Obstetrics and Gynaecology chapters
COVID-19, dengue and malaria in pregnancy
Why malaria, dengue and COVID-19 are more dangerous in pregnancy, how they affect the baby, which antimalarials are safe, how to manage dengue around delivery, and what WHO advises on COVID-19, birth and breastfeeding.
- Malaria is worse in pregnancy, especially in first pregnancies: parasites hide in the placenta, and severe anaemia, hypoglycaemia, pulmonary oedema, miscarriage, preterm birth and FGR follow.
- Chloroquine and quinine are safe; artemisinin combinations treat falciparum after the first trimester and IV artesunate treats severe malaria at any stage; primaquine is avoided because the fetus is relatively G6PD deficient.
- Dengue and COVID-19 need close watching for warning signs: use paracetamol, not NSAIDs, for dengue, avoid elective delivery in its critical phase, and offer COVID-19 vaccination in pregnancy.
On this page
Overview
Malaria and dengue are common mosquito-borne infections in Pakistan, and COVID-19 showed how a new respiratory virus can affect pregnant women. All three are more serious in pregnancy because of altered immunity, the demands of the placenta and the physiological changes of late pregnancy.
National guidance in Pakistan (for example from the National Institute of Health and the malaria control programme) is updated regularly; treatment choices and doses should always be checked against the current national guideline.
Malaria in pregnancy
Organisms and transmission
- Four main human species: Plasmodium falciparum, P. vivax, P. ovale, P. malariae. Both vivax and falciparum occur in Pakistan.
- P. falciparum carries the worst outcome for mother and fetus.
- Spread by the female Anopheles mosquito. Rarely, malaria passes to the baby across the placenta (congenital malaria).
Why pregnancy makes malaria worse
- Pregnant women are more likely to be infected than other adults.
- Parasitaemia is commoner in first pregnancies than in later ones; women seem to gain placenta-specific immunity with each pregnancy.
- Placental sequestration: infected red cells stick in the placenta. In semi-immune women from endemic areas, the placenta may be heavily infected while the peripheral blood film is negative.
A negative blood film does not exclude malaria in a pregnant woman from an endemic area. Keep a high index of suspicion and repeat the test.
Effects on the mother
- Cyclical spiking fever, which can trigger miscarriage and preterm labour.
- Severe anaemia (haemolysis plus coexisting iron and folate lack).
- Hypoglycaemia: common and may be severe, made worse by quinine.
- Pulmonary oedema from leaky capillaries, with high mortality (about 50%).
- Haemolysis causing jaundice and renal failure.
- Cerebral malaria and death with falciparum.
Effects on the fetus
- Miscarriage, preterm birth, FGR and low birthweight, stillbirth.
- Abnormal uterine artery Doppler from placental damage.
- HIV coinfection raises transmission of both infections to the baby.
Placental malaria → FGR and low birthweight; maternal fever → miscarriage and preterm labour; hypoglycaemia may be silent, so check glucose often.
Diagnosis
- Thick and thin blood films (gold standard for species and parasite count) and rapid diagnostic tests.
- Check haemoglobin, glucose, platelets, renal and liver function.
- Examine the placenta after birth when malaria is suspected.
Treatment: drug safety in pregnancy
| Drug | Use and safety in pregnancy |
|---|---|
| Chloroquine | Drug of choice for non-falciparum (e.g. vivax) and sensitive falciparum; safe in pregnancy |
| Quinine (with clindamycin) | Safe; first-trimester treatment of uncomplicated falciparum (Katzung); causes hypoglycaemia and mild uterine stimulation |
| Artemisinin-based combination therapy (ACT) | Uncomplicated falciparum in the second and third trimesters; no rise in birth defects seen in human data |
| IV artesunate | Severe malaria at any stage of pregnancy |
| Mefloquine | Considered safe in pregnancy, mainly for prophylaxis; first-trimester experience is limited (Katzung) |
| Proguanil | Safe for prophylaxis |
| Sulfadoxine-pyrimethamine | Used for intermittent preventive treatment in pregnancy (IPTp) in high-transmission areas; folate dose is kept at the standard level while it is used |
| Primaquine | Avoid in pregnancy: the fetus is relatively G6PD deficient and may haemolyse. Give it for vivax radical cure after delivery (and after G6PD testing) |
| Doxycycline | Avoid (tetracycline: teeth and bone) |
WHO guidance on ACT in the first trimester has been updated over time; follow the current WHO and national malaria guideline. Expert advice is needed because resistance patterns vary by region.
