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Overview of malaria in pregnancy

Peter A Chedraui, MD, MSc, PhD
Blair J Wylie, MD, MPH
Section Editors
Johanna Daily, MD, MSc
Vincenzo Berghella, MD
Deputy Editors
Vanessa A Barss, MD, FACOG
Elinor L Baron, MD, DTMH


Each year, 50 million women living in malaria-endemic areas become pregnant; one-half of these women live in Africa [1]. It is estimated that 10,000 women and 200,000 infants die as a result of malaria infection during pregnancy; severe maternal anemia, prematurity, and low birth weight contribute to more than half of these deaths.

Human malaria is caused by five species of Plasmodia: P. falciparum, P. vivax, P. ovale, P. malariae and P. knowlesi. Most infections are due to either P. falciparum or P. vivax, but mixed infections with more than one malarial species also occur. The majority of malaria-related deaths are due to P. falciparum.

The continued public health burden of malaria is due to a combination of factors, including:

Increasing resistance of malarial parasites to chemotherapy

Increasing resistance of the Anopheles mosquito vector to insecticides

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Literature review current through: Nov 2017. | This topic last updated: Oct 12, 2017.
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  1. http://mosquito.who.int/. (Accessed on May 08, 2008).
  2. Barber BE, Bird E, Wilkes CS, et al. Plasmodium knowlesi malaria during pregnancy. J Infect Dis 2015; 211:1104.
  3. Desai M, ter Kuile FO, Nosten F, et al. Epidemiology and burden of malaria in pregnancy. Lancet Infect Dis 2007; 7:93.
  4. Mace KE, Arguin PM. Malaria Surveillance - United States, 2014. MMWR Surveill Summ 2017; 66:1.
  5. Singh N, Saxena A, Chand SK, et al. Studies on malaria during pregnancy in a tribal area of central India (Madhya Pradesh). Southeast Asian J Trop Med Public Health 1998; 29:10.
  6. Brabin BJ. An analysis of malaria in pregnancy in Africa. Bull World Health Organ 1983; 61:1005.
  7. Diagne N, Rogier C, Cisse B, Trape JF. Incidence of clinical malaria in pregnant women exposed to intense perennial transmission. Trans R Soc Trop Med Hyg 1997; 91:166.
  8. Bergström S, Fernandes A, Schwalbach J, et al. Materno-fetal transmission of pregnancy malaria: an immunoparasitological study on 202 parturients in Maputo. Gynecol Obstet Invest 1993; 35:103.
  9. Sholapurkar SL, Gupta AN, Mahajan RC. Clinical course of malaria in pregnancy--a prospective controlled study from India. Trans R Soc Trop Med Hyg 1988; 82:376.
  10. Mbanzulu PN, Leng JJ, Kaba S, et al. [Malaria and pregnancy. Epidemiological situation in Kinshasa (Zaïre)]. Rev Fr Gynecol Obstet 1988; 83:99.
  11. McGregor IA. Epidemiology, malaria and pregnancy. Am J Trop Med Hyg 1984; 33:517.
  12. Lindsay S, Ansell J, Selman C, et al. Effect of pregnancy on exposure to malaria mosquitoes. Lancet 2000; 355:1972.
  13. Nosten F, McGready R, Simpson JA, et al. Effects of Plasmodium vivax malaria in pregnancy. Lancet 1999; 354:546.
  14. Nosten F, ter Kuile F, Maelankirri L, et al. Malaria during pregnancy in an area of unstable endemicity. Trans R Soc Trop Med Hyg 1991; 85:424.
  15. Mutabingwa TK. Malaria and pregnancy: epidemiology, pathophysiology and control options. Acta Trop 1994; 57:239.
  16. Bouyou-Akotet MK, Ionete-Collard DE, Mabika-Manfoumbi M, et al. Prevalence of Plasmodium falciparum infection in pregnant women in Gabon. Malar J 2003; 2:18.
  17. McGready R, Davison BB, Stepniewska K, et al. The effects of Plasmodium falciparum and P. vivax infections on placental histopathology in an area of low malaria transmission. Am J Trop Med Hyg 2004; 70:398.
  18. Rogerson SJ, Mkundika P, Kanjala MK. Diagnosis of Plasmodium falciparum malaria at delivery: comparison of blood film preparation methods and of blood films with histology. J Clin Microbiol 2003; 41:1370.
  19. Ismail MR, Ordi J, Menendez C, et al. Placental pathology in malaria: a histological, immunohistochemical, and quantitative study. Hum Pathol 2000; 31:85.
