What is the management of dengue fever in pregnancy?

Management of Dengue Fever in Pregnancy

Pregnant women with dengue fever require immediate hospitalization for close monitoring of maternal complications including hemorrhage, preeclampsia, and dengue shock syndrome, which occurs three times more frequently in pregnancy (15% vs 5% in non-pregnant patients). 1

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. 1 This dual testing is mandatory in pregnant women regardless of local outbreak patterns, as both viruses pose serious but different risks—dengue threatens maternal survival while Zika causes fetal malformations. 2

• For symptoms ≤7 days: NAATs are the preferred diagnostic method 2
• For symptoms >7 days: IgM antibody testing should be performed 2
• Positive IgM with negative NAAT requires confirmation by neutralizing antibody tests in all pregnant women 1

Critical pitfall: Do not wait for diagnostic test results before initiating supportive care for shock and hemorrhage. 1

Clinical Monitoring Requirements

Monitor daily for warning signs that predict progression to severe disease:

• Persistent vomiting, abdominal pain/tenderness 1
• Clinical fluid accumulation, mucosal bleeding 1
• Lethargy or restlessness 1
• Liver enlargement 1
• Rising hematocrit with concurrent thrombocytopenia (most critical indicator) 1

Perform daily complete blood count monitoring to track platelet counts and hematocrit levels. 3 Severe thrombocytopenia occurs in approximately 78% of pregnant women with dengue. 4

Fluid Management Strategy

For stable patients without shock: Ensure aggressive oral hydration with oral rehydration solutions containing electrolytes, targeting >2500 mL daily. 3

For persistent vomiting: Hospitalize for intravenous fluid therapy. 1 This is particularly important in pregnancy where dehydration can compromise placental perfusion.

For dengue shock syndrome (15% of pregnant patients): 1

• Administer initial fluid bolus of 20 mL/kg isotonic crystalloid over 5-10 minutes 3
• Reassess immediately after bolus completion 3
• Consider colloid solutions for severe shock with pulse pressure <10 mmHg 3
• Monitor continuously with cardiac telemetry and pulse oximetry 3

Critical consideration: Cautious fluid management is essential—correlate fluid administration to clinical and hematological parameters to avoid fluid overload while preventing shock. 5

Pain and Fever Management

Use acetaminophen/paracetamol at standard doses exclusively for fever and pain relief. 1 This is the safest analgesic option in pregnancy. 3

Strictly avoid NSAIDs and aspirin under all circumstances due to dramatically increased bleeding risk. 1 This is non-negotiable in dengue management.

Maternal Complications and Risks

Pregnant women face significantly elevated risks:

• Dengue shock syndrome: 15% (vs 5% in non-pregnant) 1
• Hemorrhage requiring transfusion 1
• Preeclampsia and eclampsia 1
• Vertical transmission to fetus 1
• Stillbirth and neonatal mortality 1

Important nuance: Large meta-analyses have not found statistically significant increases in preterm birth or low birth weight, though individual case reports describe these complications. 1, 4

Timing and Mode of Delivery

Continue pregnancy until platelet count rises to >50,000 cells/mm³ before considering delivery. 5 This threshold minimizes bleeding risk during labor and delivery.

Vaginal delivery is feasible when maternal condition is stable and platelet counts are adequate. 5 Cesarean section should be reserved for standard obstetric indications, though the risk of cesarean delivery may be increased. 4

For women who go into labor with thrombocytopenia: Platelet transfusion is required. 4

Discharge Criteria

Patients can be safely discharged when ALL of the following are met:

• Afebrile for ≥48 hours without antipyretics 3
• Resolution or significant improvement of symptoms 3
• Stable hemodynamic parameters for ≥24 hours without support 3
• Adequate oral intake and urine output (>0.5 mL/kg/hour) 3
• Laboratory parameters returning to normal ranges 3

Post-Discharge Instructions

• Monitor and record temperature twice daily 3
• Return immediately if temperature rises to ≥38°C on two consecutive readings or if any warning signs develop 3
• Continue close obstetric follow-up for fetal monitoring 1

Special Considerations

Dengue encephalopathy is a rare but recognized complication in pregnancy, presenting with altered sensorium, somnolence, and unresponsiveness without circulatory compromise. 5 This typically resolves spontaneously with convalescence of the infection and requires supportive care only. 5

Acalculous cholecystitis has been reported as a complication requiring recognition and appropriate imaging. 6