Malaria in pregnancy carries significant morbidity and mortality for both the mother and the fetus. Pregnant women should be advised to avoid travel to malaria-endemic areas if possible. Women who do choose to go to malarious areas can reduce their risk of acquiring malaria by following several preventive approaches (see Chapter 4). Because no preventive method is 100% effective, they should seek care promptly if symptoms of malaria develop. Pregnant women traveling to malarious areas should 1) remain indoors between dusk and dawn, if mosquitoes are active outdoors during this time; 2) if outdoors at night, wear light-colored clothing, long sleeves, long pants, and shoes and socks; 3) stay in well-constructed housing with air-conditioning and/or screens; 4) use permethrin-impregnated bed nets; and 5) use insect repellents containing DEET as recommended for adults, sparingly, but as needed (see Chapter 2). Pyrethrum-containing house sprays may also be used indoors if insects are a problem. If possible, remaining in cities or areas of cities that are at low (or lower) risk for malaria can help reduce the chances of infection. Pregnant travelers should be under the care of providers knowledgeable in the care of pregnant women in tropical areas (6).
For pregnant women who travel to areas with chloroquine-sensitive Plasmodium falciparum malaria, chloroquine has been used for malaria chemoprophylaxis for decades with no documented increase in birth defects. For pregnant women who travel to areas with chloroquine-resistant P. falciparum, mefloquine should be recommended for chemoprophylaxis during the second and third trimesters (6). For women in their first trimester, most evidence suggests that mefloquine prophylaxis causes no significant increase in spontaneous abortions or congenital malformations if taken during this period (6) (see Chapter 4).
Because there is no evidence that chloroquine and mefloquine are associated with congenital defects when used for prophylaxis, CDC does not recommend that women planning pregnancy need to wait a specific period of time after their use before becoming pregnant (6). However, if women or their health-care providers wish to decrease the amount of antimalarial drug in the body before conception, Table 9-3 provides information on the half-lives of selected antimalarial drugs. After two, four, and six half-lives, approximately 25%, 6%, and 2% of the drug remain in the body.
Doxycycline and primaquine are contraindicated for malaria prophylaxis during pregnancy, because both may cause adverse effects on the fetus (6).
Malaria must be treated as a medical emergency in any pregnant traveler. A woman who has traveled to an area that has chloroquine-resistant strains of P. falciparum should be treated as if she as illness caused by chloroquine-resistant organisms. Because of the serious nature of malaria, quinine or intravenous quinidine should be initiated, and the case should be managed in consultation with an infectious disease or tropical medicine specialist. The management of malaria in a pregnant woman should include frequent blood glucose determinations and careful fluid monitoring: these requirements may necessitate intensive care supervision.
