Dengue in pregnancy

 

 

 

 

Introduction

In the recent decade more cases of dengue in pregnancy are being reported. The clinical

manifestations, treatment and outcome of dengue in pregnant women are similar to those

of non-pregnant women but with some important differences (1, 2).

Misdiagnosis or delayed diagnosis are not uncommon due to some of the overlapping

clinical and/or laboratory features with the better recognized conditions of pregnancy.

These include eclampsia or pre-eclampsia, haemolysis, elevated liver enzymes and low

platelet count (HELLP) syndrome, pneumonia, pulmonary embolism, various obstetric

causes of per-vaginal bleeding and other infectious diseases

 

In order to recognize and diagnose dengue disease early in pregnancy, clinicians need to

maintain a high index of suspicion when dealing with pregnant women who present with

febrile illness after travelling to, or living in dengue-endemic areas.

Impact of dengue on pregnancy:

 

• Adverse pregnancy outcome (2–6)

It is still uncertain whether dengue is a significant factor for adverse pregnancy

outcomes such as preterm birth, low-birth weight and caesarean deliveries, as most
of the published data were based on hospitalized patients.

• Risk of vertical transmission (2, 6–10)

The risk of vertical transmission is well established among women with dengue
during the perinatal period (see Section 2.4.5).
 

• Significant impact of dengue at parturition (5,11)

Severe bleeding may complicate delivery and/or surgical procedures performed on
pregnant patients with dengue during the critical phase, i.e. the period coinciding with
marked thrombocytopenia with or without coagulopathy and vasculopathy.
 

Management of dengue during pregnancy:

• Early admission for close monitoring is recommended, especially for women close to

full-term/labour.

• Conservative medical and obstetrical management is the treatment of choice (12).

Challenges in recognition of dengue disease and plasma leakage in pregnancy

• Symptoms of hyperemesis during the first trimester of pregnancy resemble the

warning signs of severe dengue and this may delay the recognition of severe dengue.

• After the second trimester of pregnancy it is normal to see an increase in circulating

blood volume with generalized vasodilatation, resulting in an increased baseline heart
rate and lower baseline BP, as well as a lower baseline haematocrit. This can
confuse the diagnosis of dengue and therefore clinicians need to be alert to the
following:
 

o The lower BP and tachycardia of normal pregnancy could be misinterpreted as

hypotensive shock.

 

o The lower baseline haematocrit after the second trimester of pregnancy should be

noted. Establishing the baseline haematocrit during the first 2–3 days of fever is

Essential for early recognition of plasma leakage.
 

o Clinical signs of plasma leakage such as pleural effusion and ascites could be

difficult to elicit in the presence of a gravid uterus.

Challenges in monitoring and management

• Close observation and monitoring, prompt, adequate and appropriate replacement

therapy during the pre-, intra- and post-delivery periods are essential.

• Failure to recognize plasma leakage and/or shock early will lead to prolonged shock

and eventually massive bleeding and multi-organ failure.

• There is no difference in fluid therapy compared with the non-pregnant state (see

section on fluid management in Section 2.2). However it is important to note that the
growing gravid uterus may result in narrower tolerance of fluid accumulation in the
peritoneal and pleural cavity from plasma leakage. Hence excessive fluid
replacement should be avoided.
 

• The increased baseline heart rate and a lower baseline BP are normal physiological

changes in late pregnancy. Targeting an inappropriate heart rate and “normal” levels
of BP could result in fluid overload and respiratory distress.
 

• The presence of wounds or trauma during the critical phase of dengue with marked

thrombocytopenia, coagulopathy and vasculopathy creates a substantial risk of
severe haemorrhage.
 

• If severe haemorrhage occurs, replacement with transfusion of fresh whole

blood/fresh packed red cells should be promptly instituted (see Section 2.2.3.3).
 

• Prophylactic platelet transfusion is not recommended unless obstetrically indicated.

• Delivery should take place in a hospital where blood/blood components and a team of

skilled obstetricians and a neonatologist are available.
 

• Tocolytic agents and measures to postpone labour to a suitable time may be

considered during the critical phase of dengue illness. However there is currently a
lack of evidence on this practice.

Inevitable delivery during critical phase

 

• If delivery is inevitable, bleeding should be anticipated and closely monitored.

• Blood and blood products should be cross-matched and saved in preparation for

delivery.

• Trauma or injury should be kept to the minimum if possible.

• It is essential to check for complete removal of the placenta after delivery.

• Transfusion of platelet concentrates should be initiated during or at delivery but not

too far ahead of delivery, as the platelet count is sustained by platelet transfusion for
only a few hours during the critical phase.
 

• Fresh whole blood/fresh packed red cells transfusion should be administered as soon

as possible if significant bleeding occurs. If blood loss can be quantified, it should be
replaced immediately. Do not wait for blood loss to exceed 500 ml before
replacement, as in postpartum haemorrhage. Do not wait for the haematocrit to
decrease to low levels.
 

• Ergotamine and or oxytocin infusion as per standard obstetrical practice should be

commenced to contract the uterus after delivery to prevent postpartum haemorrhage.

Post-delivery

• Newborns with mothers who had dengue just before or at delivery, should be closely

monitored in hospital after birth in view of the risk of vertical transmission   
o At or near-term/delivery, severe foetal or neonatal dengue illness and death may
occur when there is insufficient time for the production of protective maternal
antibodies.

 

o Clinicians should be aware that presentation in either maternal or neonatal

disease may be atypical and confound diagnosis.

 

• Congenital infection could eventually be suspected on clinical grounds and then

confirmed in the laboratory.