  20. Metenou S, Suguitan AL Jr, Long C, et al. Fetal immune responses to Plasmodium falciparum antigens in a malaria-endemic region of Cameroon. J Immunol 2007; 178:2770.
  21. Malhotra I, Dent A, Mungai P, et al. Can prenatal malaria exposure produce an immune tolerant phenotype? A prospective birth cohort study in Kenya. PLoS Med 2009; 6:e1000116.
  22. Asante KP, Owusu-Agyei S, Cairns M, et al. Placental malaria and the risk of malaria in infants in a high malaria transmission area in ghana: a prospective cohort study. J Infect Dis 2013; 208:1504.
  23. Dauby N, Goetghebuer T, Kollmann TR, et al. Uninfected but not unaffected: chronic maternal infections during pregnancy, fetal immunity, and susceptibility to postnatal infections. Lancet Infect Dis 2012; 12:330.
  24. Walther B, Miles DJ, Waight P, et al. Placental malaria is associated with attenuated CD4 T-cell responses to tuberculin PPD 12 months after BCG vaccination. BMC Infect Dis 2012; 12:6.
  25. Mayor A, Bardají A, Macete E, et al. Changing Trends in P. falciparum Burden, Immunity, and Disease in Pregnancy. N Engl J Med 2015; 373:1607.
  26. Salanti A, Staalsoe T, Lavstsen T, et al. Selective upregulation of a single distinctly structured var gene in chondroitin sulphate A-adhering Plasmodium falciparum involved in pregnancy-associated malaria. Mol Microbiol 2003; 49:179.
  27. Fried M, Duffy PE. Adherence of Plasmodium falciparum to chondroitin sulfate A in the human placenta. Science 1996; 272:1502.
  28. Salanti A, Dahlbäck M, Turner L, et al. Evidence for the involvement of VAR2CSA in pregnancy-associated malaria. J Exp Med 2004; 200:1197.
  29. Crocker IP, Tanner OM, Myers JE, et al. Syncytiotrophoblast degradation and the pathophysiology of the malaria-infected placenta. Placenta 2004; 25:273.
  30. McGregor IA, Wilson ME, Billewicz WZ. Malaria infection of the placenta in The Gambia, West Africa; its incidence and relationship to stillbirth, birthweight and placental weight. Trans R Soc Trop Med Hyg 1983; 77:232.
  31. Shulman CE, Dorman EK. Importance and prevention of malaria in pregnancy. Trans R Soc Trop Med Hyg 2003; 97:30.
  32. Fried M, Duffy PE. Maternal malaria and parasite adhesion. J Mol Med (Berl) 1998; 76:162.
  33. Andrews KT, Lanzer M. Maternal malaria: Plasmodium falciparum sequestration in the placenta. Parasitol Res 2002; 88:715.
  34. Beeson JG, Rogerson SJ, Elliott SR, Duffy MF. Targets of protective antibodies to malaria during pregnancy. J Infect Dis 2005; 192:1647.
  35. Staalsoe T, Shulman CE, Bulmer JN, et al. Variant surface antigen-specific IgG and protection against clinical consequences of pregnancy-associated Plasmodium falciparum malaria. Lancet 2004; 363:283.
  36. Vleugels MP, Eling WM, Rolland R, de Graaf R. Cortisol and loss of malaria immunity in human pregnancy. Br J Obstet Gynaecol 1987; 94:758.
  37. Rasheed FN, Bulmer JN, Dunn DT, et al. Suppressed peripheral and placental blood lymphoproliferative responses in first pregnancies: relevance to malaria. Am J Trop Med Hyg 1993; 48:154.
  38. Riley EM, Schneider G, Sambou I, Greenwood BM. Suppression of cell-mediated immune responses to malaria antigens in pregnant Gambian women. Am J Trop Med Hyg 1989; 40:141.
  39. Brabin BJ, Ginny M, Sapau J, et al. Consequences of maternal anaemia on outcome of pregnancy in a malaria endemic area in Papua New Guinea. Ann Trop Med Parasitol 1990; 84:11.
  40. Diagne N, Rogier C, Sokhna CS, et al. Increased susceptibility to malaria during the early postpartum period. N Engl J Med 2000; 343:598.
  41. Severe and complicated malaria. World Health Organization, Division of Control of Tropical Diseases. Trans R Soc Trop Med Hyg 1990; 84 Suppl 2:1.
  42. Saeed BO, Atabani GS, Nawwaf A, et al. Hypoglycaemia in pregnant women with malaria. Trans R Soc Trop Med Hyg 1990; 84:349.
