What is the recommended management for dengue (Dengue Virus) in pregnancy?

Management of Dengue in Pregnancy

Pregnant women with dengue require prompt diagnostic testing, close monitoring for warning signs, and supportive care with acetaminophen for fever, adequate hydration, and hospitalization when indicated to prevent maternal and fetal complications. 1

Diagnostic Approach

• For symptomatic pregnant women, collect serum and urine specimens as soon as possible within 12 weeks of symptom onset for concurrent dengue and Zika virus nucleic acid amplification tests (NAATs) and IgM antibody testing 1, 2
• Perform dengue and Zika virus NAATs on serum collected ≤7 days after symptom onset, as this is the optimal window for viral detection 2
• If IgM antibody testing is positive without positive NAAT results, confirmatory plaque reduction neutralization tests (PRNTs) should be performed to differentiate between dengue and other flaviviruses 2, 1
• Consider local epidemiology of circulating viruses when interpreting test results 1

Clinical Assessment and Monitoring

• Monitor closely for warning signs of severe dengue, including:

  • Persistent vomiting, abdominal pain/tenderness 1
  • Clinical fluid accumulation (pleural effusion, ascites) 1
  • Mucosal bleeding (gums, nose, gastrointestinal tract) 1
  • Lethargy, restlessness, altered mental status 1
  • Liver enlargement 1
  • Rising hematocrit with concurrent thrombocytopenia 1

• Pregnant women are at higher risk for severe complications including:

  • Severe dengue with hemorrhage 3
  • Preeclampsia and gestational hypertension 3
  • Maternal death 3, 4
  • Organ dysfunction 3

Management Principles

• Provide appropriate supportive care without waiting for definitive diagnostic test results 1

• Manage fever and pain with acetaminophen/paracetamol only 1

• Strictly avoid NSAIDs and aspirin due to increased bleeding risk 1

• Ensure adequate hydration with fluids containing electrolytes 1

• Consider hospitalization for:

  • Intravenous fluid therapy if persistent vomiting occurs 1
  • Signs of plasma leakage or bleeding 5
  • Thrombocytopenia with platelet count <100,000/mm³ 6
  • Hemodynamic instability 5

• For severe dengue with significant bleeding or shock:

  • Administer blood products as needed (platelets, fresh frozen plasma) 5
  • Monitor vital signs and urine output closely 5
  • Consider intensive care unit admission for hemodynamic monitoring 5

Obstetric Management

• Monitor fetal well-being with regular ultrasound and non-stress tests, as dengue infection increases risk of:

  • Preterm birth (17.1% of cases) 6
  • Low birth weight 3
  • Fetal distress (12% of cases) 4
  • Vertical transmission of dengue virus 3

• Timing and mode of delivery:

  • For mild disease without complications, continue pregnancy with close monitoring 7
  • For severe dengue with significant coagulopathy or maternal compromise, delivery may be indicated regardless of gestational age 5
  • Cesarean section may be preferred in cases of severe thrombocytopenia to minimize bleeding risk 5
  • Be prepared for postpartum hemorrhage, which occurs in approximately 20% of dengue-affected pregnancies 4

Pitfalls and Caveats

• Physiologic hemodilution of pregnancy may mask hemoconcentration that typically occurs in dengue, delaying recognition of plasma leakage 5
• The advent of shock in a pregnant dengue patient indicates significant volume loss and requires immediate intervention 5
• Early miscarriage is common (32% in one study), requiring close monitoring in the first trimester 4
• Neonatal mortality can be high (44.5% in severe cases), necessitating specialized neonatal care 4
• Most patients seek medical treatment during the critical phase (days 3-6), when risk of complications is highest 6