Management of Severe Malaria in Pregnancy

In low-transmission areas (low malaria immunity), women in the second and third trimesters of pregnancy are more likely to develop severe malaria than other adults. It is often complicated by pulmonary oedema and hypoglycaemia.

Clinical presentation

Common features of severe malaria during pregnancy include:

High fever
Hyperparasitaemia
Low blood sugar
Severe haemolytic anaemia
Cerebral malaria
Pulmonary oedema

Pharmacological treatment of severe malaria in pregnancy

Intramuscular or intravenous artesunate is the drug of choice for the treatment of severe malaria in all trimesters of pregnancy.

Dosage

2.4 mg/kg body weight (IV or IM) given on admission (0 hour), then at 12 hours and 24 hours, for a minimum of 3 injections in 24 hours regardless of clinical recovery.

After completion of parenteral therapy, complete treatment with a full 3-day course of Artemether + Lumefantrine (ALu) or another ACT.

Consider broad-spectrum antibiotics for possible septicemia.

Administration of injectable artesunate

Injectable artesunate is available in 30 mg, 60 mg, and 120 mg strengths and is prepared in two steps:

Step 1

Dilute powder with 1 ml of 5% sodium bicarbonate solution (provided in each box)
Shake vigorously for 2–3 minutes until the solution becomes clear

Step 2

For slow intravenous infusion (3–4 minutes): add 5 ml of 5% dextrose or normal saline to obtain a concentration of 10 mg/ml
For deep intramuscular injection: add 2 ml of 5% dextrose or normal saline to obtain a concentration of 20 mg/ml

Table 1: Dilution of Artesunate for injection

Route	IV injection			IM injection
Strength	30 mg	60 mg	120 mg	30 mg	60 mg	120 mg
Sodium bicarbonate 5%	0.5	1	2	0.5	1	2
Normal saline or 5% of glucose	2.5	5	10	1	2	4
Total (ml)	3	6	12	1.5	3	6
Artesunate concentration (mg/ml)	10	10	10	20	20	20

Table 2: Dosage Schedule for Artesunate injection

Weight	Dose	ml per dose strength 60mg		Vials of Artesunate 60mg needed**
Kg	mg/kg	IV	IM*
Kg	mg/kg	10 mg/ml	20 mg/ml
34–37	2.4	9	5	2
38–41	2.4	10	5	2
42–45	2.4	11	6	2
46–50	2.4	12	6	2
51–54	2.4	13	7	3
55–58	2.4	14	7	3
59–62	2.4	15	8	3
63–66	2.4	16	8	3
67–70	2.4	17	9	3
71–75	2.4	18	9	3
76–79	2.4	19	10	4
80–83	2.4	20	10	4
84–87	2.4	21	11	4
88–91	2.4	22	11	4
92–95	2.4	23	12	4
96–100	2.4	24	12	4

Half the dose is rounded up to 1ml; *Full vial (s) might not be required for a given weight band. The left–over solution must be discarded within 1hr of preparation and must not be reused

If the patient can tolerate oral medication after 24 hours provide a full treatment course of AL. Initiate the first dose of AL 8 hours after the last injection.

Alternative

Injectable Artemether

Injectable Artemether is to be used when Artesunate is contraindicated (in case of allergy, medicine interaction or non- response) and when not available. Artemether should be administered in a dose of 3.2mg/kg loading dose IM stat (0hour) then 1.6mg/kg (24hours and 48hours).

Table 3: Artemether injectable dosage by weight

	Loading dose 0 hour		Second and subsequent doses 24, 48, hours
	Dose	Strength	Dose	Strength
Weight	3.2 mg/Kg	80 mg/ml	1.6 mg/kg	80 mg/ml
Kg	Mg	ml	mg	ml
34-37	118	1.5	59	0.7
38-41	131	1.6	66	0.8
42-45	144	1.8	72	0.9
>45	160	2.0	80	1.0

If the patient can tolerate oral medication after 24 hours provide a full treatment course of ALu. Initiate the first dose of ALu 8hours after the last injection.

Imeandikwa:

25 Mei 2026, 08:50:51

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