Background <p>Very severe thrombocytopenia, characterized by a platelet count below 20,000/µL, in pregnant women with malaria, particularly Plasmodium falciparum infection, is&#xa0;a significant concern due to its association with increased mortality.&#xa0;While not always associated with bleeding, it can be a sign of severe disease and may require prompt intervention.</p> Case presentation <p>The author presents a rare case of a successful vaginal delivery in a 22-year-old, Para II, woman from Western Ethiopia, who had very severe malarial thrombocytopenia. She started treatment with artesunate for acute malaria at the local health center, which subsequently referred her to a tertiary hospital for more comprehensive care. At this hospital, she completed a course of artesunate and received a transfusion of packed blood cells. Labor commenced spontaneously, and she delivered a live newborn without any postpartum hemorrhage. During the postpartum period, she was monitored and subsequently discharged with a significant improvement in platelet counts.</p> Conclusion <p>Malarial thrombocytopenia is one of the significant complications associated with malaria during pregnancy. It typically presents as asymptomatic, even when platelet counts are very low. In contrast to thrombocytopenia caused by other factors, early diagnosis and prompt treatment with antimalarial medications can lead to improved outcomes for both the mother and the fetus.</p>