Malaria In Pregnancy

Clinical description

Febrile illness caused by species of plasmodium, mostly plasmodium falciparum in our setting.

Increased risk of malaria infection compared to non-pregnant women, especially in primigravidas.

Maternal and Fetal complications

• Severe anaemia
• Preterm birth (<37 weeks gestation)
• Low Birth Weight (<2500g at birth)
• Abortions
• Perinatal Death
• Placental abruption
• Hypoglycaemiawhen taking quinine
• Pulmonary oedema
• Cerebral malaria

Signs and symptoms

Signs/Symptoms: Fever, chills, headache, myalgia, loss of appetite, nausea/vomiting, abdominal pains, uterine contractions, malaise, reduced fetal movements.

Signs/Symptoms of severe malaria: Dark colored urine, drowsiness/coma, mental confusion, seizures, jaundice, inability to stand, persistent vomiting, temperature >39 degrees C, anemia, poor urine output, difficulty breathing, fetal demise.

InvestigationsMalaria parasite smear, Malaria RDT, FBC, Blood Sugar

Non-pharmacological

• Insecticide-treated mosquito nets
• Intermittent Presumptive Treatment of Malaria in pregnancy (IPTp):
• Pregnant women should receive Sulfadoxine-Pyrimethamine SP1500mg/75mg SP (3 tablets of

500mg/25mg SP) after 13 weeks (second trimester). and every 4 weeks until time of delivery

• A minimum of 3 doses is required during pregnancy.
• Doses should be administered at least 4 weeks apart and given as directly observed therapy.
• Last dose of SP can be delivered safely up until the time of delivery.
• SP can be given either on an empty stomach or with food.
• HIV positive women receiving Cotrimoxazole prophylaxis should not receive SP.

Treatment

• Manage complication as for any adult; consider blood transfusion if severely anemic and close to delivery.
• The risk of death due to severe malaria is greatest in the first 24 hours after clinical presentation.
• For 1st Trimester:
• Give Quinine 600 mg TDS plus Clindamycin 300 mg TDS or 20mg/kg/day divided three times

daily, both for 7 days.

• Give Panadol 1g TDS as needed
• If Severe Malaria, give IM/IV Artesunate 2.4 mg/kg, repeat dose at 12 and 24 hours, then 3 days

of LA when able to take oral medications.

 Give IV Quinine if IM/IV Artesunate unavailable (see IV Quinine regimen below).

• If confirmed treatment failure to Quinine plus Clindamycin, treat with LA.
• For 2nd& 3rd trimesters:

Clinical description

• Give LA (Lumefrantrine 120 mg/Artemether 20 mg) 4 tabs STAT, then again in 8 hours, then BD

for 2 days.

• If Severe Malaria, give IM/IV Artesunate 2.4 mg/kg, repeat dose at 12 and 24 hours, then 3 days

of LA when able to take oral medications. Give IV Quinine if IM/IV Artesunate unavailable (see IV Quinine regimen below).

• Alternative IV Quinine Therapy
• Give Quinine 20mg/kg loading dose, followed by 10mg/kg 12-hourly for at least 24 hours, as

follows:

 Start with IV Quinine in 10% dextrose infusion or 5% dextrose in normal saline over 4 hours.

 If Quinine can’t be given by infusion: give 10mg/kg dosage by IM injection and refer.

Make sure you give 10% dextrose concentration or one bottle of 5% glucose before administration of quinine.

 If patient can’t be weighed, give 900 mg Quinine in 1 L of 5% dextrose, followed by 600 mg in 1L of 5% dextrose every 12 hours until at least 24 hours IV Quinine is given.

 If patient has received at least 24 hours of IV Quinine and can take oral medications, can switch to Quinine 600 mg TDS plus Clindamycin 300 mg TDS, both for 7 days.

 Beware of hypoglycaemia: random blood sugar should be done before and after quinine administration.

 Monitor for signs of pulmonary oedema! Give diuretic and stop fluids if overhydration.

• Side effects may include nausea, vomiting, weakness and dizziness

From the WHO Guidelines for the Treatment of Malaria, 3rd Edition, 2015.