How Does Malaria Affect Pregnancy? Which Treatments Are Safe

Malaria during pregnancy requires urgent medical assessment and prompt treatment. The infection poses severe risks to both the pregnant person and the developing baby, including maternal anemia, low birth weight, and premature delivery ^[1][2]. Fortunately, safe and highly effective antimalarial treatments are available. The specific medication prescribed will depend on the malaria species, the severity of the infection, local drug resistance, and your current trimester ^[3][4]. However, liver-clearing medications used for certain relapsing species are contraindicated (must not be used) during pregnancy ^[5].

What to do now:
Seek same-day urgent medical care if you are pregnant and have a fever or suspect you have malaria. Do not wait for a routine appointment, and do not start or stop an antimalarial drug without a clinician’s guidance.

Seek immediate emergency hospital care if you experience any of these severe warning signs:

• Confusion, seizures, fainting, or extreme weakness
• Difficulty breathing
• Jaundice (yellowing of the eyes or skin)
• Repeated vomiting or inability to keep fluids and medications down
• Reduced fetal movement (if you are far enough along to normally feel movement)

How Malaria Affects Pregnancy

Pregnancy causes changes in the immune system, making pregnant people more susceptible to malaria infections and more likely to experience severe symptoms.

Risks to the Pregnant Person

Malaria destroys red blood cells, which can lead to severe maternal anemia (a dangerously low red blood cell count) ^[1]. In cases of severe Plasmodium falciparum (P. falciparum)—the deadliest species of the malaria parasite—the infection can become life-threatening, potentially causing complications like coma, respiratory failure, or maternal mortality ^[6].

Risks to the Baby

The infection can disrupt the flow of nutrients through the placenta, leading to serious fetal complications. Both P. falciparum and P. vivax (another common malaria species) increase the risk of:

• Low birth weight and small-for-gestational-age development (a baby that is smaller than usual for the number of weeks of pregnancy) ^[2][7]
• Premature delivery (birth before 37 weeks) ^[2]
• Miscarriage and stillbirth ^[2][8]

While these risks are serious, they are increased risks, not absolute predictions. Many pregnant people recover fully and deliver healthy babies with prompt, appropriate treatment.

Safe Treatments During Pregnancy

The risks of untreated malaria far outweigh the risks of approved antimalarial drugs. Your local malaria and obstetric care team must choose your specific regimen based on the species, your health, and geographic drug resistance.

Uncomplicated Malaria

For uncomplicated cases (where there are no severe emergency symptoms), oral medications are used to clear the active parasites from the blood:

• First Trimester: The World Health Organization (WHO) recommends artemether-lumefantrine (AL) as a preferred treatment for uncomplicated P. falciparum malaria in the first trimester. Available observational data have not shown an increased risk of miscarriage, stillbirth, or major birth defects associated with its use ^[3][9].
• Second and Third Trimesters: Artemisinin-based combination therapies (ACTs), which include AL, are highly effective and are the recommended first-line treatments later in pregnancy ^[10][11].
• Chloroquine-Susceptible Species: For species like P. vivax that are acquired in regions where they are vulnerable to chloroquine, this medication remains an effective and safe option to clear the acute blood infection ^[12][4].

Severe Malaria

Severe malaria is a life-threatening emergency in any trimester and requires immediate hospital-level intensive care. The preferred and most effective treatment is intravenous (IV) artesunate ^[13][14].

Treatment should never be delayed. If IV artesunate is unavailable, the medical team will use an alternative based on local protocols (such as IV quinine), which requires careful monitoring for side effects like severe low blood sugar ^[4].

Preventing Relapse: Liver-Clearing Drugs and Pregnancy

Some malaria species (specifically P. vivax and P. ovale) can leave dormant parasites hiding in the liver. These can wake up later and cause a relapse. To completely cure these infections, doctors use 8-aminoquinoline drugs (such as primaquine or tafenoquine) to clear the liver ^[5].

Primaquine and tafenoquine are contraindicated (must not be used) during pregnancy.
These drugs can cause oxidant hemolysis (severe, rapid destruction of red blood cells) in individuals who have a genetic condition called G6PD deficiency ^[5][15]. Because fetal G6PD status is not routinely available or safe to establish during pregnancy, these medications cannot be given to a pregnant person ^[5].

What is the alternative during pregnancy?

Instead of liver-clearing drugs, your doctor may prescribe a suppressive strategy, such as a weekly dose of chloroquine prophylaxis, to prevent relapses for the remainder of your pregnancy ^[16][4]. This depends on the specific malaria species and local chloroquine resistance, and it is a clinician-directed plan, not a universal substitute for acute treatment.

What happens after delivery?

Once you have delivered, you must undergo mandatory quantitative G6PD testing before any liver-clearing drugs can be prescribed ^[17].

If you plan to breastfeed, the decision requires careful evaluation. WHO guidance restricts primaquine during breastfeeding for infants younger than 6 months, or if the infant’s G6PD status is unknown or deficient ^[18]. Tafenoquine can also transfer into breast milk ^[19]. Postpartum primaquine may only be considered during breastfeeding if both you and your infant have been tested, have normal G6PD levels, and your doctor determines it aligns with local guidelines ^[20][17]. Never start these medications without explicit clearance from your care team.