Malaria prophylaxis in pregnancy — DTM&H MCQ

Correct answer: C — Mefloquine after individual risk assessment

The correct answer is C, Mefloquine after individual risk assessment. In pregnant travellers where travel to a chloroquine-resistant area is unavoidable, mefloquine can be offered in all trimesters, with caution advised in the first trimester, and it is regarded as the antimalarial of choice for chemoprophylaxis in pregnancy against P. falciparum. It is not simply prescribed off the shelf: current UK travel medicine guidance requires an individual risk assessment weighing the destination's resistance pattern, gestation, psychiatric history (mefloquine can cause neuropsychiatric effects) and the traveller's ability to avoid travel altogether. This patient has no psychiatric history, is beyond the first trimester, and faces unavoidable exposure to a chloroquine-resistant West African region, so mefloquine after risk assessment is the most appropriate option. Why the other options are wrong: A. Primaquine after routine booking bloods: primaquine is not used for prophylaxis in this context and requires G6PD testing beforehand, not routine booking bloods; it also carries theoretical fetal risk via glucose-6-phosphate dehydrogenase status of the fetus. E. Atovaquone-proguanil as the default first choice: data on safety in pregnancy are limited, so it is not recommended as first line and is only considered if other options are unsuitable. D. Chloroquine monotherapy for West Africa: chloroquine alone gives inadequate cover because most West African P. falciparum is chloroquine-resistant. B. Doxycycline throughout pregnancy: tetracyclines are contraindicated in pregnancy due to risks of fetal dental staining and bone growth inhibition, and skeletal effects, so doxycycline cannot be used at any gestation here. Key point: mefloquine, after individualised risk-benefit assessment, is the preferred malaria chemoprophylaxis in pregnancy when travel to a chloroquine-resistant area cannot be avoided.

Reference: NaTHNaC/TravelHealthPro, Pregnancy factsheet (UK national travel health resource, supporting UKHSA Guidelines for malaria prevention in travellers from the UK, 2024): mefloquine can be offered in all trimesters for travel to high-risk P. falciparum areas when travel is unavoidable, caution advised in the first trimester. https://travelhealthpro.org.uk/factsheet/45/pregnancy