Malaria in Pregnancy

Ebako Ndip Takem1 and Umberto D’Alessandro1,2

1Medical Research Council Unit, Fajara, The Gambia
2Institute of Tropical Medicine, Antwerp, Belgium

Correspondence to: Prof. Umberto D’Alessandro, Institute of Tropical Medicine, Antwerp, Belgium. E-mail:

Published: January 2, 2013
Received: September 28, 2012
Accepted: November 11, 2012
Meditter J Hematol Infect Dis 2013, 5(1): e2013010, DOI 10.4084/MJHID.2013.010
This article is available on PDF format at:
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited


Pregnant women have a higher risk of malaria compared to non-pregnant women. This review provides an update on knowledge acquired since 2000 on P. falciparum and P.vivax infections in pregnancy. Maternal risk factors for malaria in pregnancy (MiP) include low maternal age, low parity, and low gestational age. The main effects of MIP include maternal anaemia, low birth weight (LBW), preterm delivery and increased infant and maternal mortality.
P. falciparum infected erythrocytes sequester in the placenta by expressing surface antigens, mainly variant surface antigen (VAR2CSA), that bind to specific receptors, mainly chondroitin sulphate A. In stable transmission settings, the higher malaria risk in primigravidae can be explained by the non-recognition of these surface antigens by the immune system. Recently, placental sequestration has been described also for P.vivax infections. The mechanism of preterm delivery and intrauterine growth retardation is not completely understood, but fever (preterm delivery), anaemia, and high cytokines levels have been implicated.  
Clinical suspicion of MiP should be confirmed by parasitological diagnosis. The sensitivity of microscopy, with placenta histology as the gold standard, is 60% and 45% for peripheral and placental falciparum infections in African women, respectively. Compared to microscopy, RDTs have a lower sensitivity though when the quality of microscopy is low RDTs may be more reliable.
Insecticide treated nets (ITN) and intermittent preventive treatment in pregnancy (IPTp) are recommended for the prevention of MiP in stable transmission settings. ITNs have been shown to reduce malaria infection and adverse pregnancy outcomes by 28-47%. Although resistance is a concern, SP has been shown to be equivalent to MQ and AQ for IPTp. For the treatment of uncomplicated malaria during the first trimester, quinine plus clindamycin for 7 days is the first line treatment and artesunate plus clindamycin for 7 days is indicated if this treatment fails; in the 2nd and 3rd trimester first line treatment is an artemisinin-based combination therapy (ACT) known to be effective in the region or artesunate and clindamycin for 7 days or quinine and clindamycin. For severe malaria, in the second and third trimester parenteral artesunate is preferred over quinine. In the first trimester, both artesunate and quinine (parenteral) may be considered as options. Nevertheless, treatment should not be delayed and should be started immediately with the most readily available drug.

Epidemiology. Malaria in pregnancy (MiP) is a major public health problem in endemic countries. There is a wealth of evidence showing that the risk of malaria (both infection and clinical disease) is higher in pregnant than in non-pregnant women, possibly due to the immunological, hormonal changes or other factors occurring during pregnancy. Most of the available evidence is on Plasmodium falciparum and P. vivax, though for the latter, there is much less information than for P. falciparum, while little is known on P. ovale and P. malariae, the other two human malaria species. This review will focus on P.falciparum and P. vivax, with the objective of providing an update on the recently acquired knowledge (since the year 2000).
Burden. Where transmission is stable and relatively high, mainly in sub-Saharan Africa, adults have acquired immunity against malaria, including pregnant women who, despite the immune tolerance occurring during pregnancy, are able to control but not clear malaria infections. Therefore, in this high risk group, asymptomatic infections are common while clinical malaria is relatively rare. A recent review of studies, carried out in sub-Saharan Africa between 2000 and 2011, reports that malaria prevalence in pregnant women attending antenatal clinics was 29.5% (95%CI: 22.4 -36.5) in East and Southern Africa, and 35.1% (95%CI: 28.2-41.9) in West and Central Africa, while the prevalence of placenta malaria was 26.5% (95%CI: 16.7-36.4) in East and Southern Africa, and 38% (95%CI: 28.4-47.6) in West and Central Africa.[1] More recently (studies published since 2008), the reported malaria prevalence (by microscopy unless specified otherwise) was lower, reflecting the recent decrease in malaria transmission observed in several African countries[2-11] (Table 1). Most of the prevalence estimates were done by microscopy and they would probably be higher if more sensitive methods like PCR[12] or placental histology[13] were used. In addition, blood samples were collected at different times during pregnancy, increasing the difficulty of comparing different estimates.
In areas of low, unstable malaria transmission, mainly Asia-Pacific region and South America, pregnant women have a lower acquired immunity and malaria infections are more likely to evolve towards clinical disease. The number of pregnancies occurring in these areas has been estimated at 70.5 million in 2007.[14] In the Asia-Pacific region, the median proportion of women with peripheral infection has been estimated at 15.3% and that of placenta malaria at 11%.[15] For South and Central America, less data on the burden of malaria in pregnancy is available (Table 2). In Peru, the cumulative incidence of clinical malaria in pregnant women for the period January-August 2004 and 2005 was 43.1% as compared to 31.6% in non-pregnant women.[16] This study also suggested that subclinical malaria infections may occur frequently among pregnant women in this region, despite the relatively low transmission, and that passive surveillance, i.e. data collection at health facilities, may underestimate the actual burden of MiP. In Colombia, the prevalence of malaria among parturient women attending the local hospital was 13% when determined by microscopy and 32% by PCR.[17] In the same study, the prevalence of placenta malaria was 9% by microscopy and 26% by PCR, while 2% and 13% of cord blood samples were positive by microscopy and PCR, respectively. 

Table 1.
Burden of malaria in pregnancy in sub-Saharan Africa.

  Table 2.
Malaria burden in pregnancy in Asia-Pacific and South America.

Risk Factors. Maternal factors associated with the risk of malaria in pregnancy include maternal age, parity and gestational age. It is well established that younger women (primigravidae and multigravidae), particularly adolescents, are at higher risk of malaria infection than older women,[18-20] and this is independent of parity.[20-22] Parity also affects the risk of malaria as primigravidae are at higher risk than multigravidae,[18-20,23-24] though less in low transmission settings,[15] while in epidemic areas, the risk is not affected by parity.[25] Most of the available data on malaria relate to the second and third trimesters.[12,19,26-27] The peak of malaria prevalence seems to occur during the second trimester.[28] Studies on malaria burden in the first trimester of pregnancy are scarce, but it is believed that the rates are similar to that of the second trimester. However, considering the difficulty of collecting this information (pregnant women start to attend the antenatal clinic after the first trimester), and of determining the gestational age with accuracy, it is unclear whether the risk starts to increase towards the end of the first trimester. Indeed, in Burkina Faso, malaria prevalence was higher during the first as compared to the second and third trimesters.[29]
Effects of Malaria Infection. The effect of malaria infection during pregnancy will depend on the degree of acquired immunity, which in turn depends on the intensity of transmission.
Maternal effects. Where transmission is stable, such as in most of sub-Saharan Africa, most infections are asymptomatic but increase substantially the risk of anaemia.[19,26,30-31] This occurs over a background of physiological anaemia of pregnancy due to increased blood volume. Both symptomatic and asymptomatic infections can cause anaemia. Severe anaemia is more often observed in stable transmission settings,[32-34] and more in primigravidae than in multigravidae.[35-36] Malaria infections in the first or second trimester of pregnancy increase the risk of anaemia,[24,30] though one study reported an increased risk also for infections occurring in the third trimester.[30] Preventing malaria infection by intermittent preventive treatment during pregnancy (IPTp) reduces the risk of anaemia.[27,37-38]
Where malaria transmission is unstable, malaria can cause maternal anaemia,[18,35,39-40] more in primigravidae than in multigravidae and for falciparum infections more than for vivax infections.[18,35] Nevertheless, severe anaemia is less common in these settings.[39,41]
In places where malaria transmission is stable, little is known on the importance of malaria infection as a cause of miscarriage. Where malaria transmission is unstable, malaria as a cause of miscarriage seems more common, as the majority of infections evolve towards a clinical attack with fever, which may by itself determine miscarriage. Indeed, non malarial fevers also independently increase the risk of miscarriage.[18,42] Nevertheless, asymptomatic infections, i.e. slide confirmed malaria with no history of fever in the previous 48 hours and temperature <37.5˚C, was also associated with miscarriage.[7]
Maternal mortality associated to malaria is probably under-reported. Malaria was an important cause of maternal death in some studies,[43-45] while in others it was not as frequent.[46] The substantial reduction in maternal mortality observed in Thailand after the implementation of early detection and treatment of malaria suggests that malaria is an important contributor to maternal mortality.[47] When not a direct cause of death (severe malaria),[47] malaria in pregnancy is often reported as co-morbidity, e.g. with eclampsia, in conditions associated with maternal mortality.[44,48]
Perinatal effects. Malaria increases the risk of low birth weight (LBW),[19,23,30,49-51] particularly in primigravidae, and this risk seems to be higher for infections in first or second trimester,[23-24,30,49] though in one study this was true also for infections occurring late in pregnancy.[49] In high malaria transmission settings, such an effect is due to intrauterine growth retardation (IUGR) rather than pre-term delivery, as most infections are asymptomatic. A meta-analysis of 32 cross-sectional data in Africa, showed malaria prevention in pregnancy is associated with 21% (95% CI= 14-27) reduction in LBW.[52]
In unstable transmission settings, preterm deliveries, still births and neonatal deaths have been associated with malaria.18 P.vivax infections are also associated with LBW, and this effect appears to be similar in all pregnancies. In women with a single infection of P.vivax or P.falciparum detected and treated in the first trimester, no significant effect on gestation or birth weight was observed compared to women who also attended in the first trimester but who never had malaria detected in pregnancy.[42]
New born and infant effects. Fewer studies on malaria in pregnant women have evaluated infant outcomes. Congenital malaria can occur in the neonatal period and can contribute to infant morbidity and mortality.[53] Placenta malaria, especially active infection, has been linked to neonatal and infant mortality.[53] A recent study in The Gambia has showed that malaria infection during pregnancy influences infant’s growth, independently of LBW.[54] It also increases the risk of infant’s death and perinatal mortality, by causing LBW.[39,53,55] This is confirmed by the reduction neonatal mortality, up to 60%, observed after the implementation of preventive interventions targeted to pregnant women, e.g. intermittent preventive treatment.[56-57] In primi- and secundi-gravidae, malaria prevention with IPTp or insecticide-treated bed nets was significantly associated with a 18% decreased risk of neonatal mortality.[52]
Later childhood, adolescence and adulthood effects. The long term effects of malaria in pregnancy have not been studied. However, malaria causes IUGR leading to LBW, which may be related to diseases occurring during adulthood, including some cancers and the metabolic syndrome.[58]

