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Dengue In Pregnancy: Causes, Symptoms, Treatment And Prevention

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Dengue fever in pregnancy can cause obstetric complications and vertical transmission (mother to baby) of the virus during the fetal period or delivery. This mosquito-borne viral infection is common in tropical and subtropical climates among semi-urban and urban areas. According to the World Health Organization (WHO), half of the world’s population is at risk for dengue, and nearly 100 to 400 million people are infected each year (1).

This post discusses the causes, symptoms, maternal and fetal outcomes, treatment, and prevention of dengue fever in pregnancy.

Causes And Transmission Of Dengue Fever

Dengue fever is caused by dengue viruses (DENV), which are of four subtypes. Hence, although people may develop immunity against the virus, being infected four times with different subtypes is possible. Mosquitoes of Aedes species, such as Aedes aegypti or Aedes albopictus, can spread DENV. This species can also spread chikungunya and Zika viruses (2).

DENV can spread through the following ways (2):

  • Mosquito bites: After biting an infected person, the mosquitoes become infected and transmit the virus through bites.
  • Mother-to-child transmission(MTCT): Infected pregnant women can pass the dengue virus to their babies during pregnancy or delivery (vertical transmission). Thus, cesarean deliveries do not seem to prevent transmission.

Rarely, the dengue virus spreads from laboratories, healthcare settings, or needle stick injuries or during an organ transplant or blood transfusion (with infected blood).

Symptoms Of Dengue Fever In Pregnancy

The most common symptom of dengue virus infection is fever. The following mild symptoms are also seen (3):

  • Nausea
  • Vomiting
  • Pain and aches, including headaches, pain behind the eyes, bone pain, joint pain, or muscle pain

Although the symptoms suggest dengue fever, blood tests are often done to identify the dengue virus.

One in 20 people with dengue fever may develop severe dengue, also known as dengue hemorrhagic fever (DHF), 24 to 48 hours after the fever disappears. It is a lethal complication of dengue fever with the following clinical manifestations (3):

  • Abdominal tenderness
  • Abdominal pain (belly pain)
  • Vomiting at least thrice in 24 hours
  • Nosebleeds
  • Bleeding gums
  • Vomiting blood
  • Blood in stools
  • Fatigue
  • Restlessness
  • Irritability

Severe dengue is a medical emergency requiring immediate treatment since the condition may deteriorate in a few hours.

Complications Of Dengue Fever During Pregnancy

Pregnant mothers with dengue fever can pass the virus to the baby during pregnancy or delivery and have an increased risk of premature birth. Pregnant mothers are also at an increased risk of developing severe dengue (4).

According to a prospective study published by the International Journal of Reproduction, Contraception, Obstetrics, and Gynecology (IJRCOG), the following complications are associated with dengue fever during pregnancy (5):

  • 3% of pregnant women developed thrombocytopenia (low platelet count), among which 4.1% required platelet transfusion, and 2.7% had a platelet count below 20,000 cells/mm3.
  • Oligohydramnios (low amniotic fluid)
  • Preterm birth
  • Antepartum hemorrhage
  • Fetal distress and meconium in the amniotic fluid

The pregnancy outcomes may vary depending on the gestational age. The onset of dengue in early and late pregnancy may be associated with bad outcomes. Pregnant women with fever in dengue-endemic areas are evaluated for dengue fever, especially during dengue epidemics.

Effects Of Dengue Fever On The Baby

Dengue fever can have the following effects on the fetus and newborn:

  • Low birth weight and prematurity are the most common adverse fetal outcomes, and many babies require NICU admission (5).
  • Transmission of dengue fever during fetal life can increase the risk for certain brain and spinal cord malformations.
  • Newborn contracting the DENV infection during delivery (perinatal transmission) are at increased risk for severe dengue.

According to a population-based study, dengue virus infection during pregnancy is associated with a 50% increased risk of congenital neurogenic anomalies and a four-fold risk of other congenital malformations of the brain (6).

