Is chloroquine or primaquine contraindicated during pregnancy?/nA woman has been treated for P. viv

Fråga: Is chloroquine or primaquine contraindicated during pregnancy?

A woman has been treated for P. vivax malaria with chloroquine (Klorokinfosfat) in a total dose of 1200 mg base and primaquine in a standard dose of 15 mg base once daily for two weeks. The patient is now in the 9th week of pregnancy and during the antimalarial treatment she was pregnant in the 5th to 6th week.

Sammanfattning: In resemblance with the use of chloroquine for malaria prophylaxis the drug should be considered safe for malaria treatment in standard doses during pregnancy. Primaquine is not teratogenic, but might on theoretical grounds cause fetal anaemia in a G6PD deficient fetus. However, the risk is probably low as no reports have been found in the literature and primaquine medication to the mother cannot be considered as an indication for abortion.

Svar: Primaquine is active against exoerythrocytic stages of all malaria parasites and used for radical treatment of P. vivax and P. ovale (1). The principal toxicity of primaquine is haemolytic anaemia especially in patients with a deficiency of glucose-6-phosphate dehydrogenase (G6PD) (1). It is estimated that 200-300 miljon people have G6PD deficiency (2). The prognosis of this condition is good, and specific treatment usually not needed (1).

In the last edition of Drugs in pregnancy and lactation, no reports linking use of primaquine with congenital defects have been located (3). We have done an updated Medline-search without finding any relevant original references concerning primaquine and pregnancy. In one general textbook, it is stated that primaquine is contraindicated in pregnancy, as it may cause anaemia in utero in a G6PD deficient fetus (2). However, in specific reference literature the conclusion is that if malaria treatment is required, primaquine should not be withheld (3).

Questions concerning possible risk to the fetus during malaria prophylaxis with chloroquine have previously been answered (4,5). Chloroquine is considered safe when used in standard doses (310 mg base weekly). During the first week, whole blood concentrations of chloroquine attained after standard treatment (25 mg base/kg bw) are only slightly higher than steady state concentration during prophylaxis (6).