07NTD 2022 - Dengue In Special Population
ICRInstituteForClini
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Feb 09, 2022
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About This Presentation
This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginn...
Slide Content
Dengue In Special Population
Speaker: Dr Ng TiangKoi
Infectious Disease Physician
Hospital TuankuJa’afar, Seremban
Speaker: Dr Ng TiangKoi
Infectious Disease Physician
Hospital TuankuJa’afar, Seremban
Disclaimer
•This slide was prepared for the Webinar Series on COVID-19 session on
12thFebruary2022, by DrNg TiangKoi, Infectious Disease physician at
Hospital TuankuJa’afar, Seremban, Malaysia.
•This is intended to share within healthcare professionals, not for public.
•This webinar is organisedby Malaysian Society of Infection Control and
Infectious Diseases (MyICID) & Institute for Clinical Research, NIH in
conjunction of World NTD Day 2022.
•This slide was prepared for the Webinar Series on COVID-19 session on
12thFebruary2022, by DrNg TiangKoi, Infectious Disease physician at
Hospital TuankuJa’afar, Seremban, Malaysia.
•This is intended to share within healthcare professionals, not for public.
•This webinar is organisedby Malaysian Society of Infection Control and
Infectious Diseases (MyICID) & Institute for Clinical Research, NIH in
conjunction of World NTD Day 2022.
Contents
1). Anticoagulant in dengue patients with valve replacement, VTE
2). Antiplatelet in dengue patients with cardiovascular diseases on long
term antiplatelet therapy.
3). Dengue patients with pregnancy.
1). Anticoagulant in dengue patients with valve replacement, VTE
2). Antiplatelet in dengue patients with cardiovascular diseases on long
term antiplatelet therapy.
3). Dengue patients with pregnancy.
Case 1
Ms CCY, 36 years old lady
•Mitral valve replacement for underlying severe mitral stenosis
•Taking warfarin 2mg od, compliant to medication.
•She is complaining of fever, arthralgia, myalgia for 2 days
•Still able to tolerate orally, and ambulate around. No bleeding
•Clinically well. Physical examination unremarkable finding.
•Dengue combo test: NS1 Ag positive, IgMand IgGnegative
•FBC: WBC 6 x 103/L, Hb11 g/dl, HCT 34%, Plt108 x 109 /L
•INR 2.5 /APTT 42s
Ms CCY, 36 years old lady
•Mitral valve replacement for underlying severe mitral stenosis
•Taking warfarin 2mg od, compliant to medication.
•She is complaining of fever, arthralgia, myalgia for 2 days
•Still able to tolerate orally, and ambulate around. No bleeding
•Clinically well. Physical examination unremarkable finding.
•Dengue combo test: NS1 Ag positive, IgMand IgGnegative
•FBC: WBC 6 x 103/L, Hb11 g/dl, HCT 34%, Plt108 x 109 /L
•INR 2.5 /APTT 42s
Case 2 -History
Mr ZA, 62 years old man
•Underlying T2DM, HTN, BPH and IHD (2 vessels disease)
•Stented with DES 3 months ago
•Taking DAPT (aspirin 100mg /glycine 45mg 1 tab od and clopidogrel
75mg od), metformin, insulin, atorvastatin, bisoprolol, telmisartan,
prazosin.
•Presented with 4 days of fever, dizziness and lethargy, associated with
sore throat and cough during first 2 days of fever.
•No signs and symptoms of bleeding.
Mr ZA, 62 years old man
•Underlying T2DM, HTN, BPH and IHD (2 vessels disease)
•Stented with DES 3 months ago
•Taking DAPT (aspirin 100mg /glycine 45mg 1 tab od and clopidogrel
75mg od), metformin, insulin, atorvastatin, bisoprolol, telmisartan,
prazosin.
•Presented with 4 days of fever, dizziness and lethargy, associated with
sore throat and cough during first 2 days of fever.
