Malaria in Pregnancy

Overview

Malaria in pregnancy (MIP) remains a major cause of maternal and perinatal morbidity and mortality in endemic regions. Pregnant women are particularly vulnerable due to physiological immunosuppression and altered host immunity during pregnancy.

Malaria infection during pregnancy contributes to:

• Spontaneous abortion

• Stillbirth

• Preterm labour and low birth weight (<2500 g)

• Severe maternal anaemia

• Placental malaria, leading to fetal growth restriction and neonatal complications

Pathophysiology and Risk

During pregnancy, the immunological shift toward a more tolerant immune state (Th2 dominance) decreases resistance to Plasmodium falciparum infection. The parasite adheres to chondroitin sulfate A receptors in the placenta, leading to sequestration, placental inflammation, and reduced utero-placental perfusion — impairing fetal growth.

Clinical Features

The presentation of malaria in pregnancy can range from asymptomatic parasitaemia to severe, life-threatening disease.
Common features include:

• Fever, chills, rigors

• Headache, malaise, and myalgia

• Nausea, vomiting, and loss of appetite

• Anaemia (often severe)

• Hypoglycaemia (especially with quinine therapy)

• Signs of dehydration or shock in severe cases

• Jaundice and altered mental status in complicated malaria

Diagnosis

Diagnosis must be prompt and confirmed.
Investigations include:

• Rapid diagnostic test (RDT) for P. falciparum antigen

• Thick and thin blood films for parasite detection and density

• Full Blood Count (FBC) for anaemia and thrombocytopenia

• Blood glucose (risk of hypoglycaemia, especially if on quinine)

• Liver and renal function tests if severe malaria is suspected

Treatment

1. Uncomplicated Malaria in Pregnancy

First-Line Treatment

• Artemether–Lumefantrine (AL) or

• Dihydroartemisinin–Piperaquine (DHA–PPQ)

These regimens are safe and effective in all trimesters of pregnancy and are the preferred options for uncomplicated malaria.

Second-Line Treatment

• Oral Quinine (in combination with Clindamycin if available)

  • Indicated for treatment failure or resistance to first-line therapy.

  • Caution: Monitor for hypoglycaemia, which is more common in pregnancy.

2. Severe Malaria in Pregnancy

Pregnant women — particularly in the second and third trimesters — are at high risk of developing severe malaria, characterized by:

• Altered consciousness or seizures

• Severe anaemia (Hb <7 g/dL)

• Jaundice

• Respiratory distress or pulmonary oedema

• Hypoglycaemia

• Oliguria or renal impairment

• Shock or disseminated intravascular coagulation (DIC)

Management Principles

• Admit urgently and initiate parenteral therapy immediately.

• Do not delay treatment while awaiting laboratory confirmation.

Recommended Parenteral Antimalarial Therapy

• First Trimester:

  • Intravenous Quinine (full therapeutic dose).

  • Monitor for hypoglycaemia and arrhythmias; correct promptly.

• Second and Third Trimesters:

  • Injectable Artesunate is the treatment of choice.

  • Administer full-dose regimen without delay.

  • Once the patient can tolerate oral medication, complete therapy with ACT (Artemether–Lumefantrine or DHA–Piperaquine).

Supportive Therapy

• Treat fever (paracetamol and tepid sponging).

• Correct anaemia with blood transfusion if indicated.

• Manage fluid balance carefully to avoid pulmonary oedema.

• Monitor vital signs, urine output, and blood glucose regularly.

• Provide oxygen and anticonvulsants as needed.

3. Intermittent Preventive Treatment (IPTp)

Rationale

Intermittent Preventive Treatment in pregnancy (IPTp) reduces the risk of maternal anaemia, placental parasitaemia, low birth weight, and perinatal mortality.

Drug of Choice

• Sulphadoxine–Pyrimethamine (SP)

Dosage and Administration

• One full treatment dose (3 tablets, each containing 500 mg sulphadoxine + 25 mg pyrimethamine).

• Administer monthly (at least four weeks apart) beginning in the second trimester (≥13 weeks gestation).

• Continue up to six doses during the pregnancy.

• Each dose should ideally be given under Directly Observed Therapy (DOT) to ensure compliance.

Contraindications

• Known allergy to sulfa drugs.

• HIV-positive women on cotrimoxazole prophylaxis (to avoid severe skin reactions and bone marrow suppression).

4. Additional Preventive Strategies

• Insecticide-Treated Nets (ITNs): Encourage consistent use every night.

• Environmental vector control: Eliminate mosquito breeding sites.

• Early diagnosis and treatment: For any fever in pregnancy, test for malaria immediately.

• Iron and folic acid supplementation: Prevent and correct anaemia.

Key Clinical Pearls

• Malaria in pregnancy can present atypically — any fever in an endemic area warrants immediate testing.

• Artemisinin-based combinations (ACTs) are safe and effective across all trimesters.

• Avoid delay in treating severe malaria — prompt parenteral therapy saves lives.

• IPTp with SP remains a cornerstone of preventive antenatal care in endemic regions.

• Maternal and fetal monitoring are essential throughout treatment and follow-up.