  43. White NJ. The treatment of malaria. N Engl J Med 1996; 335:800.
  44. Egwunyenga OA, Ajayi JA, Duhlinska-Popova DD. Malaria in pregnancy in Nigerians: seasonality and relationship to splenomegaly and anaemia. Indian J Malariol 1997; 34:17.
  45. Espinoza E, Hidalgo L, Chedraui P. The effect of malarial infection on maternal-fetal outcome in Ecuador. J Matern Fetal Neonatal Med 2005; 18:101.
  46. Assabri AM, Muharram AA. Malaria in pregnancy in Hodiedah, Republic of Yemen. East Mediterr Health J 2002; 8:245.
  47. Whitty CJ, Edmonds S, Mutabingwa TK. Malaria in pregnancy. BJOG 2005; 112:1189.
  48. Sangaré L, van Eijk AM, Ter Kuile FO, et al. The association between malaria and iron status or supplementation in pregnancy: a systematic review and meta-analysis. PLoS One 2014; 9:e87743.
  49. Mwangi MN, Roth JM, Smit MR, et al. Effect of Daily Antenatal Iron Supplementation on Plasmodium Infection in Kenyan Women: A Randomized Clinical Trial. JAMA 2015; 314:1009.
  50. Etheredge AJ, Premji Z, Gunaratna NS, et al. Iron Supplementation in Iron-Replete and Nonanemic Pregnant Women in Tanzania: A Randomized Clinical Trial. JAMA Pediatr 2015; 169:947.
  51. Ramharter M, Grobusch MP, Kiessling G, et al. Clinical and parasitological characteristics of puerperal malaria. J Infect Dis 2005; 191:1005.
  52. Ticconi C, Mapfumo M, Dorrucci M, et al. Effect of maternal HIV and malaria infection on pregnancy and perinatal outcome in Zimbabwe. J Acquir Immune Defic Syndr 2003; 34:289.
  53. ter Kuile FO, Parise ME, Verhoeff FH, et al. The burden of co-infection with human immunodeficiency virus type 1 and malaria in pregnant women in sub-saharan Africa. Am J Trop Med Hyg 2004; 71:41.
  54. Ayisi JG, van Eijk AM, ter Kuile FO, et al. The effect of dual infection with HIV and malaria on pregnancy outcome in western Kenya. AIDS 2003; 17:585.
  55. Steketee RW, Wirima JJ, Bloland PB, et al. Impairment of a pregnant woman's acquired ability to limit Plasmodium falciparum by infection with human immunodeficiency virus type-1. Am J Trop Med Hyg 1996; 55:42.
  56. Mount AM, Mwapasa V, Elliott SR, et al. Impairment of humoral immunity to Plasmodium falciparum malaria in pregnancy by HIV infection. Lancet 2004; 363:1860.
  57. Bloland PB, Wirima JJ, Steketee RW, et al. Maternal HIV infection and infant mortality in Malawi: evidence for increased mortality due to placental malaria infection. AIDS 1995; 9:721.
  58. Kublin JG, Patnaik P, Jere CS, et al. Effect of Plasmodium falciparum malaria on concentration of HIV-1-RNA in the blood of adults in rural Malawi: a prospective cohort study. Lancet 2005; 365:233.
  59. Bulterys PL, Chao A, Dalai SC, et al. Placental malaria and mother-to-child transmission of human immunodeficiency virus-1 in rural Rwanda. Am J Trop Med Hyg 2011; 85:202.
  60. Msamanga GI, Taha TE, Young AM, et al. Placental malaria and mother-to-child transmission of human immunodeficiency virus-1. Am J Trop Med Hyg 2009; 80:508.
  61. Brahmbhatt H, Sullivan D, Kigozi G, et al. Association of HIV and malaria with mother-to-child transmission, birth outcomes, and child mortality. J Acquir Immune Defic Syndr 2008; 47:472.
  62. Naniche D, Lahuerta M, Bardaji A, et al. Mother-to-child transmission of HIV-1: association with malaria prevention, anaemia and placental malaria. HIV Med 2008; 9:757.
  63. Ayisi JG, van Eijk AM, Newman RD, et al. Maternal malaria and perinatal HIV transmission, western Kenya. Emerg Infect Dis 2004; 10:643.
  64. Brahmbhatt H, Kigozi G, Wabwire-Mangen F, et al. The effects of placental malaria on mother-to-child HIV transmission in Rakai, Uganda. AIDS 2003; 17:2539.
  65. Gallagher M, Malhotra I, Mungai PL, et al. The effects of maternal helminth and malaria infections on mother-to-child HIV transmission. AIDS 2005; 19:1849.
