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Guidelines for the treatment of malaria – 2 edition

7.9 treatment in specific populations and situations

7.9.1 Pregnant women
Pregnant women with symptomatic acute malaria are a high-risk group, and they must
promptly receive effective antimalarial treatment. Malaria in pregnancy is associated with
low birth weight, increased anaemia and, in low-transmission areas, an increased risk of
severe malaria and death. In high-transmission settings, despite the adverse effects on
fetal growth, malaria is usually asymptomatic in pregnancy or associated with only mild,
non-specific symptoms. There is insufficient information on the safety and efficacy of
most antimalarials in pregnancy, particularly for exposure in the first trimester.

7.9.1.1 First trimester
Organogenesis occurs mainly in the first trimester; this is, therefore, the time of greatest
concern for potential teratogenicity, although development of the nervous system
continues throughout pregnancy. Although data from prospective studies are limited,
antimalarial medicines considered safe in the first trimester of pregnancy are quinine,
chloroquine, clindamycin and proguanil. Pregnant women in the first trimester with
uncomplicated falciparum malaria should be treated with quinine plus clindamycin for
seven days (and quinine monotherapy if clindamycin is not available). Artesunate plus
clindamycin for seven days is indicated if this treatment fails.
In reality, women often do not declare their pregnancies in the first trimester or are not yet
aware that they are pregnant; so all women of child bearing age should be asked about the
possibility of their being pregnant before being given antimalarials, a standard practice for
the administration of any medicine in potentially pregnant women. Nevertheless, early
pregnancies will often be exposed inadvertently to the available first-line treatment in
the population, mostly ACTs. Published prospective data on a limited number of exposed
pregnancies in the first trimester (n = 123) indicate no adverse effects of artemisinins
(and the partner drugs) on pregnancy or on the health of the fetus and neonates. The
available data are sufficient to exclude a 5.3-fold or greater increase in risk of overall major
birth defects and provide assurance in counselling women following early first trimester
exposure, indicating that there is no need for them to seek to have their pregnancy
interrupted because of this exposure. However, more data on the safety of artemisinins
in early pregnancy are urgently needed. The recently introduced Pregnancy Exposure
Registry will shed more light on the risks to patients in the first trimester of pregnancy
who are inadvertently exposed to antimalarials, including ACTs.

7.9.1.2 Second and third trimesters
There is increasing experience with artemisinin derivatives in the second and third
trimesters (over 1500 documented pregnancies). There have been no adverse effects on the
mother or fetus. The current assessment of benefits compared with potential risks suggests

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