•No signs and symptoms of bleeding.
Case 2 –Clinical finding and investigations
Conscious and alert
TachypnoeicRR 22
BP 169/78 mmHg PR 106 bpm Temp 37.5 0C SpO2 96% @ Room air
Capillary glucose 16 mmol/L
Pulse volume good, warm peripheries, CRT <2s
Lungs reduce air entry right base
Abdomen soft, tender at epigastricregion, no palpable organomegaly
FBC: wbc3.1 x103/L/ Hb15g/dl / HCT 46.6 % / Plt68 x 109 /L
pH: 7.4/PCO2: 33 / PO2: 90/ HCO3-: 18.9/ Lac 2.5
Dengue combo test: NS1 Ag and IgGPositive , IgMNegative
Conscious and alert
TachypnoeicRR 22
BP 169/78 mmHg PR 106 bpm Temp 37.5 0C SpO2 96% @ Room air
Capillary glucose 16 mmol/L
Pulse volume good, warm peripheries, CRT <2s
Lungs reduce air entry right base
Abdomen soft, tender at epigastricregion, no palpable organomegaly
FBC: wbc3.1 x103/L/ Hb15g/dl / HCT 46.6 % / Plt68 x 109 /L
pH: 7.4/PCO2: 33 / PO2: 90/ HCO3-: 18.9/ Lac 2.5
Dengue combo test: NS1 Ag and IgGPositive , IgMNegative
Crossroad of clinical management
•When to bridge anticoagulant ?
•When to stop anticoagulant / antiplatelet ?
•When to re-initiate anticoagulant /antiplatelet if stopped ?
•When to bridge anticoagulant ?
•When to stop anticoagulant / antiplatelet ?
•When to re-initiate anticoagulant /antiplatelet if stopped ?
Anticoagulant /Antiplatelet in Dengue Patients
•There are limited available evidence and no guideline on how to manage anticoagulant in dengue patients with prosthetic valves or venous thromboembolism (VTE), and antiplatelet in dengue patients with cardiovascular disease that required mono or dual antiplatelet therapy (DAPT).
•The risks of bleeding need to be balanced against the risks of thrombosis from temporary withhold anticoagulant or antiplatelet. Hence, the case management is case to case basis, based on expert opinion from various managing team with extrapolated evidence from non dengue patients.
•However, thrombocytopenia, platelet dysfunction and coagulopathies in dengue fever are dynamics.
•There are limited available evidence and no guideline on how to manage anticoagulant in dengue patients with prosthetic valves or venous thromboembolism (VTE), and antiplatelet in dengue patients with cardiovascular disease that required mono or dual antiplatelet therapy (DAPT).
•The risks of bleeding need to be balanced against the risks of thrombosis from temporary withhold anticoagulant or antiplatelet. Hence, the case management is case to case basis, based on expert opinion from various managing team with extrapolated evidence from non dengue patients.
•However, thrombocytopenia, platelet dysfunction and coagulopathies in dengue fever are dynamics.
Safe platelet cut off for anticoagulant ?
Tufanoet al. Seminars in Thrombosis and hemostasis 2011. Apr;37(3):267-74
Mild/moderate thrombocytopenia (> 50,000/mL) should not interfere
with VTE prevention decisions. In severe thrombocytopenia,
prophylaxis should be considered on an individual basis.
Tufanoet al. Seminars in Thrombosis and hemostasis 2011. Apr;37(3):267-74
Mild/moderate thrombocytopenia (> 50,000/mL) should not interfere
with VTE prevention decisions. In severe thrombocytopenia,
prophylaxis should be considered on an individual basis.
Safe platelet cut off for anticoagulant ?
•In acute and non acute VTE, the panel suggests safe anticoagulation with
LMWH at therapeutic doses for PLT between ≥50 and < 100×109 /L and
at 50% dose reduction for PLT ≥30 <50 ×109 /L.
