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Dengue: Impact in pregnancy

About Dengue

Dengue fever is caused by one of four viruses: Dengue 1, Dengue 2, Dengue 3, and Dengue 4. It is transmitted to humans via mosquito bites from infected Aedes species (Aedes aegypti or Aedes albopictus) and is a disease found in more than 100 nations throughout the world.Dengue fever affects around 3 billion people and is a common cause of sickness in pregnancy. It was estimated that more than 22,000 people die each year from severe dengue viral infection1.

From mother to child

A dengue-infected pregnant mother can transmit the virus to her fetus throughout pregnancy or shortly after birth. One documented case of dengue transmission through breast milk to date2.

Symptoms, treatment, and outcomes

Dengue fever symptoms, treatment, and outcomes in pregnant women are comparable to those seen in non-pregnant women. Due to some of the overlapping clinical and/or laboratory findings with the more well-known pregnancy disorders, misdiagnosis or delayed diagnosis occurs. Common symptom includes fever, rash, vomiting, headache etc. In case of severe dengue infection shock, thrombocytopenia, hemorrhage, hypovolemia, encephalopathy, oligohydramnios etc. could be found. Further retroocular pain, itching in palms and change in taste is a common symptom of dengue infection.

Risk Factors

Preterm birth, low birth weight, and caesarean births are all risk factors for dengue.

Significant impact of dengue during parturition: 

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 significant thrombocytopenia with or without plausibility.

Challenges in recognition of dengue disease and plasma leakage in pregnancy

Vomiting which is one of the warning signs may be taken as hyperemesis of pregnancy.Lower baseline BP, Baseline Tachycardia, and Lower baseline HCT attributed to physiological rise in blood volume.

Post-delivery observations:

Because of the danger of vertical transmission, newborns with mothers who had dengue fever just before or during delivery should be thoroughly observed in the hospital following birth. When protective maternal antibodies are not produced in time, serious foetal or neonatal dengue disease and death can occur during or shortly after birth.

Tests/investigation:

Lab diagnosis

  • Dengue HI test in paired sera showing 4-fold rise or fall: cross reactivity
  • IgM type antibodies in late acute/convalescent sera in primary infection
  • IgG type antibodies in high titer in secondary infection
  • Viral isolation:  sensitivity < 50%
  • RT- PCR: sensitivity > 90%

WHO Lab Criteria for Dengue

Probable Case:

CF + Supportive Serology: Acute HI titre> 1280, comparable IgG ELISA or +ve IgM

or occurrence at same location & time as other confirmed cases

Confirmed case: 

Isolation of virus from serum/ autopsy specimen

Demonstration of dengue virus antigen in serum/ CSF/ Autopsy tissue

Detection of dengue virus genome by PCR

Management of dengue fever in Pregnancy7

Suspect Dengue in pregnant patients coming with Fever.

  • Do baseline CBC on D1/D2 of fever.
  •  If WBC count normal/Lower side suspect dengue fever and repeat CBC after 24 hours and compare
  • Further fall in platelets/ rise in PCV.

Admission criteria:

All pregnant patients with suspected dengue are advised admission forclose monitoring.

without warning signs  (Group A)

Monitor:

  • 4 hourly Temperature charting, pulse, BP measurement.
  • Ensure urine output at least 4-6 hours. (Minimum 100 cc every 4 hours)
  • Capillary refill Time
  • Intake Output record.

Labs: Daily CBC, other investigations if necessary.

Treatment:

  • Paracetamol 500-650 mg 6 hourly. Warn the patient that fever may not settle with this dose but NOT to exceed 4 grams paracetamol in24 hours. Nor to take other NSAID like ibuprofen and diclofenac Sodium. 
  • Withhold Aspirin if she is taking it.
  •  Oral Intake encouraged. ORS, coconut water, Kanji, juice all are encouraged apart from routine food.
  • If Nausea/Vomiting of pregnancy restrict oral intake give IV fluid (NS) 100 cc/ hour.

Warning sign (Group B)

  • Monitor: Vitals(BP /Pulse pressure, Capillary Refill) hourly
  • Catheterize to know precise UOP hourly (Aim 0.5ml/kg/hour).
  • Intense fluid resuscitation(Normal saline) Bolus of 5-10ml/kg/hour X 2 hours given followed by 3-5ml/Kg/Hour as a maintenance. This is monitored by UOP and Pulsepressure.
  • Avoid induction of labour/ planned surgery in this phase.

With shock (GroupC)

  • Timely fluid management with appearance of any warning symptom practically prevents further complication.
  • Draw blood for CBC, to know HCT and SGOT, SGPT, Electrolytes, sugar etc.
  • Administration of IV fluids and paracetamol for fever management

Convalescent phase

Rise of WBC count followed by rise of platelet count, stabilization of HCT marks convalescent

phase.Watch for signs of fluid overload – cough, wheeze, tachypnea etc.

Prevention of dengue infection

  • Ant mosquito measures
  • Avoid open stagnant water in and around home
  • Bed nets
  • Long sleeved clothing
  • In house spraying repellants
  • Fogging of technical malathion before sunset since aedes aegypti are day biter.

References:

  1. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Vector-Borne Diseases (DVBD), https://www.cdc.gov/dengue/about/index.html
  2. L. E. Fatimil, A. H. Mollah, S. Ahmed et al., “Vertical transmission of dengue: first case report from Bangladesh,” The Southeast Asian Journal of Tropical Medicine and Public Health, vol. 34, no. 4, pp. 800–803, 2003.
  3. Carlos Machain-Williams et al., Maternal, Fetal, and Neonatal Outcomes in Pregnant Dengue Patients in Mexico, BioMed Research International Volume 2018, Article ID 9643083, 8 pages,https://doi.org/10.1155/2018/9643083.
  4. Sawyer H Pouliot et al., Maternal dengue and pregnancy outcomes: a systematic review, ObstetGynecolSurv,2010 Feb;65(2):107-18.10.1097/OGX.0b013e3181cb8fbc.
  5. Le Phi Hung et al., Case Report: Postpartum hemorrhage associated with Dengue with warning signs in a term pregnancy and delivery Version 1. F1000Res. 2015; 4: 1483.
  6. Dengue: Guidelines for diagnosis, treatment, prevention and control., WHO Library Cataloguing-in-Publication Data, ISBN 978 92 4 154787 1. 
  7. FOGSI Guidelines: https://www.fogsi.org/wp-content/uploads/2015/11/dpmp.pdf

Endorsed By,

Dr.Rabindra Kr. Yadav

M.B.B.S. (Ranchi)

PG diploma in Maternal & Child Health.

District Vector Borne Disease Control Officer

Department of Health,Govt.of Bihar

Hon. Secretary of IMA,Dumra Branch 

President, Olympic Association, Sitamarhi, Bihar