Atypical Presentation of Malaria in Pregnancy: A Surgeon’s Dilemma in a Resource-Restrained Setting

Severe malaria in pregnancy remains a major contributor to maternal and perinatal morbidity in sub-Saharan Africa. When complicated by thrombocytopenia and fetal distress, management is particularly challenging in resource-limited settings, creating an ethical and clinical dilemma: whether to proceed with urgent delivery or delay for maternal stabilization. We report a 31-year-old multiparous Ghanaian woman at 37 weeks and 2 days of gestation, referred with suspected pre-eclampsia and fetal distress following a recent malaria episode treated with oral Artemether-Lumefantrine. She had received five doses of intermittent preventive treatment with sulfadoxine–pyrimethamine and an insecticide-treated net, but she did not use it. Investigations revealed severe Plasmodium falciparum malaria (parasite density 22,268/μL), moderate anemia (Hb 8.9 g/dL), marked thrombocytopenia (37 × 10⁹/L), and persistent fetal tachycardia (162–187 bpm). Emergency cesarean section was deferred due to unavailable blood products. She received intravenous Artesunate and supportive care, resulting in maternal stabilization and resolution of fetal tachycardia. One week later, induction of labor led to spontaneous vaginal delivery of a healthy infant. This case underscores overlapping malaria and hypertensive disorders, declining preventive efficacy, and health-system challenges, highlighting the importance of vigilant maternal stabilization and adaptive management to improve outcomes.