  66. Singh N, Bharti PK, Singh MP, et al. What is the burden of submicroscopic malaria in pregnancy in central India? Pathog Glob Health 2015; 109:30.
  67. Cottrell G, Moussiliou A, Luty AJ, et al. Submicroscopic Plasmodium falciparum Infections Are Associated With Maternal Anemia, Premature Births, and Low Birth Weight. Clin Infect Dis 2015; 60:1481.
  68. Williams JE, Cairns M, Njie F, et al. The Performance of a Rapid Diagnostic Test in Detecting Malaria Infection in Pregnant Women and the Impact of Missed Infections. Clin Infect Dis 2016; 62:837.
  69. Cohee LM, Kalilani-Phiri L, Boudova S, et al. Submicroscopic malaria infection during pregnancy and the impact of intermittent preventive treatment. Malar J 2014; 13:274.
  70. Granja AC, Machungo F, Gomes A, et al. Malaria-related maternal mortality in urban Mozambique. Ann Trop Med Parasitol 1998; 92:257.
  71. Carles G, Bousquet F, Raynal P, et al. [Pregnancy and malaria. Study of 143 cases in French Guyana]. J Gynecol Obstet Biol Reprod (Paris) 1998; 27:798.
  72. McGregor IA. Thoughts on malaria in pregnancy with consideration of some factors which influence remedial strategies. Parassitologia 1987; 29:153.
  73. Newman RD, Hailemariam A, Jimma D, et al. Burden of malaria during pregnancy in areas of stable and unstable transmission in Ethiopia during a nonepidemic year. J Infect Dis 2003; 187:1765.
  74. Hulbert TV. Congenital malaria in the United States: report of a case and review. Clin Infect Dis 1992; 14:922.
  75. McGready R, Lee SJ, Wiladphaingern J, et al. Adverse effects of falciparum and vivax malaria and the safety of antimalarial treatment in early pregnancy: a population-based study. Lancet Infect Dis 2012; 12:388.
  76. Steketee RW, Nahlen BL, Parise ME, Menendez C. The burden of malaria in pregnancy in malaria-endemic areas. Am J Trop Med Hyg 2001; 64:28.
  77. Guyatt HL, Snow RW. Impact of malaria during pregnancy on low birth weight in sub-Saharan Africa. Clin Microbiol Rev 2004; 17:760.
  78. Akingbade OA. Embryotoxic and growth-retarding effects of malaria on pregnant mice. J Reprod Med 1992; 37:273.
  79. Duffy PE, Fried M. Plasmodium falciparum adhesion in the placenta. Curr Opin Microbiol 2003; 6:371.
  80. Nathwani D, Currie PF, Douglas JG, et al. Plasmodium falciparum malaria in pregnancy: a review. Br J Obstet Gynaecol 1992; 99:118.
  81. Okoko BJ, Ota MO, Yamuah LK, et al. Influence of placental malaria infection on foetal outcome in the Gambia: twenty years after Ian Mcgregor. J Health Popul Nutr 2002; 20:4.
  82. Redd SC, Wirima JJ, Steketee RW, et al. Transplacental transmission of Plasmodium falciparum in rural Malawi. Am J Trop Med Hyg 1996; 55:57.
  83. Mayor A, Bardají A, Felger I, et al. Placental infection with Plasmodium vivax: a histopathological and molecular study. J Infect Dis 2012; 206:1904.
  84. Poespoprodjo JR, Fobia W, Kenangalem E, et al. Adverse pregnancy outcomes in an area where multidrug-resistant plasmodium vivax and Plasmodium falciparum infections are endemic. Clin Infect Dis 2008; 46:1374.
  85. Singh N, Shukla MM, Sharma VP. Epidemiology of malaria in pregnancy in central India. Bull World Health Organ 1999; 77:567.
  86. Bôtto-Menezes C, Silva Dos Santos MC, Lopes Simplício J, et al. Plasmodium vivax Malaria in Pregnant Women in the Brazilian Amazon and the Risk Factors Associated with Prematurity and Low Birth Weight: A Descriptive Study. PLoS One 2015; 10:e0144399.
  87. Suguitan AL Jr, Leke RG, Fouda G, et al. Changes in the levels of chemokines and cytokines in the placentas of women with Plasmodium falciparum malaria. J Infect Dis 2003; 188:1074.
  88. Fried M, Muga RO, Misore AO, Duffy PE. Malaria elicits type 1 cytokines in the human placenta: IFN-gamma and TNF-alpha associated with pregnancy outcomes. J Immunol 1998; 160:2523.
  89. Fried M, Kurtis JD, Swihart B, et al. Systemic Inflammatory Response to Malaria During Pregnancy Is Associated With Pregnancy Loss and Preterm Delivery. Clin Infect Dis 2017; 65:1729.
