Malaria in pregnancy remains a significant global health challenge, posing substantial risks for both pregnant women and infants. An estimated 125 million pregnancies are exposed to malaria annually, causing over 100,000 deaths in pregnant women and 200,000 deaths in neonates each year. Despite significant advancements in prevention and treatment, malaria during pregnancy continues to contribute to high rates of maternal mortality, perinatal death, low birth weight, and preterm delivery in endemic areas. While malaria primarily affects people in the Global South, modern migration patterns have led to an increasing number of cases in non-endemic areas. North Dakota, which has one of the highest per capita rates of refugee resettlement in the United States, serves as a representative example of the challenge of providing culturally competent care to globally diverse populations. In these non-endemic areas, delayed diagnosis may occur due to low clinical suspicion and provider inexperience with tropical infectious disease. This case report highlights the need for heightened clinical awareness of malaria in pregnant migrants from endemic regions and the importance of incorporating a global health perspective into routine prenatal care. A 31-year-old G4P2 female at 29 weeks gestation presented to a hospital in Fargo, North Dakota, with nausea, vomiting, and weakness. Having recently arrived from a refugee camp in Kenya, this was her first healthcare encounter in the United States. Initial workup revealed mild anemia, thrombocytopenia, and labs suggestive of dehydration, leading to a presumptive diagnosis of nausea and vomiting of pregnancy. She was given intravenous fluids and her symptoms transiently improved. Over the next few weeks she was managed as an outpatient with anti-emetics and oral hydration but continued to deteriorate, experiencing severe fatigue, weight loss, and persistent vomiting. At 33 weeks’ gestation, a routine hemoglobin test at a WIC appointment revealed a critically low level of 4.5 g/dL, prompting immediate hospital admission. Further investigation demonstrated elevated bilirubin (2.3 mg/dL), elevated AST (55 U/L), low haptoglobin (<8 mg/dL), and an elevated lactate dehydrogenase (687 U/L) suggesting severe hemolytic anemia. A peripheral blood smear confirmed intraerythrocytic Plasmodium falciparum parasites with 0.1% parasitemia. Infectious disease recommended the initiation of artemether-lumefantrine (Coartem) for treatment of malaria in pregnancy. During her seven day hospital stay she received five units of packed red blood cells. She responded well to treatment, and repeat malaria smear before discharge was negative. Following discharge, biweekly antenatal surveillance was conducted due to ongoing concerns about fetal growth and amniotic fluid volume. At 38 weeks, labor was induced for IUGR. She had an uncomplicated vaginal delivery of a healthy male infant, weighing 6 lb 0.7 oz, with APGAR scores of 7 and 9. Placental pathology revealed no residual parasites, and the neonate underwent routine malaria monitoring for four weeks with no signs of infection. This case underscores the diagnostic complexity of malaria in pregnancy, particularly in non-endemic regions where clinical suspicion may be low. Malaria may initially masquerade as hyperemesis gravidarum or anemia of pregnancy, delaying diagnosis and treatment. Though malaria can cause serious disease in all populations, pregnant women and their neonates are particularly vulnerable as parasites can sequester in the placenta, leading to impaired fetal oxygenation and nutrient transfer and ultimately contributing to IUGR, preterm birth, and maternal anemia. In severe cases, complications such as hypoglycemia, pulmonary edema, and cerebral malaria can develop significantly increasing maternal morbidity and mortality Despite global efforts to control malaria, challenges remain, including drug resistance, limited access to healthcare in some endemic regions, and the emergence of cases in non-endemic areas due to migration. Prevention strategies include insecticide-treated bed nets, chemoprophylaxis in high-risk populations, and recently developed malaria vaccines. For pregnant patients, prompt diagnosis and treatment with artemisinin-based combination therapies (ACTs) are critical to reducing adverse outcomes. Healthcare systems must adapt to these demographic changes by implementing robust screening protocols, providing ongoing education for clinicians, and ensuring access to diagnostic tools and treatments for uncommon conditions. Incorporating global health curricula into medical education and fostering multidisciplinary collaborations with infectious disease specialists and public health experts are essential steps toward improving outcomes for immigrant and refugee populations. This case also highlights the importance of ongoing research into the epidemiology, prevention, and treatment of malaria in pregnancy. As global migration patterns continue to evolve, healthcare providers must be equipped with the knowledge and resources to meet the needs of diverse populations. By embracing a global health perspective, clinicians can better address the unique challenges posed by infectious diseases like malaria, ultimately improving outcomes for mothers and infants both at home and abroad.
Weisner et al. (2026) studied this question.