Blood Transfus2019; 17: 171-80 DOI 10.2450/2018.0143-18
•In acute and non acute VTE, the panel suggests safe anticoagulation with
LMWH at therapeutic doses for PLT between ≥50 and < 100×109 /L and
at 50% dose reduction for PLT ≥30 <50 ×109 /L.
Blood Transfus2019; 17: 171-80 DOI 10.2450/2018.0143-18
•Retrospective cohort study of adult dengue patients on antiplatelet therapy for ischaemicheart disease or stroke. Decision on continuation or discontinuation of antiplatelet therapy was made on clinical grounds, in discussion with the patients, by the attending physician
•Primary outcome: composite outcome of major adverse cardiac and cerebrovascular events (MACCE), and all-cause mortality in-hospital and for 1-year post discharge.
•Secondary outcomes: platelet and blood transfusion, and occurrence of dengue haemorrhagicfever (DHF), dengue shock syndrome, dengue with warning signs and severe dengue according to WHO criteria.
•Primary outcome: composite outcome of major adverse cardiac and cerebrovascular events (MACCE), and all-cause mortality in-hospital and for 1-year post discharge.
•Secondary outcomes: platelet and blood transfusion, and occurrence of dengue haemorrhagicfever (DHF), dengue shock syndrome, dengue with warning signs and severe dengue according to WHO criteria.
Result
•66 patients (15 were continued antiplatelet therapy)
•40 patients (61%) were on antiplatelet therapy for ischemic heart disease, 25 patients (38%) for ischemic stroke and 1 patient for both conditions. (*11 patients had PCI with coronary stent)
•Patients who were continued on antiplatelet therapy had a higher median Charlson’scomorbidity index at 6 (IQR: 3-7) vs4 (IQR: 2-5), higher median platelet nadir at 60 000/µL (IQR: 23 000-131 000/µL) vs27 000/µL (IQR: 13 000-47 000/µL) for those whose antiplatelet therapy were discontinued.
•5 patients developed non-fatal ischemic stroke (among 2/15 who continued, 3/51 who discontinued antiplatelet. No patient had coronary artery stent thrombosis or major cardiac events.
•Discontinuation of antiplatelet therapy did not result in higher composite outcome (p=0.192). Continuation of antiplatelet therapy did not result in more platelet or blood transfusion (p=0.489 and p=0.567 respectively), DHF (p=0.923).
•Author suggested that discontinuation or continuation of antiplatelet therapy based on clinical judgementin dengue with thrombocytopenia, is largely safe but further studies are needed.
•66 patients (15 were continued antiplatelet therapy)
•40 patients (61%) were on antiplatelet therapy for ischemic heart disease, 25 patients (38%) for ischemic stroke and 1 patient for both conditions. (*11 patients had PCI with coronary stent)
•Patients who were continued on antiplatelet therapy had a higher median Charlson’scomorbidity index at 6 (IQR: 3-7) vs4 (IQR: 2-5), higher median platelet nadir at 60 000/µL (IQR: 23 000-131 000/µL) vs27 000/µL (IQR: 13 000-47 000/µL) for those whose antiplatelet therapy were discontinued.
•5 patients developed non-fatal ischemic stroke (among 2/15 who continued, 3/51 who discontinued antiplatelet. No patient had coronary artery stent thrombosis or major cardiac events.
•Discontinuation of antiplatelet therapy did not result in higher composite outcome (p=0.192). Continuation of antiplatelet therapy did not result in more platelet or blood transfusion (p=0.489 and p=0.567 respectively), DHF (p=0.923).
•Author suggested that discontinuation or continuation of antiplatelet therapy based on clinical judgementin dengue with thrombocytopenia, is largely safe but further studies are needed.
Safety Evidence Of Antiplatelet Interruption
Cochrane Database of Systematic Reviews 2018, Issue 7. Art. No.: CD012584.