Pregnant women are at higher risk of contracting malaria than non-pregnant women. This increased susceptibility can be explained by the immunological changes induced by pregnancy, by hormonal factors,[59] and by the higher attractiveness of pregnant women to mosquitoes.[60-61] In addition, P. falciparum -infected erythrocytes in pregnant women bind to specific receptors, i.e. chondroitin sulphate A (CSA), and sequester in the placenta.[62-63] They rarely bind to the other two commonly described receptors in non-pregnant individuals, i.e. CD36 and the intracellular adhesion molecule (ICAM-1). In pregnancy, the parasite antigens expressed on infected erythrocytes are collectively known as variant surface antigen-pregnancy associated malaria (VSAPAM). They are different from those expressed in non-pregnant individuals and in stable transmission settings are not recognised by the immune system, explaining the higher risk in primigravidae.[64] The binding of the variant surface antigen (VAR2CSA) with chondroitin sulphate A has been implicated in the pathology of falciparum malaria in pregnancy.[65-68] The VAR2CSA belongs to the family of the erythrocyte membrane protein (PfEMP1), is encoded by the var2csa gene and its expression has been described in pregnant women with falciparum malaria.[69] Levels of anti-VAR2CSA specific IgGs increase with parity, cannot be found in men and are associated with a favourable pregnancy outcome[64-66] so that the malaria risk decreases with increasing parity. Besides the antibody responses to VSAPAM, cytokine responses such as Th1, Th2, interleukins, TNF and regulators, IFN gamma,[70-72] and monocytes[73] have been observed in pregnant women with malaria. Rosetting, a phenomenon consisting of parasite-free erythrocytes surrounding parasite-infected erythrocytes and commonly observed in non-pregnant individuals, has been implicated in the pathogenesis of severe malaria[74-75] but is uncommon in pregnant women with falciparum malaria.[76]
The sequestration of P. vivax in the placenta, though until recently thought not to occur, has been described,[77-78] with the involvement of ICAM-1 and CSA as receptors.
The effects of hormonal changes on pregnancy associated malaria have been described in few studies and are subject to debate. Increased cortisol levels have been associated with increased risk of malaria in pregnant women.[79]
The increased attractiveness of pregnant women to mosquitoes may be explained by physiological and behavioural changes occurring during pregnancy. Physiological changes include increased exhaled breath and increased abdominal temperature that may render pregnant women more easily detectable by mosquitoes. Behavioural changes are represented by the fact that pregnant women urinate twice as frequently as non-pregnant women, resulting in an increased exposure to mosquito bites at night because they have to leave the protection of their bed nets.[60-61]
Malaria-associated placental changes have been described for stable[72,80] and unstable transmission settings.[73,81] They include presence of parasites, inflammatory changes and hemozoin (pigment) deposition. Placental changes have been characterised into four levels, i.e. acute (parasites present, malaria pigment absent), chronic (parasites and malaria pigment present), past infection (no parasite but pigment present) and no infection (both parasites and malaria pigment absent).[82] Recently, a 2-parameter grading system, distinguishing between inflammation and pigment deposition, has been proposed as it correlates with pregnancy outcomes, in both a stable transmission setting in Tanzania, and an unstable setting in Thailand.[73]
It is unclear what the mechanism at the basis of malaria-related preterm delivery is, though fever, anaemia, and high levels of TNF alpha or interleukin 10 have been identified as important risk factors.[18,83-84]
LBW due to IUGR is associated with maternal anaemia,[83,85] and elevated levels of cytokines.[70] Although the exact mechanism has not been elucidated, it appears to be due to chronic infections that cause reduced foetal circulation and placental insufficiency.[86] Placental endocrine changes related to falciparum infection have been suggested as another possible mechanism leading to IUGR.[87]
P.vivax is different from P. falciparum as it infects immature erythrocytes (reticulocytes), limiting the parasite densities. In addition, it can relapse during pregnancy due to the activation of liver hypnozoites. Vivax parasites do not frequently express variant surface antigens, at the basis of placenta sequestration, so that this does not occur frequently.[81] Therefore, P. vivax probably affects birth weight, and increases the risk of miscarriage and preterm birth through a systemic rather than a local effect. Nevertheless, the mechanisms at the basis of these observations are not completely understood.

Clinical Presentation
Diagnosis. The diagnosis of malaria in pregnancy is essential to prevent its deleterious effects to the mother and the foetus. Unfortunately, the clinical signs of malaria in pregnant women are usually non specific, and where transmission is stable, most infections are asymptomatic. Therefore, suspected malaria cases should be confirmed by parasitological diagnosis,[88] usually by microscopy and/or rapid diagnostic tests. Nevertheless, other methods such as PCR and placental histology can be also used, though the latter can be done only after delivery so that it cannot be used for the management of infections occurring during pregnancy.
Microscopy is one of the most widely used methods for diagnosing malaria, including during pregnancy. It has some advantages such as the possibility of determining the parasite density and species. However, its major disadvantage, besides the need of a regular power supply, is its sensitivity, which cannot go below 10-15 parasites per l. Therefore, a substantial proportion of infected pregnant women would not be detected because of extremely low parasite densities or of parasites sequestered in the placenta, though both conditions have deleterious effects on the mother’s and her offspring’s health.
Several studies have investigated the use of microscopy for the diagnosis of MiP in stable malaria transmission settings in Africa.[89-91] When taking placenta histology as the reference test, the sensitivity of peripheral blood microscopy for _P. falciparum infections (4 studies) was 60% (95% CI=50-69) and that of placental microscopy 45% (95% CI=34-56).[13]
In settings with unstable malaria transmission, there are few studies on the sensitivity of microscopy on peripheral blood collected during pregnancy.[13]
Rapid diagnostic tests (RDT), detecting circulating malaria antigens, can also be used. Generally, the sensitivity of RDTs for the diagnosis of malaria in pregnancy is lower than that of microscopy. However, the time needed for the diagnosis is shorter than for microscopy and the training required for their use is minimal. Although RDT can detect malaria antigens, they cannot estimate the parasite density. The sensitivity of RDT on peripheral blood using peripheral microscopy as a reference test is estimated at 81% (95% CI= 55-95), and the sensitivity of RDT on placental blood was 81% (95% CI= 62-92) using placental microscopy as the reference.[13]
PCR, which detects parasite DNA, can also be used for the diagnosis of malaria infection but is not readily available in health facilities. In stable transmission settings, the sensitivity of PCR was >80% when using microscopy as the reference.[13] PCR sensitivity has not been estimated against placental histology as reference test.
Severe malaria. Severe malaria in pregnancy is more common in unstable transmission settings because of the lower immunity pregnant women have. Generally, women in the second and third trimesters of pregnancy are at a higher risk of developing severe malaria compared to non-pregnant adults. In low transmission settings, severe malaria in pregnancy is usually associated with pulmonary oedema, hypoglycaemia and severe anaemia. Mortality in pregnant women with severe malaria and treated with either artesunate and quinine varied between 9% and 12%.[92]

Prevention and Treatment
Prevention. The most widely used interventions to prevent malaria in pregnancy are insecticide-treated bed nets (ITN), including Long-Lasting Insecticidal Nets (LLINs), and intermittent preventive treatment in pregnancy (IPTp).
While ITNs have shown a substantial reduction in malaria morbidity and mortality in children,[93-96] in pregnant women, it has been associated with a decrease in maternal parasitaemia (38%), anaemia (41%) and LBW (28%),[97] and 47% reduction in maternal anaemia.[98] In one study, there was no evidence of a reduction in anaemia and parasitaemia.[99]
IPTp is the administration of therapeutic doses of an antimalarial, currently sulfadoxine-pyrimethamine (SP), at least twice during pregnancy, in the second and third trimester, irrespective of the presence of a malaria infection. The WHO recommends its use and many sub-Saharan African countries have included it in their malaria control program. In stable transmission settings, many trials have shown that SP given as IPTp is efficacious in preventing the adverse consequences of malaria during pregnancy (Table 3).[100-104] However, SP resistance represents a major threat. A study in Benin has showed that, despite the presence of molecular markers of resistance, SP remained efficacious.[105] This has been confirmed by a review reporting that IPTp with SP is effective up to a certain level of SP resistance.[106] Nevertheless, finding an alternative to SP for IPTp is important. Adding amodiaquine to SP was efficacious but not better than SP alone.[107] Mefloquine (MQ), thanks to its long elimination half-life, could be a good alternative to SP as it would provide a long post-treatment prophylactic period. Indeed, a trial in Benin showed that for IPTp MQ was as good as SP in preventing LBW. MQ was more efficacious than SP in preventing placental malaria, clinical malaria and maternal anaemia at delivery. However, MQ was less well tolerated than SP, potentially compromising its large scale use as IPTp.[108-109]

Table 3. 
Trials on Intermittent Preventive Treatment in pregnancy.

