Treatment of dengue hemorrhagic fever during pregnancy is quite complicated because doctors must think about the safety of the mother, along with the fetus she is carrying.

WHO data estimates that there are 50 to 100 million dengue infections per year worldwide. Also, an estimated 500,000 people experienced dengue hemorrhagic fever (DHF) and 20,000 deaths due to dengue infection.

Treatment of Dengue Hemorrhagic Fever in Pregnancy
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How to Diagnose Dengue Hemorrhagic Fever in Pregnancy

Dengue Hemorrhagic fever in pregnancy is an important concern in health. This is due to changes in physiology during pregnancy so that dengue infection can manifest worse in pregnant women.

Pregnant women with dengue infection should get adequate therapy along with close supervision and regular monitoring. The balance between meeting fluid requirements with excess fluid and signs of plasma leakage needs to be closely monitored by medical personnel.

The clinical symptoms of dengue infection in pregnant women are the same as in other normal adults. Some clinical symptoms that can be experienced by pregnant women are fever, headache, heartburn, and vomiting. Some patients may present with a sudden high fever and accompanied by retro-orbital pain, arthralgia, myalgia, and skin rashes. Patients also visit health services with complaints of bleeding signs such as petechiae, epistaxis, gum bleeding, or hematemesis.

However, often dengue hemorrhagic fever in pregnancy is difficult to be distinguished from other pregnancy complications, such as HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) and pregnancies with other tropical infectious diseases.

On physical examination can be found an increase in temperature, manifestations of bleeding, and positive tourniquet test (Rumpel-leede test). Other signs that doctors must know are dehydration signs in patients.

On laboratory examination, hemoconcentration can be found, which is marked by an increase in hematocrit, thrombocytopenia, and leukopenia. In supporting facilities, the examination of dengue IgM and IgG antibodies can help establish the diagnosis.

Effects of Dengue Infection on Pregnancy

In a serial case report in Sri Lanka involving 26 pregnant patients with dengue infection, there was only 1 first trimester patient who had dengue infection (3.8%). whereas 2 patients in the second trimester (7.7%), 20 third trimester patients (77%), and 3 postpartum patients (11.5%).

Dengue hemorrhagic fever in pregnancy can cause an increase in preterm birth and low birth weight. A retrospective study involving 53 study subjects reported that dengue infection in pregnancy could result in preterm labor (41%), heavy bleeding at delivery (9.3%), and retroplacental hematoma (1.9%). Fetal outcomes include prematurity (20%), intrauterine fetal death (3.8%), late miscarriage (3.8%), acute fetal distress (7.5%), maternal-fetal transmission (5.6%), and neonatal mortality (1.9%). However, it should be noted that the number of subjects in this study is only small.

In some cases, shock can occur. In babies born without abnormalities from mothers who suffer from dengue infection during pregnancy, serum IgG antibody antibodies can be found progressively for up to 8-12 months.

Another thing to note is to distinguish dengue infection from other diseases that can occur in pregnancy, such as HELLP Syndrome. In HELLP syndrome, there is usually no fever. Bleeding can occur if there has been a manifestation of DIC (disseminated intravascular coagulation). HELLP syndrome is rarely found in changes in leukocytes, and decreased hematocrit can occur. In addition, there can also be an increase in liver enzymes accompanied by hemolysis. Both HELLP syndrome and dengue infection can cause thrombocytopenia.

One of the problems that can occur in cases of dengue hemorrhagic fever in pregnancy is the difficulty in diagnosing plasma leakage. Failure to observe plasma leakage and early signs of shock can result in prolongation of shock and cause massive bleeding accompanied by multi-organ failure.

In case reports in Thailand, pregnant women usually show low hematocrit levels. Low hematocrit levels and increased hematocrit levels in pregnancy can be caused by plasma leakage or changes in normal physiology in pregnancy.

In addition, the enlarged uterus also makes it difficult to examine plasma leakage clinically (for example, in ascites or pleural effusion). Thus, a routine examination of abdominal ultrasound to examine free fluid in the abdominal cavity and chest radiograph to check for free fluid in the pleural cavity can be considered if there is a possibility of plasma leakage.

Treatment of Dengue Hemorrhagic Fever in Pregnant Women

Treatment of dengue hemorrhagic fever in pregnant women is almost the same as the treatment in adults. In cases of dengue infection without complications, treatment is given conservatively. Pregnant women with dengue infection should be treated separately from other pregnant women.

Conservative treatment is performed on patients by doing bed rest, providing a soft diet, and consuming 1.5 to 2.5 liters of water a day. If the patient experiences severe nausea, vomiting, oral fluids should be limited. The remaining fluid deficiency can be given intravenously at a dose of 100 cc/hour of normal saline.

The doctor can also prescribe symptomatic drugs to relieve the patient's symptoms. Paracetamol can be given to relieve fever. Antibiotics are not routinely indicated. Antibiotics are only given if dengue infection is proven to be accompanied by a secondary bacterial infection.

Transfusion and aggressive fluid administration are based on indications. Usually, platelet transfusion is given if the platelet count is less than 20,000 / mm3, or there are manifestations of spontaneous bleeding.

During treatment, regular monitoring should be carried out for pregnant women to monitor their vital signs. Hemoglobin and hematocrit measurement tests, as well as periodic monitoring of fetal distress signs, should also be performed. The critical period is generally at 24-48 hours from the onset of symptoms.

The 2011 WHO guidelines stated that pregnant women with dengue infection are high-risk patients, which can cause the complexity of management. Pregnant women patients who suffer from dengue fever must be hospitalized. During treatment, patients must get fluid therapy. Blood sampling must be performed to obtain the patient's initial hematocrit data.

Fluid therapy is done by giving isotonic fluids such as normal saline or lactated ringer at a dose of 5-7 ml/kg weight/hour given for 1-2 hours. Then the liquid is reduced to 3-5 ml/kg/hour for 2-4 hours and finally reduced to 2-3 ml/kg/hour, according to the patient's response.

During the administration of fluid therapy, the patient must be under strict periodic monitoring. The hematocrit examination can be performed to monitor the response to fluid therapy. If the hematocrit is fixed or only slightly increases, the liquid dose is maintained at 2-3 ml/kg body weight/hour. If there is a rapid increase in hematocrit or deterioration of vital signs, the dose of fluid can be increased to 5-10 ml/kg/hour for 1-2 hours.

After administration of fluids, a re-evaluation of the patient's vital signs must be carried out. Giving fluids to pregnant women should receive special attention from doctors. Uterus enlargement that occurs during pregnancy causes a decrease in tolerance of fluid accumulation that can occur in the body of pregnant women. This causes the doctor to be able to monitor fluid administration closely so that complications do not occur from excess fluid.

Dengue hemorrhagic fever is not an indication of pregnancy termination. As much as possible, pregnant women with dengue infection are managed conservatively. If pregnancy termination cannot be avoided, bleeding complications must be anticipated. Childbirth must be done by minimizing trauma. Apart from that, it must be ensured that the placenta has come out completely, and no remaining placenta is left in the uterus. If there is significant bleeding, the blood transfusion with whole blood or fresh packed red cells must be given immediately. Oxytocin should be given in doses according to obstetric guidelines to prevent postpartum hemorrhage. Neonates must be closely monitored so that vertical transmission can be diagnosed as early as possible.

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