What to know
- Pregnant women diagnosed with malaria are more likely to develop severe disease and should generally be admitted to a hospital.
- Malaria in pregnant women is associated with high risks of both maternal and perinatal morbidity and mortality.
- Atovaquone-proguanil, doxycycline/ tetracycline, primaquine, and tafenoquine are not recommended for use in pregnant women.
Clinical resources
CDC Malaria Hotline
Healthcare providers can call the CDC Malaria Hotline for clinical consultation about malaria diagnosis and treatment:
- Monday – Friday, 9 a.m. 5 p.m. EST: (770) 488-7788
- After hours, weekends, and federal holidays: (770) 488-7100
Reference Algorithm for Diagnosis and Management of Malaria for a summary of the recommended steps to evaluate, diagnose, and treat malaria patients.
Use Malaria Treatment Tables for drug recommendations, as well as adult and pediatric dosing.
Malaria in pregnant women
While the mechanism is poorly understood, pregnant women have a reduced immune response and, therefore, less effectively clear infections, including with malaria. 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 perinatal death. These adverse effects are most associated with Plasmodium falciparum, though they can also be seen with Plasmodium vivax.
Uncomplicated malaria treatment
Acute blood stage treatment regimens for uncomplicated malaria in pregnant women are the same as other adults, except that atovaquone-proguanil and doxycycline/ tetracycline should not be used.
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 well tolerated, and if the benefits are deemed to outweigh the potential risks.
Doxycycline and tetracycline are generally not indicated for use in pregnant women. However, in rare instances, doxycycline (but not tetracycline) can be used in combination with quinine if other treatment options are not available or are not well tolerated, and the benefits of adding doxycycline are deemed to outweigh the 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 are contraindicated 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 a week. After delivery, pregnant women with normal quantitative G6PD activity require subsequent treatment with primaquine phosphate or tafenoquine. See anti-relapse treatment for additional information.
For breastfeeding mothers, infants should be tested for G6PD deficiency. If the infant has normal activity, oral primaquine phosphate or tafenoquine can be given to the mother. Women who are unable to take primaquine or tafenoquine after delivery should be maintained on weekly chloroquine chemoprophylaxis for a total of one year following the acute malaria episode. If infection was acquired in an area with chloroquine resistance, consultation with the CDC Malaria Hotline or a malaria expert is advised.
Severe malaria treatment
Pregnant women diagnosed with severe malaria should be closely monitored and treated with parenteral antimalarial therapy. See treatment of severe malaria for additional information.