Current strategies

Anti-malaria for pregnant women

Options for malaria control during pregnancy

• Drugs– Chemoprophylaxis

– Intermittent preventive treatment during pregnancy (IPTp)

– Febrile case management• Insecticide Treated Nets (ITNs)• Prevention and treatment of anemia

– Hematinic supplementation– Nutritional counseling

• Vaccines?

Intermittent preventive treatment (IPTp): an alternative strategy

• Most studied regimen: Sulfadoxine-pyrimethamine (SP) 2 curative courses (3 tablets)– One course during second trimester– One course during third trimester

• Inexpensive• Easily deliverable (can be given under direct

observation)• Safe• Efficacious

Intermittent preventive treatment-- the two dose SP strategy

Weeks of gestation

Conception Birth

20 3010

Course 124-28 wks

Course 230-36 wks

Fetal growth velocity

IPTp with SP: summary of evidence and benefits

• 2 doses of IPT with SP is associated with: – Reduction in 3rd trimester maternal

anemia – Reduction in placental malaria

parasitemia– Reduction in low birth weight

• At least 2 doses required for optimal benefit

• Regimen is safe and well tolerated

Case management of malaria in pregnancy

Safe drugs

• Chloroquine• Quinine / quinidine • Proguanil, chlorproguanil• Pyrimethamine• Sulfonamides• Dapsone (+pyrimethamine=

Maloprim)• Mefloquine (prophylaxis)• Clindamycin (300 mg qid, 5-7

days)• Artemisinins (2nd and 3rd)

Drugs with questionable safety or insufficient data

• Mefloquine (treatment dose)• Artemisinins (1st)• Amodiaquine• Azithromycin• Lumefantrine (component of

coartem/Riamet)• Combination therapy

– Artemisinin derivative with other drugs

– Lapdap (chlorproguanil-dapsone)

– Atovaquone-proguanil (Malarone)

– Amodiaquine-SP

Anti-malarials contra-indicated in pregnancy

• Tetracycline• Doxycycline• Halofantrine• Primaquine• Tafenoquine• Note: if serious illness, and where limited

number of drugs are available, it is necessary to balance the risk of maternal death with the hypothetical risks to the infant

Drugs that should not be used during pregnancy

• Tetracycline– Cause abnormalities of skeletal and muscular growth,

tooth development, lens/cornea• Doxycycline

– Risk of cosmetic staining of primary teeth is undetermined

– Excreted into breast milk• Primaquine

– Harmful to newborns who are relatively Glucose-6-Phosphatase-Dehydrogenase (G6PD) deficient

• Halofantrine– No conclusive studies in pregnant women– Has been shown to cause unwanted effects, including

death of the fetus, in animals