DENGUE IN PREGNANCY BY DR SHASHWAT JANI

DENGUE IN PREGNANCY BY DR SHASHWAT JANI

1. Dr. Shashwat Jani
M. S. ( Obs – Gynec ), F.I.A.O.G.
Diploma in Advance Laparoscopy ( FRANCE )
Consultant Assistant Professor,,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : [phone].
E-mail : [email protected]

2. Dengue
 40% of world’s population live in Dengue
prone zone.
 WHO estimates at least 100million
infections occur every year including
500,000 DHF cases and nearly 22000 deaths.
 Early detection and access to proper
medical care reduces fatality from 20% to
below 1 %.
15-Jan-20
Dr Shashwat Jani.
99099 44160.
2

3. 15-Jan-20
Dr Shashwat Jani.
99099 44160.
3

4. Dengue Cases Notified to W.H.O.
1990–2015
15-Jan-20
Dr Shashwat Jani.
99099 44160.
4

5. Dengue/DHF situation in India
(Dengue cases & deaths since 2015)
Year Cases Deaths
2015 99913 220
2016 129166 245
2017 188401 325
2018 (till

July 2018) 14233 30
Source: NVBDCP India
Dengue / DHF situation in India

(Dengue cases & deaths since 2015)
15-Jan-20
Dr Shashwat Jani.
99099 44160.
5

6. Dengue
•Dengue is an Arbovirus of the Flavi viridae family
and Flavi virus genus.
•Aedes Aegypti And Aedes Albopictus Are the
Two Most Important Vectors Of Dengue.
•There are four serotypes of the dengue virus
(DEN-1, DEN-2, DEN-3, and DEN-4).
•Indian isolates of DV-2 were classified into
genotype-V. However recently Genotype IV is
more predominant.
15-Jan-20
Dr Shashwat Jani.
99099 44160.
6

7. Clinical Presentation
Four main characteristic manifestations of
dengue illness are :

1) Continuous high fever lasting 2-7 days;
2) Hemorrhagic tendency as shown by a positive
tourniquet test, petechiae or epistaxis;
3) Thrombocytopenia (platelet count <100×109/l);
and
4) Evidence of plasma leakage manifested by
haemoconcentration (an increase in haematocrit
20% above average for age, sex and population),
pleural effusion and ascites, etc .
15-Jan-20
Dr Shashwat Jani.
99099 44160.
7

8. Dengue Fever Is Classified Into
3 Different Phases Based
On The Symptoms & The Severity
Of The Disease Presentation.
15-Jan-20
Dr Shashwat Jani.
99099 44160.
8

9. 15-Jan-20
Dr Shashwat Jani.
99099 44160.
9

10. 15-Jan-20
Dr Shashwat Jani.
99099 44160.
10

11. Tourniquet Test
How To Perform?
•Inflate the BP cuff on the
upper arm to a point midway
between the SBP & DBP for 5
minutes
•A positive test : ≥20 petechiae
per 2.5 cm
2

(1 inch
2
)

Helpful in the early febrile phase (< 3 days) esp.

-When the platelet count is still normal
-When diagnosis is in doubt
15-Jan-20
Dr Shashwat Jani.
99099 44160.
11

12. WARNING SIGNS
Signs of SEVERE DENGUE & high possibility of RAPID
PROGRESSION TO SHOCK
1.Persistent vomiting
2.Abdominal pain or tenderness
3.Mucosal bleed
4.Restlessness or lethargy
5.Clinical fluid accumulation (pleural effusion, ascites)
6.Liver enlargement > 2 cm
7.Laboratory : Increase in HCT with rapid decrease in platelet

15-Jan-20
Dr Shashwat Jani.
99099 44160.
12

13. Diagnosis
•NS1 Antigen test,
Primary test done for
diagnosis. ( Day 3 )
•IgM antibody capture
ELISA (MACELISA)
comes as diagnostic
reagent strips. ( Day 5 )
•RT–PCR is confirmatory
with 95% specificity.
15-Jan-20
Dr Shashwat Jani.
99099 44160.
13

14. Dengue In Pregnancy
Challenges
•Admit All Pregnant women suspected with
dengue
•Diagnosis & Assessment Challenges
–Baseline HR is higher
–Baseline blood pressure is lower
(pulse pressure are wider)
–HCT elevation may be masked haemodilution in 2
nd

& 3
rd
trimester
–Detection of third space loss is difficult with gravid
uterus


15-Jan-20
Dr Shashwat Jani.
99099 44160.
14

15. •Risk of bleeding is highest during period of
plasma leakage
–Avoid LSCS @ IOL during critical phase
–Avoid procedure @ manoeuvres that may provoke
labour during critical phase

•Differential Diagnosis
–Toxemia
–HELLP Syndrome

15-Jan-20
Dr Shashwat Jani.
99099 44160.
15

16. Risk Of Vertical Transmission
•The risk of vertical transmission is well
established among women with dengue during
the perinatal period.
•Dengue fever does not warrant termination of
pregnancy.
•There is insufficient data of probable
embriopathy to mothers who had DF in first
trimester.
15-Jan-20
Dr Shashwat Jani.
99099 44160.
16

17. Obstetric Complications
•Preterm birth
•Low-birth weight
•Oligohydramnios
•Antepartum and postpartum haemorrhage
•Foetal distress
•Miscarriages
•Intrauterine death
•Neonatal death
15-Jan-20
Dr Shashwat Jani.
99099 44160.
17