  90. Dong S, Kurtis JD, Pond-Tor S, et al. CXC ligand 9 response to malaria during pregnancy is associated with low-birth-weight deliveries. Infect Immun 2012; 80:3034.
  91. Suguitan AL Jr, Cadigan TJ, Nguyen TA, et al. Malaria-associated cytokine changes in the placenta of women with pre-term deliveries in Yaounde, Cameroon. Am J Trop Med Hyg 2003; 69:574.
  92. Aidoo M, McElroy PD, Kolczak MS, et al. Tumor necrosis factor-alpha promoter variant 2 (TNF2) is associated with pre-term delivery, infant mortality, and malaria morbidity in western Kenya: Asembo Bay Cohort Project IX. Genet Epidemiol 2001; 21:201.
  93. Schmiegelow C, Minja D, Oesterholt M, et al. Malaria and fetal growth alterations in the 3(rd) trimester of pregnancy: a longitudinal ultrasound study. PLoS One 2013; 8:e53794.
  94. Rijken MJ, Papageorghiou AT, Thiptharakun S, et al. Ultrasound evidence of early fetal growth restriction after maternal malaria infection. PLoS One 2012; 7:e31411.
  95. Griffin JB, Lokomba V, Landis SH, et al. Plasmodium falciparum parasitaemia in the first half of pregnancy, uterine and umbilical artery blood flow, and foetal growth: a longitudinal Doppler ultrasound study. Malar J 2012; 11:319.
  96. Briand V, Saal J, Ghafari C, et al. Fetal Growth Restriction Is Associated With Malaria in Pregnancy: A Prospective Longitudinal Study in Benin. J Infect Dis 2016; 214:417.
  97. Rijken MJ, De Livera AM, Lee SJ, et al. Quantifying low birth weight, preterm birth and small-for-gestational-age effects of malaria in pregnancy: a population cohort study. PLoS One 2014; 9:e100247.
  98. Dorman EK, Shulman CE, Kingdom J, et al. Impaired uteroplacental blood flow in pregnancies complicated by falciparum malaria. Ultrasound Obstet Gynecol 2002; 19:165.
  99. Kaushik A, Sharma VK, Sadhna, et al. Malarial placental infection and low birth weight babies. Mater Med Pol 1992; 24:109.
  100. Tuikue Ndam NG, Fievet N, Bertin G, et al. Variable adhesion abilities and overlapping antigenic properties in placental Plasmodium falciparum isolates. J Infect Dis 2004; 190:2001.
  101. Kalilani L, Mofolo I, Chaponda M, et al. The effect of timing and frequency of Plasmodium falciparum infection during pregnancy on the risk of low birth weight and maternal anemia. Trans R Soc Trop Med Hyg 2010; 104:416.
  102. Cates JE, Unger HW, Briand V, et al. Malaria, malnutrition, and birthweight: A meta-analysis using individual participant data. PLoS Med 2017; 14:e1002373.
  103. van Geertruyden JP, Thomas F, Erhart A, D'Alessandro U. The contribution of malaria in pregnancy to perinatal mortality. Am J Trop Med Hyg 2004; 71:35.
  104. Schwetz, J, Peel, M. Congenital malaria and placental infections among Negroes of Central Africa. Trans R Soc Trop Med Hyg 1934; 28:167.
  105. Subramanian D, Moise KJ Jr, White AC Jr. Imported malaria in pregnancy: report of four cases and review of management. Clin Infect Dis 1992; 15:408.
  106. COVELL G. Congenital malaria. Trop Dis Bull 1950; 47:1147.
  107. Darie H, Haba M. [Congenital malaria]. Med Trop (Mars) 1992; 52:175.
  108. Lee WW, Singh M, Tan CL. A recent case of congenital malaria in Singapore. Singapore Med J 1996; 37:541.
  109. Centers for Disease Control and Prevention (CDC). Congenital malaria--Nassau County, New York, 2004. MMWR Morb Mortal Wkly Rep 2005; 54:383.
  110. Looareesuwan S, Phillips RE, White NJ, et al. Quinine and severe falciparum malaria in late pregnancy. Lancet 1985; 2:4.
  111. Anya SE. Seasonal variation in the risk and causes of maternal death in the Gambia: malaria appears to be an important factor. Am J Trop Med Hyg 2004; 70:510.
  112. Dicko A, Mantel C, Thera MA, et al. Risk factors for malaria infection and anemia for pregnant women in the Sahel area of Bandiagara, Mali. Acta Trop 2003; 89:17.