There is no evidence that one of the methods is better than the other[110] and the combined use appears to be better than individual use.
A different approach is systematic screening for malaria infections at regular intervals and treatment of the positive women, which may be more appropriate in settings where malaria transmission is low and the risk of infection between antenatal visits is also low. It has already be shown to have similar protective efficacy than IPTp but additional trials for a more thorough evaluation of this intervention are probably needed.[26] Due to drug resistant malaria, it has been the only form of malaria control on the Thai-Burmese border for more than 20 years, impacting significantly on maternal mortality rates.[47]
In future, vaccines specifically designed to prevent MiP may become available; VAR2CSA, in the early stages of development, seems the most promising candidate.[111-116] However, there are still several uncertainties, including the number of antigenic variants to be combined for an optimal response, the timing of the vaccine, e.g. during pregnancy or at puberty, whether only first pregnancies should be targeted, and the length of follow up for children born to vaccinated mothers.[111-112,117]
Treatment. It is recommended that pregnant women with malaria are treated after parasitological confirmation of the diagnosis, reducing the unnecessary exposure to antimalarials of both the mother and the foetus.
First trimester. Clinical trials on the safety and efficacy of antimalarials in pregnancy usually exclude women in the first trimester of pregnancy so that the evidence is based on observational studies (Table 4). Artemisinin derivatives were relatively safe (n=1937) in the first trimester of pregnancy[42,118-119] and the cumulative failure rate reported in only one study was 6.6% across all trimesters (n=461).[118] No major adverse event was observed in 377 women with known pregnancy outcome and exposed to artemisinins in the first trimester.[42,119-121] However, only 1 study[120] out of 4, was a randomised controlled trial though the treatment was given during a mass campaign and the exposure was thus inadvertent; the birth weight of newborns delivered by women exposed to artesunate during the first trimester was similar to that of the other pregnant women. According to recommendations,[88] chloroquine, quinine, clindamycin and proguanil can be considered safe in the first trimester.
In case of uncomplicated malaria in the first trimester, a combination of quinine + clindamycin for 7 days is recommended.
In case of severe malaria, parenteral antimalarials are recommended.[88] In the first trimester, the risk of hypoglycaemia is lower and the uncertainties on the safety of the artemisinins derivatives are greater. Nevertheless, considering that treatment should not be delayed and that artesunate reduces the risk of death, both artesunate and quinine (parenteral) may be considered as options. Treatment should be started immediately with the most readily available drug.[90]
Second and third trimesters. There is more experience on the use of artemisinin derivatives in the second and third trimesters of pregnancy. Evidence is available from both trials[122-127] and observational studies[128-131] involving pregnant women (Table 4). Data available indicate that ACTs are relatively safe for the foetus when taken after the first trimester of pregnancy. A recent review of treatment studies carried out in pregnant women from 1998-2009, reported a parasitological failure >5% in 3 out of 11 trials.[132] In the second trimester, ACTs that are known to be effective in the area, or 7 days artesunate+ clindamycin, or 7 days quinine+ clindamycin are recommended for uncomplicated malaria.[88] In case of severe malaria, parenteral artesunate is preferable because it saves the life of the mother. Several studies have shown that the kinetics of artemisinins derivatives, most specifically of the active metabolite dihydroartemisinin, is modified during pregnancy.[133-134]
Amodiaquine (AQ) has been shown to be efficacious in pregnant women with falciparum malaria in Ghana and Tanzania.[122,125] Day 28 parasitological failure rates were 3% for AQ monotherapy,[122] 0-1% for the combination AQ+SP,[122,125] and 4.5% for the combination AS+AQ.[125] It was relatively safe and well tolerated and associated with some minor side effects (nausea, weakness, dizziness). Blood dyscrasias were not a problem associated with its use. A pharmacokinetics study on AQ for treatment of P.vivax in pregnancy conducted in Thailand indicates the doses are similar to that of non-pregnant adults.[131,135]
There are fewer reports on the efficacy and safety of mefloquine (MQ) for MiP. High cure rates have been reported in Thailand, for the combination of MQ+AS (cure rate of 98.2% at day 63).[126] One study reported minor side effects.[109] However, there are concerns about still births and neuropsychiatric disorders. There are currently some ongoing clinical studies which will provide useful data on the safety, efficacy and pharmacokinetics of MQ in pregnant women (Table 5). The combination AS+ MQ is being evaluated in studies in Africa and Asia (NCT00852423, NCT00701961, NCT01054248, CTRI/2009/091/001055TEMP, NCT01054248).

Table 4.
Treatment trials and clinical studies on malaria in pregnancy.

Table 5. Registered ongoing trials on malaria treatment in pregnant women.

In Uganda, in an area of relatively high transmission and hence with pregnant women having some acquired immunity, artemether-Lumefantrine (AL) was efficacious, with cure rates >95%.[136-137] However, in Thailand the cure rate at day 42 was only 82%,[138] possibly due to the low day 7 lumefantrine concentrations. AL was safe and well tolerated.[136-138] As for other antimalarial treatments, pharmacokinetics may be altered during pregnancy, with plasma concentrations lower than expected.[129,139] AL is currently being evaluated in Thailand and in four sites in sub-Saharan Africa (NCT01054248, NCT00852423).
Dihydroartemisinin piperaquine (DHAPQ) was highly effective in women with multiple recrudescent infections on the Thai-Burmese border.[140] DHAPQ is used in the Western Pacific for malaria in pregnant women.[141] DHA-PQ is currently being evaluated in 3 studies in Africa and Asia (NCT00852423, NCT01054248, NCT01231113). Cure rates and PK are reassuring.
In Thailand, atovaquone-proguanil in combination with artesunate (AAP) was associated with high cure rates (>95%) and was relatively safe,[123,142] though the sample size was small. In Thailand, plasma concentrations of AAP were lower in pregnant than in non pregnant women.[143]

This review shows that although the deleterious effects of MiP to both the mother and the child are well documented, the mechanisms involved are still relatively unknown, particularly where transmission is low and unstable. The diagnosis of MiP is challenging, as peripheral microscopy will miss a large proportion of infected women with parasites sequestered in the placenta. MiP can be prevented by currently available control methods, i.e. ITNs and IPTp, but the challenge is attaining a high coverage, particularly for women with the highest risk such as adolescent primigravidae. It is still unclear what would be the alternative to SP for the IPTp.
The burden of P. vivax MiP, which is substantial in the Asia-Pacific region and in South America has been relatively neglected. It is generally believed that vivax infections are milder than falciparum ones, but this is based on few studies. There is also the need of having more sensitive diagnostic methods for vivax infections, as it would help improving early diagnosis and appropriate management. Finally, information of the safety and efficacy of antimalarials during pregnancy is growing, though this is true mainly for the second and third trimester. For the first trimester, treatment options are still extremely limited and evidence is mainly based on pharmacovigilance data on accidental exposures.


