Doctors Revision

Obstetrics

Malaria in Pregnancy

Malaria infection occurring during pregnancy, which poses significant risks to both mother and fetus. Requires specific prevention and treatment strategies.

Also known as: Pregnancy Malaria

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Referral and warning signs

When to refer

Refer ALL Severe Malaria cases URGENTLY. Refer uncomplicated 1st trimester malaria if Quinine unavailable/intolerated. Refer non-responders.

Red flags

  • Signs of severe malaria
  • Inability to tolerate oral medication
  • Persistent vomiting
  • High fever unresponsive to antipyretics

Signs and symptoms

  • Fever, chills, headache, joint pains, malaise.
  • Nausea, vomiting.
  • Anaemia.
  • May be atypical/asymptomatic in semi-immune.
  • Severe Malaria: Impaired consciousness, seizures, respiratory distress, shock, jaundice, severe anaemia, hypoglycaemia, renal failure, pulmonary oedema.

Risk factors

  • Living in malaria-endemic area.
  • Low parity (Primigravida/Secundigravida highest risk).
  • HIV co-infection.
  • Adolescent pregnancy.
  • Sickle cell disease.
  • Lack of IPTp-SP / ITN use.

Diagnosis

Clinical assessment

Suspect in any pregnant woman with fever/history of fever in endemic area. Assess for severity.

Investigations

  • Malaria Parasite Test (RDT or Microscopy/BS): Test ALL pregnant women with fever.
  • Haemoglobin (Hb) level.
  • Assess severity criteria if positive.

Diagnostic criteria

Positive RDT or Microscopy in a pregnant woman.

Management

Non-pharmacological management

  • Use of Insecticide-Treated Nets (ITNs).
  • Environmental management.

Pharmacological treatment

  • Intermittent Preventive Treatment (IPTp): Sulfadoxine/Pyrimethamine (SP) 3 tablets monthly from >13 weeks until delivery (min 3 doses). DOT at ANC. Not if on Cotrimoxazole.
  • Treatment (Uncomplicated): 1st Trimester: Quinine PO TID x 7d. 2nd/3rd Trimester: Artemether/Lumefantrine (AL) PO BID x 3d (First line) OR DHA-PPQ PO OD x 3d.
  • Treatment (Severe): All Trimesters: Parenteral Artesunate IV/IM (preferred) OR IM Artemether OR IV Quinine (monitor glucose). Follow with oral ACT course.
  • Supportive care for severe malaria.

Monitoring

Clinical response. Repeat malaria test if fever persists >3d. Monitor glucose with Quinine. Monitor Hb.

Complications

  • Maternal: Severe anaemia, Hypoglycaemia, Pulmonary oedema, Cerebral malaria, Death.
  • Fetal/Neonatal: Miscarriage, Stillbirth, Preterm birth, IUGR, LBW, Congenital malaria (rare).

Prevention

  • IPTp with SP.
  • Consistent use of ITNs.
  • Prompt diagnosis and treatment.

Patient education

  • Importance of prevention (ITNs, IPTp-SP).
  • Risks of malaria in pregnancy.
  • Complete full course of treatment.
  • Recognizing danger signs.
  • Seeking prompt care for fever.

Uganda-specific notes

Highly endemic. IPTp-SP and ITNs key strategies. AL first-line 2nd/3rd tri. Artesunate preferred for severe malaria. Quinine requires glucose monitoring.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.2.4

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 2, Section 2.5.2 (Malaria Treatment Details)

  • National Malaria Treatment Guidelines, MOH Uganda

    (Detailed malaria protocols)

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