Pregnancy outcomes and risk of placental malaria after artemisinin-based and quinine-based treatment for uncomplicated falciparum malaria in pregnancy: a WorldWide Antimalarial Resistance Network systematic review and individual patient data meta-analysis
Authors: Saito Makoto , Mansoor Rashid , Kennon Kalynn , Anvikar Anupkumar R. , Ashley Elizabeth A. , Chandramohan Daniel , Cohee Lauren M. , D’Alessandro Umberto , Genton Blaise , Gilder Mary Ellen , Juma Elizabeth , Kalilani-Phiri Linda , Kuepfer Irene , Laufer Miriam K. , Lwin Khin Maung , Meshnick Steven R. , Mosha Dominic , Muehlenbachs Atis , Mwapasa Victor , Mwebaza Norah , Nambozi Michael , Ndiaye Jean-Louis A. , Nosten François , Nyunt Myaing , Ogutu Bernhards , Parikh Sunil , Paw Moo Kho , Phyo Aung Pyae , Pimanpanarak Mupawjay , Piola Patrice , Rijken Marcus J. , Sriprawat Kanlaya , Tagbor Harry K. , Tarning Joel , Tinto Halidou , Valéa Innocent , Valecha Neena , White Nicholas J. , Wiladphaingern Jacher , Stepniewska Kasia , McGready Rose , Guérin Philippe J. 
Published: June 2020

Background

Malaria in pregnancy, including asymptomatic infection, has a detrimental impact on foetal development. Individual patient data (IPD) meta-analysis was conducted to compare the association between antimalarial treatments and adverse pregnancy outcomes, including placental malaria, accompanied with the gestational age at diagnosis of uncomplicated falciparum malaria infection.

Methods

A systematic review and one-stage IPD meta-analysis of studies assessing the efficacy of artemisinin-based and quinine-based treatments for patent microscopic uncomplicated falciparum malaria infection (hereinafter uncomplicated falciparum malaria) in pregnancy was conducted. The risks of stillbirth (pregnancy loss at ≥ 28.0 weeks of gestation), moderate to late preterm birth (PTB, live birth between 32.0 and < 37.0 weeks), small for gestational age (SGA, birthweight of < 10th percentile), and placental malaria (defined as deposition of malaria pigment in the placenta with or without parasites) after different treatments of uncomplicated falciparum malaria were assessed by mixed-effects logistic regression, using artemether-lumefantrine, the most used antimalarial, as the reference standard. Registration PROSPERO: CRD42018104013.

Results

Of the 22 eligible studies (n = 5015), IPD from16 studies were shared, representing 95.0% (n = 4765) of the women enrolled in literature. Malaria treatment in this pooled analysis mostly occurred in the second (68.4%, 3064/4501) or third trimester (31.6%, 1421/4501), with gestational age confirmed by ultrasound in 91.5% (4120/4503). Quinine (n = 184) and five commonly used artemisinin-based combination therapies (ACTs) were included: artemether-lumefantrine (n = 1087), artesunate-amodiaquine (n = 775), artesunate-mefloquine (n = 965), and dihydroartemisinin-piperaquine (n = 837). The overall pooled proportion of stillbirth was 1.1% (84/4361), PTB 10.0% (619/4131), SGA 32.3% (1007/3707), and placental malaria 80.1% (2543/3035), and there were no significant differences of considered outcomes by ACT. Higher parasitaemia before treatment was associated with a higher risk of SGA (adjusted odds ratio [aOR] 1.14 per 10-fold increase, 95% confidence interval [CI] 1.03 to 1.26,p = 0.009) and deposition of malaria pigment in the placenta (aOR 1.67 per 10-fold increase, 95% CI 1.42 to 1.96,p < 0.001).

Conclusions

The risks of stillbirth, PTB, SGA, and placental malaria were not different between the commonly used ACTs. The risk of SGA was high among pregnant women infected with falciparum malaria despite treatment with highly effective drugs. Reduction of malaria-associated adverse birth outcomes requires effective prevention in pregnant women.