What is the recommended treatment for Kalaazar (Visceral Leishmaniasis) during pregnancy?

Treatment of Kalaazar (Visceral Leishmaniasis) During Pregnancy

Liposomal Amphotericin B (L-AmB) is the first-choice treatment for visceral leishmaniasis during pregnancy due to its safety profile and efficacy. 1, 2

First-Line Treatment

• Liposomal Amphotericin B is strongly recommended as the first-choice drug for pregnant women with visceral leishmaniasis due to fewer maternal-fetal adverse effects 1, 3
• Dosage: 1 mg/kg body weight daily (starting with 0.5 mg/kg and titrating up) until reaching a total dose of 20 mg/kg body weight 2
• Studies have shown that L-AmB cures visceral leishmaniasis during pregnancy with no harmful effects on the fetus 2
• L-AmB is classified in pregnancy category B, making it the safest option among available treatments 1

Medications to Avoid During Pregnancy

Pentavalent Antimonials (Sodium Stibogluconate)

• Sodium stibogluconate should be avoided during pregnancy, especially in the first and second trimesters 4
• Associated with high rates of spontaneous abortion (11 out of 16 pregnant women experienced abortion between 16-22 weeks of gestation) 4
• Abortions typically occurred on the 22nd-24th day of treatment 4
• Also associated with maternal deaths from hepatic encephalopathy (4.9% mortality rate in one study) 5

Miltefosine

• Miltefosine is contraindicated during pregnancy 1
• Embryofetal toxicity and teratogenicity have been observed in animal studies at doses lower than those recommended for humans 1
• Female patients with reproductive potential should have a negative pregnancy test before starting therapy 1
• Effective contraception is required during treatment and for 5 months afterward 1

Pentamidine

• Pentamidine is typically not recommended for antileishmanial treatment during pregnancy 1
• Associated with significant adverse effects including hypoglycemia, hyperglycemia, pancreatitis, and nephrotoxicity 1

Azoles (Fluconazole, Ketoconazole)

• Azoles are typically not warranted or recommended for antileishmanial treatment during pregnancy 1
• Associated with hepatotoxicity and potential teratogenic effects 1

Monitoring During Treatment

• Regular ultrasonographic monitoring of pregnancy progression is essential 2
• Monitor renal function, liver function, and electrolytes before and during treatment 1
• For L-AmB, monitor for infusion-related reactions and electrolyte abnormalities 1
• Follow-up of both mother and child for at least 6 months post-delivery is recommended 2

Special Considerations

• The benefits of treating clinically manifest visceral leishmaniasis during pregnancy typically outweigh the risks, as untreated disease can lead to maternal deaths, miscarriages, preterm deliveries, and small-for-gestational-age infants 1
• Congenital transmission of leishmaniasis is possible, making treatment imperative 3
• Patient-specific factors, including comorbidities, should be considered when selecting therapy and determining dosage 1

Treatment Algorithm

1. Confirm diagnosis of visceral leishmaniasis through appropriate testing
2. Assess pregnancy status and trimester
3. Initiate L-AmB therapy at 1 mg/kg/day (starting with 0.5 mg/kg and titrating up) to a total dose of 20 mg/kg 2
4. Monitor closely for adverse effects and fetal development
5. Follow up both mother and infant for at least 6 months after delivery 2

Common Pitfalls to Avoid

• Delaying treatment of symptomatic visceral leishmaniasis during pregnancy can lead to severe maternal and fetal complications 1
• Using sodium stibogluconate during early or mid-pregnancy due to high risk of abortion 4
• Failing to provide adequate contraceptive counseling when using miltefosine in women of childbearing potential 1
• Inadequate monitoring of renal function during amphotericin B therapy 1