Pregnant women, particularly in the second and third trimesters of pregnancy are more likely to develop severe malaria than other adults, often complicated by pulmonary oedema and hypoglycaemia. Maternal mortality is approximately 50%, which is higher than in non-pregnant adults. Fetal death and premature labour are common. The role of early Caesarean section for the viable live fetus is unproven, but is recommended by many authorities. Obstetric advice should be sought at an early stage, the paediatricians alerted, and blood glucose checked frequently. Hypoglycaemia should be expected and is often recurrent if the patient is receiving quinine. Antimalarials should be given in full doses. Severe malaria may also present immediately following delivery. Postpartum bacterial infection is a common complication in these cases. Falciparum malaria has also been associated with severe mid-trimester haemolytic anaemia in Nigeria. This often requires transfusion, in addition to antimalarial treatment and folate supplementation.
Parenteral antimalarials should be given to pregnant women with severe malaria in full doses without delay. Artesunate or artemether are preferred over quinine in the second and third trimesters because quinine is associated with recurrent hypoglycaemia. Recent evidence shows that in non pregnant adults with severe malaria in areas of low transmission, artesunate was superior to quinine, reducing mortality by 35% compared to quinine, which makes artesunate the preferred option in the second and third trimesters. In the first trimester, the risk of hypoglycaemia associated with quinine is lower, and the uncertainties over the safety of the artemisinin derivatives are greater. However, weighing these risks against the above evidence in favour of the efficacy of artesunate, and until more evidence becomes available, both artesunate and quinine may be considered as options. Treatment must not be delayed so if only one of the drugs artesunate, artemether or quinine is available it should be started immediately.
EVIDENCE: treatment for severe falciparum malaria in pregnant women
Interventions: AS, artemether, quinine (all parenteral)
Summary of RCTs: none.
Expert comment: complications of severe malaria are more frequent in pregnant women than in non-pregnant adults. Artesunate reduces the mortality of severe malaria in non pregnant adults compared with quinine in low transmission situations. The artemisinin derivatives (artesunate and artemether) may also have safety advantages compared with quinine in the second and third trimesters of pregnancy because they do not cause recurrent hypoglycaemia. In the first trimester, the risk of hypoglycaemia associated with quinine is lower, and the uncertainties over the safety of the artemisinin derivatives are greater.
Basis of decision: expert opinion.
Recommendation: use the parenteral antimalarial treatment locally available for severe malaria in full doses. Where available, AS is the first, and artemether the second option in the second and third trimesters.
In the first trimester, until more evidence becomes available, both artesunate and quinine may be considered as options.