DOI: 10.1002/14651858.CD012584.pub2.
Cochrane Database of Systematic Reviews 2018, Issue 7. Art. No.: CD012584.
DOI: 10.1002/14651858.CD012584.pub2.
All Cause Mortality (Up to 30 days)
All Cause Mortality (Up to 6 months)
Risk Of Ischaemic Events (within 30 days)
Safety Of Antiplatelet Interruption
•Plasma half-life of aspirin is only 20 minutes.
•However, the effects of aspirin may last up to ≈10 days (life span of platelet),
because platelets cannot generate new COX. After a single dose of aspirin,
platelet COX activity recovers by ≈10% per day as a function of platelet
turnover.Although it may takes 10 days to restore normal COX activity when
total platelet population is renewed, it has been shown that if as little as 20%
of platelets have normal COX activity, hemostasis may be normal*.
•Marrow suppression +/-peripheral destruction of platelet causing
thrombocytopenia in dengue fever and platelet dysfunction may prolonged
the effect of aspirin.
*Eric H. Awtryand Joseph Loscalzo. Circulation. 2000;101:1206–1218
•Plasma half-life of aspirin is only 20 minutes.
•However, the effects of aspirin may last up to ≈10 days (life span of platelet),
because platelets cannot generate new COX. After a single dose of aspirin,
platelet COX activity recovers by ≈10% per day as a function of platelet
turnover.Although it may takes 10 days to restore normal COX activity when
total platelet population is renewed, it has been shown that if as little as 20%
of platelets have normal COX activity, hemostasis may be normal*.
•Marrow suppression +/-peripheral destruction of platelet causing
thrombocytopenia in dengue fever and platelet dysfunction may prolonged
the effect of aspirin.
*Eric H. Awtryand Joseph Loscalzo. Circulation. 2000;101:1206–1218
Situations to consider :
•Significant bleeding
•Phase of dengue fever
•Presence of warning signs /severe dengue
•Platelet trend
•Risk of thrombosis
•Risk of bleeding
Multi-disciplinary team approach, always discuss and make decision together with patient and/or family.
Approach To Anticoagulant / Antiplatelet In DF
•Significant bleeding
•Phase of dengue fever
•Presence of warning signs /severe dengue
•Platelet trend
•Risk of thrombosis
•Risk of bleeding
Multi-disciplinary team approach, always discuss and make decision together with patient and/or family.
Approach To Anticoagulant / Antiplatelet In DF
With Significant Bleeding
•Stop the anticoagulant or antiplatelet
•Antidote if available ( VitK for warfarin, Idarucizumabfor Dabigatrand)
•Fresh Frozen Plasma (FFP) or ProthrombinComplex Concentrate (PCC)
•Platelet Concentrate and/or Packed cell or Whole Blood transfusion
•Stabilise the haemodynamic
•Stop the anticoagulant or antiplatelet
•Antidote if available ( VitK for warfarin, Idarucizumabfor Dabigatrand)
•Fresh Frozen Plasma (FFP) or ProthrombinComplex Concentrate (PCC)
•Platelet Concentrate and/or Packed cell or Whole Blood transfusion
•Stabilise the haemodynamic
Without Significant Bleeding
•Withhold anticoagulant /antiplatelet in DF with any of following:
A). Severe Dengue
B). Platelet < 50 x 109/L
•Consider withhold anticoagulant / antiplatelet in DF in febrile phase with warning signs or platelet reducing trend to between 50 -100 x 109/L, especially in those with high risk of bleeding, but relatively lower thrombosis risk.
•If anticoagulant needed for dengue patients with high risk of thrombosis but relatively low risk of bleeding, switch DOAC/ Warfarin (VKA) to LMWH/ Conventional heparin infusion when INR subtherapeuticif platelet 50 -100 x 109/L or even earlier with platelet > 100 x 109/L in febrile phase.
