4.3 Parasitic infections


For clinical signs and diagnosis, refer to the Clinical guidelines, MSF.

4.3.1 Malaria5

Malaria in pregnancy is associated with low birth weight, increased anaemia and, in lowtransmission areas, an increased risk of severe malaria and death.
The diagnosis should, if possible, be confirmed by rapid test or microscopic examination (thick or thin smear).

Uncomplicated falciparum malaria

The treatment of choice is an artemisinin-based combination therapy (ACT) for 3 days.

Table 4.1 - Dosage of ACT

ACT

Formulation

Dosage

artemether/lumefantrine
(AL or co-artemether)

Co-formulated tablets,
20 mg artemether/120 mg lumefantrine per tab,
blister of 24 tab

4 tab twice daily on D1, D2, D3

artemether/lumefantrine
(AL or co-artemether)

Co-formulated tablets,
80 mg artemether/480 mg lumefantrine per tab,
blister of 6 tab

1 tab twice daily on D1, D2, D3

artesunate (AS)
+ sulfadoxine/pyrimethamine (SP)

Co-blister containing:
6 tab 100 mg AS
+ 3 tab 500/25 mg SP

2 tab AS once daily on D1, D2, D3
+ 3 tab SP as a single dose on D1

artesunate (AS)
+ amodiaquine (AQ)

Co-formulated tablets,
100 mg AS/270 mg AQ base per tab,
blister of 6 tab

2 tab once daily on D1, D2, D3

Co-blister containing:
12 tab 50 mg AS
+ 12 tab 153 mg AQ base

4 tab AS + 4 tab AQ
once daily on D1, D2, D3

artesunate/mefloquine
(AS/MQ)

Co-formulated tablets,
100 mg AS/220 mg MQ per tab,
blister of 6 tab

2 tab once daily on D1, D2, D3

dihydroartemisine/piperaquine
(DHA/PPQ)

Coformulated tablets,
40 mg DHA/320 mg PPQ
Blister of 9 tab

Women 36 to < 60 kg
3 tab once daily on D1, D2, D3

Coformulated tablets,
40 mg DHA/320 mg PPQ
Blister of 12 tab

Women 60 to < 80 kg
4 tab once daily on D1, D2, D3

Note:
The combination AS/SP is contra-indicated in HIV-infected women taking cotrimoxazole preventive therapy.

Quinine is an alternative:
quinine PO: 30 mg/kg/day in 3 divided doses for 7 days
Reduced susceptibility to quinine has been observed in South-East Asia and Amazon region.
In these areas, quinine is given in combination with clindamycin PO: 20 mg/kg/day in 2 divided doses for 5 days.

Doxycycline is contra-indicated.

Severe malaria

artesunate slow IV (or, if not feasible, IM into the anterior thigh):
2.4 mg/kg on admission then 12 hours and 24 hours after admission (H0, H12, H24), then once daily
Note: dilution of the artesunate solution depends on the route of administration (10 mg/ml for IV route, 20 mg/ml for IM route), refer to the MSF handbook Essential drugs.
or
artemether IM (into the anterior thigh):
3.2 mg/kg on admission then 1.6 mg/kg once daily

As soon as the patient can tolerate oral treatment (but after at least 24 hours of parenteral treatment), administer a 3-day course of ACT (Table 4.1).
Do not use the combination AS/MQ if the patient developed neurological signs during the acute phase.

IV quinine (± clindamycin) is an alternative.
quinine IV infusion (dosage is expressed in quinine dihydrochloride):
Loading dose: 20 mg/kg diluted in glucose solution, administered over 4 hours.
Then 5% glucose to keep the vein open over the next 4 hours.
Then maintenance dose: 10 mg/kg over 8 hours, every 8 hours (or, better, alternate 4 hours of quinine diluted in 5% glucose and 4 hours of 5% glucose).
Do not administer loading dose to patients who have received oral quinine or mefloquine within the previous 24 hours. In these cases, start with the maintenance dose.
Monitor the patient closely (risk of pulmonary oedema and hypoglycaemia).
As soon as the patient has received at least 3 doses of parenteral quinine and can tolerate oral treatment, change to quinine PO to complete 7 days of treatment or administer a 3-day course of ACT (Table 4.1).
If the combination AS/MQ is used as oral completion treatment following IV quinine, start AS/MQ 12 hours after the last dose of quinine.

Malaria due to P. vivax, P. malariae, P. ovale

Irrespective of the age of the pregnancy:
chloroquine PO:
D1, D2: 10 mg base/kg
D3: 5 mg base/kg

Although P. vivax is considered benign, severe cases have been reported. The treatment of severe malaria should be the same whatever the species.

4.3.2 Amoebiasis

Pregnant women appear to have an increased risk of severe disease and death6.

The diagnosis is established by microscopic examination of fresh stools. If the result is positive:
tinidazole PO: 2 g/day in 2 divided doses for 3 days
or metronidazole PO: 1.5 g/day in 3 divided doses for 5 days

4.3.3 Ascariasis and ancylostomiasis (hookworms)

For symptomatic infection or infection proven by faecal exam:
albendazole PO: 400 mg as a single dose

Do not administer during the first trimester of pregnancy.

In the event of ancylostomiasis, treat the associated anaemia (Section 4.1).