"Prima-no in pregnancy": primaquine waits until after delivery.
Vivax relapses come from liver hypnozoites. Chloroquine clears the blood stage in pregnancy, but the radical cure (primaquine) is delayed until after birth.
Supportive care
- Treat fever with paracetamol; correct dehydration carefully (risk of pulmonary oedema).
- Monitor glucose frequently, especially on quinine.
- Treat anaemia; transfuse if severe.
- Monitor the fetus; uterine contractions often settle once fever is controlled.
Prevention
- Insecticide-treated bed nets, repellents and covering clothing.
- Intermittent preventive treatment in pregnancy (IPTp) in areas of moderate to high transmission, as set by the national programme.
- Women from non-endemic areas should avoid travel to malarious areas in pregnancy; if travel is essential, use bite prevention and expert-chosen chemoprophylaxis.
Dengue in pregnancy
Basics
- Dengue virus, spread by the bite of infected Aedes mosquitoes (mainly Aedes aegypti), which bite in the daytime. Pakistan has repeated seasonal outbreaks, usually after the monsoon.
- Most infections are mild or silent. Symptoms start about 4-10 days after the bite.
- A second infection with a different virus type raises the risk of severe dengue.
Clinical features
- High fever, severe headache, pain behind the eyes, muscle and joint pain ("break-bone fever"), nausea, vomiting, rash, swollen glands.
- Warning signs (often appear as the fever settles): severe abdominal pain, persistent vomiting, fast breathing, bleeding from gums or nose, blood in vomit or stool, restlessness, cold pale skin, extreme weakness.
- Severe dengue: plasma leakage with shock, serious bleeding, organ failure.
Investigations
- NS1 antigen (early in the illness) and dengue IgM/IgG serology (later).
- Serial platelet count and haematocrit: falling platelets with a rising haematocrit suggests plasma leakage.
- Liver enzymes and clotting.
Why pregnancy is tricky
- Normal pregnancy dilutes the haematocrit and raises heart rate, so early leakage is harder to spot.
- Dengue can mimic pre-eclampsia or HELLP syndrome (low platelets, raised liver enzymes, abdominal pain).
- Fetal and neonatal risks: preterm birth, low birthweight, fetal distress, and rarely transmission to the baby, especially if the mother is ill around delivery.
- Delivery during the critical (leakage) phase risks severe postpartum haemorrhage from low platelets.
Management
- No specific antiviral: supportive care.
- Paracetamol for fever and pain. Avoid NSAIDs and aspirin, which increase bleeding risk; avoid intramuscular injections.
- Careful fluid management: oral fluids for mild cases; IV crystalloid with close monitoring for warning signs, avoiding fluid overload.
- Admit pregnant women with warning signs, severe dengue or near term; involve obstetrics, medicine and anaesthesia.
- Avoid elective induction or caesarean during the critical phase where possible; plan for PPH (active third stage, blood and platelets available).
- Inform the paediatric team; watch the baby for fever and low platelets after birth.
- Prevention: remove standing water, use repellents and nets, cover the skin, especially by day.
In dengue, paracetamol only; NSAIDs and aspirin are avoided because of bleeding risk.
COVID-19 in pregnancy
- Caused by SARS-CoV-2, a respiratory virus.
- Pregnant women are not more likely to catch it, but if infected are at higher risk of severe illness than non-pregnant women of the same age. Higher risk with older age, obesity, hypertension and diabetes.