•Multi-disciplinary team management with cardiologist, haematologist, intensivist/anaesthetist, patient and patient’s family for decision making.
•Withhold anticoagulant /antiplatelet in DF with any of following:
A). Severe Dengue
B). Platelet < 50 x 109/L
•Consider withhold anticoagulant / antiplatelet in DF in febrile phase with warning signs or platelet reducing trend to between 50 -100 x 109/L, especially in those with high risk of bleeding, but relatively lower thrombosis risk.
•If anticoagulant needed for dengue patients with high risk of thrombosis but relatively low risk of bleeding, switch DOAC/ Warfarin (VKA) to LMWH/ Conventional heparin infusion when INR subtherapeuticif platelet 50 -100 x 109/L or even earlier with platelet > 100 x 109/L in febrile phase.
•Multi-disciplinary team management with cardiologist, haematologist, intensivist/anaesthetist, patient and patient’s family for decision making.
Clinical Course Of Dengue Fever
Muhammad ZamanKhan Assir2011
Muhammad ZamanKhan Assir2011
Re-initiate Anticoagulant/ Antiplatelet
•Generally, anticoagulant or antiplatelet can be resumed once dengue
patient in recovery phase and platelet improving trend to ≥ 50 x 109/L,
unless any specific contra-indication.
•Generally, anticoagulant or antiplatelet can be resumed once dengue
patient in recovery phase and platelet improving trend to ≥ 50 x 109/L,
unless any specific contra-indication.
Case 3
28-year-old G1P0 at 32w 6d
•Referred from private for sepsis.
•Presented with only high grade fever for 1 day, without other
specific symptoms.
•BP on arrival 90/60mmHg , pulse 106 bpm T 370C (taken PCM)
•FBC: Hb12.9/hct38.3/plt250/wbc13.9
•Given 2 pints NS bolus in Casualty àRepeated BP 100/66mmHg
•Followed by drip I pint NS / 2 hours (~3mls/kg/hr)
28-year-old G1P0 at 32w 6d
•Referred from private for sepsis.
•Presented with only high grade fever for 1 day, without other
specific symptoms.
•BP on arrival 90/60mmHg , pulse 106 bpm T 370C (taken PCM)
•FBC: Hb12.9/hct38.3/plt250/wbc13.9
•Given 2 pints NS bolus in Casualty àRepeated BP 100/66mmHg
•Followed by drip I pint NS / 2 hours (~3mls/kg/hr)
22/2
01320856
23/2
062818002240
24/2
0356
Hb(g/dl)1211.110.810.211.011.5
HCT (%)34.531.528.930.030.832.6
Plt(x109 /L)2291821821277565
Wcc(103 /L)12.089.108.897.47.096.91
AST/ALT 95/56
HCO3-181616151414
Lactate1.00.80.91.21.61.6
peripherieswarmWarmwarmwarmwarmwarm
CRT<2s<2s<2s<2s<2s<2s
Temp ( 0C)373738383837.5
BP (mmHg)90/60100/6698/64100/6096/5898/60
Pulse/
volume
106/
good
104/
good
118/
good
120/
good
126/
good
120/
good
symptomsnilnilnildyspnoedyspnoe
IO 6122/11206752/2260
*Dengue NS1 +ve
01320856
23/2
062818002240
24/2
0356
Hb(g/dl)1211.110.810.211.011.5
HCT (%)34.531.528.930.030.832.6
Plt(x109 /L)2291821821277565
Wcc(103 /L)12.089.108.897.47.096.91
AST/ALT 95/56
HCO3-181616151414
Lactate1.00.80.91.21.61.6
peripherieswarmWarmwarmwarmwarmwarm
CRT<2s<2s<2s<2s<2s<2s
Temp ( 0C)373738383837.5
BP (mmHg)90/60100/6698/64100/6096/5898/60
Pulse/
volume
106/
good
104/
good
118/
good
120/
good
126/
good
120/
good
symptomsnilnilnildyspnoedyspnoe
IO 6122/11206752/2260
*Dengue NS1 +ve
Progress of patient
24/2
05170815
Fluid was stopped and
ptwas transferred to ICU
for NIPPV
Hb11.611.9
HCt32.534.5
Plt5355
Wcc7.447.97
Ast/alt 106/62
HCO314
Lactate1.4
peripheriesWarm warm
CRT <2s<2s
BP 100/58102/64
Pulse/volume110/good106/good
IO+9L
24/2
05170815
Fluid was stopped and
ptwas transferred to ICU
for NIPPV
Hb11.611.9
HCt32.534.5
Plt5355
Wcc7.447.97
Ast/alt 106/62
HCO314
Lactate1.4
peripheriesWarm warm
CRT <2s<2s
BP 100/58102/64
Pulse/volume110/good106/good
IO+9L
Physiological changes in pregnancy
Dilutionalanaemia
}Expansion of blood volume (~1.5L) with relatively lesser
increment of red blood cell from the maternal
erythropoietin drive, cause Hband Hctlevels drop during
pregnancy.
