Malaria in Pregnancy

Last updated: April 25, 2025

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Malaria in Pregnancy

Malaria in pregnancy is a significant public health concer, particularly in Sub-saharan Africa and Southeast Asia. It is caused by Plasmodium falciparum (mainly in Africa) and Plasmodium vivax (mainly in Asia). Pregnant women are more succeptible to malaria due to immunologic changes and placental sequestration of Plasmodium falciparum parasites. Primigravidas have a higher prevalence of placental malaria, especially in areas with stable transmission i.e. endemic regions.

Malaria during pregnancy accounts for 15% of severe anaemia in pregnant women, 30% of preventable low birth weight and 5% of infant ortality. Each year, more than 30 million women in Africa become pregnant in malaria-endemic areas.

Population and the effects on malaria in pregnancy

Population	Malaria in pregnancy
Primigravida	Higher prevalence of placental malaria than multigravidas since the placenta is immunologically naive. Local immunity develops with subsequent pregnancies
Stable (endemic) transmission areas	Pregnant women are semi-immune and have a low prevalence of peripheral parasitaemia but a high prevalence of placental malaria. Women are often asymptomatic due to low peripheral parasitaemia hence the need for intermittent-preventive treatment
Unstable tranmission areas	Pregnant women have low-acquired immunity and are more likely to be symptomatic, and develop severe malaria and anaemia
HIV-positive	More likely to have malaria parasitaemia than HIV-negative women. May also have decreased efficacy of antimalarials in controlling the infection

Pathophysiology of malaria in pregnancy
- Immunosuppression
  - Hormonal changes e.g. increased progesterone and cortisol suppress maternal immune response. Primigravidas have a higher cortisol levels than multigravidas.
- Placental malaria
  - The placenta is immunologically privileged making it easier for Plasmodium falciparum to evade clearance
  - Plasmodium falciparum infected erythrocytes express variable surface antigens (VSAs) that bind to chondroitin sulfate A (CSA) on the syncytiotrophoblasts lining the intervillous space in the placenta
  - Parasites are sequestrated in the intervillous space causing altered placental integrity → reduced nutrient and oxygen transport → low-birth weight and fetal growth restriction
  - Severe anaemia also contributes towards low birth weight and fetal growth restriction
Signs and symptoms
- Fever and chills
- Headache
- Malaise
- Jaundice
- Seizures
- Respiratory distress
Investigations
- Peripheral blood smear for microscopy: for parasitaemia
- Placental blood smear or biopsy postpartum: to confirm placental malaria
- Rapid diagnostic tests (RDTs): to detect histidine-rich proteins (HRP-2) for Plasmodim falciparum
Supportive treatment of malaria in pregnancy
- Foetal monitoring
- Prevent hypoglycaemia particularly if taking quining
- Correct anaemia
- Antipyretics
Treatment of uncomplicated malaria
- First trimester: PO quinine for 7 days
- Second and third trimester: PO artemether-lumefantrine or quinine
Treatment of severe malaria
- IV quinine or artesunate
Prevention of malaria in pregnancy
- Intermittent preventive treatment for malaria in pregnancy (IPTp) using 3 tablets of sulphadoxine-pyrimethamine (SP)
  - Administer at each visit after quickening and ensure a minimum of 2 doses with an interval of at least 4 weeks
  - Taken at quickening since fetal growth velocity is highest after this period
  - Withold high-dose folic acid tablets when taking SP and resume 14 days after IPTp if needed
  - HIV+ women on daily corimoxazole chemoprophylaxis do not need SP for IPTp
- Long-lasting insecticidal nets (LLINs)
Maternal complications of malaria
- Severe anaemia (2 – 15%)
- Cerebral malaria
- Hypoglycaemia
- Pulmonary oedema
- Acute renal failure
- Maternal death
- Hypertension*
- Placental infection
- Puerperal sepsis
Fetal complications of malaria
- Intrauterine growth restriction (13 – 70%)
- Low birth weight (20%)
- Preterm birth (8 – 36%)
- Congenital malaria (5%)
- Neonatal and infant death
- Miscarriage
- Stillbirth
- Fetal anaemia

Reference Intervals ›

Biochemistry

ACTH	P: <80 ng/L
ALT	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alk. phosphatase	P: 30–130 U/L
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
ADH	P: 0.9–4.6 pmol/L
AST	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
CRP	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol AM	P: 450–700 nmol/L
Cortisol Midnight	P: 80–280 nmol/L
CK ♂	P: 25–195 U/L
CK ♀	P: 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P: 2–8 U/L ♂; >25 menopause
GGT ♂	P: 11–51 U/L
GGT ♀	P: 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron ♂	S: 14–31 μmol/L
Iron ♀	S: 11–30 μmol/L
Lactate (venous)	P: 0.6–2.4 mmol/L
Lactate (arterial)	P: 0.6–1.8 mmol/L
LDH	P: 70–250 U/L
LH	P: 3–16 U/L
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
PTH	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin ♂	P: <450 U/L
Prolactin ♀	P: <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin (erect)	P: 2.8–4.5 pmol/mL/h
Renin (recumbent)	P: 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
T4	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
TIBC	S: 54–75 μmol/L
Triglycerides	P: 0.50–2.3 mmol/L
T3	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate ♂	P: 210–480 μmol/L
Urate ♀	P: 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol cr.
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids ♂	28–30 μmol/24h
17-Oxogenic steroids ♀	21–66 μmol/24h
17-Oxosteroids ♂	17–76 μmol/24h
17-Oxosteroids ♀	14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
RBC ♂	4.5–6.5 ×10¹²/L
RBC ♀	3.9–5.6 ×10¹²/L
Hb ♂	130–180 g/L
Hb ♀	115–160 g/L
PCV ♂	0.4–0.54 L/L
PCV ♀	0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelets	150–400 ×10⁹/L
Reticulocytes	0.8–2.0% / 25–100 ×10⁹/L
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (bpm)
Neonate	140–160
Infant <1yr	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Respiratory Rate (tachypnoea)
0–2 months	≥60/min
2–12 months	≥50/min
1–5 years	≥40/min
>5 years	≥30/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Haemoglobin (g/dL)
Term newborn	13–20
1 month	11–18
2 months	10–15
1–2 years	10–13
>2 years	11–14
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

Calculator ›

Malaria in Pregnancy

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