Treating Severe Malaria in Pregnancy: A Review of the Evidence

Abstract

Severe malaria in pregnancy is a large contributor to maternal morbidity and mortality. Intravenous quinine has traditionally been the treatment drug of choice for severe malaria in pregnancy. However, recent randomized clinical trials (RCTs) indicate that intravenous artesunate is more efficacious for treating severe malaria, resulting in changes to the World Health Organization (WHO) treatment guidelines. Artemisinins, including artesunate, are embryo-lethal in animal studies and there is limited experience with their use in the first trimester. This review summarizes the current literature supporting 2010 WHO treatment guidelines for severe malaria in pregnancy and the efficacy, pharmacokinetics, and adverse event data for currently used antimalarials available for severe malaria in pregnancy. We identified ten studies on the treatment of severe malaria in pregnancy that reported clinical outcomes. In two studies comparing intravenous quinine with intravenous artesunate, intravenous artesunate was more efficacious and safe for use in pregnant women. No studies detected an increased risk of miscarriage, stillbirth, or congenital anomalies associated with first trimester exposure to artesunate. Although the WHO recommends using either quinine or artesunate for the treatment of severe malaria in first trimester pregnancies, our findings suggest that artesunate should be the preferred treatment option for severe malaria in all trimesters.

An overview of malaria in pregnancy

“…29 Pregnant women are three times more likely to be affected by severe malaria. 30 The World Health Organization defines severe malaria as parasitemia with evidence of end organ dysfunction ( Table 1). The presenting features of severe malaria can include severe anemia, hypoglycemia, acute respiratory distress syndrome, renal failure and cerebral malaria.…”

“…The presenting features of severe malaria can include severe anemia, hypoglycemia, acute respiratory distress syndrome, renal failure and cerebral malaria. 30 The median mortality of severe MIP is 39% (range 8-100%). 30 Severe malaria must be treated promptly with intensive care and parenteral antimalarial medication to reduce mortality.…”

“…30 The median mortality of severe MIP is 39% (range 8-100%). 30 Severe malaria must be treated promptly with intensive care and parenteral antimalarial medication to reduce mortality. 31…”

Medicines dispensers' knowledge on the implementation of an artemisinin-based combination therapy policy for the treatment of uncomplicated malaria in Tanzania

“…In pregnancy, malaria can lead to birth complications, an increased risk of communicable and noncommunicable diseases, and a high risk of both maternal and perinatal morbidity and mortality . Malaria in pregnancy contributes to an estimated 100 000 neonatal deaths and 10 000 maternal deaths annually . In Nigeria, up to 11% of maternal deaths and 30% of childhood deaths are due to malaria .…”

“…However, SP remains the medicine of choice for intermittent preventive treatment in pregnancy (IPTp) in Tanzania and across Africa . ACT is also the recommended first‐line treatment in the second and third trimesters of pregnancy for uncomplicated malaria, with quinine still recommended for severe malaria across all trimesters as dihydroartemisinin/piperaquine (DPQ) as well as for second‐line treatment . This is because of the suspected teratogenic effects of artemether during the first trimester.…”