Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Print this page Email this page Users Online: 229

  Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 264-267  

Dengue in pregnancy


Department of Obstetrics and Gynecology, AFMC, Pune, Maharashtra, India

Date of Submission02-Oct-2019
Date of Decision20-Dec-2019
Date of Acceptance20-Dec-2019
Date of Web Publication3-Jun-2020

Correspondence Address:
Sushil Chawla
Department of Obstetrics and Gynecology, AFMC, Pune, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_195_19

Rights and Permissions
  Abstract 


Background: Dengue is a viral fever commonly seen in the Southeast Asia. It is spread by Aedes mosquito and is health menace, in our country. Dengue during pregnancy can affect the mother and the fetus. This study was done to study the effect of dengue fever on the fetomaternal outcome. Aim and Objectives:The aim was to study the effect of dengue during pregnancy on fetomaternal outcome. Materials and Methods: A prospective observational study was done to include the patients who were diagnosed with dengue using enzyme-linked immunosorbent assay based test, for a period of 2 years. Results: A total of 31 cases of dengue were diagnosed during a period of 2 years. Nine patients required platelet transfusions. Five patients were admitted to the intensive care unit (ICU) and nine newborns were admitted to neonatal ICU (NICU). Conclusion: Dengue during pregnancy leads to obstetric complications such as preterm labor, oligohydramnios, and NICU admissions.

Keywords: Complications, dengue in pregnancy, thrombocytopenia in pregnancy


How to cite this article:
Bhardwaj D, Chawla S, Sahoo I, Rathore P, Sharma A, Siddique N. Dengue in pregnancy. Med J DY Patil Vidyapeeth 2020;13:264-7

How to cite this URL:
Bhardwaj D, Chawla S, Sahoo I, Rathore P, Sharma A, Siddique N. Dengue in pregnancy. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Oct 25];13:264-7. Available from: https://www.mjdrdypv.org/text.asp?2020/13/3/264/285759




  Introduction Top


Dengue is the most rapidly spreading mosquito-borne viral disease in the world. In the last half a century, it has engulfed both the rural and urban areas equally, all across the world. The incidence has increased 30-fold with increasing geographic expansion to new countries, and over 50% of the world's population live in areas where they are at risk of the disease, and approximately 50% live in dengue-endemic countries. An estimated 50 million dengue infections occur annually.[1],[2]

Dengue is caused by the dengue virus (1–4 serotypes), which is one of the most important arboviruses in tropical and subtropical regions. Concern regarding pregnant women becoming infected with dengue has increased recently due to rise in infection in adolescent and adult women. The incidence of dengue cases has gradually increased in India in the last decade, and the newspapers are abundantly showing its presence all over the country. Some studies have reported that an epidemiological shift in dengue viruses and climate change might be responsible for the observed increase in dengue burden across India.[3],[4]

Physiological changes that occur during pregnancy (such as hemodilution) can mask the thrombocytopenia, leukopenia, or hemoconcentration associated with dengue, and common obstetric problems can cause hematological and hepatic issues, masking the disease. These may make it difficult to differentiate dengue fever and its complications from common obstetric conditions, leading to misdiagnosis or delayed diagnosis.[5],[6]

Currently, it is unclear if dengue infection in a pregnant woman results in serious health consequences for the mother or the child. Previous research has suggested higher proportions of preterm birth and low birth weight in infants born to mothers who had dengue during pregnancy. There is also some evidence that the risk of severe dengue and of hospitalization due to dengue is higher among pregnant compared with nonpregnant women and complications such as bleeding during the antenatal period, and increased cesarean section rates are more in pregnant women with dengue.[6],[7] However, most of the studies had small sample sizes or other methodological problems and thus with the aim to enhance our knowledge of the clinical profile, maternal, and fetal outcome of dengue fever during pregnancy and to investigate these issues in greater detail, and with greater power to explore the association between symptomatic dengue during pregnancy and maternal mortality, a descriptive observational study was carried out at a tertiary care hospital of Southern India.

Objective

The aim was to study the fetomaternal outcome in pregnant women who were diagnosed with dengue fever.


  Materials and Methods Top


The study was approved by the Institutional Ethical Committee of Armed Forces Medical College, Pune, during their meeting on April 13, 2016.

A descriptive observational study was carried out at a tertiary care health center of Southern India, for a period of 2 years from May 2016 to April 2018. The study included all the pregnant women reporting with fever to the health-care facility; however, the study population was formed by women presenting with fever and diagnosed with dengue after they tested positive for dengue using an enzyme-linked immunosorbent assay based test for nonstructural-1 (NS-1) antigen of dengue.

