What is the recommended treatment for Kala-azar (Visceral Leishmaniasis) during pregnancy?

Treatment of Kala-azar (Visceral Leishmaniasis) During Pregnancy

Liposomal Amphotericin B (L-AmB) is strongly recommended as the first-choice treatment for visceral leishmaniasis during pregnancy due to its favorable safety profile and effectiveness. 1

First-Line Treatment

• L-AmB is classified as pregnancy category B, making it the safest option among available treatments for visceral leishmaniasis during pregnancy 1, 2
• Treatment is imperative for pregnant women with kala-azar as untreated disease can lead to maternal deaths, miscarriages, preterm deliveries, and small-for-gestational-age infants 2, 3
• Good maternal and fetal outcomes have typically been reported with L-AmB therapy for visceral leishmaniasis in pregnant women 2

Medications to Avoid During Pregnancy

• Miltefosine is contraindicated during pregnancy due to embryofetal toxicity and teratogenicity observed in animal studies 1, 2
• Pentavalent antimonials (Sodium Stibogluconate) should be avoided, especially during the first and second trimesters, as they may increase the risk of abortions/miscarriages and preterm deliveries 2, 4
• A study from Bangladesh reported that 11 out of 16 pregnant women treated with Sodium Antimony Gluconate experienced abortions, particularly those in early to mid-pregnancy (16-22 weeks) 4

Dosing and Administration

• The recommended dosing for L-AmB is similar to non-pregnant patients 1
• Close monitoring for adverse effects is essential during treatment 2, 1
• Monitor renal function, liver function, and electrolytes before and during treatment 1
• Watch for infusion-related reactions and electrolyte abnormalities during L-AmB administration 1

Clinical Considerations

• The benefits of treating clinically manifest visceral leishmaniasis during pregnancy typically outweigh the risks 2, 3
• Patient-specific factors, including comorbidities, should be considered when selecting therapy and determining dosage 2, 1
• Untreated visceral leishmaniasis during pregnancy has been associated with severe maternal and fetal complications including maternal deaths, miscarriages, and preterm deliveries 1, 3

Treatment Algorithm

1. Confirm diagnosis of visceral leishmaniasis through appropriate testing 1
2. Assess pregnancy status and trimester 1
3. Initiate L-AmB therapy as first-line treatment 1, 3, 5
4. Monitor closely for adverse effects and fetal development 1
5. Continue treatment until clinical and parasitological cure is achieved 1

Common Pitfalls to Avoid

• Delaying treatment of symptomatic visceral leishmaniasis during pregnancy can lead to severe maternal and fetal complications 1, 3
• Using pentavalent antimonials in early or mid-pregnancy due to high risk of abortion 4
• Using miltefosine at any stage of pregnancy due to its teratogenic potential 2, 1
• Inadequate monitoring of renal function during amphotericin B therapy 1

Expected Outcomes

• With appropriate L-AmB treatment, patients with visceral leishmaniasis typically show hematological improvement within a week and complete hematological response within 4-6 weeks 6
• Early studies with conventional amphotericin B demonstrated cure of kala-azar during pregnancy with no harmful effects on the fetus 5