malaria prophylaxis and pregnancy

Last edited 12/2019 and last reviewed 02/2023

Seek expert advice.

Pregnant women are at an increase risk of both developing severe malaria and fatality when compared to non pregnant women.

• diagnosis of falciparum malaria in pregnancy can be particularly difficult as parasites may not be detectable in blood films due to sequestration in the placenta.
• if malaria is suspected expert advice should be sought at an early stage
• complications such as severe anaemia, hypoglycaemia, jaundice, renal failure, hyperpyrexia and pulmonary oedema may occur
• malaria may result in miscarriage, premature delivery, maternal and/or neonatal death

Congenital malaria is rare, but occurs more commonly with Plasmodium vivax than with the other malaria parasites of humans

Pregenant women should be advised against traveling to a malarious area. If it is unavoidable, inform about the risks which malaria present and the risks and benefits of antimalarial prophylaxis.

• advice about avoidance of mosquito bite since pregnant women are particularly attractive to mosquitoes
• if possible pregnant women should remain indoors between dusk and dawn and if this is unavoidable they should adhere rigorously to bite precautions
• DEET should be used in a concentration of not more than 50%
• nursing mothers should wash repellents off their hands and breast skin prior to handling infants
• chemoprophylaxis
• chloroquine and proguanil:
• safe in all trimesters of pregnancy
• useful in in areas where P. falciparum strains are sensitive.
• if proguanil is used, prescribe folic acid 5 mg daily
• mefloquine
• can be used in the second and third trimesters (caution in first trimester)
  • women who have taken mefloquine inadvertently just prior to or during the first trimester should be advised that this does not constitute an indication to terminate the pregnancy
• use of mefloquine prophylaxis in pregnancy requires careful harm-benefit analysis. In instances where transmission and drug resistance is high and mefloquine is the agent of first choice, mefloquine may be advised in the second and third trimesters of pregnancy.
• doxycycline
• generally contraindicated in pregnancy (can be considered under special circumstances before 15 weeks' gestation )
• Advisory Committee on Malaria Prevention in UK Travellers (ACMP's) view is that doxycycline should not be used in breast feeding unless there is no alternative agent and its use is felt to be essential
• atovaquone/proguanil:
• ACMP advises against the use of atovaquone/proguanil for antimalarial chemoprophylaxis in pregnancy

The amount of medication in breast milk will not protect the infant from malaria. Therefore, the breastfeeding child needs his or her own prophylaxis (1)

Check the respective summary of product characteristics before prescribing any of the medications mentioned above.

Reference:

• (1) Public Health England (PHE) 2019. Guidelines for malaria prevention in travelers from the United Kingdom