Obstetrics and Gynecology

Pregnancy Outcome in Women with Dengue

Infection in Northern India
Prabhat Agrawal*, Ruchika Garg†, Soumya Srivastava†, Urvashi Verma†, Rekha Rani†

Abstract
Background: Dengue is the most prevalent mosquito-borne infection worldwide. Vertical transmission after maternal dengue
infection to the fetus and pregnancy losses in relation to dengue infection have been reported. Objective: The aim of the
study was to assess the maternal and fetal consequences of dengue fever (DF) infection during pregnancy. Methodology:
A retrospective analysis of all pregnant women with DF was done over a period of 1 year. Clinical, laboratory, maternal and
fetal outcomes and early neonatal outcomes were collected from patients with confirmed dengue infection. Result: An upward
trend was observed with a striking feature of severe thrombocytopenia in 36% cases. Oligohydramnios and low birth weight
were the most common and peculiar outcomes. Preterm delivery with increased risk of cesarean section was noted. Vertical
transmission occurs in pregnancy but no evidence of congenital anomaly could be traced.
Keywords: Dengue fever, pregnancy, dengue hemorrhagic fever

D
engue fever (DF) is a febrile disease found in
the tropics. It is a major public health problem
in tropical countries. It is caused by virus
serotypes of the genus Flavivirus, family flaviviridae,
Group IV ssRNA. Dengue is transmitted to humans by
mosquito Aedes aegypti.
Despite previous outbreaks, a large number of people
remain susceptible because there are four different
strains of the dengue virus.
Dengue infection in pregnancy carries the risk of
hemorrhage in both the mother and the newborn.
There is serious risk of premature birth and fetal death.
In case of infection close to term, there is risk of vertical
transmission.
METHODOLOGY
A retrospective analysis of all pregnant women with
confirmed dengue infection during pregnancy admitted
in July 2011 to December 2012 in PG Dept. of Medicine
and Dept. of Obstetrics and Gynecology at SN Medical
College, Agra was conducted in 25 patients. Dengue
*Lecturer
PG Dept. of Medicine
†Lecturer
Dept. of Obstetrics and Gynecology
SN Medical College, Agra, Uttar Pradesh
Address for correspondence
Dr Prabhat Kumar Agrawal
D-1, Sulahkul Nagar, Bodla Road, Agra, Uttar Pradesh
E-mail: ruchikagargsnmc@gmail.com
infection was confirmed either by presence of specific
immunoglobulin M (IgM) capture enzyme-linked
immunosorbent assay (ELISA) or dengue nonstructural
proteins (NS) antigen and the outcome is illustrated in
Table 1.
RESULT
In our study on 25 patients suffering with DF, data was
collected regarding obstetric and fetal outcome during
a period of 1 year. An upward trend was observed with
72% as multigravida and 28% as primigravida. DF was
seen in 24%, dengue hemorrhagic fever (DHF) in 56%,
dengue shock syndrome (DSS) in 20%. Twelve percent
patients were in first trimester, 12% in second trimester
and 76% in third trimester. Dengue serology IgM was
positive in 20 cases (80%), NSAg positive in 17 cases
(68%) and both IgM and NSAg positive in 14 cases
(56%). There were six cases of early pregnancy with DF,
out of which four (16%) had abortion and two cases (8%)
could progress to term. There was no mortality seen in
early pregnancy. Second and third trimester had varied
presentation. Preterm delivery was seen in 17 cases
(68%), in three cases (12%) pregnancy progressed to term.
Eight patients (32%) underwent emergency lower-
segment cesarean section (LSCS) (4 for fetal distress and
4 for cephalopelvic disproportion), while 11 patients
(44%) delivered normally. Antepartum hemorrhage
(APH) due to abruptio placentae was seen in eight
patients (32%), postpartum hemorrhage (PPH) was
found in six patients (32%), oligohydramnios in 52%

Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014 1053
Obstetrics and Gynecology

Table 1. Diagnosis and Outcome of Pregnancy in Women with Dengue Infection Included in the Study
Gestational Platelet count Clinical Obstetric Neonatal
NSAg1 IgM Ab. Maternal morbidity
age unit (µ/mL) diagnosis outcome outcome
36 WKS (P), Preterm labor (PTL) with fetal Emergency (Em.) LBW, neonatal
56,000 +ve –ve DF
Primi (P) distress (FD) LSCS jaundice
31 WKS (M), Mild oligohydramnios Managed
82,000 +ve +ve DF with PIH Term AGA baby
Multi (M) (Oligo.) conservatively
IgM
Chronic fever Em. PTL LSCS
30 WKS (M) 20,000 +ve malaria APH with PTL with Oligo. LBW, ARDS
with DHF with PPH
+ve
8 WKS (P) 28,000 +ve –ve DHF Pain with bleeding P/V Missed abortion

30 WKS (M) 50,000 +ve +ve DHF Mild pain with rash Managed till term AGA baby
Anomaly scan and fetal ECHO
18 WKS (P) 25,000 –ve +ve DF Missed abortion
(N)
Mild Oligo. with pain Managed
13 WKS (M) 18,500 –ve +ve DHF Term AGA baby
abdomen conservatively
Cardiopulmonary
39 WKS (M) 28,000 +ve +ve DSS ARDS with Oligo. and shock Expired
arrest
DHF with prev. Rexplored-6L
38 WKS (M) 38,000 –ve +ve Post-LSCS hemoperitoneum LBW, ARDS
1 LSCS Blood removed
Intracranial
APH with PET with Oligo. Em. with LSCS
35 WKS (M) 27,000 +ve +ve DHF hemorrhage ICH
with FD PPH
(Expired)
36 WKS Preterm delivery LBW twins with
26,000 +ve +ve DF with PET APH with PROM with Oligo.
Twins (M) (PTD) ARDS
29 WKS (P) 1,29,000 –ve +ve DSS Managed conservatively NVD at term AGA baby
PTD with PPH
36 WKS (M) 14,000 +ve +ve DHF with ICH PTL with Oligo. LBW
Cardiac arrest
DHF with
36 WKS (M) 18,000 +ve +ve cerebral APH with Oligo with IUD PTD Fresh stillbirth
edema
20,000 APH with Oligo. with FD with Em. LSCS with
35 WKS (M) +ve +ve DSS with FD LBW
PTL PPH
82,000 Em. LSCS with
36 WKS (P) –ve –ve DHF with DIC APH with FD with PTL LBW (Expired)
PPH
7 WKS (M) 84,000 –ve +ve DF Bleeding P/V Missed abortion
35 WKS (M) 21,000 +ve +ve DSS Oligo. with APH with FD IUD
LBW with ICH
28 WKS (P) 22,000 +ve +ve DHF PTL with Oligo. with DIC PTD with IUGR
with rash (Expired)
29 WKS (P) 16,000 +ve +ve DSS IUD
DHF with
34 WKS (M) 20,000 +ve +ve Oligo. with anemia with BPV PTD
ARDS
Oligo. with APH with anemia
35 WKS (M) 68,000 –ve +ve DHF with PET PTD with PPH LBW
with PTL
Oligo. with H/O prolonged Em LSCS with
32 WKS (M) 74,000 +ve –ve DF with ARDS LBW
fever PPH
Em LSCS with LBW (Exp.) with
38 WKS (M) 20,000 +ve +ve DHF Hematuria with LP's
PPH (Expired) ARDS (Expired)
LBW with ICH
6 WKS (M) 15,000 +ve –ve DHF Bleeding tendency Missed abortion
with rash (Expired)

