4.3 Parasitic infections


For clinical signs and diagnosis, see Clinical guidelines, MSF.

4.3.1 Malaria5

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

Uncomplicated falciparum malaria

The treatment of choice in all trimesters 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 2 times daily on D1, D2, D3

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

1 tab 2 times daily on D1, D2, D3

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 59 kg
3 tab once daily on D1, D2, D3

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

Women 60 to 79 kg
4 tab once daily on D1, D2, D3

Note: the combination AS/SP is contra-indicated in HIV-infected women taking co-trimoxazole preventive therapy.

Quinine is an alternative:
quinine PO: 10 mg/kg 3 times daily for 7 days
In South-East Asia and Amazon region, quinine should be given in combination with clindamycin PO: 10 mg/kg 2 times daily 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 guide Essential drugs, MSF.
or, if not available,
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 (5% or 10%), 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, P. knowlesi

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 Ancylostomiasis (hookworms) and ascariasis 

albendazole PO: 400 mg single dose (or, if not available, mebendazole PO: 100 mg 2 times daily for 3 days)
Do not administer during the first trimester of pregnancy. Wait until the second trimester before administering treatment. 

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