Need for guidelines for the combined management of pregnancy and dengue: a retrospective study from an Indian tertiary care maternity hospital

Abstract

The incidence of dengue has risen in India in recent years. Evidence suggests that dengue in pregnancy may be associated with adverse maternal and fetal outcomes. The aim of our study was to analyse outcomes in pregnant women with confirmed dengue infection who had the benefit of close monitoring and intensive management at a tertiary maternity facility. We reviewed hospital data of 44 (0.11%) such women at Fernandez Hospital, a tertiary maternity unit, during the five-year period from 2011 to 2016. Maternal and fetal variables were collected from case sheets.

Dengue haemorrhagic fever was seen in 15.9% and dengue shock syndrome in one fatal case (2.2%). Thrombocytopenia was seen in 31 cases (70.4%) and 14 (31.81%) received platelets transfusions. Fetal outcomes in our series were favourable, except for one stillbirth, with 45.4% preterm deliveries and 15.9% small for gestational age babies. Dengue in pregnancy is definitely associated with maternal and fetal morbidity and mortality. A high index of suspicion of dengue is required in pregnant women with pyrexia and thrombocytopenia.

Keywords

Dengue fever pregnancy dengue shock syndrome thrombocytopenia retrospective observational study India

Introduction

Dengue has a wide clinical presentation ranging from being asymptomatic to uncomplicated fever or dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS).¹ In India, there is an overall increase in the incidence of dengue and associated deaths.² Dengue is associated with maternal and fetal morbidity with the stillbirth rate in the range of 6.6–47%.^3–6 Preterm birth and low birthweight are the most common adverse pregnancy outcomes.⁷

World Health Organization guidelines are available for the management of dengue fever but are deficient on maternal and fetal management.¹ A systematic review⁷ recommended that a pregnancy during which dengue is diagnosed needs to be monitored. However, many obstetric units in India may be able to monitor the pregnancy but lack facilities for appropriate management if severe complications are anticipated or ensue.

Materials and Methods

Electronic medical records of antenatal patients admitted to Fernandez Hospital, a tertiary maternity unit, during the five-year period from 2011 to 2016 were searched for a diagnosis of dengue, confirmed by the presence of NS1 antigen or dengue IgM antibodies.

Demographic variables were extracted. Laboratory data were also extracted for each patient and included platelet counts and liver function tests (LFTs). Other data collected related to co-morbidities. We also noted whether the patient was admitted to the intensive care unit (ICU) or had a blood product transfusion and whether their clinical picture was that of uncomplicated dengue fever, DHF or DSS. Fetal outcomes were also extracted and were grouped into admissions to the neonatal intensive care unit, stillbirth or neonatal death.

Results

Out of a total of 41,899 deliveries in our institution, 44 had a confirmed diagnosis of dengue (prevalence 1:952). This prevalence, however, represents only patients requiring admission. Ten presented in the first and second trimester of pregnancy and 34 in the third. Table 1 shows the estimated gestational age at the time of diagnosis and the number of cases delivered during acute infection. The majority manifested as uncomplicated dengue fever (n = 36, 81.8%), but seven (15.9%) developed DHF and one (2.2%) had DSS (Table 2).

Table 1.

Gestational age at presentation and number delivered during acute infection.

Gestational age (weeks)	Cases (n)	Continued pregnancy (n (%))	Delivered in acute infection (n (%))
<27	10	10 (100)	0
28–31	3	3 (100)	0
32–36	26	11 (42.3)	15 (57.6)
>37	5	2 (40)	3 (60)

Table 2.

Clinical grading of dengue infection.

	n = 44
Characteristics	n	%
Dengue fever	36	81.8
Dengue haemorrhagic fever	7	15.9
Dengue shock syndrome	1	2.2

Platelets were < 100 × 10⁹/L in 31 (70.4%) (Table 3) and LFTs were abnormal (defined as alanine transaminase > 14–59 U/L) in 25 (56.8%). Jaundice and pre-eclampsia were seen in 14 and eight cases, respectively. Eighteen (40.9%) required ICU care. Other complications which were reversible were acute lung injury, encephalitis and acute kidney injury in three individuals (Table 3). Postpartum haemorrhage (PPH) was observed in five (13.6%), and severe pre-eclampsia in eight (18.2%), five of whom suffered from HELLP syndrome.

