What is the management approach for congenital dengue in pregnant women?

Management of Congenital Dengue in Pregnant Women

Pregnant women with dengue infection require intensive monitoring and supportive care to prevent severe maternal and fetal complications, including dengue shock syndrome and vertical transmission to the fetus. 1

Maternal Risk Assessment and Management

Diagnosis and Initial Evaluation

• Test serum (and CSF if clinically indicated) for dengue antibodies in pregnant women presenting with:
  • Fever
  • Meningitis or encephalitis symptoms
  • Unexplained symptoms in dengue-endemic areas 1
• Report confirmed cases to local health departments for surveillance 1

Maternal Monitoring

• Close monitoring for dengue shock syndrome, which affects approximately 15% of pregnant women compared to 5% of the non-pregnant population 1
• Regular assessment for:
  • Thrombocytopenia (occurs in ~52% of cases)
  • Signs of plasma leakage
  • Liver damage
  • Acute kidney injury (occurs in ~18% of cases)
  • Respiratory distress (ARDS occurs in ~18% of cases) 1, 2

Supportive Care

• Management is primarily supportive as no specific antiviral treatments are available 3
• Maintain adequate hydration while avoiding fluid overload
• Monitor vital signs and platelet counts
• Prepare for potential hemorrhagic complications, especially postpartum hemorrhage (occurs in ~25% of cases) 2

Fetal Assessment and Management

Fetal Evaluation

• Detailed ultrasound examination 2-4 weeks after maternal infection onset to evaluate for structural abnormalities 1
• Consider testing amniotic fluid, chorionic villi, or fetal serum for evidence of dengue infection, though sensitivity and specificity are not well established 1

Delivery Planning

• Prepare for potential complications including:
  • Preterm birth (occurs in ~34% of cases)
  • Low birth weight (occurs in ~30% of cases)
  • Postpartum hemorrhage 2
• Delivery in a tertiary care center with neonatal intensive care capabilities is recommended due to high risk of complications 2

Neonatal Evaluation and Management

Assessment of Newborns

When an infant is born to a mother with confirmed dengue infection during pregnancy:

• Complete physical examination with special attention to:
  • Neurological status
  • Hepatosplenomegaly
  • Rash
  • Evidence of plasma leakage or hemorrhage 1
• Laboratory testing:
  • Complete blood count with platelet count
  • Liver function tests
  • Serum for dengue-specific IgM and RT-PCR for dengue virus 1

Follow-up Care

• Close monitoring for late-onset symptoms
• Developmental follow-up for infants with confirmed congenital dengue

Prevention Strategies

Vector Control and Personal Protection

• Pregnant women in dengue-endemic areas should:
  • Apply EPA-registered insect repellents (including DEET at <50% concentration) to skin and clothing 3
  • Wear long-sleeved shirts and long pants when outdoors
  • Avoid outdoor activities during peak mosquito-feeding times
  • Use screened windows, doors, air conditioning, and bed nets 3

Important Considerations

Maternal Mortality Risk

• Dengue in pregnancy is associated with high maternal mortality (15.9% in severe cases) 2
• Early recognition and referral to tertiary care centers is crucial for preventing serious adverse events 4

Vertical Transmission

• Vertical transmission of dengue from mother to child has been documented in prospective cohort studies, though transmission rates vary 1
• Infection of the placenta and transmission to the fetus may account for adverse perinatal outcomes 1

Common Pitfalls to Avoid

• Delayed recognition of dengue in pregnant women with fever in endemic areas
• Failure to monitor for postpartum hemorrhage, which is a significant complication
• Inadequate preparation for potential preterm delivery and neonatal complications
• Underestimating the severity of dengue in pregnancy, which carries higher risks than in non-pregnant individuals

Early diagnosis, intensive monitoring, and supportive care in a tertiary center are the cornerstones of managing congenital dengue to reduce maternal and fetal morbidity and mortality.