Dengue In Pregnancy
DENGUE & PREGNANCY : DENGUE & PREGNANCY Dr.NEETA MISRA SENIOR CONSULTANT- OBS & GYNAE HOLY FAMILY HOSPITAL Presented at CME, south delhi forum of obs/gynae
INTRODUCTION : Dengue, the most common arboviral illness transmitted worldwide. It is caused by infection with 1 of the 4 serotypes of dengue virus, family Flaviviridae, genus Flavivirus (single-stranded nonsegmented RNA viruses). Dengue is transmitted by mosquitoes of the genus Aedes(aegypti & albopictus), which are widely distributed in subtropical and tropical areas of the world. Mosquito bites usually at dusk & dawn , in shady areas specially indoors & when the weather is cloudy.
TRANSMISSION : Dengue virus transmission follows two general patterns —epidemic dengue and hyperendemic dengue. Epidemic dengue transmission occurs when dengue virus is introduced into a region as an isolated event that involves a single viral strain. If the number of vectors and susceptible pediatric and adult hosts is sufficient, explosive transmission can occur, with an infection incidence of 25%-50%.
TRANSMISSION : Hyperendemic dengue transmission is characterized by the continuous circulation of multiple viral serotypes in an area where a large pool of susceptible hosts and a competent vector (with or without seasonal variation) are constantly present. Hyperendemic transmission appears to be a major risk for dengue hemorrhagic fever.
GLOBAL BURDEN : •WHO has classified it as a global healthy burden. Two fifths of the world (2.5 billion people) population are at risks • 50-100 million people are infected every year • 250,000 people progress to dengue hemorrhagic fever each year • 25,000 death each year • Missing data on non-hospitalised and less severe cases It is now endemic in more than 100 countries.
DENGUE INFECTED AREAS : DENGUE INFECTED AREAS
DENGUE & ITS EFFECT : • Clinical manifestation • Effect of pregnancy on dengue • Effect of dengue on pregnancy • Effect of dengue infection on fetus and neonate • Vertical transmission • Management in pregnant women
CLINICAL MANIFESTATIONS : Fever in persons with symptomatic dengue fever may be as high as 41°C. The fever typically begins on the third day and lasts 5-7 days, abating with the cessation of viremia. Fever is often preceded by chills, erythematous mottling of the skin, and facial flushing (a sensitive and specific indicator of dengue fever). Patients are at risk for development of dengue hemorrhagic fever or dengue shock syndrome at approximately the time of defervescence Headache is usually generalized. Retroorbital pain is common and is often described as severe. Patients may report nausea and vomiting.
CLINICAL MANIFESTATIONS : We typically see a maculopapular or macular confluent rash over the face, thorax, and flexor surfaces, with islands of skin sparing. The rash typically begins on day 3 and persists 2-3 days. Patients may have severe myalgias, particularly of the lower back, arms, and legs, and arthralgias, especially of the knees and shoulders.(nicknamed as break bone fever or bone crusher disease). Hemorrhagic manifestations may range from small amounts of bleeding from the nose or gums to melena, menorrhagia, or hematemesis.
RASH OF DENGUE FEVER : RASH OF DENGUE FEVER Typical confluent rash of dengue fever. More over thorax , back , face & flexor surfaces.
CLINICAL MANIFESTATIONS : Abdominal pain is reported; often, abdominal pain in conjunction with restlessness, change in mental status, hypothermia, and a drop in the platelet count presages the development of dengue hemorrhagic fever. Patients report fatigue and malaise. Patients may report conjunctival injection, sore throat, and cough. Cardiomyopathy is reported, with tachycardia during the febrile period and bradycardia and conduction defect. Myocarditis and congestive heart failure are rare.
DIAGNOSIS : The following case definitions for the diagnosis of dengue fever and dengue hemorrhagic fever or dengue shock syndrome have been developed: The clinical description of dengue fever is an acute febrile illness of 2-7 days duration associated with 2 or more of the following: Severe headache Retroorbital pain Severe myalgias Arthralgia Characteristic rash Hemorrhagic manifestations Leukopenia
DIAGNOSIS : Laboratory criteria for diagnosis include one or more of the following: Isolation of the dengue virus (NS1 antigen)from serum, plasma, leukocytes, or autopsy samples Demonstration of a 4-fold or greater change in reciprocal immunoglobulin G (IgG) or immunoglobulin M (IgM) antibody titers to one or more dengue virus antigens in paired serum samples Earliest abnormality detected in complete blood count is progressive leucopenia which should alert the physician.
DIAGNOSIS : Cases are classified as suspected if they are compatible with the clinical description. Cases are classified as probable if they are compatible with the clinical definition and satisfy one or more of the following criteria: Supportive serology (reciprocal hemagglutination-inhibition antibody titer greater than 1280, comparable IgG EIA titers, or positive IgM antibody test in late acute or convalescent-phase serum specimen) Occurrence at the same location and time as other confirmed cases of dengue fever A confirmed case is one that is compatible with the clinical definition and is confirmed by the laboratory.
