Remarks

• Limited exposures to other ACTs (artesunate-amodiaquine, artesunate-mefloquine and dihydroartemisinin-piperaquine) suggest that the current evidence is insufficient to make a recommendation for routine use of theseother ACTs in the first trimester of pregnancy. However, consistent with the previous WHO recommendation thatprovided for limited use of ACTs if the first-line recommended medicine was not available, these other ACTs maybe considered for use where artemether-lumefantrine is not a recommended ACT for uncomplicated malaria or isnot available, given the demonstrated poorer outcomes of quinine treatment, along with the challenges of adherence to a seven-day course of treatment.
• Antifolates are contraindicated in the first trimester of pregnancy. Therefore, ACTs containing sulfadoxine-pyrimethamine are contraindicated during the first trimester of pregnancy.
• There is currently no documented record of the use of artesunate-pyronaridine during the first trimester ofpregnancy.
• Continued pharmacovigilance and clinical research, including prospective controlled trials on the efficacy andsafety of antimalarial medicines for the treatment of malaria in pregnancy, should be supported and funded.

Practical info As with the deployment of any new malaria treatment recommendations, pharmacovigilance and adverse events and pregnancy outcome surveillance systems should be strengthened.