  1. Chico RM, Mayaud P, Ariti C, Mabey D, Ronsmans C, and Chandramohan D, Prevalence of malaria and sexually transmitted and reproductive tract infections in pregnancy in sub-Saharan Africa: a systematic review. JAMA. 2012; 307(19): 2079-86. PMid:22665107 
  2. Teklehaimanot HD, Teklehaimanot A, Kiszewski A, Rampao HS, and Sachs JD, Malaria in Sao Tome and principe: on the brink of elimination after three years of effective antimalarial measures. Am J Trop Med Hyg. 2009; 80(1): 133-40. PMid:19141851 
  3. Lee PW, Liu CT, Rampao HS, do Rosario VE, and Shaio MF, Pre-elimination of malaria on the island of Principe. Malar J. 2010; 9: 26. PMid:20089158 PMCid:2823607  
  4. Beiersmann C, Bountogo M, Tiendrebeogo J, De Allegri M, Louis VR, Coulibaly B, Ye M, and Mueller O, Falciparum malaria in young children of rural Burkina Faso: comparison of survey data in 1999 with 2009. Malar J. 2011; 10: 296. PMid:21989335 PMCid:3200185  
  5. Bouyou-Akotet MK, Mawili-Mboumba DP, Kendjo E, Mabika-Mamfoumbi M, Ngoungou EB, Dzeing-Ella A, Pemba-Mihindou M, Ibinga E, Efame-Eya E, Planche T, Kremsner PG, and Kombila M, Evidence of decline of malaria in the general hospital of Libreville, Gabon from 2000 to 2008. Malar J. 2009; 8: 300. PMid:20017905 PMCid:2806380  
  6. Otten M, Aregawi M, Were W, Karema C, Medin A, Bekele W, Jima D, Gausi K, Komatsu R, Korenromp E, Low-Beer D, and Grabowsky M, Initial evidence of reduction of malaria cases and deaths in Rwanda and Ethiopia due to rapid scale-up of malaria prevention and treatment. Malar J. 2009; 8: 14. PMid:19144183 PMCid:2653503  
  7. Graves PM, Osgood DE, Thomson MC, Sereke K, Araia A, Zerom M, Ceccato P, Bell M, Del Corral J, Ghebreselassie S, Brantly EP, and Ghebremeskel T, Effectiveness of malaria control during changing climate conditions in Eritrea, 1998-2003. Trop Med Int Health. 2008; 13(2): 218-28. PMid:21176056 PMCid:3499407  
  8. Bhattarai A, Ali AS, Kachur SP, Martensson A, Abbas AK, Khatib R, Al-Mafazy AW, Ramsan M, Rotllant G, Gerstenmaier JF, Molteni F, Abdulla S, Montgomery SM, Kaneko A, and Bjorkman A, Impact of artemisinin-based combination therapy and insecticide-treated nets on malaria burden in Zanzibar. PLoS Med. 2007; 4(11): e309. PMid:17988171 PMCid:2062481  
  9. O'Meara WP, Bejon P, Mwangi TW, Okiro EA, Peshu N, Snow RW, Newton CR, and Marsh K, Effect of a fall in malaria transmission on morbidity and mortality in Kilifi, Kenya. Lancet. 2008; 372(9649): 1555-62. 
  10. Ceesay SJ, Casals-Pascual C, Erskine J, Anya SE, Duah NO, Fulford AJ, Sesay SS, Abubakar I, Dunyo S, Sey O, Palmer A, Fofana M, Corrah T, Bojang KA, Whittle HC, Greenwood BM, and Conway DJ, Changes in malaria indices between 1999 and 2007 in The Gambia: a retrospective analysis. Lancet. 2008; 372(9649): 1545-54. 
  11. Ceesay SJ, Casals-Pascual C, Nwakanma DC, Walther M, Gomez-Escobar N, Fulford AJC, Takem EN, Nogaro S, Bojang KA, Corrah T, Jaye MC, Taal MA, Sonko AAJ, and Conway DJ, Continued Decline of Malaria in The Gambia with Implications for Elimination. PLoS ONE. 2010; 5(8): e12242. PMid:20805878 PMCid:2923605  
  12. Rantala AM, Taylor SM, Trottman PA, Luntamo M, Mbewe B, Maleta K, Kulmala T, Ashorn P, and Meshnick SR, Comparison of real-time PCR and microscopy for malaria parasite detection in Malawian pregnant women. Malar J. 2010; 9: 269. PMid:20925928 PMCid:2984567  
  13. Kattenberg JH, Ochodo EA, Boer KR, Schallig HD, Mens PF, and Leeflang MM, Systematic review and meta-analysis: rapid diagnostic tests versus placental histology, microscopy and PCR for malaria in pregnant women. Malar J. 2011; 10: 321. PMid:22035448 PMCid:3228868  
  14. Dellicour S, Tatem AJ, Guerra CA, Snow RW, and ter Kuile FO, Quantifying the number of pregnancies at risk of malaria in 2007: a demographic study. PLoS Med. 2010; 7(1): e1000221. PMid:20126256 PMCid:2811150 
  15. Rijken MJ, McGready R, Boel ME, Poespoprodjo R, Singh N, Syafruddin D, Rogerson S, and Nosten F, Malaria in pregnancy in the Asia-Pacific region. Lancet Infect Dis. 2012; 12(1): 75-88. 
  16. Parekh FK, Hernandez JN, Krogstad DJ, Casapia WM, and Branch OH, Prevalence and risk of Plasmodium falciparum and P. vivax malaria among pregnant women living in the hypoendemic communities of the Peruvian Amazon. Am J Trop Med Hyg. 2007; 77(3): 451-7. PMid:17827359 
  17. Campos IM, Uribe ML, Cuesta C, Franco-Gallego A, Carmona-Fonseca J, and Maestre A, Diagnosis of gestational, congenital, and placental malaria in Colombia: comparison of the efficacy of microscopy, nested polymerase chain reaction, and histopathology. Am J Trop Med Hyg. 2011; 84(6): 929-35. PMid:21633030 PMCid:3110370  
  18. Poespoprodjo JR, Fobia W, Kenangalem E, Lampah DA, Warikar N, Seal A, McGready R, Sugiarto P, Tjitra E, Anstey NM, and Price RN, Adverse pregnancy outcomes in an area where multidrug-resistant plasmodium vivax and Plasmodium falciparum infections are endemic. Clin Infect Dis. 2008; 46(9): 1374-81. PMid:18419439 PMCid:2875100  
  19. Ayoola OO, Whatmore A, Balogun WO, Jarrett OO, Cruickshank JK, and Clayton PE, Maternal malaria status and metabolic profiles in pregnancy and in cord blood: relationships with birth size in Nigerian infants. Malar J. 2012; 11: 75. PMid:22429464 PMCid:3325162 
  20. Hamer DH, Singh MP, Wylie BJ, Yeboah-Antwi K, Tuchman J, Desai M, Udhayakumar V, Gupta P, Brooks MI, Shukla MM, Awasthy K, Sabin L, MacLeod WB, Dash AP, and Singh N, Burden of malaria in pregnancy in Jharkhand State, India. Malar J. 2009; 8: 210. PMid:19728882 PMCid:2744702 
  21. Espinoza E, Hidalgo L, and Chedraui P, The effect of malarial infection on maternal-fetal outcome in Ecuador. J Matern Fetal Neonatal Med. 2005; 18(2): 101-5. PMid:16203594  
  22. Walker-Abbey A, Djokam RR, Eno A, Leke RF, Titanji VP, Fogako J, Sama G, Thuita LH, Beardslee E, Snounou G, Zhou A, and Taylor DW, Malaria in pregnant Cameroonian women: the effect of age and gravidity on submicroscopic and mixed-species infections and multiple parasite genotypes. Am J Trop Med Hyg. 2005; 72(3): 229-35. PMid:15772312 
  23. Valea I, Tinto H, Drabo MK, Huybregts L, Sorgho H, Ouedraogo JB, Guiguemde RT, van Geertruyden JP, Kolsteren P, and D'Alessandro U, An analysis of timing and frequency of malaria infection during pregnancy in relation to the risk of low birth weight, anaemia and perinatal mortality in Burkina Faso. Malar J. 2012; 11: 71. PMid:22433778 PMCid:3338396 
  24. Kalilani L, Mofolo I, Chaponda M, Rogerson SJ, and Meshnick SR, 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(6): 416-22. PMid:20207387  
  25. Newman RD, Hailemariam A, Jimma D, Degifie A, Kebede D, Rietveld AE, Nahlen BL, Barnwell JW, Steketee RW, and Parise ME, Burden of malaria during pregnancy in areas of stable and unstable transmission in Ethiopia during a nonepidemic year. J Infect Dis. 2003; 187(11): 1765-72. PMid:12751034 
  26. Tagbor H, Bruce J, Agbo M, Greenwood B, and Chandramohan D, Intermittent screening and treatment versus intermittent preventive treatment of malaria in pregnancy: a randomized controlled non-inferiority trial. PLoS ONE. 2010; 5(12): e14425. PMid:21203389 PMCid:3010999  
  27. Wilson NO, Ceesay FK, Obed SA, Adjei AA, Gyasi RK, Rodney P, Ndjakani Y, Anderson WA, Lucchi NW, and Stiles JK, Intermittent preventive treatment with sulfadoxine-pyrimethamine against malaria and anemia in pregnant women. Am J Trop Med Hyg. 2011; 85(1): 12-21. PMid:21734118 PMCid:3122337 
  28. Agbor-Enoh ST, Achur RN, Valiyaveettil M, Leke R, Taylor DW, and Gowda DC, Chondroitin sulfate proteoglycan expression and binding of Plasmodium falciparum-infected erythrocytes in the human placenta during pregnancy. Infect Immun. 2003; 71(5): 2455-61. PMid:12704116 PMCid:153269  
  29. Coulibaly SO, Gies S, and D'Alessandro U, Malaria burden among pregnant women living in the rural district of Boromo, Burkina Faso. Am J Trop Med Hyg. 2007; 77(6 Suppl): 56-60. PMid:18165475 