1054 Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014

Table 2. Comparison of Results of our Study with that
of Basurko et al.
Basurko C Our study
Premature labor 41% 52%
Oligohydramnios 46% 52%
APH 9.3% 32%
PPH 10% 36%
IUD 3.8% 8%
Abortions 3.8% 16%
FD 7.5% 16%
Neonatal death 1.9% 18%
APH = Antepartum hemorrhage; PPH = Postpartum hemorrhage;
IUD = Intrauterine device; FD = Fetal distress.
and low birth weight (LBW) in 52%. Two patients had
intrauterine device (IUD) (8%). Out of all live births
(68%), five neonates expired during early neonatal
period and four (16%) babies required neonatal
intensive care unit (NICU). Maternal mortality was seen
in three cases (12%) common causes of which were PPH
and shock. No congenital anomaly could be traced in
the babies born. The comparisons of the results of our
study with that of Basurko et al is given in Table 2.
DISCUSSION
Classical DF is defined as an acute febrile illness
with high continuous fever for 3 days or more, with
two or more other clinical manifestations involving
headache, retro-orbital pain, myalgia, arthralgia, rash,
hemorrhagic manifestation or leukopenia, and is
supported by serology or occurrence at same location
and time as other confirmed cases (World Health
Organization [WHO] guidelines).
According to WHO definition of DHF all four of the
following criteria must be fulfilled: Fever, hemorrhagic
tendency, thrombocytopenia and evidence of plasma
leak as evidenced by hematocrit 20% higher than
expected or a drop in hematocrit of 20% or more
from the baseline following intravenous (IV) fluid,
pleural effusion or ascites. DHF is characterized
by fever, hemorrhagic tendencies (petechial
hemorrhages, gum bleeding, generalized rash),
thrombocytopenia and evidence of plasma leakage,
as well as possible association with hepatomegaly
and circulatory disturbances. DSS is manifested
when DHF symptoms include rapid and weak pulse,
narrow pulse pressure <20 mmHg and hypotension.
Platelet deficiency is a constant feature in dengue
infection. With DHF, increased vascular permeability
Obstetrics and Gynecology
resulting in hemoconcentration and plasma leakage
is evidenced by pleural effusion, ascites and
hypoproteinemia. Some of these syndromes may
be confused with HELLP (hemolysis, elevated liver
enzyme and low platelet count) syndrome but a high
index of suspicion of dengue infection is required. The
physiological changes of pregnancy have to be kept in
mind before interpreting the laboratory findings. The
normal hematocrit range in pregnant woman may be
as low as 34% (normal for a nonpregnant woman is
37-47%). There are various other entities in pregnancy
resembling dengue viz. idiopathic thrombocytopenic
purpura (ITP), systemic lupus erythematosus (SLE)
and antiphospholipid antibody syndrome (APA
syndrome) or inherited diseases or pregnancy-
related complications such as pre-eclampsia, sepsis
or disseminated intravascular coagulation in obstetric
cases may cause thrombocytopenia. In 75% of the
cases, thrombocytopenia cannot be attributed to any
of these etiologies.
CONCLUSIONS
Thus DF led to poor maternal and perinatal
outcomes in our setting. Preventive measures should
be employed in the region. Dengue in pregnancy
requires early diagnosis and treatment. A high index
of clinical suspicion is essential in any pregnant
female with fever during epidemics. Further
studies are mandatory as evidence-based data in
the management of dengue specific for pregnancy,
are sparse. Travel during pregnancy to dengue
endemic areas poses a risk to both mother and fetus.
Pregnancies complicated by dengue infection require
close monitoring for potential maternal and fetal
complications. The striking feature observed was the
presence of severe thrombocytopenia in 78% patients,
oligohydramnios and LBW being common in 52%
cases.
In addition, coexistence of other vector-borne diseases
was also noted. Transplacental infection occurs,
but protective antibodies pass transplacentally
