USE OF QUININE IN PREGNANCY

Quinine is an antimalarial drug which has rapid schizontocidal activity against the erythrocytic forms of all Plasmodium species. It is the treatment of choice for acute chloroquine-resistant falciparum malaria, but is not considered suitable for malaria prophylaxis. Quinine may also be used in the treatment of leg cramps where other treatments have been ineffective.

Concerns have been raised regarding the use of quinine during pregnancy as it has been shown to have oxytocic effects and to increase insulin secretion, resulting in iatrogenic hypoglycaemia which may be severe, particularly in late pregnancy.

Several case reports have described major adverse fetal outcomes following quinine overdose during pregnancy. These have included reports of stillbirth, congenital deafness, hypoplasia of the optic nerve, and anomalies of the CNS, limbs, face and heart. There is, however, no evidence that the use of therapeutic doses of quinine for the treatment of acute malaria during pregnancy is associated with an increased risk of congenital malformations or other adverse fetal outcomes.

Updated WHO guidelines (2023) recommend a combination of artemether and lumefantrine for the treatment of uncomplicated P. falciparum malaria infection in the first trimester, based on findings from a large meta-analysis. Quinine is recommended as a second-line therapy to artemisinin-based combination therapies in the second and third trimester, based on findings from a large meta-analysis. Untreated or inadequately treated maternal malaria infection poses a serious risk to both the mother and the fetus, and quinine treatment should not be withheld on account of pregnancy. There are no available data relating to the use of quinine in the treatment of nocturnal leg cramps during pregnancy.

Additional fetal monitoring may be recommended in cases of supratherapeutic exposure to quinine, especially following such exposure in the first trimester. Other risk factors may also be present in individual cases which may independently increase the risk of adverse pregnancy outcome. Clinicians are reminded of the importance of consideration of such factors when performing case-specific risk assessments. Discussion with UKTIS is recommended in all cases.

Important: Please ensure that the selected antimalarial will provide appropriate prophylaxis for the area of travel. Advice is available from a number of sources (e.g., UKHSA,^[1] WHO^[2], BNF,^[3] Fit For Travel,^[4] Travel Health Pro,^[5] RCOG^[6] and TRAVAX^[7]).