Pregnant women present for antenatal care at SMRU’s Wang Pa clinic on the Thai-Myanmar border. Photo by Gerhard Jörén, © MORU/SMRU 2016. All rights reserved.
Artemisinins, the most effective antimalarials available, should replace quinine as the recommended optimal treatment of falciparum malaria during first-trimester pregnancy, according to a new study led by the Shoklo Malaria Research Unit in collaboration with researchers from Burnet Institute and The University of Melbourne published in The Lancet Infectious Diseases.
The observational study which assessed data from antenatal clinics on the Thai-Myanmar border from 1994-2013, found no evidence of an increased risk of miscarriage or of major congenital malformations associated with first-line treatment with an artemisinin derivative compared with quinine.
The study’s authors recommend that global health authorities should reconsider treatment protocols for first-trimester antimalarial treatment.
“These results have important implications for malaria treatment and control policies, and future studies of artemisinin safety,” the study’s lead author, Ms Kerryn Moore said.
“Quinine is comparatively poorly tolerated, less effective, and, associated with a shorter time to recurrence less effective than artemisinin, but is still the recommended treatment for malaria in first trimester.”
Currently the World Health Organization recommends the effective artemisinin combination treatments for first-line treatment of falciparum malaria, except in the first trimester of pregnancy because of safety concerns.
This is the first study to estimate the effects of initial and recurrent first-trimester malaria, its symptomatology, and its treatment on miscarriage. It also includes the largest number of confirmed first-trimester malaria treatments with artemisinins or quinine.
Lead author and Burnet malaria researcher, Ms Moore said that women who get malaria in their first trimester of pregnancy are more likely to miscarry, so safe and effective treatment is imperative.
“Because of the risk of miscarriage or congenital abnormalities, doctors are justifiably worried about drugs in the first trimester of pregnancy. We found no evidence that treatment of malaria with artemisinins in the first trimester increased the risk of miscarriage compared with quinine treatment,” Ms Moore said.
However, the study could not determine whether artemisinins change the risk of congenital malformations.
“The best way to assess a relationship between artemisinin treatment and rare outcomes such as congenital malformations is by endorsing artemisinins now, with robust monitoring to capture the outcomes of treated women.”
More than 125 million pregnant women are infected with malaria each year, increasing the risk of maternal and infant death, and affecting the development of children born to mothers infected during pregnancy.
Medical records of 55,636 women who visited Shoklo Malaria Research Unit (SMRU) antenatal clinics in Thailand from 1994 were assessed. The study estimated that malaria in first trimester increased the risk of miscarriage by 60 per cent. Recurrent malaria in first trimester, which can be the result of ineffective treatment, increased the risk of miscarriage more than three-fold. However, the risk of miscarriage following treatment with artemisinins was not higher, and possibly even lower, than after treatment of malaria with quinine.
Led by researchers at the Shoklo Malaria Research Unit (Thailand), The University of Melbourne (Australia), and Burnet Institute (Australia), among others, the study was funded by the Wellcome Trust (UK) and the Bill & Melinda Gates Foundation (US).
The study, Safety of artemisinins in first trimester of prospectively followed pregnancies: an observational study, is available online.