## Drug Selection in Pregnant Kala-azar **Key Point:** Liposomal amphotericin B is the safest choice for visceral leishmaniasis in pregnancy because it has minimal teratogenic risk and does not cross the placental barrier significantly. ### Why Liposomal Amphotericin B in Pregnancy? 1. **Teratogenicity Profile:** - Amphotericin B is a large, hydrophilic molecule with poor placental penetration - No established teratogenic effects in human pregnancy - Safe in all trimesters 2. **Dosing in Pregnancy:** - Liposomal formulation: 3–5 mg/kg IV daily for 10–15 days - Reduces nephrotoxicity compared to conventional amphotericin B - Achieves adequate parasite clearance 3. **Clinical Efficacy:** - Cure rate >95% in visceral leishmaniasis - Rapid parasite clearance protects both mother and fetus ### Contraindicated Drugs in Pregnancy | Drug | Reason for Contraindication | Trimester Risk | |------|------------------------------|----------------| | **Miltefosine** | Teratogenic (embryotoxic in animal models); Category X | All trimesters | | **Sodium stibogluconate** | Potential teratogenicity; limited safety data | All trimesters | | **Paromomycin** | Aminoglycoside; ototoxicity and nephrotoxicity risk | All trimesters | | **Liposomal Amphotericin B** | **Safe; minimal placental transfer** | **All trimesters** | **High-Yield:** WHO and Indian guidelines recommend liposomal amphotericin B as the drug of choice for kala-azar in pregnant women. Conventional amphotericin B is acceptable but carries higher nephrotoxicity risk. **Clinical Pearl:** Untreated visceral leishmaniasis in pregnancy carries high maternal and fetal mortality (~10–15% maternal mortality). Treatment with liposomal amphotericin B is strongly indicated and outweighs any residual risk. **Mnemonic:** **LAMP** = **L**iposomal **A**mphotericin B in **M**aternal **P**regnancy [cite:Harrison 21e Ch 220; NVBDCP Guidelines 2020]
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