Thrombocytopenia
}Hemodilution, increase consumption and aggregation
cause thrombocytopenia in 7-8% of all pregnancies,
occur usually during 2ndhalf of pregnancy.
Dilutionalanaemia
}Expansion of blood volume (~1.5L) with relatively lesser
increment of red blood cell from the maternal
erythropoietin drive, cause Hband Hctlevels drop during
pregnancy.
Thrombocytopenia
}Hemodilution, increase consumption and aggregation
cause thrombocytopenia in 7-8% of all pregnancies,
occur usually during 2ndhalf of pregnancy.
Physiological changes in pregnancy (Cardio)
VariableChange
Cardiac output (CO)Increased by 30–50%
Stroke volume (SV)Increases to a maximum of 85 mL at
20 weeks of gestation
Heart rate (HR)Increased (~90–100 bpm at rest during
3rd trimester)
Systemic vascular resistancesDecrease 21% (nadir at 20–24 weeks)
Pulmonary vascular resistancesDecrease by 34%
Pulmonary capillary wedge
pressure
No significant change
Colloid osmotic pressureDecreased by 14%
Hemoglobin concentrationDecreased
CPG Management of Dengue Infection in Adults (3rd Edition)
VariableChange
Cardiac output (CO)Increased by 30–50%
Stroke volume (SV)Increases to a maximum of 85 mL at
20 weeks of gestation
Heart rate (HR)Increased (~90–100 bpm at rest during
3rd trimester)
Systemic vascular resistancesDecrease 21% (nadir at 20–24 weeks)
Pulmonary vascular resistancesDecrease by 34%
Pulmonary capillary wedge
pressure
No significant change
Colloid osmotic pressureDecreased by 14%
Hemoglobin concentrationDecreased
CPG Management of Dengue Infection in Adults (3rd Edition)
Physiological changes in pregnancy (Resp)
AntonellaLoMauroet al. Breathe201511:297-301 Hegewaldet al. clinic in chest meds 32.1 (2011): 1-13
Blood gases
Respalkalosis with compensated metabolic acidosis in third trimester
pH: 7.4-7.45, PaCO2: 28-31mmHg, PaO2: 101-105mmHg, HCO3-: 18-21
AntonellaLoMauroet al. Breathe201511:297-301 Hegewaldet al. clinic in chest meds 32.1 (2011): 1-13
Blood gases
Respalkalosis with compensated metabolic acidosis in third trimester
pH: 7.4-7.45, PaCO2: 28-31mmHg, PaO2: 101-105mmHg, HCO3-: 18-21
Maternal Outcome
CPG Management of Dengue Infection in Adults (3rd Edition)
}Higher percentage of severe dengue infection occurred among pregnant
women compared to non-pregnant
}Significant bleeding due to thrombocytopenia is not common.
