What is the further management for a post-cesarean section (LSCS) patient with Plasmodium vivax malaria who has been given Flamingo 120mg (anti-malarial medication)?

Post-LSCS Patient with P. vivax Malaria After Flamingo 120mg

Immediate Next Steps

Complete the chloroquine course with remaining doses at 24 and 48 hours (600mg then 300mg), add primaquine 15mg daily for 14 days to prevent relapse, and monitor for post-operative complications and hemolysis. 1, 2

Complete Blood-Stage Treatment

• Administer chloroquine 600mg base at 24 hours after the initial dose (assuming Flamingo 120mg refers to an artemisinin derivative or initial chloroquine dose), followed by 300mg base at 48 hours to complete the standard 1,500mg total dose regimen 3, 1
• If Flamingo represents an artemisinin-based treatment, chloroquine can still be used as it remains first-line for P. vivax in most regions 1, 4
• Monitor thick blood smear on day 3 - if parasitemia has not decreased markedly, consider alternative therapy 3, 1

Radical Cure with Primaquine

This is the critical step that prevents relapse and is often omitted:

• Administer primaquine 15mg base daily for 14 days starting concurrently with or immediately after chloroquine 3, 1, 2
• Check G6PD status before primaquine - if unavailable and patient is not from high-risk populations (Asian, Mediterranean descent), proceed with caution and close monitoring 3, 5
• In populations with severe G6PD deficiency (notably Asians), limit primaquine to 5 days maximum due to life-threatening hemolysis risk 3, 5
• If G6PD deficiency is confirmed, consider weekly primaquine 45mg for 8 weeks with close monitoring as an alternative 5

Post-Operative Monitoring

Pregnant/postpartum women require aggressive treatment but careful monitoring:

• Chloroquine is safe postpartum and during breastfeeding 3
• Primaquine is contraindicated during breastfeeding until infant's G6PD status is known - if breastfeeding, defer primaquine and provide weekly chloroquine prophylaxis until weaning 4
• Monitor for post-cesarean complications including infection, hemorrhage, and wound healing 3
• Check hemoglobin - if Hb <6 g/dL with respiratory distress or <4 g/dL, transfusion is indicated 3

Fever and Symptom Management

• Use acetaminophen/paracetamol for fever control - avoid aspirin in postpartum period due to bleeding risk 3
• Ensure adequate hydration - febrile illness causes dehydration; give oral rehydration solution if signs of dehydration present 3
• Sponge with tepid water for high fevers 3

Follow-Up Protocol

• Return on day 2 for blood smear results if not already confirmed positive 3, 1
• Repeat thick smear if symptoms persist beyond 3 days - alternative therapy needed if parasitemia unchanged 3, 1
• Check hemoglobin at 2 weeks if any artemisinin derivatives were used, as delayed hemolysis can occur 4
• Ensure all 14 doses of primaquine are completed under supervision if possible 3, 1

Critical Pitfalls to Avoid

The most common error is omitting primaquine, leading to relapse:

• Relapse occurs in 3 weeks on average without primaquine, with some relapses occurring months later 6, 7
• Inadequate supervision leads to treatment failure - ideally observe all doses 1
• Do not assume fever is solely from malaria - consider post-operative infections, endometritis, pneumonia, or urinary tract infection in post-LSCS patients 1, 8
• Mixed P. falciparum/P. vivax infections occur in 8-15% of cases and may manifest 3-4 weeks after vivax clearance 7

Special Considerations for Breastfeeding

• If breastfeeding, defer primaquine until weaning or until infant G6PD testing confirms normal status 4
• Provide weekly chloroquine 300mg base prophylaxis until primaquine can be safely administered 4
• This prevents relapse without exposing potentially G6PD-deficient infant to primaquine through breast milk 4