Artemether-Lumefantrine
Artemether-lumefantrine (AL) is a fixed-dose artemisinin-based combination therapy (ACT) and the WHO-recommended first-line treatment for uncomplicated Plasmodium falciparum malaria in the second and third trimesters of pregnancy. In the first trimester, data are more limited but increasingly reassuring: large observational studies including the WHO-coordinated WWARN database and the PREGACT trial have not demonstrated increased rates of miscarriage, stillbirth, or major congenital malformations compared to quinine. WHO updated guidance (2015, reaffirmed 2023) endorses ACT use — including AL — in the first trimester when it is the only available effective treatment, acknowledging that untreated or undertreated falciparum malaria in pregnancy carries high risks of maternal death, severe anaemia, hypoglycaemia, pulmonary oedema, cerebral malaria, miscarriage, preterm birth, fetal growth restriction, and perinatal death. Quinine plus clindamycin remains the preferred regimen in settings where first-trimester ACT alternatives exist and clinical capacity allows. The drug is not indicated for severe or complicated malaria (IV artesunate is the standard of care) or for non-falciparum species without falciparum co-infection.