  30. Huynh BT, Fievet N, Gbaguidi G, Dechavanne S, Borgella S, Guezo-Mevo B, Massougbodji A, Ndam NT, Deloron P, and Cot M, Influence of the timing of malaria infection during pregnancy on birth weight and on maternal anemia in Benin. Am J Trop Med Hyg. 2011; 85(2): 214-20. PMid:21813837 PMCid:3144815  
  31. Bouyou-Akotet MK, Ionete-Collard DE, Mabika-Manfoumbi M, Kendjo E, Matsiegui PB, Mavoungou E, and Kombila M, Prevalence of Plasmodium falciparum infection in pregnant women in Gabon. Malar J. 2003; 2: 18. PMid:12919637 PMCid:183856  
  32. van Eijk AM, Ayisi JG, Slutsker L, Ter Kuile FO, Rosen DH, Otieno JA, Shi YP, Kager PA, Steketee RW, and Nahlen BL, Effect of haematinic supplementation and malaria prevention on maternal anaemia and malaria in western Kenya. Trop Med Int Health. 2007; 12(3): 342-52. PMid:21176056 PMCid:3499407 
  33. Tarimo SD, Appraisal on the prevalence of malaria and anaemia in pregnancy and factors influencing uptake of intermittent preventive therapy with sulfadoxine-pyrimethamine in Kibaha district, Tanzania. East Afr J Public Health. 2007; 4(2): 80-3. PMid:18085136 
  34. Achidi EA, Kuoh AJ, Minang JT, Ngum B, Achimbom BM, Motaze SC, Ahmadou MJ, and Troye-Blomberg M, Malaria infection in pregnancy and its effects on haemoglobin levels in women from a malaria endemic area of Fako Division, South West Province, Cameroon. J Obstet Gynaecol. 2005; 25(3): 235-40. PMid:23130816 PMCid:3498373  
  35. Guyatt HL and Snow RW, The epidemiology and burden of Plasmodium falciparum-related anemia among pregnant women in sub-Saharan Africa. Am J Trop Med Hyg. 2001; 64(1-2 Suppl): 36-44. 
  36. Shulman CE, Marshall T, Dorman EK, Bulmer JN, Cutts F, Peshu N, and Marsh K, Malaria in pregnancy: adverse effects on haemoglobin levels and birthweight in primigravidae and multigravidae. Trop Med Int Health. 2001; 6(10): 770-8. PMid:11679125  
  37. Gies S, Coulibaly SO, Ouattara FT, and D'Alessandro U, Individual efficacy of intermittent preventive treatment with sulfadoxine-pyrimethamine in primi- and secundigravidae in rural Burkina Faso: impact on parasitaemia, anaemia and birth weight. Trop Med Int Health. 2009; 14(2): 174-82. PMid:21176056 PMCid:3499407  
  38. Kayentao K, Kodio M, Newman RD, Maiga H, Doumtabe D, Ongoiba A, Coulibaly D, Keita AS, Maiga B, Mungai M, Parise ME, and Doumbo O, Comparison of intermittent preventive treatment with chemoprophylaxis for the prevention of malaria during pregnancy in Mali. J Infect Dis. 2005; 191(1): 109-16. PMid:15593011 
  39. Luxemburger C, McGready R, Kham A, Morison L, Cho T, Chongsuphajaisiddhi T, White NJ, and Nosten F, Effects of malaria during pregnancy on infant mortality in an area of low malaria transmission. Am J Epidemiol. 2001; 154(5): 459-65. PMid:11532788 
  40. Rodriguez-Morales AJ, Sanchez E, Vargas M, Piccolo C, Colina R, Arria M, and Franco-Paredes C, Pregnancy outcomes associated with Plasmodium vivax malaria in northeastern Venezuela. Am J Trop Med Hyg. 2006; 74(5): 755-7. PMid:16687675 
  41. O'Donnell A, Raiko A, Clegg JB, Weatherall DJ, and Allen SJ, Southeast Asian ovalocytosis and pregnancy in a malaria-endemic region of Papua New Guinea. Am J Trop Med Hyg. 2007; 76(4): 631-3. PMid:17426161 
  42. McGready R, Lee SJ, Wiladphaingern J, Ashley EA, Rijken MJ, Boel M, Simpson JA, Paw MK, Pimanpanarak M, Mu O, Singhasivanon P, White NJ, and Nosten FH, 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(5): 388-96. 
  43. Romagosa C, Ordi J, Saute F, Quinto L, Machungo F, Ismail MR, Carrilho C, Osman N, Alonso PL, and Menendez C, Seasonal variations in maternal mortality in Maputo, Mozambique: the role of malaria. Trop Med Int Health. 2007; 12(1): 62-7. PMid:17207149 
  44. 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(5): 510-3. PMid:15155982 
  45. Ali AA, Okud A, Khojali A, and Adam I, High incidence of obstetric complications in Kassala Hospital, Eastern Sudan. J Obstet Gynaecol. 2012; 32(2): 148-9. PMid:23130816 PMCid:3498373  
  46. Somigliana E, Sabino A, Schrettenbrunner C, Nkurunziza R, Okello E, and Manenti F, A comprehensive and integrated project to improve reproductive health at Oyam district, northern Uganda: insights from maternal death review at the district hospital. Arch Gynecol Obstet. 2011; 283(3): 645-9. PMid:21113718 
  47. McGready R, Boel M, Rijken MJ, Ashley EA, Cho T, Moo O, Paw MK, Pimanpanarak M, Hkirijareon L, Carrara VI, Lwin KM, Phyo AP, Turner C, Chu CS, van Vugt M, Price RN, Luxemburger C, ter Kuile FO, Tan SO, Proux S, Singhasivanon P, White NJ, and Nosten FH, Effect of early detection and treatment on malaria related maternal mortality on the north-western border of Thailand 1986-2010. PLoS ONE. 2012; 7(7): e40244. PMid:22815732 PMCid:3399834  
  48. Adam I, Elhassan EM, Mohmmed AA, Salih MM, and Elbashir MI, Malaria and pre-eclampsia in an area with unstable malaria transmission in Central Sudan. Malar J. 2011; 10: 258. PMid:21899731 PMCid:3224261  
  49. Cottrell G, Mary JY, Barro D, and Cot M, The importance of the period of malarial infection during pregnancy on birth weight in tropical Africa. Am J Trop Med Hyg. 2007; 76(5): 849-54. PMid:17488903 
  50. Kassam SN, Nesbitt S, Hunt LP, Oster N, Soothill P, and Sergi C, Pregnancy outcomes in women with or without placental malaria infection. Int J Gynaecol Obstet. 2006; 93(3): 225-32. PMid:20695826 PMCid:3465272  
  51. Akum AE, Kuoh AJ, Minang JT, Achimbom BM, Ahmadou MJ, and Troye-Blomberg M, The effect of maternal, umbilical cord and placental malaria parasitaemia on the birthweight of newborns from South-western Cameroon. Acta Paediatr. 2005; 94(7): 917-23. PMid:16188815 
  52. Eisele TP, Larsen DA, Anglewicz PA, Keating J, Yukich J, Bennett A, Hutchinson P, and Steketee RW, Malaria prevention in pregnancy, birthweight, and neonatal mortality: a meta-analysis of 32 national cross-sectional datasets in Africa. Lancet Infect Dis. 2012. 
  53. Bardaji A, Sigauque B, Sanz S, Maixenchs M, Ordi J, Aponte JJ, Mabunda S, Alonso PL, and Menendez C, Impact of malaria at the end of pregnancy on infant mortality and morbidity. J Infect Dis. 2011; 203(5): 691-9. PMid:21199881 PMCid:3071276 
  54. Walther B, Miles DJ, Crozier S, Waight P, Palmero MS, Ojuola O, Touray E, van der Sande M, Whittle H, Rowland-Jones S, and Flanagan KL, Placental malaria is associated with reduced early life weight development of affected children independent of low birth weight. Malar J. 2010; 9: 16. PMid:20074331 PMCid:2841609  
  55. Diamond-Smith N, Singh N, Gupta RK, Dash A, Thimasarn K, Campbell OM, and Chandramohan D, Estimating the burden of malaria in pregnancy: a case study from rural Madhya Pradesh, India. Malar J. 2009; 8: 24. PMid:19210797 PMCid:2647551  
  56. Titaley CR, Dibley MJ, Roberts CL, and Agho K, Combined iron/folic acid supplements and malaria prophylaxis reduce neonatal mortality in 19 sub-Saharan African countries. Am J Clin Nutr. 2010; 92(1): 235-43. PMid:20504976 
  57. Menendez C, Bardaji A, Sigauque B, Sanz S, Aponte JJ, Mabunda S, and Alonso PL, Malaria prevention with IPTp during pregnancy reduces neonatal mortality. PLoS ONE. 2010; 5(2): e9438. 
  58. Christensen DL, Kapur A, and Bygbjerg IC, Physiological adaption to maternal malaria and other adverse exposure: low birth weight, functional capacity, and possible metabolic disease in adult life. Int J Gynaecol Obstet. 2011; 115 Suppl 1: S16-9. PMid:22099434 
  59. Rogerson SJ, Hviid L, Duffy PE, Leke RF, and Taylor DW, Malaria in pregnancy: pathogenesis and immunity. Lancet Infect Dis. 2007; 7(2): 105-17. 
  60. Lindsay S, Ansell J, Selman C, Cox V, Hamilton K, and Walraven G, Effect of pregnancy on exposure to malaria mosquitoes. Lancet. 2000; 355(9219): 1972. 
  61. Ansell J, Hamilton KA, Pinder M, Walraven GE, and Lindsay SW, Short-range attractiveness of pregnant women to Anopheles gambiae mosquitoes. Trans R Soc Trop Med Hyg. 2002; 96(2): 113-6. 
  62. Cserti CM and Dzik WH, The ABO blood group system and Plasmodium falciparum malaria. Blood. 2007; 110(7): 2250-8.  PMid:17502454  
