Among drugs that are well studied and without known direct fetal-damaging effects, adverse drug reaction profiles can guide use based on disease prevalence and drug-resistance patterns.
- Chloroquine is widely used because it is inexpensive and well tolerated, with only pruritus, mouth ulcers, and gastrointestinal upset as the most common adverse effects.
- Mefloquine is usually well tolerated, but can cause dose-related neuropsychiatric effects; it is contraindicated in those with a history of epilepsy or psychiatric disease.
- Sulfadoxine and pyrimethamine are not normally used as prophylaxis for any patient, due to the risk of toxic epidermal necrolysis and Stevens-Johnson syndrome, and the possible risk of jaundice and kernicterus if used in the third trimester of pregnancy.
- Quinine, which can be used for treatment or prophylaxis, may cause hypoglycemia, an effect that is more pronounced during pregnancy and requires close monitoring of blood glucose levels.5,7
Given these reaction profiles, chloroquine or mefloquine are usually the best choice with their superior safety and efficacy.
Figure
Best protection: Avoidance
Chloroquine and mefloquine are the safest antimalarials for use in pregnant women, but personal protection measures are also critical. Above, an Anopheles stephensi mosquito expelling a droplet of blood from its abdomen after having engorged itself on its human host’s blood. (Source: CDC.)
Recommendations from others
The World Health Organization (WHO) recommends pregnant women avoid travel to malarial regions. If travel is required, WHO recommends chloroquine as first-line prophylaxis in pregnancy (plus proguanil if the region exhibits emerging chloroquine resistance). In areas with proven chloroquine resistance, mefloquine is the drug of choice. Other antimalarials—such as quinine, pyrimethamine, sulfadoxine, and artesunate—should not be withheld if the preferred drugs are not available, or if the infection is life-threatening.2
The Centers for Disease Control and Prevention (CDC) also recommends avoiding travel to malaria-endemic regions during pregnancy, but if travel is necessary, the CDC advises use of chloroquine (or mefloquine in regions with chloroquine resistance). The CDC discourages the use of atovaquone/proguanil, doxycycline, and primaquine, due to known adverse fetal effects or inadequate experience in pregnancy.6
Acknowledgments
The opinions and assertions contained herein are the private views of the authors and not to be construed as official, or as reflecting the views of the US Air Force Medical Service or the US Air Force at large.