At a glance
- Malaria in pregnant women is associated with high risks of both maternal and perinatal morbidity and mortality.
- Use the Malaria Treatment Tables (Table 4) for specific drug and dosing recommendations for uncomplicated malaria in pregnant women.
- Pregnant women diagnosed with severe malaria should be treated aggressively with parenteral antimalarial therapy as described below.
Overview
While the mechanism is poorly understood, pregnant women have a reduced immune response and, therefore, less effectively clear malaria infections. In addition, malaria parasites sequester and replicate in the placenta. Pregnant women are three times more likely to develop severe disease than non-pregnant women who acquire malaria in the same geographic area. Malaria infection during pregnancy can lead to miscarriage, premature delivery, low birth weight, congenital infection, and/or perinatal death.
Uncomplicated malaria treatment
Pregnant women of all gestational ages diagnosed with uncomplicated malaria acquired in areas with chloroquine-resistant P. falciparum can be treated with artemether-lumefantrine, mefloquine, or a combination of quinine sulfate and clindamycin. Quinine treatment should continue for seven days for P. falciparum infections acquired in Southeast Asia and for three days for infections acquired elsewhere; clindamycin treatment should continue for seven days regardless of where the infection was acquired.
For pregnant women diagnosed with uncomplicated malaria caused by P. malariae, P. ovale, chloroquine-sensitive P. vivax, or chloroquine-sensitive P. falciparum infection, prompt treatment with chloroquine or hydroxychloroquine (treatment schedule as for non-pregnant adult patients) is recommended. For chloroquine-resistant P. vivax infections, artemether-lumefantrine, quinine plus clindamycin, or mefloquine should be given instead.
Doxycycline and tetracycline are generally not indicated for use in pregnant women. However, in rare instances, doxycycline or tetracycline can be used in combination with quinine if other treatment options are not available or are not being tolerated, and the benefit of adding doxycycline or tetracycline is judged to outweigh the risks.
Atovaquone-proguanil is not indicated for use in pregnant women because of the paucity of data on its safety in pregnant women. However, for pregnant women diagnosed with uncomplicated malaria caused by chloroquine-resistant P. falciparum infection, atovaquone-proguanil may be used if other treatment options are not available or are not being tolerated, and if the potential benefit is judged to outweigh the potential risks.
P. vivax or P. ovale anti-relapse treatment
For P. vivax or P. ovale infections, primaquine phosphate and tafenoquine for radical treatment of hypnozoites should not be given during pregnancy. Pregnant patients with P. vivax or P. ovale infections should be maintained on chloroquine chemoprophylaxis for the duration of their pregnancy. The chemoprophylactic dose of chloroquine phosphate is 300 mg base (500 mg salt) orally once per week. After delivery, for pregnant patients with normal G6PD activity infected with P. vivax or P. ovale infections, subsequent treatment with primaquine phosphate or tafenoquine as described above is needed but will depend on breastfeeding. If not breastfeeding, either drug can be used depending on the regimen used to treat the acute malaria episode (see section on P. vivax and P. ovale above). For women who are breastfeeding, infants should be tested for G6PD deficiency and if found to have normal activity, oral primaquine phosphate can be given to the mother. Tafenoquine is not recommended during breastfeeding. Women who after delivery cannot take primaquine or tafenoquine should be maintained on weekly chloroquine chemoprophylaxis for a total of one year after the acute malaria episode.