Pregnant women were included irrespective of the period of gestation of contracting the disease and were followed up till delivery, and all babies were followed up to 6 weeks postpartum. An informed and written consent was taken, a pro forma was used to collect maternal and neonatal data related to consequences of the disease antenatally, intrapartum, and postpartum on mother and the newborn.

The new revised World Health Organization clinical classification and case definitions were used to categorize the dengue patients-dengue with or without warning signs, and severe dengue infection.

Dengue without warning signs presents as an acute febrile illness with at least two of the following: nausea/vomiting, rash, aches and pains, leukopenia, and a positive tourniquet test. Warning signs are defined as abdominal pain, persistent vomiting, fluid accumulation, mucosal bleeding, lethargy, liver enlargement, and increasing hematocrit with decreasing platelets, and at least one must be observed to fulfill the diagnosis of dengue with warning signs. Severe dengue is associated with severe plasma leakage, severe bleeding, or organ failure.

All the patients were admitted to the hospital and managed in the antenatal ward or intensive care unit (ICU) depending on the clinical condition of the patients. These patients were managed along with the cross consultation with the physician and the hematologist, when required. Patients were managed with antipyretics, adequate hydration, and blood product transfusion as necessary.

Strict maternal and fetal surveillance were done to identify complications early. Platelet counts were done once or twice as required, depending on the clinical profile. The data were collected for the demographic characteristics of the patients, period of gestation at which dengue was detected, mode of delivery, medical complications in the mother, ICU, and neonatal ICU (NICU) admissions of the mother and the neonate, respectively. It also included details of the patients requiring transfusions of blood products.


  Results Top


During the study period, there were a total of 4592 deliveries. A total of 297 patients (6.5%) were admitted with fever during the pregnancy or postpartum period. A total of 31 patients (0.67%) were diagnosed and admitted with dengue (NS-1 positive) during this period.

The mean age of the patients was 23 years. The mean period of gestation at the presentation of these patients was 29.6 weeks. The majority of the patients, i.e., 19 patients presented to us in the third trimester of the pregnancy and included 14 primigravidae [Table 1].
Table 1: Demographics of the patients

Click here to view


The majority of the women (84%) came to the hospital only with fever and had no warning signs, and only a small proportion of women diagnosed with dengue fever had presented with warning signs or severe dengue. The common presentations during the clinical profile were – fever with myalgia, headache, rash all over the body, joint pains, and bleeding per vaginum and one patient presented with epistaxis. Pregnant women presenting with hemorrhagic rashes were seen in nine cases. Nine patients were transfused with blood components during the illness. Five patients required ICU care and monitoring. There was no maternal mortality during the study period at our center.

Twenty patients were seen with thrombocytopenia (<1.5 L/mm [3]) at presentation, and during the course of the disease, platelet count was thrombocytopenic in 30 cases. Two patients had platelet count below 20,000/mm [3] and 12 patients had platelet count below 50,000/mm [3]. Nine women required platelet and packed red blood cell's transfusions.

In the first trimester, the dengue behaved as an all or none phenomenon for the pregnancy well-being and all the four cases aborted during or after the illness. There was one case of intrauterine fetal demise in woman who presented with fever at 14 weeks. Eight patients had preterm delivery and 19 women delivered at term. Twelve newborns required NICU care >48 h for various reasons – prematurity, meconium aspiration syndrome, and respiratory distress syndrome, but there was no case of fetal anomaly. Nine patients were delivered by cesarean section due to various indications. One newborn died in NICU due to complications related to prematurity [Table 2].
Table 2: Clinical and perinatal characteristics of the patients

Click here to view


Oligohydramnios was noticed in five women. One lady developed postpartum hemorrhage and one woman had postabortal bleeding requiring transfusion. Five women had preterm labor. Five women were admitted to ICU for medical complications such as pulmonary edema and bleeding tendencies for hemodynamic monitoring. None of the newborns showed any feature of vertical transmission of dengue.


