Which drug is effective and safe for acute malaria in pregnancy? Reviewing the evidence

Abstract

During pregnancy, a woman living or travelling in a malaria endemic area is more at risk of contracting the disease and developing a severe infection and dying than a non-pregnant woman. Despite this increased morbidity and mortality in pregnancy, there are almost no studies on which to base recommendations on the use of antimalarial drugs in this vulnerable group. This is because, paradoxically, the emphasis is often put on the safety of the unborn child rather than that of the infested mother. As a result of this neglect, tens of thousands of pregnant women (and their fetuses) are dying every year of a very preventable and treatable infection. In recent years, some trials have been conducted, especially in areas of high resistance in Plasmodium falciparum in South East Asia. The results show that quinine plus clindamycin is the treatment of choice in the first trimester, while artemisinin treatment should be used in the second and third trimesters in the treatment of uncomplicated malaria. For severe malaria, parenteral artesunate is the treatment of choice. However these studies have also shown that the pharmacokinetic properties of most antimalarials are altered during gestation and that the doses used in non-pregnant adults are often not adapted to pregnancy. Urgent efforts are required to optimize the treatment of malaria in pregnancy. © 2009 Wiley-Liss, Inc.