  63. Fairhurst RM and Wellems TE, Modulation of malaria virulence by determinants of Plasmodium falciparum erythrocyte membrane protein-1 display. Curr Opin Hematol. 2006; 13(3): 124-30. PMid:16567953  
  64. Staalsoe T, Shulman CE, Bulmer JN, Kawuondo K, Marsh K, and Hviid L, Variant surface antigen-specific IgG and protection against clinical consequences of pregnancy-associated Plasmodium falciparum malaria. Lancet. 2004; 363(9405): 283-9. 
  65. Salanti A, Dahlback M, Turner L, Nielsen MA, Barfod L, Magistrado P, Jensen AT, Lavstsen T, Ofori MF, Marsh K, Hviid L, and Theander TG, Evidence for the involvement of VAR2CSA in pregnancy-associated malaria. J Exp Med. 2004; 200(9): 1197-203. PMid:15520249 PMCid:2211857  
  66. Tuikue Ndam NG, Salanti A, Bertin G, Dahlback M, Fievet N, Turner L, Gaye A, Theander T, and Deloron P, High level of var2csa transcription by Plasmodium falciparum isolated from the placenta. J Infect Dis. 2005; 192(2): 331-5.  PMid:15962229  
  67. Ofori MF, Staalsoe T, Bam V, Lundquist M, David KP, Browne EN, Akanmori BD, and Hviid L, Expression of variant surface antigens by Plasmodium falciparum parasites in the peripheral blood of clinically immune pregnant women indicates ongoing placental infection. Infect Immun. 2003; 71(3): 1584-6. PMid:12595482 PMCid:148875 
  68. Duffy PE and Fried M, Plasmodium falciparum adhesion in the placenta. Curr Opin Microbiol. 2003; 6(4): 371-6. 
  69. Sander AF, Salanti A, Lavstsen T, Nielsen MA, Theander TG, Leke RG, Lo YY, Bobbili N, Arnot DE, and Taylor DW, Positive selection of Plasmodium falciparum parasites with multiple var2csa-type PfEMP1 genes during the course of infection in pregnant women. J Infect Dis. 2011; 203(11): 1679-85. PMid:21592998 PMCid:3096795  
  70. Thevenon AD, Zhou JA, Megnekou R, Ako S, Leke RG, and Taylor DW, Elevated levels of soluble TNF receptors 1 and 2 correlate with Plasmodium falciparum parasitemia in pregnant women: potential markers for malaria-associated inflammation. J Immunol. 2010; 185(11): 7115-22. PMid:20980627 PMCid:2988086  
  71. Achidi EA, Apinjoh TO, and Titanji VP, Malaria parasitemia and systemic cytokine bias in pregnancy. Int J Gynaecol Obstet. 2007; 97(1): 15-20. PMid:20695826 PMCid:3465272 
  72. Sarr D, Aldebert D, Marrama L, Frealle E, Gaye A, Brahim HO, Niang M, Dangou JM, Mercereau-Puijalon O, Lehesran JY, and Jambou R, Chronic infection during placental malaria is associated with up-regulation of cycloxygenase-2. Malar J. 2010; 9: 45. PMid:20144201 PMCid:2831904  
  73. Parekh FK, Davison BB, Gamboa D, Hernandez J, and Branch OH, Placental histopathologic changes associated with subclinical malaria infection and its impact on the fetal environment. Am J Trop Med Hyg. 2010; 83(5): 973-80. PMid:21036823 PMCid:2963955  
  74. Cockburn IA, Mackinnon MJ, O'Donnell A, Allen SJ, Moulds JM, Baisor M, Bockarie M, Reeder JC, and Rowe JA, A human complement receptor 1 polymorphism that reduces Plasmodium falciparum rosetting confers protection against severe malaria. Proc Natl Acad Sci U S A. 2004; 101(1): 272-7. PMid:14694201 PMCid:314175  
  75. Horata N, Kalambaheti T, Craig A, and Khusmith S, Sequence variation of PfEMP1-DBLalpha in association with rosette formation in Plasmodium falciparum isolates causing severe and uncomplicated malaria. Malar J. 2009; 8: 184. PMid:19650937 PMCid:3224928  
  76. Rogerson SJ, Beeson JG, Mhango CG, Dzinjalamala FK, and Molyneux ME, Plasmodium falciparum rosette formation is uncommon in isolates from pregnant women. Infect Immun. 2000; 68(1): 391-3. PMid:10603414 PMCid:97147  
  77. Chotivanich K, Udomsangpetch R, Suwanarusk R, Pukrittayakamee S, Wilairatana P, Beeson JG, Day NP, and White NJ, Plasmodium vivax adherence to placental glycosaminoglycans. PLoS ONE. 2012; 7(4): e34509. PMid:22529919 PMCid:3328474  
  78. Carvalho BO, Lopes SC, Nogueira PA, Orlandi PP, Bargieri DY, Blanco YC, Mamoni R, Leite JA, Rodrigues MM, Soares IS, Oliveira TR, Wunderlich G, Lacerda MV, del Portillo HA, Araujo MO, Russell B, Suwanarusk R, Snounou G, Renia L, and Costa FT, On the cytoadhesion of Plasmodium vivax-infected erythrocytes. J Infect Dis. 2010; 202(4): 638-47. PMid:20617923 
  79. Bouyou-Akotet MK, Adegnika AA, Agnandji ST, Ngou-Milama E, Kombila M, Kremsner PG, and Mavoungou E, Cortisol and susceptibility to malaria during pregnancy. Microbes Infect. 2005; 7(11-12): 1217-23. PMid:16002311  
  80. Adebami OJ, Owa JA, Oyedeji GA, Oyelami OA, and Omoniyi-Esan GO, Associations between placental and cord blood malaria infection and fetal malnutrition in an area of malaria holoendemicity. Am J Trop Med Hyg. 2007; 77(2): 209-13. PMid:17690388 
  81. McGready R, Davison BB, Stepniewska K, Cho T, Shee H, Brockman A, Udomsangpetch R, Looareesuwan S, White NJ, Meshnick SR, and Nosten F, 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(4): 398-407. PMid:15100454 
  82. Ismail MR, Ordi J, Menendez C, Ventura PJ, Aponte JJ, Kahigwa E, Hirt R, Cardesa A, and Alonso PL, Placental pathology in malaria: a histological, immunohistochemical, and quantitative study. Hum Pathol. 2000; 31(1): 85-93. 
  83. Tako EA, Zhou A, Lohoue J, Leke R, Taylor DW, and Leke RF, Risk factors for placental malaria and its effect on pregnancy outcome in Yaounde, Cameroon. Am J Trop Med Hyg. 2005; 72(3): 236-42. PMid:15772313 
  84. Suguitan AL, Jr., Cadigan TJ, Nguyen TA, Zhou A, Leke RJ, Metenou S, Thuita L, Megnekou R, Fogako J, Leke RG, and Taylor DW, Malaria-associated cytokine changes in the placenta of women with pre-term deliveries in Yaounde, Cameroon. Am J Trop Med Hyg. 2003; 69(6): 574-81. PMid:14740871 
  85. Adam I, Elhassan EM, Haggaz AE, Ali AA, and Adam GK, A perspective of the epidemiology of malaria and anaemia and their impact on maternal and perinatal outcomes in Sudan. J Infect Dev Ctries. 2011; 5(2): 83-7. 
  86. Conroy AL, McDonald CR, Silver KL, Liles WC, and Kain KC, Complement activation: a critical mediator of adverse fetal outcomes in placental malaria? Trends Parasitol. 2011; 27(7): 294-9.  PMid:21493146 
  87. Umbers AJ, Boeuf P, Clapham C, Stanisic DI, Baiwog F, Mueller I, Siba P, King CL, Beeson JG, Glazier J, and Rogerson SJ, Placental malaria-associated inflammation disturbs the insulin-like growth factor axis of fetal growth regulation. J Infect Dis. 2011; 203(4): 561-9. PMid:21216864 PMCid:3071224 
  88. WHO, Guidelines for the treatment of malaria, Second edition. 2010: Geneva, Switzerland. p. 1-32.
  89. Mayor A, Moro L, Aguilar R, Bardaj A, Cister P, Serra-Casas E, Sigaque B, Alonso PL, Ordi J, and Menndez C, How Hidden Can Malaria Be in Pregnant Women? Diagnosis by Microscopy, Placental Histology, Polymerase Chain Reaction and Detection of Histidine-Rich Protein 2 in Plasma. Clinical Infectious Diseases. 2012; 54(11): 1561-1568. PMid:22447794  
  90. Mockenhaupt FP, Ulmen U, von Gaertner C, Bedu-Addo G, and Bienzle U, Diagnosis of placental malaria. J Clin Microbiol. 2002; 40(1): 306-8. PMid:11773140 PMCid:120131  
  91. VanderJagt TA, Ikeh EI, Ujah IO, Belmonte J, Glew RH, and VanderJagt DJ, Comparison of the OptiMAL rapid test and microscopy for detection of malaria in pregnant women in Nigeria. Trop Med Int Health. 2005; 10(1): 39-41. PMid:15655012  
  92. Dondorp A, Nosten F, Stepniewska K, Day N, and White N, Artesunate versus quinine for treatment of severe falciparum malaria: a randomised trial. Lancet. 2005; 366(9487): 717-25. 
  93. Leenstra T, Phillips-Howard PA, Kariuki SK, Hawley WA, Alaii JA, Rosen DH, Oloo AJ, Nahlen BL, Kager PA, and ter Kuile FO, Permethrin-treated bed nets in the prevention of malaria and anemia in adolescent schoolgirls in western Kenya. Am J Trop Med Hyg. 2003; 68(4 Suppl): 86-93. PMid:12749490 
  94. ter Kuile FO, Terlouw DJ, Kariuki SK, Phillips-Howard PA, Mirel LB, Hawley WA, Friedman JF, Shi YP, Kolczak MS, Lal AA, Vulule JM, and Nahlen BL, Impact of permethrin-treated bed nets on malaria, anemia, and growth in infants in an area of intense perennial malaria transmission in western Kenya. Am J Trop Med Hyg. 2003; 68(4 Suppl): 68-77. PMid:12749488 
