a 27-year - old pregnant g4p2 ( 28th gw ) , born in western africa but living in italy since 2012 , presented to the emergency department ( ed ) of our institution with headache , vomiting , diarrhea , and pelvic and low back pain . she contracted malaria in 2007 in western africa , but did not mention this on admission . ed laboratory tests were within the normal range , except for a slight increase in lactic dehydrogenase ( ldh ; 310 mg / dl ) and mild anemia ( hemoglobin [ hb ] ; 9.9 g / dl , table 1 ) . she was admitted to the obstetric ward and prophylactic ceftriaxone ( 2 g / day ) was administered . almost 24 h after admission , peak hyperthermia ( 39.4 ) was reached , with concomitant loss of consciousness . she recovered in approximately 15 min ; residual aphasia and evident cognitive impairment improved slowly over a few hours . no pathological abnormalities of the central nervous system were found during an urgent head computed tomography scan . respiratory and hemodynamic parameters remained stable ( spo2 99% in room air , blood pressure [ bp ] = 135/70 mmhg , heart rate [ hr ] = 95 beats per minute [ bpm ] ) . blood samples were drawn again ( table 1 ) and exhibited increased c - reactive protein ( crp ; 218.68 mg / l ) , bilirubin ( 2.95 mg / dl , direct = 1.18 mg / dl ) and ldh ( 466 mg / dl ) levels . notably , hb decreased to 7.8 g / dl and malaria parasites were found on examination of the peripheral blood smear ( blood parasites , 7% ) . infectious disease ( i.d . ) specialist prescribed quinine ( 600 mg ) for 2 h ( bolus ) followed by 2 g in 24 h , plus clindamycin ( 600 mg ) every 8 h to achieve tight control of glycemia , bp and electrocardiography.because fetal parasitemia and hemolysis were strongly suspected , a cd was planned . the patient 's general condition was stable ; no coagulation abnormalities were present and the platelet count was slightly lower than normal ( plt 98.000 /ml ) . therefore , 1000 ml of lactated ringer 's solution and ranitidine ( 100 mg ) were administered intravenously . in a sitting position , spinal anesthesia was performed at the l3-l4 interspace . using a 25-gauge whitacre needle , hyperbaric bupivacaine 0.5% ( 10 mg ) with sufentanil ( 5 g ) the patient was left in a supine position with left uterine displacement ; the surgery was initiated when the anesthetic block reached the t4 level . bp decreased slightly ( from 134/85 mmhg to 120/68 mmhg ) , then remained stable throughout surgery . at birth , the baby had slight respiratory depression ( apgar score of 8 at 1 and 5 min ) , and a bloodless umbilical cord on inspection . her weight was 1.77 kg and she required immediate oxygen support with a nasal cannula for hypoxemia ( spo2 rapidly decreased to < 80% in room air after aspiration ) . oxytocin ( 20 iu ) in 5% dextrose ( 500 ml at 125 ml / h ) was started immediately after birth . postoperative analgesia was obtained with a patient - controlled analgesia pump that delivered 1 mg / h of morphine for 24 h , with boluses of 2 mg possible on patient request every hour . plasmodium falciparum was identified only 4 days later by real - time polymerase chain reaction . blood parasites decreased over time ( 1% in the final blood sample , after 5 days ) . the patient 's antibiotic therapy continued and her symptoms were completely resolved two days after childbirth ; 24 h after birth , oxygen therapy for the baby was discontinued . blood samples drawn from the baby and the umbilical cord revealed no parasites , nor any signs of fetal hemolysis . among infectious diseases , malaria is most frequently imported into developed countries   due to its wide diffusion in africa , india and southeast asia . plasmodium falciparum is the most - common etiologic agent in africa ; p. vivax , ovale , malariae and knowlesi ( recently identified ) represent causes of infection in asia and other endemic regions . infection is transmitted by the bite of female anopheline mosquitoes , which inoculates sporozoites that are taken up by hepatocytes ; maturation then occurs over 710 days to produce schizonts . during the next stage of development , merozoites are released into the blood , which invade red blood cells and mature into gametocytes or schizonts over a period of 2472 h ( depending on the species ) . mature schizonts rupture erythrocytes and cause hemolysis and further release of merozoites into the bloodstream . the characteristic clinical manifestations of disease are both caused by hemolysis : hyperpyrexia occurring every 4872 h and global organ hypoperfusion caused by adhesion of schizonts to the lining of small blood vessels and resulting occlusion of capillary beds . during their maturation cycle , p.vivax and ovale also pass through a hypnozoite stage that allows the parasite to hide in hepatocytes for long periods before recrudescence . the clinical manifestations of malaria can vary from no symptoms to mild - to - severe systemic involvement . manifestations may include hematological compromise with anemia , thrombocytopenia , coagulopathy with possible disseminated intravascular coagulation ( in the worst cases ) , shock , respiratory insufficiency   that frequently requires supportive therapies in intensive care , neurological involvement , ranging from mild cognitive impairment to coma ; acute kidney injury , and hypoglycemic crisis . in africa , 25% of pregnant women experience malarial infection in regions of stable transmission , compared to 13.7% of pregnancies in areas of low transmission . pregnancy increases susceptibility to severe infection and complications ( such as anemia , hypoglycemia , and pulmonary edema ) because of pregnancy - associated alterations in acquired immune responses and the tendency of falciparum species to become sequestered in the placenta . therefore , death rates from severe malaria in pregnancy are two- to ten - fold higher compared to the non - pregnant population ; moreover , malaria doubles the risk of low birth weight and stillbirth . furthermore , the risk of transplacental transmission of the parasite is not negligible : in one study , more than half ( 57% ) of women with peripheral parasitemia had placental malaria , 3.8% of whom had parasites in their umbilical cord blood . the main risk factor for malaria transmission is the severity of infection at the time of delivery ( high - density peripheral and placental parasitemia ) . if fetal transmission occurs , the baby has a higher risk of anemia with congenital malaria , as seen in 833% of births . in our case , i.d . specialist consulted after the patient 's hyperpyrexia and loss of consciousness suspected malaria , so peripheral blood film was screened for parasites , even though the patient had not recently traveled to endemic areas . the literature contains no information concerning possible plasmodium falciparum infection relapse in non - endemic areas ; therefore , we speculate that increasing estrogen and progesterone concentrations , commensurate with advances in pregnancy , decrease the mother 's immunity by reducing natural killer t - cell activity , and possibly also b - cell activity , thus causing a relapse of dormant plasmodium . in our case , although it is unlikely that plasmodium falciparum reactivation occurred more than two years after possible contact with the parasite , a clear diagnosis of malaria was possible because parasites were identified in the peripheral blood smear . the infection responded to antimalarial therapy ; after the first episode of neurologic impairment , our patient showed no signs of cerebral malaria . her bp and breathing were stable throughout the cd , while the platelet count was slightly lower than normal ( plt 98.000 /ml ) . though few studies have evaluated neuraxial anesthesia in parturients with malaria , we selected spinal anesthesia for the cd due to the absence of significant thrombocytopenia , coagulopathy , secondary bacterial sepsis , or cerebral malaria with raised intracranial pressure ( icp ) . in two other recent cases , cd was performed under general anesthesia due to severe systemic sepsis , which required a subsequent admission to the intensive care unit for mechanical ventilation due to respiratory failure or multiorgan failure caused by leptospira co - infection . in our case , the mother 's parasitemia was severe ( 7% ) , but there was no worsening of her general condition after the loss of consciousness episode . accordingly , after initial support with an oxygen cannula , the baby was weaned rapidly ; her general condition was stable , with no malarial parasites identified in peripheral blood smears . in conclusion , fortunately , transplacental transmission is uncommon , but the baby may suffer due to anemia in the mother , with low birth weight or stillbirth occurring in the worst scenarios . it remains unclear whether pregnancy itself can stimulate an infection relapse in people from endemic areas . however , in the absence of signs of sepsis , coagulation abnormalities or raised icp , spinal anesthesia can be used as an alternative to general anesthesia .