Management for Dengue Hemorrhagic Fever

in Pregnancy: A Case Report

Rajuddin

, Lutfi Nogroho

Division of Reproductive Endocrinology & infertility, Department Obstetric & Gynecology, university of Syiah Kuala,

Banda Aceh ,Indonesia

Department Obstetric & Gynecology, university of Syiah Kuala, Banda Aceh ,Indonesia

Keywords: Dengue Hemorrhagic Fever, pregnancy, thrombocytopenia

Abstract:

Dengue hemorrhagic fever is a common tropical disease in Indonesia. Nowadays, the incidence

has been increasing among adults and more cases of dengue fever and dengue hemorrhagic fever

in pregnancy are being reported. We managed one case of dengue hemorrhagic fever during

pregnancy which developed during antepartum periods. We diagnosed dengue hemorrhagic fever

during pregnancy with clinical pictures of fever, hem concentration, thrombocytopenia and

serological test. This case was treated conservatively. The patient has recovery and has already

discharged. The patient came again after 3 days with chief complaint water broke history

previous C section, so we decided to perform emergency C Section. Patient and the baby were in

good condition before discharged. Where dengue is endemic, dengue infection should be highly

suspected in cases of febrile pregnant women. A knowledge of its diagnosis and management

plays a vital role for an obstetrician, particularly regarding to the mode of delivery. Supportive

care with analgesics, bed rest, adequate fluid replacement and maintenance of electrolyte balance

forms the main stay of treatment. The management of most cases was conservative.

1 INTRODUCTION

Dengue fever has become a major health problem

especially in tropical countries. Nowadays, the

incidence has been increasing among adults and

more cases of dengue fever and dengue hemorrhagic

fever in pregnancy are being reported. Dengue

infection in pregnancy increases the risk of

haemorrhage for both the mother and the newborn.

Increased incidence of preterm births and fetal

deaths has been reported due to dengue infection in

pregnancy.(Undurraga,2015) In the literature only

about 400 cases of dengue during pregnancy have

been reported, mainly describing the maternal and

fetal outcomes.(Paixao,2016)

Diagnosis of dengue

infection affects obstetric management, particularly

the mode of delivery due to the potential risk of

haemorrhage secondary to thrombocytopenia. A

knowledge of its diagnosis and management plays a

vital role. We report a case of dengue fever in

pregnant woman 36 weeks gestational age with

history previous C section.

Dengue, a mosquitos-borne flavivirus infection,

is hyperendemic in Indonesia. Dengue hemorrhagic

fever is a leading cause of hospitalization of children

in Southeast Asia. During the past three decades in

Indonesia. A number of patients who have dengue

hemorrhagic fever has increased by several years.

Hence, one should be aware of an increase in

incidence of the infection during pregnancy. We

managed one patient who developed dengue

infection during third trimester. She was admitted to

the Zainoel Abidin general hospital Banda Aceh and

serologic test showed primary dengue infection. The

effect on pregnancy and management are discussed

here.

2 CASE REPORT

A 21-year- old, gravida 2 woman who had been a

life long citizen Banda aceh was hospitalized in at

36 weeks gestational age with previous c section 1

time. She had undergone high fever for 3 days and

epistaxis associated with malaise. She was admitted

Rajuddin, . and Nogroho, L.

Management for Dengue Hemorrhagic Fever in Pregnancy: A Case Report.

DOI: 10.5220/0008788601830187

In Proceedings of the 2nd Syiah Kuala International Conference on Medicine and Health Sciences (SKIC-MHS 2018), pages 183-187

ISBN: 978-989-758-438-1

183

9 month of pregnancy, acording to last menstrual

period correspond due to 36 weeks gestational age

(wga). Patient did ANC regularly every month at

Obgyn. She went to the Obgyn for ultrasound her

pregnancy 4 times. The last ultrasound 2 weeks ago

said that the estimation fetal weight about 2000

gram, mother and fetal was in good condition. she

complained of high fever with petechiae at both

hand and headache that began 1 days prior to

admission at the Zainoel Abidin Hospital Banda

Aceh. She complained epistaxis before she came to

the Hospital. She developed epigastric pain and

vomitting. She also has spontaneous bleeding from

her nose, headache, tenderness in both leg and

epigastric pain, defecation and mixturition within

normal limit. She didnt complaint contraction, blody

show and water broke. no have flu symptomp. no

history of fluor albus. Active fetal movement.

