Severe malaria in pregnancy — DTM&H MCQ

Correct answer: C — Intravenous artesunate with obstetric and critical care review

The correct answer is C, intravenous artesunate with obstetric and critical care review. This patient has severe falciparum malaria (prostration, hypotension with systolic below 100 mmHg, hyperparasitaemia at 5%, and vomiting preventing oral therapy) in pregnancy, which is a medical emergency regardless of gestation. UK guidance states that severe malaria in any trimester of pregnancy should be treated as in any other patient, with intravenous artesunate preferred over quinine because of superior mortality reduction, and management must involve joint obstetric, infectious disease and critical care input given the risks of hypoglycaemia, pulmonary oedema, fetal distress and preterm labour. Why the other options are wrong: A. Delay treatment until fetal ultrasound is arranged: severe malaria carries high maternal and fetal mortality if treatment is delayed; ultrasound has no role in acute management and delaying antimalarial therapy for imaging is never appropriate. B. Chloroquine with antiemetics and oral fluids: Plasmodium falciparum from West Africa is essentially universally chloroquine-resistant, and severe disease with vomiting requires parenteral, not oral, therapy. E. Primaquine to prevent placental sequestration: primaquine is contraindicated in pregnancy due to fetal haemolysis risk and has no activity against blood-stage parasites, so it cannot treat sequestration or acute severe disease. D. Oral quinine and clindamycin at home: this regimen is for uncomplicated malaria only; severe disease with hypotension and vomiting mandates hospital admission, parenteral treatment and close monitoring, not home management. Key point: any feature of severe malaria (hyperparasitaemia, hypotension, prostration, impaired oral intake) in pregnancy demands immediate intravenous artesunate with combined obstetric and critical care management, at any gestation.

Reference: UK malaria treatment guidelines 2016 (PHE Advisory Committee on Malaria Prevention for UK Travellers, Journal of Infection 2016;72:635-649): severe malaria in any trimester of pregnancy should be treated as for any other patient with artesunate preferred over quinine (Grade 1C). https://www.journalofinfection.com/article/S0163-4453(16)00047-5/fulltext