Table 3.

Maternal morbidity.

Characteristics	n = 44
	n	%
Platelets < 100 × 10⁹/L	31	70.4
Abnormal LFT	25	56.8
ICU care	18	40.9
Jaundice	14	31.8
Platelet transfusion	14	31.8
Pre-eclampsia	8	18.2
Acute lung injury	1	2.5
Encephalitis	1	2.5
Acute kidney injury	1	2.5

We observed that the presence of thrombocytopenia was associated with a higher proportion of other complications such as liver dysfunction, multiorgan dysfunction, and acute kidney injury and disseminated intravascular coagulation.

In our series, there was one maternal death. She was a primigravida referred at 36 weeks of gestation with dengue and thrombocytopenia. In view of oligohydramnios and presumed fetal compromise, Caesarean section (CS) was performed after correcting the thrombocytopenia and she delivered a live baby She developed multiorgan dysfunction and required dialysis for acute kidney injury but nevertheless developed DSS and died on the second postoperative day.

The overall CS rate was high (37, 84.1%), the indications for which were presumed fetal compromise in 13 cases (35.1%), HELLP syndrome in five (13.5%), oligohydramnios in four (10.8%), previous CS in eight (21.6%), pre-eclampsia in three (8.1%) and maternal request, large fetus for gestational age, dengue fever and intrauterine fetal death in one case each. One intrauterine fetal death was a case of previous CS with thrombocytopenia who opted for repeat CS. Low platelet count necessitated general anaesthesia as opposed to regional anaesthesia for CS in nine cases.

In terms of fetal outcomes, there were no miscarriages but one baby was stillborn as discussed above. Of 44 babies, 23 (52.3%) were delivered at term and 20 (45.4%) were preterm. Table 4 shows other fetal outcomes.

Table 4.

Neonatal outcome.

	n = 44
Characteristics	n	%
GA < 37 weeks	20	45.4
SGA babies	7	17.5
NICU admissions	13/43	29.5
Stillbirth	1	2.2
Neonatal death	0	0

GA, gestational age; SGA, small for gestational age.

Neonatal intensive care was required for 13/43 babies (41.8%) due to prematurity and/or respiratory distress. The stillbirth occurred in a gravida 3 woman who was referred with DHF, sepsis and pre-eclampsia, and who delivered a baby weighing 2.2 kg at 34 weeks of gestation. Tests on 18 live-born neonates (who delivered during acute maternal infection) confirmed that four were dengue-positive and one had thrombocytopenia, requiring platelet transfusion.

Discussion

Dengue infection is now endemic in India and reported cases have increased from 28,292 in 2010 to 111,880 in 2016.² Consequently, women of reproductive age across the country are at risk of dengue infection during pregnancy and higher rates of adverse fetal and maternal outcomes have proved to be associated with the infection.⁷ In pregnant women with fever and thrombocytopenia, healthcare professionals should consider the possibility of dengue.

Elevated liver enzymes and low platelet count is seen in both dengue and HELLP syndrome. If blood pressure is >140/90 mmHg with the presence of proteinuria, elevated liver enzymes and low platelet count, HELLP syndrome is presumed. The clinical management as well as maternal and fetal outcome differ, based on whether the primary cause is dengue infection or HELLP syndrome is co-existing with dengue infection.⁹

Complications of DHF and DSS may occur despite appropriate management in the initial period.

Managing dengue in pregnancy is challenging because elective interventions in the critical phase of dengue illness can lead to life-threatening complications. This suggests the need for clinicians to compare their experiences of managing these cases and to share learning on the optimum treatment of complications. There is need to encourage the use of specifically treated bed nets for pregnant women. There is also a compelling need to develop consensus and evidence-based guidelines for the identification and safe management of dengue in pregnancy.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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