DENGUE HAEMORRHAGIC FEVER : Criteria for the diagnosis of dengue hemorrhagic fever include confirmed case of dengue infection and hemorrhagic tendencies as evidenced by one or more of the following: A positive result from the tourniquet test Petechiae, ecchymoses, or purpura Bleeding from the mucosa, gastrointestinal tract, injection sites, or other sites Hematemesis or melena and thrombocytopenia (<100,000 cells/μL) and evidence of plasma leakage due to increased vascular permeability that manifests as one or more of the following: greater than 20% rise in average hematocrit level for age and sex, greater than 20% drop in hematocrit level following volume replacement compared to baseline, or signs of plasma leakage (eg, pleural effusion, ascites, hypoproteinemia)
DHF : DHF
DENGUE SHOCK SYNDROME : Dengue shock syndrome is diagnosed in cases meeting all of the above criteria plus evidence of circulatory failure, such as the following: Rapid, weak pulse Narrow pulse pressure (<20 mm Hg), with increased peripheral vascular resistance (PVR) and elevated diastolic pressure Hypotension Cool, clammy skin Altered mental status, although the patient may initially remain alert The onset of shock may be subtle, indicated by raised diastolic pressure and increased PVR in an alert patient.
EFFECT OF PREGNANCY ON DENGUE : Normal Physiological changes of pregnancy can make the diagnosis of dengue fever difficult – Coagulation profile changes – Hemodilution – Cardiovascular system changes • Diagnosis of dengue fever during pregnancy is challenging as it leads to confusion with other pregnancy complications like- – HELLP syndrome – Thrombocytopenia – Impaired liver function – Capillary leakage
ATYPICAL MANIFESTATIONS : More common during pregnancy • Neurological – Encephalopathy, encephalitis, thrombosis • Gastrointestinal – Hepatitis, acute pancreatitis • Renal – Renal failure, hemolytic uremic syndrome • Cardiac – Myocarditis, pericarditis • Musculoskeletal – Myositis, rhabdomyositis
EFFECTS OF DENGUE ON PREGNANCY : First trimester Abortions , infections Second Trimester Severe bleeding Abruption Threatened preterm labour Deranged coagulation profile Frequent transfusions
EFFECT OF DENGUE ON PREGNANCY : Third trimester Abruption Increased incidence of Cesarean section DIC Post partum PPH Infections Hematoma formation d/t deranged coagulation profile Delayed wound healing Low birth weight babies Maternal death due to DIC , Coagulopathy , Renal failure Increased chances of Dengue shock syndrome , Dengue hemorrhagic fever
VERTICAL TRANSMISSION : Rare, unrecognized 8 cases reported in Thailand 1.6% IgM positive in cord blood (Malaysia) Differential diagnosis from bacterial infection Awareness of vertical infection particularly in dengue endemic area holds importance Vertical transmission occurs at or near time of delivery. Infants have clinical features of fever , thrombocytopenia , hepatomegaly & circulatory insufficiency.
MANAGEMENT : Dengue fever is usually a self-limited illness Only supportive care is required. Crocin may be used to treat patients with symptomatic fever. Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids should be avoided. Patients with known or suspected dengue fever should have their platelet count and hematocrit measured daily from the third day of illness until 1-2 days after defervescence. Patients with a rising hematocrit level or falling platelet count should have intravascular volume deficits replaced. Patients who improve can continue to be monitored in an outpatient setting. Patients who do not improve should be admitted to the hospital for continued hydration.
MANAGEMENT : Successful management of severe dengue requires careful attention to fluid management and proactive treatment of hemorrhage. Intravascular volume deficits should be corrected with isotonic fluids such as RL . Boluses of 10-20 mL/kg should be given over 20 minutes and may be repeated. If this fails to correct the deficit, the hematocrit value should be determined, and, if it is rising &If the patient does not improve after this, blood transfusion should be considered. Patients with internal or gastrointestinal bleeding may require transfusion. Patients with coagulopathy may require fresh frozen plasma.
CRITERIA FOR DISCHARGE : Patients with dengue hemorrhagic fever or dengue shock syndrome may be discharged from the hospital when they meet the following criteria: Afebrile for 24 hours without antipyretics Good appetite, clinically improved condition Adequate urine output Stable hematocrit level At least 48 hours since recovery from shock Absence of respiratory distress Platelet count greater than 50,000 cells/μL
VACCINATION : No vaccine is currently available for the prevention of dengue infection. Immunogenic, safe tetravalent vaccines have been developed and are undergoing clinical trials. The only way to prevent dengue virus acquisition is to avoid being bitten by a vector mosquito. Exposure to one of the four serotypes of dengue offers no immunity against other types & makes the patient more susceptible to more severe symptoms. Therefore vaccine testing has to be taken very carefully & not in the areas where disease in endemic for fear of severe reactions with attenuated virus vaccines.
VACCINES : VACCINES
PREVENTION : PREVENTION The most effective measure to control dengue fever is to limit the spread of virus. This can be achieved only by eradication of dengue vector- aedes mosquito. All of us should join hands & decrease its spread by taking these few simple measures- 1.Check mosquito breeding sites like crevices , old stagnant water , coolers , water pots etc . 2.Use mosquito nets & repellents.
PREVENTION : PREVENTION 3.Prevent mosquito bites during transmission season by wearing protective clothings. 4. Use of mosquito larvicidal agents eg.Temiphos. 5. Use of anti mosquito sprays like DDT , malathion etc to be undertaken in hospitals.
CONCLUSION : Incidence of dengue infection during pregnancy is still underestimated Maternal age – younger mothers are more susceptible (less seropositive) Increase pregnancy complications in both mothers and fetus No vaccination& only prophylactic medication Avoid dengue infection particularly during late pregnancy
THANK YOU : THANK YOU