On examination patient was conscious. She was

febrile 39.1 Celsius degrees. Her heart rate was

120/min, blood pressure was 110/70mmhg,

respiratory rate was 21 breaths/min. pulse rate was

120/min. Lungs were clear and no cardiac murmurs

were noted. She was started Intense fluid

resuscitation.( Normal saline) Bolus of 5-10

ml/kg/hour 1-2 hours given followed by 3-5

ml/Kg/Hour as a maintainance. Paracetamol 500 mg

and Ranitidine for epigastric pain. she was treated

with antipiretic drugs for 2 days.The fundal eight

was compatible with 36 weeks gestational age. The

fetal hearth rate was reassuring. Petechiae sized 1-2

mm in diameter were found around the arms.

Her hemoglobin was 10.3 g/dl; Hct 32%; TLC

11.000 cells/cumm; platelet count 108,000

cells/cumm; SGOT(315U/L) and SGPT (15U/L);

NS1Ag negative and IgG and IgM for dengue were

positive. Laboratory findings included the highest

level of hemoglobin concentrations 0f 10.7 g/dl,

hematocrit of 34% , and the lowest platelets of

35.000 on the fifth day. other laboratory findings

were within normal limit. She was diagnosed as

having dengue hemorrhagic fever grade II during

pregnancy and treated with intravenous fluid

replacement and close monitoring of vital sign and

laboratory every 12 hours. After 2 days admission,

the epigastric pain dissapeared and the vital signs

were within normal limits. On the sixth day, the

patient gradually recovered and the hematocrit was

32% with platelet count 45.000. on the ninth day the

platelet count 125.000 She was discharged on the

tenth day. Serologic study indicated primary Dengue

infection. At 37 weeks gestation, she came with

water broke. We decided to perform emergency C

section because history previous C section. Born a

healthy male baby weighing 2650 grams by C

section with an APGAR score at 1 min 9, and 5 min

of 10. No abnormality was detected.

3 DISCUSSION

Treatment and outcome of dengue in pregnant

women are similar to those of nonpregnant women.

Misdiagnosis or delayed diagnosis are often because

of the overlapping clinical and/or laboratory

features. The clinical and laboratory features are

similar with other disease that accompanied the

pregnancy. For examples HELLP syndrome,

pneumonia, pulmonary embolism, various obstetric

causes of pervaginal bleeding and other infectious

diseases.(Friedman,2016) Adverse pregnancy

outcome is still uncertain whether dengue is a

significant factor for adverse

Pregnancy outcomes such as preterm birth, low-

birth weight and caesarean deliveries. The risk of

vertical transmission is well established among

women with dengue during the perinatal period.

Significant impact of dengue at parturition are

severe bleeding may complicate delivery and/or

surgical procedures that performed on pregnant

patients with dengue during the critical phase, i.e.

the period coinciding with marked

thrombocytopenia with or without plasma leak.

Dengue fever does not warrant termination of

pregnancy. There is insufficient data of Probable

embryo developmental disorder to mothers who had

Dengue infection in first trimester.(Ribeiro,2015)

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. Oxytocin infusion should be

SKIC-MHS 2018 - The 2nd Syiah Kuala International Conference on Medicine and Health Sciences

184

Figure 1: Dengue case management modified from WHO guideline for Dengue Hemorrhagic fever

given for uterine contraction after delivery to

prevent postpartum haemorrhage. Misoprostol may

be given for post partum hemorrhage

Prophylaxis/treatment. Intramuscular injections are

to be avoided.(Chitra,2015)

2.3 Management of dengue hemorrhagic

fever in pregnancy

All pregnant patients with suspected DHF are

advised for close monitoring.

DF without warning signs: (Group

A).(Friedman,2016)

Monitor:

• 4 hourly Temperature charting , pulse,

Blood Pressure and Pulse pressure.

• Ensure urine output at least 4-6 hours.

• ( minimum 100 cc every 4 hours)

• Capillary refill Time

• Intake Out put record.

• Labs : Daily Complete Blood Count ,

other investigations if necessary.

Treatment:

•

Paracetamol 500-650 every 6 hours.

Warn the patient that fever may not

settle with this dose but NOT to exceed 4

grams paracetamol in 24 hours. Nor to take

other NSAID like ibuprofen and diclofenac

Sodium.

• Oral Intake encouraged such as Oral

rehydration solution, coconut water, Kanji,

juice all are encouraged apart from routine

food. Aim of at least 2.5 litres. If

Nausea/Vomitting of pregnancy restrict

oral intake give IV fluid (NS) 100 cc/ hour.



