Treatment of Malaria: Guidelines For Clinicians (United States)

Part 3: Alternatives for Pregnant Women and Treatment of Severe Malaria
Alternatives for Pregnant Women

Malaria infection in pregnant women is associated with high risks of both maternal and perinatal morbidity and mortality. 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 acquiring infections from the same area. Malaria infection during pregnancy can lead to miscarriage, premature delivery, low birth weight, congenital infection, and/or perinatal death.

For pregnant women diagnosed with uncomplicated malaria caused by P. malariae, P. vivax, P. ovale, or chloroquine-sensitive P. falciparum infection, prompt treatment with chloroquine (treatment schedule as with non-pregnant adult patients) is recommended. Alternatively, hydroxychloroquine, may be given instead. For women in their second or third trimesters, artemether-lumefantrine is an additional option. For pregnant women diagnosed with uncomplicated malaria caused by chloroquine-resistant P. falciparum infection, women in the second and third trimesters can be treated with artemether-lumfantrine, and for all trimesters, mefloquine or a combination of quinine sulfate and clindamycin is recommended. Quinine treatment should continue for 7 days for infections acquired in Southeast Asia and for 3 days for infections acquired elsewhere; clindamycin treatment should continue for 7 days regardless of where the infection was acquired. For pregnant women diagnosed with uncomplicated malaria caused by chloroquine-resistant P. vivax infection, prompt treatment with artemether-lumfantrine (second and third trimesters) or mefloquine (all trimesters) is recommended.

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.

According to its U.S. labels, atovaquone/proguanil is not indicated for use in pregnant women because there are no adequate, well-controlled studies 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.

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 prophylaxis for the duration of their pregnancy. The chemoprophylactic dose of chloroquine phosphate is 300mg base (=500 mg salt) orally once per week. After delivery, for pregnant patients with P. vivax or P. ovale infections who do not have G6PD deficiency, subsequent treatment with primaquine phosphate or tafenoquine is needed, but will depend on breastfeeding. If not breastfeeding, either drug can be used. For women who are breastfeeding infants with normal G6PD activity, primaquine phosphate can be given. Tafenoquine is not recommended during breastfeeding. Pregnant women diagnosed with severe malaria should be treated aggressively with parenteral antimalarial therapy as described below.

Treatment of Severe Malaria

Patients who are considered to have manifestations of more severe disease should be treated aggressively with parenteral antimalarial therapy regardless of the species of malaria seen on the blood smear. If severe malaria is strongly suspected but a laboratory diagnosis cannot be made at that time, blood should be collected for diagnostic testing as soon as it is available and parenteral antimalarial drugs should be started.

Page last reviewed: March 27, 2019