}Increased risk for haemorrhage in the presence of dengue shock
syndrome (DSS).
•Machado CR, Machado ES, Denis Rohloff R, et al. Is Pregnancy Associated with Severe Dengue? A Review of Data from the Rio de Janeiro
Surveillance Information System. PLoS Negl Trop Dis. 2013;7(5):5–8.
•Adam I, Jumaa AM, Elbashir HM, et al. Maternal and perinatal outcomes of dengue in PortSudan, Eastern Sudan. Virol J. 2010;7:153.
•Pouliot SH, Xiong X, Harville E, et al. Maternal dengue and pregnancy outcomes: a systematic review. Obstet Gynecol Surv. 2010;65(2):107–18.
CPG Management of Dengue Infection in Adults (3rd Edition)
}Higher percentage of severe dengue infection occurred among pregnant
women compared to non-pregnant
}Significant bleeding due to thrombocytopenia is not common.
}Increased risk for haemorrhage in the presence of dengue shock
syndrome (DSS).
•Machado CR, Machado ES, Denis Rohloff R, et al. Is Pregnancy Associated with Severe Dengue? A Review of Data from the Rio de Janeiro
Surveillance Information System. PLoS Negl Trop Dis. 2013;7(5):5–8.
•Adam I, Jumaa AM, Elbashir HM, et al. Maternal and perinatal outcomes of dengue in PortSudan, Eastern Sudan. Virol J. 2010;7:153.
•Pouliot SH, Xiong X, Harville E, et al. Maternal dengue and pregnancy outcomes: a systematic review. Obstet Gynecol Surv. 2010;65(2):107–18.
•6071 pregnant women, 292 were exposed to dengue during pregnancy.
•Miscarriage OR 3·51 (95% CI 1·15–10·77, I²=0·0%, p=0·765)
•Stillbirth crude relative 6·7 (95% CI 2·1–21·3)
•Preterm birth OR 1·71 (95% CI 1·06–2·76, I²=56·1%, p=0·058)
•Low birth weight OR 1·41 (95% CI 0·90–2·21, I²=0·0%, p=0·543)
Pregnancy Outcome
Lancet Infect Dis. July 2016.
•Miscarriage OR 3·51 (95% CI 1·15–10·77, I²=0·0%, p=0·765)
•Stillbirth crude relative 6·7 (95% CI 2·1–21·3)
•Preterm birth OR 1·71 (95% CI 1·06–2·76, I²=56·1%, p=0·058)
•Low birth weight OR 1·41 (95% CI 0·90–2·21, I²=0·0%, p=0·543)
Pregnancy Outcome
Lancet Infect Dis. July 2016.
•14 from 1048 studies that identified were included.
•Risk of adverse fetal outcomes from maternal DENV infection with a pooled RR of 0.96 (95% CI: 0.85–1.09, I2= 49.6%) for premature birth, RR of 0.99 (95%CI: 0.87–1.12, I2= 35.1%) for low birth weight, OR of 1.77 (95% CI: 0.99–3.15, I2= 17.5%) for miscarriage and RR of 3.42 (95% CI: 0.76–15.49, I2= 54.8%) for stillbirth.
•Subgroup analysis of studies in symptomatic participants still did not indicate DENV infection appeared to be a risk factor for premature birth, low birth weight and miscarriage as well.
Pregnancy Outcome
•Risk of adverse fetal outcomes from maternal DENV infection with a pooled RR of 0.96 (95% CI: 0.85–1.09, I2= 49.6%) for premature birth, RR of 0.99 (95%CI: 0.87–1.12, I2= 35.1%) for low birth weight, OR of 1.77 (95% CI: 0.99–3.15, I2= 17.5%) for miscarriage and RR of 3.42 (95% CI: 0.76–15.49, I2= 54.8%) for stillbirth.