The patterns of brain anomalies in dengue virus infections are similar to those in congenital Zika syndrome and include (7)

  • Microcephaly
  • Atrophy or hypoplasia of the cerebral cortex and other brain anomalies
  • Skeletal system birth defects, such as clubfoot or arthrogryposis (contracture of joints)
  • Vision problems

Although this study suggests that flaviviruses other than the Zika virus can cause birth defects (congenital malformations), the link between DENV infection and birth defects is not well understood. However, the dengue virus is isolated from the brain tissue of the affected babies.

Treatment For Dengue Fever In Pregnancy

There is no specific cure, such as antiviral medications for dengue fever. Instead, doctors may prescribe symptomatic treatment. Obstetric manifestations of dengue fever are also managed conservatively (treatments avoiding surgeries and complex interventions). Dengue in pregnant women is treated with pregnancy-safe medications that do not harm the mother or fetus.

The following treatments are usually provided for pregnant women with dengue fever (3):

  • Acetaminophen(paracetamol) is prescribed for fever and pain symptoms. It is recommended to avoid other fever and pain medications, such as aspirin, naproxen sodium (Aleve), and ibuprofen (Motrin) since they may increase the risk of bleeding.
  • Rest and adequate hydration, often with electrolyte solutions.
  • Intravenous (IV) fluids and electrolytes treat signs of dehydration.
  • Blood transfusions for severe blood loss and blood pressure is continuously monitored.
  • Platelets transfusion, if the platelet count is low.

Doctors may recommend hospitalization if there is a possibility of obstetric or other complications and if there are symptoms of organ damage such as liver damage due to dengue fever. Pregnant women with mild symptoms can stay at home during treatment if there is no risk for severe dengue or other obstetric complications. However, seek immediate medical care for warning signs such as dehydration, bleeding, low blood pressure, or worsening of existing symptoms during home care.

Prevention of Dengue Fever In Pregnancy

Avoid traveling to dengue-endemic areas during pregnancy. However, if you reside in or travel to areas with risk of dengue infection, the following preventive measures can protect you from mosquito bites (8):

  • Use an Environmental Protection Agency (EPA)-approved mosquito repellant
  • Stay in houses or hotels with mosquito screens on the windows and doors
  • Use bed mosquito nets if possible
  • Wear long sleeves and long pants
  • Drain any stagnant water around the house

All EPA-approved insect repellents are effective and safe for use in pregnant and breastfeeding women. You may use such a repellant with one of the following active ingredients (8):

  • DEET
  • IR3535
  • Picaridin (KBR 3023 or icaridin)
  • 2-undecanoate
  • Para-menthane-diol (PMD)
  • Lemon eucalyptus oil (OLE)

Use repellants with a higher percentage of active ingredients since they offer longer protection. Further, seek medical advice before traveling to dengue-endemic areas for appropriate recommendations and vaccination.

Dengue Vaccine

An effective way to prevent dengue fever is dengue vaccination. Dengvaxia (CYD-TDV) from Sanofi Pasteur is licensed and available in some countries for people between nine and 45 years. Three doses of vaccine are administered with a six-month gap between each shot.

In 2017, Sanofi Pasteur announced the risk of dengue infection after vaccination with this live, attenuated, tetravalent dengue vaccine in those who have not previously been infected with the dengue virus. Thus, the WHO recommends the vaccine only for people with previously confirmed dengue virus infection (9).

Studies with small databases do not show evidence of pregnancy-related adverse outcomes. However, many countries do not approve of taking dengue vaccines during pregnancy since the risks are unknown (10).

Dengue fever can have harmful maternal and fetal outcomes, which are conservatively managed. Self-protection from mosquito bites is recommended to avoid dengue infection. Pay attention to the warning signs of severe dengue for 24 to 48 hours after your fever has passed, and seek medical care if there are signs of severe infection.

References:

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Dr Bisny T. Joseph

Dr. Bisny T. Joseph is a Georgian Board-certified physician. She has completed her professional graduate degree as a medical doctor from Tbilisi State Medical University, Georgia. She has 3+ years of experience in various sectors of medical affairs as a physician, medical reviewer, medical writer, health coach, and Q&A expert. Her interest in digital medical education and patient education made... more