  95. Jayasooriya S, Hislop A, Peng Y, Croom-Carter D, Jankey Y, Bell A, Dong T, Rowland-Jones S, Rickinson A, Walther M, and Whittle H, Revisiting the effect of acute P. falciparum malaria on Epstein-Barr virus: host balance in the setting of reduced malaria endemicity. PLoS ONE. 2012; 7(2): e31142. PMid:22347443 PMCid:3275582  
  96. Phillips-Howard PA, Nahlen BL, Kolczak MS, Hightower AW, ter Kuile FO, Alaii JA, Gimnig JE, Arudo J, Vulule JM, Odhacha A, Kachur SP, Schoute E, Rosen DH, Sexton JD, Oloo AJ, and Hawley WA, Efficacy of permethrin-treated bed nets in the prevention of mortality in young children in an area of high perennial malaria transmission in western Kenya. Am J Trop Med Hyg. 2003; 68(4 Suppl): 23-9. PMid:12749482 
  97. ter Kuile FO, Terlouw DJ, Phillips-Howard PA, Hawley WA, Friedman JF, Kariuki SK, Shi YP, Kolczak MS, Lal AA, Vulule JM, and Nahlen BL, Reduction of malaria during pregnancy by permethrin-treated bed nets in an area of intense perennial malaria transmission in western Kenya. Am J Trop Med Hyg. 2003; 68(4 Suppl): 50-60. PMid:12749486 
  98. Njagi JK, Magnussen P, Estambale B, Ouma J, and Mugo B, Prevention of anaemia in pregnancy using insecticide-treated bednets and sulfadoxine-pyrimethamine in a highly malarious area of Kenya: a randomized controlled trial. Trans R Soc Trop Med Hyg. 2003; 97(3): 277-82. 
  99. Browne EN, Maude GH, and Binka FN, The impact of insecticide-treated bednets on malaria and anaemia in pregnancy in Kassena-Nankana district, Ghana: a randomized controlled trial. Trop Med Int Health. 2001; 6(9): 667-76.  PMid:11555433  
  100. Diakite OS, Kayentao K, Traore BT, Djimde A, Traore B, Diallo M, Ongoiba A, Doumtabe D, Doumbo S, Traore MS, Dara A, Guindo O, Karim DM, Coulibaly S, Bougoudogo F, Ter Kuile FO, Danis M, and Doumbo OK, Superiority of 3 over 2 doses of intermittent preventive treatment with sulfadoxine-pyrimethamine for the prevention of malaria during pregnancy in mali: a randomized controlled trial. Clin Infect Dis. 2011; 53(3): 215-23.  PMid:21765069  
  101. Menendez C, Bardaji A, Sigauque B, Romagosa C, Sanz S, Serra-Casas E, Macete E, Berenguera A, David C, Dobano C, Naniche D, Mayor A, Ordi J, Mandomando I, Aponte JJ, Mabunda S, and Alonso PL, A randomized placebo-controlled trial of intermittent preventive treatment in pregnant women in the context of insecticide treated nets delivered through the antenatal clinic. PLoS ONE. 2008; 3(4): e1934 
  102. Asa OO, Onayade AA, Fatusi AO, Ijadunola KT, and Abiona TC, Efficacy of intermittent preventive treatment of malaria with sulphadoxine-pyrimethamine in preventing anaemia in pregnancy among Nigerian women. Matern Child Health J. 2008; 12(6): 692-8.  PMid:18274885  
  103. Tukur IU, Thacher TD, Sagay AS, and Madaki JK, A comparison of sulfadoxine-pyrimethamine with chloroquine and pyrimethamine for prevention of malaria in pregnant Nigerian women. Am J Trop Med Hyg. 2007; 76(6): 1019-23. PMid:17556604 
  104. Challis K, Osman NB, Cotiro M, Nordahl G, Dgedge M, and Bergstrom S, Impact of a double dose of sulphadoxine-pyrimethamine to reduce prevalence of pregnancy malaria in southern Mozambique. Trop Med Int Health. 2004; 9(10): 1066-73. PMid:15482398  
  105. Bertin G, Briand V, Bonaventure D, Carrieu A, Massougbodji A, Cot M, and Deloron P, Molecular markers of resistance to sulphadoxine-pyrimethamine during intermittent preventive treatment of pregnant women in Benin. Malar J. 2011; 10: 196. PMid:21767415 PMCid:3199903  
  106. ter Kuile FO, van Eijk AM, and Filler SJ, Effect of sulfadoxine-pyrimethamine resistance on the efficacy of intermittent preventive therapy for malaria control during pregnancy: a systematic review. JAMA. 2007; 297(23): 2603-16.  PMid:17579229 
  107. Clerk CA, Bruce J, Affipunguh PK, Mensah N, Hodgson A, Greenwood B, and Chandramohan D, A randomized, controlled trial of intermittent preventive treatment with sulfadoxine-pyrimethamine, amodiaquine, or the combination in pregnant women in Ghana. J Infect Dis. 2008; 198(8): 1202-11.  PMid:18752443 
  108. Briand V, Denoeud L, Massougbodji A, and Cot M, Efficacy of intermittent preventive treatment versus chloroquine prophylaxis to prevent malaria during pregnancy in Benin. J Infect Dis. 2008; 198(4): 594-601.  PMid:18598190
  109. Briand V, Bottero J, Noel H, Masse V, Cordel H, Guerra J, Kossou H, Fayomi B, Ayemonna P, Fievet N, Massougbodji A, and Cot M, Intermittent treatment for the prevention of malaria during pregnancy in Benin: a randomized, open-label equivalence trial comparing sulfadoxine-pyrimethamine with mefloquine. J Infect Dis. 2009; 200(6): 991-1001.  PMid:19656069
  110. Ndyomugyenyi R, Clarke SE, Hutchison CL, Hansen KS, and Magnussen P, Efficacy of malaria prevention during pregnancy in an area of low and unstable transmission: an individually-randomised placebo-controlled trial using intermittent preventive treatment and insecticide-treated nets in the Kabale Highlands, southwestern Uganda. Trans R Soc Trop Med Hyg. 2011; 105(11): 607-16. PMid:21962292  
  111. Hviid L, The role of Plasmodium falciparum variant surface antigens in protective immunity and vaccine development. Hum Vaccin. 2010; 6(1): 84-9. PMid:19823032  
  112. Menendez C, Alonso P, and Universitat de B, Guidelines and considerations for testing malaria vaccines in pregnant women. Hum Vaccin. 2010; 6(1): 21-6. PMid:19946207 
  113. Crompton PD, Pierce SK, and Miller LH, Advances and challenges in malaria vaccine development. J Clin Invest. 2010; 120(12): 4168-78. PMid:21123952 PMCid:2994342 
  114. Duffy PE and Fried M, Antibodies that inhibit Plasmodium falciparum adhesion to chondroitin sulfate A are associated with increased birth weight and the gestational age of newborns. Infect Immun. 2003; 71(11): 6620-3. PMid:14573685 PMCid:219546 
  115. Magistrado PA, Minja D, Doritchamou J, Ndam NT, John D, Schmiegelow C, Massougbodji A, Dahlback M, Ditlev SB, Pinto VV, Resende M, Lusingu J, Theander TG, Salanti A, and Nielsen MA, High efficacy of anti DBL4varepsilon-VAR2CSA antibodies in inhibition of CSA-binding Plasmodium falciparum-infected erythrocytes from pregnant women. Vaccine. 2011; 29(3): 437-43.  PMid:21075162 
  116. Duffy PE and Fried M, Pregnancy malaria: cryptic disease, apparent solution. Mem Inst Oswaldo Cruz. 2011; 106 Suppl 1: 64-9. 
  117. Hviid L, The case for PfEMP1-based vaccines to protect pregnant women against Plasmodium falciparum malaria. Expert Rev Vaccines. 2011; 10(10): 1405-14.  PMid:21988306  
  118. McGready R, Cho T, Keo NK, Thwai KL, Villegas L, Looareesuwan S, White NJ, and Nosten F, Artemisinin antimalarials in pregnancy: a prospective treatment study of 539 episodes of multidrug-resistant Plasmodium falciparum. Clin Infect Dis. 2001; 33(12): 2009-16. PMid:11712093  
  119. Manyando C, Mkandawire R, Puma L, Sinkala M, Mpabalwani E, Njunju E, Gomes M, Ribeiro I, Walter V, Virtanen M, Schlienger R, Cousin M, Chipimo M, and Sullivan FM, Safety of artemether-lumefantrine in pregnant women with malaria: results of a prospective cohort study in Zambia. Malar J. 2010; 9: 249. PMid:20809964 PMCid:2944339  
  120. Deen JL, von Seidlein L, Pinder M, Walraven GE, and Greenwood BM, The safety of the combination artesunate and pyrimethamine-sulfadoxine given during pregnancy. Trans R Soc Trop Med Hyg. 2001; 95(4): 424-8. 
  121. Adam I, Elhassan EM, Omer EM, Abdulla MA, Mahgoub HM, and Adam GK, Safety of artemisinins during early pregnancy, assessed in 62 Sudanese women. Ann Trop Med Parasitol. 2009; 103(3): 205-10. PMid:19341535 
  122. Tagbor H, Bruce J, Browne E, Randal A, Greenwood B, and Chandramohan D, Efficacy, safety, and tolerability of amodiaquine plus sulphadoxine-pyrimethamine used alone or in combination for malaria treatment in pregnancy: a randomised trial. Lancet. 2006; 368(9544): 1349-56. 
  123. McGready R, Ashley EA, Moo E, Cho T, Barends M, Hutagalung R, Looareesuwan S, White NJ, and Nosten F, A randomized comparison of artesunate-atovaquone-proguanil versus quinine in treatment for uncomplicated falciparum malaria during pregnancy. J Infect Dis. 2005; 192(5): 846-53.  PMid:16088834  
