://clinicaltrials.gov/ct2/show/NCT02163447.

Figure 1.

Schedule of study follow-up. Diagram depicting documented malaria exposure during pregnancy and maternal and child interventions over study period. The infants were delivered at 31.6 weeks of gestation and transferred to Mbale hospital for neonatal care for a week before discharge. At 1 and 2 year’s postnatal ages the twins were evaluated using the Bayley’s Scales of Infant and Toddler Development–Third Edition. This figure appears in color at www.ajtmh.org.

Figure 2.

Growth trajectory over the first 2 years of life. Head circumference, length/height, and weight taken at all scheduled and unscheduled visits (months calculated as number of days from birth/30.42). The dotted gray reference line is the 50 percentile based on the World Health Organization growth chart for girls. This figure appears in color at www.ajtmh.org.