  Discussion Top


In this study, the women had a mean age of 23 years, which was similar to the previous study by Friedman et al., Kariwasam in a Sri Lankan study, and Sharma et al.[5],[7],[8],[9] The gravidity of the patients in our study indicated that most of these women were with their first or second pregnancy and it was similar to the previous studies.[5],[6],[7],[10] About 63% of the patients in our study had presented to us in the third trimester, and this was similar to the study by Chitra and Panicker et al.[5],[6],[9],[10] The majority of the case in our study was nonsevere and the most common presentation was with myalgia, fever, and headache.[8],[10]

Nine of 31 women (29%) in our study required blood component transfusions, thereby strengthening the findings of the study by Kariyawasam and Senanayake and Chitra and Panicker.[8],[10]

About 25% of the women in our study had preterm labor and 16% also showed oligohydramnios. These findings were similar to the review by Pouliot et al.[5],[11] There were 12 newborns who required NICU admissions >48 h, and the findings were similar to findings by Sharma et al.[5],[6],[9],[11] and none of the newborns showed any features of vertical transmission, while Tan et al.[12] showed a vertical transmission of 1.6%, in women delivering 63 newborns and were positive for dengue using dengue-specific IgM.


  Conclusion Top


This study highlights the clinical pattern and the natural course of dengue in pregnancy. The gestational age at the presentation of dengue fever appeared to be significant. Early onset or late onset in pregnancy appeared to have a bad prognosis. In contrast, nonsevere dengue was not associated with any apparent adverse maternal, fetal, or neonatal outcomes and requires only symptomatic treatment. Thus, all cases require fetomaternal monitoring to avoid adverse outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control. New Edition. Geneva: World Health Organization; 2009. Available from: http://www.who.int/tdr/publications/documents/dengue-diagnosis.pdf. [Last accessed on 2019 Oct 04].  Back to cited text no. 1
    
2.
Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, et al. The global distribution and burden of dengue. Nature 2013;496:504-7.  Back to cited text no. 2
    
3.
World Health Organization. Dengue and Severe Dengue: Fact Sheet No 117. Geneva: World Health Organization; 2012. Available from: http://www.who.int/mediacentre/factsheets/fs117/en/index.html. [Last accessed on 2019 Sep 30].  Back to cited text no. 3
    
4.
Malhotra N, Chanana C, Kumar S. Dengue infection in pregnancy. Int J Gynaecol Obstet 2006;94:131-2.  Back to cited text no. 4
    
5.
Friedman EE, Dallah F, Harville EW, Myers L, Buekens P, Breart G, et al. Symptomatic dengue infection during pregnancy and infant outcomes: A retrospective cohort study. PLoS Negl Trop Dis 2014;8:e3226.  Back to cited text no. 5
    
6.
Machain-Williams C, Raga E, Baak-Baak CM, Kiem S, Blitvich BJ, Ramos C. Maternal, fetal, and neonatal outcomes in pregnant dengue patients in Mexico. Biomed Res Int 2018;2018:9643083.  Back to cited text no. 6
    
7.
Paixao ES, Harron K, Campbell O, Teixeira MG, Costa MD, Barreto ML, et al. Dengue in pregnancy and maternal mortality: A cohort analysis using routine data. Sci Rep 2018;8:9938.  Back to cited text no. 7
    
8.
Kariyawasam S, Senanayake H. Dengue infections during pregnancy: Case series from a tertiary care hospital in Sri Lanka. J Infect Dev Ctries 2010;4:767-75.  Back to cited text no. 8
    
9.
Sharma S, Jain S, Rajaram S. Spectrum of Maternofetal Outcomes during Dengue Infection in Pregnancy: An Insight. Infectious Diseases in Obstetrics and Gynecology 2016;4.  Back to cited text no. 9
    
10.
Chitra TV, Panicker S. Maternal and fetal outcome of dengue fever in pregnancy. J Vector Borne Dis 2011;48:210-3.  Back to cited text no. 10
    
11.
Pouliot SH, Xiong X, Harville E, Paz-Soldan V, Tomashek KM, Breart G, et al. Maternal dengue and pregnancy outcomes: A systematic review. Obstet Gynecol Surv 2010;65:107-18.  Back to cited text no. 11
    
12.
Tan PC, Rajasingam G, Devi S, Omar SZ. Dengue infection in pregnancy: Prevalence, vertical transmission, and pregnancy outcome. Obstet Gynecol 2008;111:1111-7.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2]



 

Top
   
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
   Abstract
  Introduction
   Materials and Me...
  Results
  Discussion
  Conclusion
   References
   Article Tables

 Article Access Statistics
    Viewed366    
    Printed20    
    Emailed0    
    PDF Downloaded74    
    Comments [Add]    

Recommend this journal