What is the treatment for severe malaria in pregnancy?

Treatment of Severe Malaria in Pregnancy

Intravenous artesunate is the first-line treatment for severe malaria in all trimesters of pregnancy and should be initiated immediately as a medical emergency. 1, 2

Immediate Management Algorithm

First-Line Treatment: Intravenous Artesunate

• Administer IV artesunate for 3 doses regardless of trimester, as it is superior to quinine with faster parasite clearance and shorter ICU stays 1
• Once the patient is clinically improved (parasitemia <1%) and able to take oral medications, switch to a full course of artemisinin-based combination therapy (ACT) such as artemether-lumefantrine 1
• Artesunate has demonstrated better efficacy and safety compared to quinine in pregnant women, with no increased risk of miscarriage, stillbirth, or congenital anomalies even with first-trimester exposure 2

Critical Timing Considerations

• Never delay treatment waiting for preferred medications - untreated malaria causes far greater harm to mother and fetus than any theoretical drug risks 3
• Severe malaria in pregnancy is life-threatening and must be treated as a medical emergency requiring immediate intervention 1

Trimester-Specific Guidance

First Trimester

• While animal studies showed embryo-lethal effects with artemisinins, human data from multiple studies found no increased risk of congenital malformations with artesunate use 3, 2
• A meta-analysis showed artesunate had an adjusted hazard ratio of 0.73 for miscarriage and 0.29 for stillbirth compared to quinine 3
• Artesunate should be the preferred treatment even in first trimester given its superior safety profile compared to quinine 2

Second and Third Trimesters

• Artesunate is unequivocally recommended as first-line treatment 1, 3
• After initial IV artesunate, transition to artemether-lumefantrine at standard non-pregnant adult doses once oral intake is tolerated 3

Critical Supportive Care Measures

Intensive Care Management

• Use restrictive fluid management to avoid pulmonary or cerebral edema, as this does not worsen kidney function or tissue perfusion 1
• For acute kidney injury, consider acetaminophen 1 gram every 6 hours for 72 hours for renoprotective effects 1
• Start antibiotics only if concomitant bacterial infection is suspected; continue only if blood cultures are positive 1

Obsolete Interventions to Avoid

• Exchange blood transfusion is no longer indicated with the availability of artesunate, as it has not demonstrated improved outcomes 1

Pregnancy-Specific Complications

Pregnant women face heightened risks including:

• Increased incidence of severe anemia 4
• Acute respiratory distress syndrome and pulmonary edema 4
• Maternal death if inadequately treated 5
• Stillbirth, low birth weight, and miscarriage 6, 5

Common Pitfalls to Avoid

• Do not withhold artesunate in first trimester when it is the most effective option available - the risks of untreated severe malaria vastly exceed any theoretical artemisinin risks 3, 2
• Do not use quinine as first-line when artesunate is available, as quinine carries greater risks including increased miscarriage/stillbirth and premature birth 3
• Do not delay ICU-level care - severe malaria complications require intensivist management according to current guidelines 1