•Subgroup analysis of studies in symptomatic participants still did not indicate DENV infection appeared to be a risk factor for premature birth, low birth weight and miscarriage as well.
Pregnancy Outcome
Delivery
CPG Management of Dengue Infection in Adults (3rd Edition)
}Dengue infection is not an indication for elective delivery.
}Majority of patients can be allowed to progress to spontaneous vaginal delivery.
}Premature labour occurs during the acute infection. It is advisable to delay the delivery until acute infection resolve with tocolytic(nifedipine, atosiban) if indicated and appropriate by Obstetrician.
•ChitraTV,PanickerS.Maternalandfetaloutcomeofdenguefeverinpregnancy.JVectorBorneDis.2011;48(4):210–3.
•KariyawasamS,SenanayakeH.Dengueinfectionsduringpregnancy:CaseseriesfromatertiarycarehospitalinSriLanka.JInfectDevCtries.2010;4(11):767–75.
•Close fetalmonitoring is required in this group of patients to detect fetaldistress and decision for delivery can be made
•All pregnant mothers with dengue should be co-managed in hospitals by physician, anaesthetist and obstetrician.
CPG Management of Dengue Infection in Adults (3rd Edition)
}Dengue infection is not an indication for elective delivery.
}Majority of patients can be allowed to progress to spontaneous vaginal delivery.
}Premature labour occurs during the acute infection. It is advisable to delay the delivery until acute infection resolve with tocolytic(nifedipine, atosiban) if indicated and appropriate by Obstetrician.
•ChitraTV,PanickerS.Maternalandfetaloutcomeofdenguefeverinpregnancy.JVectorBorneDis.2011;48(4):210–3.
•KariyawasamS,SenanayakeH.Dengueinfectionsduringpregnancy:CaseseriesfromatertiarycarehospitalinSriLanka.JInfectDevCtries.2010;4(11):767–75.
•Close fetalmonitoring is required in this group of patients to detect fetaldistress and decision for delivery can be made
•All pregnant mothers with dengue should be co-managed in hospitals by physician, anaesthetist and obstetrician.
Delivery
CPG Management of Dengue Infection in Adults (3rd Edition)
CPG Management of Dengue Infection in Adults (3rd Edition)
Summary (Anticoagulant/ Antiplatelet in DF)
•Noclearguidelineavailableonthemanagementofanticoagulantandantiplateletinpatientswithdenguefever.
•Risksofbleedingneedtobebalancedagainsttherisksofthrombosis.
•Multi-disciplineapproachisrequired.
•Noclearguidelineavailableonthemanagementofanticoagulantandantiplateletinpatientswithdenguefever.
•Risksofbleedingneedtobebalancedagainsttherisksofthrombosis.
•Multi-disciplineapproachisrequired.
Summary (Dengue in pregnancy)
•HCTvalueinpregnantwomenisusuallylowercomparedtonormaladultduetophysiologicalhaemodilution.
•Dengueinfectioninpregnancyhasahigherriskofdevelopingseveredengueandmortality.
•Dengueinfectioninpregnancyhasahigheradversefetaloutcome.
•Routineplatelettransfusionisnotindicatedunlessthereispresenceofbleedingmanifestationorpatientisplannedforoperativeorinstrumentaldelivery.
•Intramuscularinjectionmustbeavoidedinpregnantpatientswiththrombocytopaenia.
•HCTvalueinpregnantwomenisusuallylowercomparedtonormaladultduetophysiologicalhaemodilution.
•Dengueinfectioninpregnancyhasahigherriskofdevelopingseveredengueandmortality.
•Dengueinfectioninpregnancyhasahigheradversefetaloutcome.
•Routineplatelettransfusionisnotindicatedunlessthereispresenceofbleedingmanifestationorpatientisplannedforoperativeorinstrumentaldelivery.
•Intramuscularinjectionmustbeavoidedinpregnantpatientswiththrombocytopaenia.
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