- Baby: infection is linked with preterm birth. Transmission before or during birth is possible but very rare; most infected newborns recover.
- Mode of delivery: COVID-19 alone is not a reason for caesarean section; decide on obstetric grounds and the woman's wishes.
- After birth: mothers with suspected or confirmed COVID-19 can breastfeed, hold the baby skin to skin and room in, with good respiratory hygiene.
- Vaccination: COVID-19 vaccines are not live and can be given in pregnancy; they protect against severe illness, hospital admission and death, and may give some protection to the baby.
- Hospital care follows standard medical treatment for severe disease, with attention to oxygenation, VTE prophylaxis (pregnancy plus infection raises clot risk) and fetal monitoring; follow current national guidance.
Do not stop breastfeeding or separate mother and baby just because the mother has COVID-19; WHO advises keeping them together with infection precautions.
Comparison
| Feature | Malaria | Dengue | COVID-19 |
|---|---|---|---|
| Agent | Plasmodium (protozoan) | Dengue virus | SARS-CoV-2 |
| Spread | Anopheles (night) | Aedes (day) | Respiratory droplets |
| Key maternal danger | Anaemia, hypoglycaemia, pulmonary oedema | Plasma leakage, bleeding | Severe pneumonia |
| Key fetal effect | FGR, preterm birth, stillbirth | Preterm birth, low birthweight | Preterm birth |
| Drug point | Avoid primaquine; quinine causes hypoglycaemia | Avoid NSAIDs and aspirin | Vaccine is safe in pregnancy |
Official sources: WHO: Dengue and severe dengue (checked 11 Nov 2026); WHO: COVID-19, pregnancy, childbirth and the postnatal period (checked 11 Nov 2026).
Expect: falciparum as the most dangerous species; higher parasitaemia in first pregnancies; placental sequestration with a negative blood film; maternal anaemia, hypoglycaemia and pulmonary oedema; FGR and preterm birth; safe drugs (chloroquine, quinine, proguanil, mefloquine, ACT after the first trimester, IV artesunate for severe disease) and primaquine avoided because of fetal G6PD deficiency; bed nets and IPTp; dengue spread by day-biting Aedes, warning signs, NS1 testing, paracetamol rather than NSAIDs, and avoiding delivery in the critical phase; COVID-19 raising severe illness and preterm birth, no caesarean for infection alone, breastfeeding allowed and vaccination advised.
Quick revision
- Malaria: falciparum worst; primigravidae most affected; placenta may hide parasites.
- Complications: anaemia, hypoglycaemia, pulmonary oedema, miscarriage, preterm birth, FGR.
- Safe: chloroquine, quinine (+ clindamycin), proguanil, mefloquine; ACT after first trimester; IV artesunate for severe malaria.
- Avoid: primaquine (fetal G6PD), doxycycline.
- Dengue: Aedes, day-biting; watch warning signs and platelets; paracetamol only; avoid delivery in critical phase.
- COVID-19: more severe in pregnancy; preterm birth; caesarean only for obstetric reasons; breastfeed; vaccinate.
Written by The House Job from standard references (Obstetrics by Ten Teachers; Basic and Clinical Pharmacology by Katzung).
FAQ
Why are women in their first pregnancy more affected by malaria?
Protective immunity against parasites that bind the placenta builds up over successive pregnancies, so first-time mothers have the least protection and the highest parasite loads.
Can chloroquine be given in pregnancy?
Yes. It is considered safe and is the drug of choice for vivax and chloroquine-sensitive malaria; it is primaquine that must wait until after delivery.
Why is aspirin unsafe in dengue?
Dengue lowers platelets and can cause bleeding, and aspirin and other NSAIDs further impair platelet function and raise the bleeding risk.
Should a pregnant woman with COVID-19 have a caesarean section?
No, not for the infection alone; the mode of birth depends on obstetric factors and her wishes.