and fetal effect may be minimal given sufficient
immune response. In near term disease, severe fetal
or neonatal illness or death may occur. Such illness
may also predispose the newborn to subsequent DHF.
Conservative medical and obstetrical management is
the treatment of choice. Only women who went into
labor required platelet transfusion. Outcome seemed
to correlate with the gestational age at which dengue
infection was acquired.
Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014 1055
Obstetrics and Gynecology
Suggested Reading
1. Restrepo BN, Isaza DM, Salazar CL, Ramírez JL, Upegui
GE, Ospina M, et al. Prenatal and postnatal effects
of dengue infection during pregnancy. Biomedica
2003;23(4):416-23.
2. Tan PC, Rajasingam G, Devi S, Omar SZ. Dengue infection
in pregnancy: prevalence, vertical transmission, and
pregnancy outcome. Obstet Gynecol 2008;111(5):1111-7.
3. Christiane Fernandes Alvarenga, Vânia Glória Silami,
Patrícia Brasil, Maria Elizabeth Herdy Boechat, Janice
■■■■
...Cont’d from page 1047
On laparotomy, dense adhesions between anterior
abdominal wall and uterus were noted. Peritoneal
spillage of blood with flimsy adhesions all around
was seen. Uterus was bulky, 16-week size, soft bag
like, with bilateral hematosalpinx. Adhesions
were removed with sharp and blunt dissection.
Due to adhesions and pinpoint stenosed cervix,
total abdominal hysterectomy with right salpingo-
oophorectomy and left salpingectomy was done (Fig. 1).
Cut section of uterus showed complete cervical stenosis
with a band like structure in the lower part of uterus.
Cavity contained old dark blood. Postoperative period
was uneventful, and preoperative abdominal pain,
tenderness completely subsided.
Discussion
Acquired cervical stenosis is most commonly
associated with uterine malignancy, extensive surgical
manipulation at cervix and menopause. The incidence
observed for cervical stenosis widely varies from
0% to 26%.1 In our case, we do not know the exact cause
of cervical stenosis. There is possibility of placenta
previa associated with transverse lie. Poothavelil et
al reported a case of hematometra following cesarean
section for placenta previa.2 In our case; it could be the
1056 Indian Journal of Clinical Practice, Vol. 24, No. 11, April 2014
Coelho, Rita Maria Ribeiro Nogueira. Dengue during
pregnancy: a study of thirteen Cases. Am J Infect Dis
2009;5(4):288-93.
4. Basurko C, Carles G, Youssef M, Guindi WE. Maternal
and fetal consequences of dengue fever during pregnancy.
Eur J Obstet Gynecol Reprod Biol 2009;147(1):29-32.
5. Ismail NA, Kampan N, Mahdy ZA, Jamil MA, Razi ZR.
Dengue in pregnancy. Southeast Asian J Trop Med Public
Health 2006;37(4):681-3.
6. Phupong V. Dengue fever in pregnancy: a case report.
BMC Pregnancy Childbirth 2001;1(1):7.
extension of lower uterine incision, while taking out
transverse lie baby and inadvertent taking of posterior
lip of cervix with incision line while closing. Thomas et
al reported a similar case of cervical stenosis following
cesarean section and vesicovaginal fistula (VVF)
repair.3 Cervical stenosis, most of the time, presents
with features of hematometra and in premenopausal
women it presents with endometriosis like features.
Inflammation is the cause of pain in abdomen. We were
not able to do cervical dilatation and hematometra
drainage because of fear of perforation and it could not
have relieved symptoms.
References
1. Suh-Burgmann EJ, Whall-Strojwas D, Chang Y, Hundley D,
Goodman A. Risk factors for cervical stenosis after
loop electrocautery excision procedure. Obstet Gynecol
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2. Poothavelil MB, Hamdi I, Zunjurwad G. Occlusion of
upper genital tract following lower segment caesarean
section for placenta praevia. Sultan Qaboos Univ Med J
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3. Thomas S, Roy P, Biswas B, Jose R. Complete cervical
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