That malaria and pregnancy is an unfortunate combination, has been known for almost one hundred years. A woman’s immune system is weaker when she is pregnant thereby giving the malarial pathogens a greater chance to take hold. The risk of spontaneous abortions, premature births and stillborn children is thus thirty per cent higher in pregnant women who contract malaria. The placenta in particular is a relatively safe place for malaria parasites which compete with the foetus for nutrients in the mother's blood. The severe anaemia which may result can lead to a poor oxygen supply to the unborn baby causing low birth weight and a reduced chance of survival for the child.

Increased risk

The harmful effects vary for women native to areas where malaria is prevalent from those experienced by non-immune women, such as tourists and expatriates. In non-immune women tropical malaria is a direct threat to both mother and child. The same applies to pregnant women who come from areas where malaria is seasonal. For women who come from areas where malaria is prevalent throughout the year it is the child who is especially at risk. This is particularly true for a first pregnancy. The mother may not become seriously ill herself but the malaria can cause severe anaemia which leads to reduced birth weight for the child.

Malaria prevention

Those travelling to areas where malaria is prevalent should be aware of the possible consequences of contracting malaria when pregnant. This is particularly true of tropical malaria.

Mosquitoes carry not only malaria, but also dengue fever and yellow fever. A good protection against all these diseases begins with preventing mosquito bites. Mosquitoes are active in the evening and at night. Clothing which covers all exposed skin and mosquito nets serve as a first barrier. These can be impregnated with permethrin for extra protection. Anti-mosquito products containing DEET are also effective. There is no evidence that either permethrin or DEET in concentrations of up to thirty per cent have adverse effects on the foetus.

Should you take anti-malaria tablets?

In addition to the protection mentioned above, anti-malaria tablets may also be needed. Millions of pregnant women have used chloroquine and proguanil successfully for decades. These drugs are not hazardous to the foetus but some parasites have become resistant to them. For this reason they are no longer commonly prescribed. An alternative, Lariam, can be safely used during the second and third trimesters of pregnancy. Lariam is not, however, licensed for use in the first twelve weeks of pregnancy or in the three months prior to pregnancy. However, to date the use of Lariam during the first trimester of pregnancy does not appear to increase the risk of birth defects or spontaneous abortion compared to the use of other anti-malarial medication. Pregnant women are recommended to avoid travelling to areas where multi-resistant strains of malaria are known to be prevalent. Because the risk that malaria constitutes in pregnancy outweighs the potential risk of adverse effects on the foetus of Lariam use, Lariam is recommended as an anti-malaria drug for women who must travel to areas where multi-resistant strains of malaria are found.

Little is known about the side effects of Malarone, an alternative anti-malaria drug. Because of this, it is not recommended that women use this drug during pregnancy. Doxycycline, another alternative, is known to cause tooth discolouration and distortion of bone growth in the foetus. This drug is also not recommended during pregnancy.

Lariam should not be taken during the first twelve weeks of pregnancy or the last three months before becoming pregnant. According to the data available to date about the use of lariam during the first trimester of pregnancy, the risks of birth defects or miscarriage are the same as those associated with other anti-malarial medications. Pregnant women should not visit the areas with high risk of multi-resistant forms of malaria. Since the risk of malaria in pregnancy is a greater threat than the possible fatal adverse effects of lariam, this drug is prescribed to all pregnant women who nonetheless go to the areas where the risk of multi-resistant forms of malaria is high.

The effects of malarone are not well studied yet. Therefore, this drug must not be taken shortly before and during pregnancy. Doxycycline causes teeth discoloration and affects fatal bone growth. This means that this medication must not be taken by pregnant women.

High-risk areas

In tropical Africa, where the risk of contracting malaria is greatest, no one single prevention method can offer complete protection. The consequences of a possible infection can be so severe that a pregnant woman may be advised not to travel. Destinations that should be avoided are: West Africa, Southeast Asia, Papua, Papua New Guinea, some islands in the Pacific Ocean and the Amazon. Pregnant women who still wish to travel to these destinations will receive a prescription for the most appropriate anti-malaria drugs but with a clear warning as to the possible adverse effects on the unborn child.

Treatment

Quinine remains the cornerstone of any course of treatment for malaria during pregnancy. The main side effect of quinine is hypoglycaemia (low blood-sugar levels), but it is possible to control and treat this.

So long as the disease is recognised quickly and treated appropriately, women who do contract malaria during pregnancy can expect a complete recovery. Delays in diagnosis make treatment more difficult and less successful.

Malaria in pregnancy can be completely cured if the disease was detected in a timely manner and adequate treatment was given. Any delays in diagnosis and treatment can make it more difficult to conduct a successful treatment.