Severe malaria in pregnancy in the United States: A case report and management considerations

Malaria in pregnancy is associated with substantial maternal and fetal morbidity, yet pregnancy-specific guidance remains limited, particularly in non-endemic settings where low clinical suspicion, non-specific symptoms, and testing barriers may delay diagnosis. This report presents a case of severe third-trimester Plasmodium falciparum malaria and reviews management considerations. A nulliparous patient at 36 weeks and 4 days of gestation presented to a U.S. community hospital with fever, headache, and abdominal discomfort, after recent travel to Ghana. Initial evaluation showed maternal fever, fetal tachycardia, thrombocytopenia, and an equivocal peripheral smear. Artemether–lumefantrine was started and escalated to artesunate when repeat testing confirmed Plasmodium falciparum with 5.4% parasitemia, meeting criteria for severe malaria. The patient experienced spontaneous preterm prelabor rupture of membranes and worsening thrombocytopenia, prompting transfer to a tertiary center. She underwent induction of labor, delivered vaginally, developed preeclampsia with severe features, and recovered with antimalarial therapy. The newborn remained stable, and congenital malaria was ruled out. This case highlights the importance of prevention, the diagnostic challenges of malaria in pregnancy, rapid progression to severe disease, and gaps in pregnancy-specific guidance. Algorithms integrating trimester-specific therapy dosing, fetal surveillance, delivery thresholds, and neonatal screening may help standardize care. • Travel history is fundamental when evaluating fever in pregnancy. • Repeated malaria testing in pregnancy is essential when clinical suspicion is high. • Malaria in pregnancy needs guidance on fetal surveillance and delivery timing.