Maternal stabilization and deferred caesarean delivery for fetal tachycardia in late-pregnancy falciparum malaria with severe thrombocytopenia and no platelet support: a case report from Ghana

Thrombocytopenia is a common and usually self-limiting feature of malaria, but a markedly low platelet count can make emergency caesarean delivery for non-reassuring fetal status a high-risk undertaking where platelet concentrates and fresh frozen plasma are unavailable. We report a case in which this constraint, arising from late-pregnancy P. falciparum malaria initially referred as suspected pre-eclampsia, led to a period of maternal treatment, intrauterine resuscitation and close surveillance rather than immediate operative delivery. A 31-year-old Ghanaian woman, gravida 5 para 3 with one previous spontaneous abortion, at 37 weeks + 2 days dated by a reliable first-trimester scan, was referred with suspected pre-eclampsia (blood pressure 144/96 mmHg, dipstick proteinuria positive, fetal heart rate 165 beats/min), reduced fetal movement and lower abdominal pain, two weeks after oral artemether-lumefantrine for malaria. On arrival, blood pressure was 135/68 mmHg, dipstick proteinuria was negative, and cardiotocography showed a baseline of 179–186 beats/min with moderate variability, accelerations present and no decelerations. Microscopy identified P. falciparum trophozoites (22,268 parasites/µL); haemoglobin was 8.9 g/dL, platelet count was 37 × 10 9 /L (severe thrombocytopenia) and urinalysis showed ketonuria (+ + + ). The available record did not document a WHO severe malaria feature and repeat assessment did not support pre-eclampsia or HELLP syndrome. With platelet concentrates and fresh frozen plasma unavailable, immediate caesarean delivery was considered high risk. The treating team gave intrauterine resuscitation (intravenous fluids, left lateral position and oxygen), intravenous artesunate (2.4 mg/kg; 204 mg at 0, 12 and 24 h) and close maternal–fetal surveillance with stated criteria for escalation to delivery. Fetal tachycardia improved within 6–8 h and resolved by 24 h; the platelet count rose from 37 to 91 and 137 × 10 9 /L by hospital day 4. At 39 weeks, after obstetric reassessment, labour was induced. She delivered vaginally a 3.6-kg infant with Apgar scores of 8 and 9 at 1 and 5 min, respectively. Mother and infant remained clinically well through six weeks of two-weekly follow-up. Thrombocytopenia is a common complication of malaria in pregnancy, including uncomplicated malaria, and usually recovers with effective antimalarial treatment. When fetal tachycardia complicates late-pregnancy malaria, treatable maternal causes should be addressed first; in resource-constrained settings without platelet or plasma support, time-limited maternal treatment with close fetal surveillance and explicit escalation criteria may be safer than immediate operative delivery. The case also illustrates recurrence of parasitaemia two weeks after a standard three-day artemether-lumefantrine course in late pregnancy, when drug exposure is known to be reduced, although recurrence could not be distinguished from reinfection. The favourable outcome does not establish the safety or effectiveness of expectant management but highlights the need to document and balance competing maternal and fetal risks.