18. Management
Symptomatic Treatment :
•Intravenous fluid replacement.
•Broad spectrum antibiotics.
•Antipyretics : PCM - 500 – 650 mg 6hrly .
( Not > than 4 gm / 24 hrs ).
NO NSAIDS.
•Blood transfusion and Blood component therapy.
•Monitor maternal vital parameters.
•Monitor serum electrolytes.
•Monitor blood coagulation profiles.
15-Jan-20
Dr Shashwat Jani.
99099 44160.
18

19. Initial Fluid Resuscitation
•Crystalloid
–Normal Saline
–10-20 ml/kg ideal body wt
–Repeat x2
•Consider Colloid 3
rd
cycle
•Other Causes Of Persistent Shock
–OCCULT BLEEDING
–Septic
–Cardiogenic
IDEAL BODY WEIGHT
Male: 50.0kg + 0.91(height-152.4)cm
Female: 45.5kg + 0.91(height-152.4)cm
15-Jan-20
Dr Shashwat Jani.
99099 44160.
19

20. Blood Product
•Suspect occult bleeding if HCT drops and no
obvious bleeding
–Fresh Packed Cell
•5-10 ml/kg
–Fresh Whole Blood
•10-20 ml/kg
•Repeat
–Further blood loss
–No appropriate raise of HCT
•Prophylactic transfusion?
Fresh Blood: < 5 days
15-Jan-20
Dr Shashwat Jani.
99099 44160.
20

21. ICU referral & Respiratory Support
•Indications for ICU referral
•Emergency Intubation
•Elective intubation
–Main objectives is
•to support gas exchange &
•reduce metabolic cost of breathing
15-Jan-20
Dr Shashwat Jani.
99099 44160.
21

22. Haemodynamic Support
•FLUID RESUSCITATION IS CRUCIAL !!!
•Should be initiated first & adequately
•Vasopressor may be consider if MAP
persistently <60mmHg despite adequate
resuscitation (dopamine, noradrenaline)
* While vasopressor increase BP, tissue hypoxia
may be further compromised by
vasoconstriction
15-Jan-20
Dr Shashwat Jani.
99099 44160.
22

23. Management Of Labour
In Critical Phase Of Dengue
 Blood and blood products should be cross-
matched and saved in preparation for delivery.
 Trauma or injury should be kept to the minimum
if possible.
 It is essential to check for complete removal of
the placenta after delivery.
 Transfusion of platelet concentrates should be
initiated during or at delivery but not too far ahead
of delivery, as the platelet count is sustained by
platelet transfusion for only a few hours during
the critical phase.
15-Jan-20
Dr Shashwat Jani.
99099 44160.
23

24.  Fresh whole blood/fresh packed red cells
transfusion should be administered as soon as
possible.
 Do not wait for blood loss to exceed 500 ml
before replacement, as in postpartum
haemorrhage.
 Do not wait for the haematocrit to decrease
to low levels.
 Ergotamine and or oxytocin infusion as per
standard obstetrical practice should be
commenced to contract the uterus after delivery
to prevent postpartum haemorrhage.
15-Jan-20
Dr Shashwat Jani.
99099 44160.
24

25. 15-Jan-20
Dr Shashwat Jani.
99099 44160.
25

26. Post Delivery
•Closely monitored baby and mother in hospital
after birth in view of the risk of vertical
transmission
• At or near-term/delivery, severe foetal or
neonatal dengue illness and death may occur ,
when there is insufficient time for production of
protective maternal antibodies.
15-Jan-20
Dr Shashwat Jani.
99099 44160.
26

27. Do’S
Suspect Dengue in each acute febrile illness
Admit Probable dengue in pregnancy for close monitoring.
CBC ( PCV - Haematocrit) is the sole Lab parameter needed
for monitoring. Serology NOT necessary.
Watchful vigilance for warning sign specially when fever
starts subsiding.
Diagnose shock to be detected early where intense fluid
management helps.( NS only)
Eminent Delivery : Fresh blood and platelets to be kept
ready and transfused as mentioned.
Baby To be evaluated for congenital Dengue.
Timely Intervention brings down fatality from 20% to 1%.
15-Jan-20
Dr Shashwat Jani.
99099 44160.
27

28. Don’t

 No Intramuscular Injections
 No Hypotonic IV fluid
 No IV fluid for Group A if adequate oral intake.
 No steroids /Antibiotics
15-Jan-20
Dr Shashwat Jani.
99099 44160.
28

29. Home Care ADVICE LEAFLET for Dengue Patient

15-Jan-20
Dr Shashwat Jani.
99099 44160.
29

30. Home Care Advice Leaflet for Dengue Patient

15-Jan-20 30

31. Prevention
•Larval control
•Adult mosquito control
•Personal protection
•Insect repellent
•Vaccine
( Contraindicated in Pregnancy & Breastfeeding )

15-Jan-20
Dr Shashwat Jani.
99099 44160.
31

32. 15-Jan-20
Dr Shashwat Jani.
99099 44160.
32

33. To Conclude….
 Dengue in pregnancy is associated with high
morbidity & mortality. It requires early diagnosis
and treatment.
 Health-care providers should consider dengue
in the differential diagnosis of pregnant women
with fever during epidemics in endemic areas.
 Early diagnosis and prompt management is
crucial for reducing the maternal and fetal
morbidity and mortality.
15-Jan-20
Dr Shashwat Jani.
99099 44160.
33

34.  There is no role for termination
of pregnancy before term unless
there is an obstetric indication.

 Induction of labour or caesarean
section should be avoided during the
critical phase.
15-Jan-20
Dr Shashwat Jani.
99099 44160.
34

35. 15-Jan-20
Dr Shashwat Jani.
99099 44160.
35