Drug treatment and prevention of malaria in pregnancy: a critical review of the guidelines

Abstract

Background Malaria caused by Plasmodium falciparum in pregnancy can result in adverse maternal and fetal sequelae. This review evaluated the adherence of the national guidelines drawn from World Health Organization (WHO) regions, Africa, Eastern Mediterranean, Southeast Asia, and Western Pacific, to the WHO recommendations on drug treatment and prevention of chloroquine-resistant falciparum malaria in pregnant women. Methods Thirty-five updated national guidelines and the President’s Malaria Initiative (PMI), available in English language, were reviewed. The primary outcome measures were the first-line anti-malarial treatment protocols adopted by national guidelines for uncomplicated and complicated falciparum malaria infections in early (first) and late (second and third) trimesters of pregnancy. The strategy of intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) was also addressed. Results This review evaluated the treatment and prevention of falciparum malaria in pregnancy in 35 national guidelines/PMI-Malaria Operational Plans (MOP) reports out of 95 malaria-endemic countries. Of the 35 national guidelines, 10 (28.6%) recommend oral quinine plus clindamycin as first-line treatment for uncomplicated malaria in the first trimester. As the first-line option, artemether–lumefantrine, an artemisinin-based combination therapy, is adopted by 26 (74.3%) of the guidelines for treating uncomplicated or complicated malaria in the second and third trimesters. Intravenous artesunate is approved by 18 (51.4%) and 31 (88.6%) guidelines for treating complicated malaria during early and late pregnancy, respectively. Of the 23 national guidelines that recommend IPTp-SP strategy, 8 (34.8%) are not explicit about directly observed therapy requirements, and three-quarters, 17 (73.9%), do not specify contra-indication of SP in human immunodeficiency virus (HIV)-infected pregnant women receiving cotrimoxazole prophylaxis. Most of the guidelines (18/23; 78.3%) state the recommended folic acid dose. Conclusion Several national guidelines and PMI reports require update revisions to harmonize with international guidelines and emergent trends in managing falciparum malaria in pregnancy. National guidelines and those of donor agencies should comply with those of WHO guideline recommendations although local conditions and delayed guideline updates may call for deviations from WHO evidence-based guidelines.

Midwives’ experiences of reducing maternal morbidity and mortality from postpartum haemorrhage (PPH) in Eastern Nigeria

“…Studies have found that (prophylactic) treatment for malaria in countries with moderate to high prevalence of malaria helps to inhibit or minimize the effects of malarial parasites on the red blood cells, thus reducing the risks of maternal anaemia, placental malaria, preterm birth and pregnancy loss [ 1 , 38 , 39 ]. To minimize the risks of poor compliance, women should be given options of malaria treatment with minimal side effects [ 38 ].…”

An Exploration of Midwives’ Experiences of Reducing Maternal Morbidity and Mortality From Postpartum Haemorrhage (PPH) in Rural Communities in Eastern Nigeria.

“…Prophylactic malaria treatment was another strategy used to reduce the risks of anaemia during pregnancy. Studies have found that prophylactic treatment for malaria or existing malaria in countries with moderate to high prevalence of malaria helps to inhibit or minimize the risks of the invasion activities of malarial parasites on the red blood cells, thus reducing the risks of maternal anaemia, placental malaria, premature labour, and pregnancy loss (1,(38)(39). To minimize the risks of poor compliance with malaria treatment, women should be given options of medication with minimal side effects (38).…”

Enfermedades tropicales y embarazo: revisión narrativa

“…Si no se dispone de artesunato, en la gestación avanzada se prefiere el arteméter a la quinina, dado que esta última se asocia a un riesgo de hipoglicemia del 50 % (45). El artesunato es embriotóxico en estudios en animales, motivo de preocupación especialmente en el primer trimestre del embarazo, sin embargo, estudios posteriores en humanos no han mostrado efectos teratogénicos (46,47). Los derivados de la artemisina (artesunato y arteméter) son activos frente a todas las fases del ciclo asexual intraeritrocítico y gametocitocidas, con efecto comprobado ante el P. falciparum multirresistente.…”

“…En el tratamiento de la malaria por P. falciparum no complicada en la gestante, se disponen de diferentes drogas antimaláricas que deben ser indicadas conjuntamente con los expertos. La cloroquina es el tratamiento de elección en la malaria por P. vivax no complicado, esta droga es considerada segura para las embarazadas, debe ser indicada en el tratamiento inicial y de forma profiláctica, una vez a la semana hasta la finalización del embarazo ydurante los seis meses que dura la lactancia materna exclusiva (45)(46)(47).…”