MALARIA: Intermittent Preventive Treatment of malaria in pregnancy using SulfadoxinePyrimethamine (IPTp-SP)

Updated WHO Policy Recommendation (October 2012)
_____________________________________________________________________
During the last few years, WHO has observed a slowing of efforts to scale-up intermittent
preventive treatment of pregnant women (IPTp) for malaria with SulfadoxinePyrimethamine (SP) in a number of countries in Africa. While there are several reasons for
this, confusion among health workers about SP administration for IPTp may also be playing a
role. For this reason, WHO is clarifying its recommendations, and urging national health
authorities to disseminate these recommendations widely and ensure their correct
application.
In several countries in Africa, some  Plasmodium falciparum parasites carry quintuple
mutations linked to SP resistance which are associated with in vivo therapeutic failure to SP.
IPTp with SP remains effective in preventing the adverse consequences of malaria on
maternal and fetal outcomes in areas where a high proportion of Plasmodium falciparum
parasites carry these quintuple mutations
1
 . Therefore, IPTp with SP should still be
administered to women in such areas.
All possible efforts should be made to increase access to IPTp with SP in all areas with
moderate-to-high transmission in Africa, as part of antenatal care services. Based on new
evidence the following updated recommendations are provided.
• In areas of moderate-to-high malaria transmission, IPTp with SP is recommended for all
pregnant women at each scheduled antenatal care visit. WHO recommends a schedule
of four antenatal care visits.
-   The first IPTp-SP dose should be administered as early as possible during the 2
nd
 
 trimester
2
 of gestation
        - Each SP dose should be given at least 1 month apart
        - The last dose of IPTp with SP can be administered up to the time of delivery, without safety
concerns
        - IPTp should ideally be administered as directly observed therapy (DOT)
        - SP can be given either on an empty stomach or with food
        - Folic acid at a daily dose equal or above 5 mg should not be given together with SP as this
counteracts its efficacy as an antimalarial
3
        - SP should not be administered to women receiving cotrimoxazole prophylaxis
                                                           
1
The findings of an observational study in Tanzanian women in an area with high levels of quintuple mutation strongly
associated with drug resistance and where the parasite dhps resistance mutation of codon 581 was also  present showed
increased placental parasite density and inflammatory changes in women reporting IPTp with SP use. This needs further
investigation although it is important to note that this specific dhps resistance mutation is currently not common.
2
 IPTp administration should be avoided during the 1
st
 trimester of gestation but should start as soon as possible in the 2
nd
trimester. The fact that a woman has entered the second trimester can be determined by the onset of quickening or by
measurement of fundal height by ANC health personnel.  
3
WHO recommends daily iron and folic acid supplementation in pregnant women at the dose of 30-60 mg of elemental iron and
0.4 mg of folic acid, to reduce the risk of low birth weight infants, maternal anaemia and iron deficiency at term.