Management of Dengue in Pregnancy
Pregnant women with dengue require immediate supportive care with close monitoring for shock and hemorrhage, strict use of acetaminophen only for fever (never NSAIDs/aspirin), aggressive fluid management with electrolyte-containing solutions, and vigilant surveillance for warning signs of progression to severe disease—all while recognizing that pregnancy increases the risk of dengue shock syndrome to 15% compared to 5% in non-pregnant populations. 1, 2
Diagnostic Approach
Collect both 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. 2 This dual testing is critical because:
- Pregnant women must always be tested for both viruses due to different but serious complications each poses 1
- Positive IgM antibody results with negative NAAT results require confirmation by neutralizing antibody tests 2
- Consider local epidemiology and clinical findings when interpreting results 2
Clinical Monitoring: Warning Signs
Monitor closely for the following warning signs that indicate progression to severe disease: 2
- Persistent vomiting
- Abdominal pain or tenderness
- Clinical fluid accumulation
- Mucosal bleeding
- Lethargy or restlessness
- Liver enlargement
- Rising hematocrit with concurrent thrombocytopenia
Supportive Care Management
Fluid Management
Ensure adequate hydration with fluids containing electrolytes; hospitalize for intravenous fluid therapy if persistent vomiting occurs. 2, 3 Cautious fluid management must correlate with clinical and hematological parameters, as pregnant women have greater volume compensation due to physiologic changes, and shock indicates significant volume loss. 4, 5
Pain and Fever Control
Use acetaminophen/paracetamol exclusively for fever and pain management. 1, 2, 3 Strictly avoid NSAIDs and aspirin due to increased bleeding risk from thrombocytopenia. 1, 2, 3
Shock and Hemorrhage Management
Provide appropriate supportive care to monitor for and treat shock and hemorrhage without waiting for diagnostic test results. 2 The principle is to prioritize maternal well-being prior to addressing fetal issues. 5
Pregnancy-Specific Complications
Maternal Risks
Dengue poses acute maternal mortality risk with: 1
- Increased risk for hemorrhage
- Preeclampsia and eclampsia
- Peripartum complications including atonic postpartum hemorrhage 6
- Dengue shock syndrome affects 15% of pregnant women versus 5% of non-pregnant population 7
Fetal and Neonatal Risks
- Stillbirth and neonatal mortality 7
- Vertical transmission can occur, though transmission rates vary 7
- No statistically significant increase in preterm birth or low birth weight in large meta-analyses 7
Timing and Mode of Delivery
Continue pregnancy until platelet count rises above 50,000 cells/cumm before considering delivery. 4 This threshold allows for safer vaginal or cesarean delivery with reduced bleeding risk. Emergency cesarean section may be necessary in severe cases but carries risk of rebleeding and hemodynamic instability during the atypical defervescence period. 5
Hospitalization Criteria
Consider hospitalization, particularly for: 2
- Persistent vomiting requiring IV fluid therapy
- Any warning signs present
- Severe dengue or dengue shock syndrome
- Third trimester patients requiring closer monitoring 6
- Need for multidisciplinary care coordination 6
Common Pitfalls to Avoid
- Do not delay supportive care while awaiting diagnostic confirmation 2
- Do not use NSAIDs or aspirin as they increase bleeding risk in thrombocytopenic patients 1, 2, 3
- Do not mistake dengue for primary obstetric complications—patients presenting with cough/breathlessness or vaginal bleeding may be misdiagnosed as pulmonary embolism or obstetric hemorrhage 8
- Do not overlook atypical presentations such as dengue encephalopathy, which can present with altered sensorium and must be differentiated from other causes 4
- Do not assume normal vital signs exclude severe disease—physiologic changes in pregnancy provide greater compensation before decompensation occurs 5