Malaria in Pregnancy

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Pregnancy makes women more likely to get malaria or die from malaria. Malaria infection is more severe during pregnancy while pregnancy and its outcomes can become complicated by it. The effects of malaria on the pregnant mother include a severe form of the illness, anaemia, miscarriage, pre-term labour, and post-partum haemorrhage.  Risks to the foetus include foetal anaemia, pre-maturity, intra-uterine growth restriction, low birth weight, stillbirth, congenital malaria, and increased perinatal mortality. Preventive measures must be emphasised (i.e. Insecticide-treated Nets [ITNs] and Intermittent Preventive Treatment in pregnancy [IPTp] under direct observation) while confirmed cases must be treated promptly.  

 

Treatment of Malaria in pregnancy

Treatment Objectives

  • To ensure prompt and effective case management

Non-pharmacological treatment 

  • None 

Pharmacological treatment:

Treatment of Uncomplicated Malaria in the First Trimester

  • Quinine, oral, (may be given as monotherapy if Clindamycin is not available)
  • 10 mg/kg (max. 600 mg) 8 hourly for 7 days

And

  • Clindamycin, oral, 10 mg/kg, twice daily for 7 days

Note: The drug of choice for uncomplicated malaria for pregnant women in the first  trimester is oral Quinine.  ACTs are not recommended for use in the first trimester.  However,  their  use  should  not  be  withheld  in  cases  where  they  are  considered to be life-saving, or where other antimalarials are considered to be  unsuitable. Treatment of Uncomplicated Malaria in the Second and Third Trimesters  

  • Artesunate + Amodiaquine co-blistered formulation  (Regimen  for  TWICE  DAILY  DOSING)

The dose in mg/body weight is: Amodiaquine 10 mg/kg + Artesunate 4 mg/kg, taken as  two divided doses daily for three (3) days, after meals. (See table in Uncomplicated Malaria section) 

Or

  • Artemether and Lumefantrine, oral (see table under Uncomplicated Malaria) 

Or

  • Quinine, oral, (See above under Treatment of Uncomplicated Malaria in the First Trimester)

Treatment of Severe Malaria in Pregnancy (All trimesters and puerperium)

Evidence Rating: [A]

  • Artesunate, IV or IM, 

Then

ACT, oral, for 3 days

(See section on Treatment of Severe Malaria)

 

Or 

  • Quinine, IV or IM,

Then

Quinine + clindamycin combination, oral,

(See section on Treatment of Severe Malaria)

Treatment of Severe Malaria in Pregnancy (Second and Third trimesters and Puerperium)

  • Artemether, IM, 

Then

3 days of oral ACT

(See section on Treatment of Severe Malaria)

Intermittent Preventative Treatment in Pregnancy (IPTp)

IPTp  consists  of  giving  the  fixed-dose  combination  medication Sulphadoxine-Pyrimethamine (SP) in treatment doses at predefined intervals after quickening (16 gestational weeks). Current recommendation  is  that  IPTp with sulfadoxine-pyrimethamine (IPTp-SP) be given to all pregnant women at each scheduled antenatal care visit except during the first trimester. WHO recommends a schedule of four focused antenatal care visits for normal pregnancy. In Ghana, the national malaria control strategy reserves SP for the purpose of intermittent preventive treatment only. 

To prevent the development of drug resistance, SP is not to be used for other purposes such as treatment of acute attacks of malaria. 

  • Sulphadoxine (500 mg)-Pyrimethamine (25 mg), oral, 

Note: Co-administered as Directly Observed Therapy (DOT) during antenatal visits on  at least 3 occasions and at most on 7 occasions 

Dose of  IPTp

 Antenatal visit

Recommended gestational  weeks

Health worker to  administer

IPTp1

First ANC visit after quickening 

16

Midwives, Medical officers, Family physicians, Obstetricians

IPTp2

At least one month after the first dose.

20

Midwives, Medical officers, Family physicians, Obstetricians, Physician assistants,  Community Health  Officers, Community Health Nurses

IPTp3

At least one month after the second dose.

24

IPTp4-7

At least one month after each dose.

28, 32, 36, 40

Note: Pregnant women with the following conditions shall be exempted from using SP:

  • First trimester of pregnancy (< 13 weeks gestation)
  • G6PD enzyme deficiency
  • Severe liver disease or unexplained recurrent jaundice
  • Known allergy to any sulpha drugs or allergy to pyrimethamine
  • History of previous reaction to SP
  • Recent treatment with a sulpha drug such as co-trimoxazole (within 4 weeks)
  • Post-dates pregnancy (gestation beyond 36 weeks)
  • Breastfeeding
  • Acute case of malaria (treat as above)

Owing to antagonism between folic acid and SP, folic acid supplementation should be delayed and started one week after SP administration. For additional information on IPTp and malaria in pregnancy, refer to the latest Ghana Health Service training manuals and guidelines on the subject.