  124. McGready R, Cho T, Samuel, Villegas L, Brockman A, van Vugt M, Looareesuwan S, White NJ, and Nosten F, Randomized comparison of quinine-clindamycin versus artesunate in the treatment of falciparum malaria in pregnancy. Trans R Soc Trop Med Hyg. 2001; 95(6): 651-6. 
  125. Mutabingwa TK, Muze K, Ord R, Briceno M, Greenwood BM, Drakeley C, and Whitty CJ, Randomized trial of artesunate+amodiaquine, sulfadoxine-pyrimethamine+amodiaquine, chlorproguanal-dapsone and SP for malaria in pregnancy in Tanzania. PLoS ONE. 2009; 4(4): e5138. PMid:19352498 PMCid:2662423  
  126. McGready R, Brockman A, Cho T, Cho D, van Vugt M, Luxemburger C, Chongsuphajaisiddhi T, White NJ, and Nosten F, Randomized comparison of mefloquine-artesunate versus quinine in the treatment of multidrug-resistant falciparum malaria in pregnancy. Trans R Soc Trop Med Hyg. 2000; 94(6): 689-93. 
  127. Kalilani L, Mofolo I, Chaponda M, Rogerson SJ, Alker AP, Kwiek JJ, and Meshnick SR, A randomized controlled pilot trial of azithromycin or artesunate added to sulfadoxine-pyrimethamine as treatment for malaria in pregnant women. PLoS ONE. 2007; 2(11): e1166. PMid:18000538 PMCid:2048661 
  128. Tarning J, Kloprogge F, Piola P, Dhorda M, Muwanga S, Turyakira E, Nuengchamnong N, Nosten F, Day N, White N, Guerin P, and Lindegardh N, Population pharmacokinetics of Artemether and dihydroartemisinin in pregnant women with uncomplicated Plasmodium falciparum malaria in Uganda. Malaria Journal. 2012; 11(1): 293. PMid:22913677 PMCid:3502166 
  129. Tarning J, McGready R, Lindegardh N, Ashley EA, Pimanpanarak M, Kamanikom B, Annerberg A, Day NP, Stepniewska K, Singhasivanon P, White NJ, and Nosten F, Population pharmacokinetics of lumefantrine in pregnant women treated with artemether-lumefantrine for uncomplicated Plasmodium falciparum malaria. Antimicrob Agents Chemother. 2009; 53(9): 3837-46. PMid:19564366 PMCid:2737887 
  130. Schlagenhauf P, Blumentals WA, Suter P, Regep L, Vital-Durand G, Schaerer MT, Boutros MS, Rhein H-G, and Adamcova M, Pregnancy and Fetal Outcomes After Exposure to Mefloquine in the Pre- and Periconception Period and During Pregnancy. Clinical Infectious Diseases. 2012. PMid:22495078 PMCid:3348951  
  131. Rijken MJ, McGready R, Jullien V, Tarning J, Lindegardh N, Phyo AP, Win AK, Hsi P, Cammas M, Singhasivanon P, White NJ, and Nosten F, Pharmacokinetics of amodiaquine and desethylamodiaquine in pregnant and postpartum women with Plasmodium vivax malaria. Antimicrob Agents Chemother. 2011; 55(9): 4338-42. PMid:21709098 PMCid:3165320 
  132. McGready R, White NJ, and Nosten F, Parasitological efficacy of antimalarials in the treatment and prevention of falciparum malaria in pregnancy 1998 to 2009: a systematic review. BJOG. 2011; 118(2): 123-35. 
  133. Tarning J, Rijken MJ, McGready R, Phyo AP, Hanpithakpong W, Day NP, White NJ, Nosten F, and Lindegardh N, Population pharmacokinetics of dihydroartemisinin and piperaquine in pregnant and nonpregnant women with uncomplicated malaria. Antimicrob Agents Chemother. 2012; 56(4): 1997-2007. PMid:22252822 PMCid:3318332  
  134. McGready R, Stepniewska K, Ward SA, Cho T, Gilveray G, Looareesuwan S, White NJ, and Nosten F, Pharmacokinetics of dihydroartemisinin following oral artesunate treatment of pregnant women with acute uncomplicated falciparum malaria. Eur J Clin Pharmacol. 2006; 62(5): 367-71.  PMid:16552504 
  135. Tarning J, Chotsiri P, Jullien V, Rijken MJ, Bergstrand M, Cammas M, McGready R, Singhasivanon P, Day NP, White NJ, Nosten F, and Lindegardh N, Population pharmacokinetic and pharmacodynamic modeling of amodiaquine and desethylamodiaquine in women with Plasmodium vivax malaria during and after pregnancy. Antimicrob Agents Chemother. 2012. PMid:22926572 PMCid:3486620  
  136. Piola P, Nabasumba C, Turyakira E, Dhorda M, Lindegardh N, Nyehangane D, Snounou G, Ashley EA, McGready R, Nosten F, and Guerin PJ, Efficacy and safety of artemether-lumefantrine compared with quinine in pregnant women with uncomplicated Plasmodium falciparum malaria: an open-label, randomised, non-inferiority trial. Lancet Infect Dis. 2010; 10(11): 762-9. 
  137. Kaye DK, Nshemerirwe R, Mutyaba TS, and Ndeezi G, A randomized clinical trial comparing safety, clinical and parasitological response to artemether-lumefantrine and chlorproguanil-dapsone in treatment of uncomplicated malaria in pregnancy in Mulago hospital, Uganda. J Infect Dev Ctries. 2008; 2(2): 135-9.  PMid:19738339  
  138. McGready R, Tan SO, Ashley EA, Pimanpanarak M, Viladpai-Nguen J, Phaiphun L, Wustefeld K, Barends M, Laochan N, Keereecharoen L, Lindegardh N, Singhasivanon P, White NJ, and Nosten F, A randomised controlled trial of artemether-lumefantrine versus artesunate for uncomplicated plasmodium falciparum treatment in pregnancy. PLoS Med. 2008; 5(12): e253. PMid:19265453 PMCid:2605900  
  139. McGready R, Stepniewska K, Lindegardh N, Ashley EA, La Y, Singhasivanon P, White NJ, and Nosten F, The pharmacokinetics of artemether and lumefantrine in pregnant women with uncomplicated falciparum malaria. Eur J Clin Pharmacol. 2006; 62(12): 1021-31. PMid:17053895  
  140. Rijken MJ, McGready R, Phyo AP, Lindegardh N, Tarning J, Laochan N, Than HH, Mu O, Win AK, Singhasivanon P, White N, and Nosten F, Pharmacokinetics of dihydroartemisinin and piperaquine in pregnant and nonpregnant women with uncomplicated falciparum malaria. Antimicrob Agents Chemother. 2011; 55(12): 5500-6. PMid:21947392 PMCid:3232755 
  141. Poespoprodjo JR, Fobia W, Kenangalem E, Hasanuddin A, Sugiarto P, Tjitra E, Anstey NM, and Price RN, Highly effective therapy for maternal malaria associated with a lower risk of vertical transmission. J Infect Dis. 2011; 204(10): 1613-9. PMid:21908728 PMCid:3192188  
  142. McGready R, Keo NK, Villegas L, White NJ, Looareesuwan S, and Nosten F, Artesunate-atovaquone-proguanil rescue treatment of multidrug-resistant Plasmodium falciparum malaria in pregnancy: a preliminary report. Trans R Soc Trop Med Hyg. 2003; 97(5): 592-4. 
  143. McGready R, Stepniewska K, Edstein MD, Cho T, Gilveray G, Looareesuwan S, White NJ, and Nosten F, The pharmacokinetics of atovaquone and proguanil in pregnant women with acute falciparum malaria. Eur J Clin Pharmacol. 2003; 59(7): 545-52.  PMid:12955371 
  144. Kabanywanyi AM, Macarthur JR, Stolk WA, Habbema JD, Mshinda H, Bloland PB, Abdulla S, and Kachur SP, Malaria in pregnant women in an area with sustained high coverage of insecticide-treated bed nets. Malar J. 2008; 7: 133. PMid:18644118 PMCid:2500040  
  145. Campos PA, Valente B, Campos RB, Goncalves L, Rosario VE, Varandas L, and Silveira H, Plasmodium falciparum infection in pregnant women attending antenatal care in Luanda, Angola. Rev Soc Bras Med Trop. 2012; 45(3): 369-74. PMid:22760138  
  146. Martinez-Espinosa FE, Daniel-Ribeiro CT, and Alecrim WD, Malaria during pregnancy in a reference centre from the Brazilian Amazon: unexpected increase in the frequency of Plasmodium falciparum infections. Mem Inst Oswaldo Cruz. 2004; 99(1): 19-21. 
  147. Karunajeewa HA, Salman S, Mueller I, Baiwog F, Gomorrai S, Law I, Page-Sharp M, Rogerson S, Siba P, Ilett KF, and Davis TM, Pharmacokinetics of chloroquine and monodesethylchloroquine in pregnancy. Antimicrob Agents Chemother. 2010; 54(3): 1186-92. PMid:20086162 PMCid:2825967  
  148. Nyunt MM, Adam I, Kayentao K, van Dijk J, Thuma P, Mauff K, Little F, Cassam Y, Guirou E, Traore B, Doumbo O, Sullivan D, Smith P, and Barnes KI, Pharmacokinetics of sulfadoxine and pyrimethamine in intermittent preventive treatment of malaria in pregnancy. Clin Pharmacol Ther. 2010; 87(2): 226-34. PMid:19776738 
  149. McGready R, Thwai KL, Cho T, Samuel, Looareesuwan S, White NJ, and Nosten F, The effects of quinine and chloroquine antimalarial treatments in the first trimester of pregnancy. Trans R Soc Trop Med Hyg. 2002; 96(2): 180-4.