(Friedman,2016)

Doctor on duty should be notified if : less

Urine output, vomiting, lethargy, narrowing of

pulse pressure, delayed capillary refill.>2

seconds Warning symptoms and signs for

capillary leak are to be looked for vigilantly

specially so when fever starts subsiding. As

warning signs hallmarks capillary leak and she

can progress to severe Dengue .These are

patients for IV fluid therapy.(Chitra,2015)

• Abdominal pain and tenderness

• Persistent vomiting

• Lethargy, restlessness

• Liver enlargement >2 cm , Capillary refill

getting delayed. UOP less

• Mucosal Bleed : epistaxis, gum bleed

petechiae.

• Rise in HCT (20% of baseline)

• DHF with Warning sign (Group

B).(Friedman 2016)

Management for Dengue Hemorrhagic Fever in Pregnancy: A Case Report

185

Figure 2: Treatment Algorithm for Dengue Hemorrhagic Fever in pregnancy modified from WHO Guideline

Check vitals sign every hours. Catheterize to

know precise urine output hourly ( Aim

0.5ml/kg/hour). Intense fluid resuscitation.( Normal

saline) Bolus of 5-10 ml/kg/hour 1- 2 hours given

followed by 3-5ml/Kg/Hour as a maintenance. This

is monitored by urine output and Pulse pressure.

Avoid induction of labour/ planned surgery in this

phase.(Ribeiro,2015)

DHF with shock on admission (Group C), these

patients need institutional management in ICCU

setup. Timely fluid management with appearance of

any warning symptom practically prevents further

Compensated shock

(Systolic pressure maintaned, Narrow pulse pressure)

ormal saline 5-10 ml/k

/hr for 1

Improvement in

vitals pulse volume

capillary refill temp

0f extrimities

Reduce sline gradually

5-7ml/kg/hr for 1-2 hr

3-5ml/kg/hr for 2-4 hr

2-3 ml/kg/hr for 2-4 hr

yes

2nd bolus of normal

saline10-20 ml/kg/hr

Improvement

HCT

High

Severe overt

bleed

Colloid 10-20

ml/kg/hr evaluate

to consider blood

transfusion if no

clinical

improvement

Urgent blood

transfusion

HCT

Low

yes No

Improvement

As clinical movement

is noted, reduced fluids

accordingly

Further boluses may be

needed for next 24-48

hours

Stop IV fluids at 48

hours

yes

SKIC-MHS 2018 - The 2nd Syiah Kuala International Conference on Medicine and Health Sciences

186

complication before transferring this

patient.(Chitra,2015)

• Draw blood for CBC, to know HCT.

• Also for group cross match, SGOT,SGPT,

Electrolytes, sugar etc.

• Fluids Bolus given as (NS) 10cc /kg over

15 minutes before transfer

• And second bolus as 10ml/kg for next 1

hour during transfer

• Hand over all reports , fluid bolus

details for reference for further

treatment.

Prophylactic platelet transfusion is NOT

recommended unless delivery is inevitable ( in

coming 6 hours) platelet count > 50000/CC, and

75000/cc for operative delivery. Clinically stable

Dengue with Low or very Low platelet count in

critical/recovery phase didn’t need platelet

transfusion. Platelet transfusion may be given in

presence of Overt bleeding with Low platelet counts.

Platelet transfusion was generally avoided unless

there was significant bleeding or platelet counts less

than 20.000.(Schexneider,2015)

Operative delivery for obstetric indications only.

Avoid Planned induction and surgery. The presence

of wounds or trauma during the critical phase of

dengue with marked thrombocytopenia, and plasma

leak creates a substantial risk of severe

haemorrhage. Delivery should take place in a

hospital where blood/blood components and a team

of skilled obstetricians and a neonatologist are

available.(Kariyawasam,2016)

4 CONCLUSIONS

Dengue fever in pregnancy most often is treated

conservatively. Platelet count may fall rapidly but no

active intervention required unless patient is in

labour or has bleeding disorder. Dengue infection in

pregnancy may have resulted in maternal morbidity

and mortality. Gestational age of occurrence of

dengue fever seems to have a role early or late in

pregnancy had a poor prognosis. Treatment for

dengue infection in pregnancy is supportive and

need attention to fluid balance, maintaining

normothermia, platelet count and monitoring for

shock and consideration of delivery management.

Severe thrombocytopenia requiring initial

resuscitation with blood and blood products prior to

and during delivery. Platelet transfusion may be

given in presence of Overt bleeding with Low

platelet counts. Platelet transfusion was generally

avoided unless there was significant bleeding or

platelet counts less than 20.000. A thorough

investigation should be conducted so as to confirm

the infection and prevent further maternal and fetal

complications.

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