Case Study 13 – Pregnancy

[26-year-old]

Dengue Clinical Management

Acknowledgements
This curriculum was developed with technical assistance from the University of Malaya Medical Centre. Materials were contributed by the
Ministry of Health, Singapore, the United States Centers for Disease Control and Prevention, and the University of Malaya Medical Centre.
 26-year-old, 67 kg (BW)
FBC:
G1P0 at 35 weeks, booked at 32 weeks,
Hb 9.4
LMP: 29.6.05, EDD: 5.4.06
HCT 0.29
WBC 13.8
History Plt 238
Fever x 1 day Urine
Chills & rigors Protein 1+
Frequency Ketone 3+
No body ache, headache, abdominal WBC 35
pain, diarrhoea, vomiting, bleeding RBC 24
Bacteria +
Physical examination: Leucocyte esterase +
BP:150/90
HR: 140/min Diagnosis:
Temp: 39.4°C
PA: 34/52 gravid uterus, cephalic 1. Pregnancy-induced hypertension
Others: unremarkable
2. Urinary tract infection

Case study 13 - Pregnancy 2 of 13

 PROGRESS

Management
IV ampicillin 1 gm qid
IVD 2 pints NS + 3 pints D5% / 24hrs (104ml/hr)

Day 2 Day 3, 01:00

Still febrile Developed shortness of breath and
Temperature: 38.2°C desaturated to 86% on room air
Developed vomiting, poor appetite Repeated vomiting and cough since
Blood pressure: 136/70 evening
Pulse rate: 116/min No abdominal pain
Changed to IV cefuroxime 750mg tid Temperature: 38.6°C
Blood pressure: 148/78
Pulse rate: 124/min
Respiratory rate: 22
I/O: 4100ml/1500ml for Day 2 SaO2: 98% on 10L/min O2
RS: crepitations heard up to mid-zone
mainly on the left side

Case study 13 - Pregnancy 3 of 13

 DAY 3: Medical review at 04:00

Mildly dehydrated 1. What are the possible reasons

Temperature: 38.8°C to account for her desaturation?
Blood pressure: 120/90
Pneumonia
Pulse rate: 120 Pulmonary embolism
Respiratory rate: 36/min Fluid overload
Tachypnoeic
Mild bilateral pitting edema 2. What investigations should be
JVP not elevated done?
RS: Crepitations over left lung
No calf swelling FBC
Septic workout
ABG
Chest X-ray: D-dimer
Opacities over left mid-zone CXR
and lower zone ECG
ECG: sinus tachycardia, Spiral CT thorax
T inversion in lead III ECHO

Case study 13 - Pregnancy 4 of 13

 PROGRESS

ABG:
PH 7.44
PCO2 21 Spiral CT scan:
PO2 97
WhatNoisfilling
the defect
diagnosis?
noted within the main
HCO3 14 pulmonary vessels and segmental branches
BE -8 Bilateral pleural effusion with atelectasis of the
SaO2 97% adjacent lung
INR 1.1 Dengue haemorrhagic fever
APTT 54.4 2 3 3 4
Day
TT 17.9
Fever
D-Dimer positive 08:36 14:57 22:44 15:17
Thrombocytopenia HB 9.1 9.2 9.5 10.4
Na 135 of leakage:
Evidence HCT 0.29 0.28 0.30 0.32
K 3.3
pleural effusionWBC
clinically and radiologically
Urea 1.8 12.5 8.2 8.8 10.7
Creat HCT65has increasedPLT
(from baseline
198
0.29
146
to 0.32)
126 99
Uric acid 269

Case study 13 - Pregnancy 5 of 13

 DAY 5

03:55 Day 3 4 5
Blood pressure: 170/110 22:44 15:17 07:19
Pulse rate: 96/min >48hrs
Nifedipine 10mg stat HB 9.5 10.4 11.2
HCT 0.30 0.32 0.35
14:30 WBC 8.8 10.7 9.4
Developed generalized PLT 126 99 43
maculopapular rash TCO2 20.5 22.5 18.1
Fever settled
Petechiae noted over right
upper limb Dengue IgM & IgG: negative (D4)
Blood pressure: 120/60
Pulse rate: 94/min Management:
500ml NS infusion over 2 hours
Maintenance: 4 pint NS/24hrs (83 ml/hr)
Change to IVI ceftriaxone

Case study 13 - Pregnancy 6 of 13

 DISCUSSION

3. Does
1. Why negative
is there acute
denguebreathlessness during
IgG/IgM results the febrile
exclude phase
the diagnosis
ofofdengue
dengue? infection on Day 4 of illness?
NoVascular permeability gradually increases and usually
reaches its peak during the critical phase of dengue;
Dengue
hence, IgM becomes
clinically positiveplasma
significant only from Day 5usually
leakage of illness.
will
be observed during critical phase.
However,
2. What largetest
diagnostic volumes
can beofdone
oral fluid intake the
to confirm coupled
diagnosis
with large
of dengue volumes
infection in of
theintravenous
early phase?fluid during the
febrile phase could result in an excessive increase in
Dengue NS-1 Ag hydrostatic pressure and aggravate
intravascular
plasma leakage
Polymerase with excessive
chain reaction fluid
(PCR) for extravasated
dengue virus into
the pulmonary interstitial space.
Virus isolation

Case study 13 - Pregnancy 7 of 13

 DAY 5

21:45
Temperature: 37.2°C
Day 4 5 5 5
Blood pressure: 118/74
Pulse rate: 108/min 15:17 07:19 19:38 23:23
Urine output: ~70ml/hr HB 10.4 11.2 13.1 14.2
Increase IVD to 110ml/hr NS
HCT 0.32 0.35 0.41 0.43
23:30 WBC 10.7 9.4 8.2 10.1
Temperature: 37.0°C 14
PLT 99 43 15
Blood pressure: 132/78
Pulse rate: 98/min TCO2 22.5 18.1 14.9 16.6
CTG reduced variability

Decision: What is the risk of delivery at this stage?

Not to provoke delivery
Avoid LSCS
Risk of bleeding is very high whether it is a
Increase IVD to 125ml/hr NS
Transfuse 4 units platelet
spontaneous or LSCS delivery.
concentrate

Case study 13 - Pregnancy 8 of 13

 DAY 6

08:30
Fetal bradycardia Day 6 6 6 7
USS: No fetal heart beat 09:31 14:05 18:44 01:03
13:45
Blood pressure: 160/120 X 3 >96h
08:40
Nifedipine SR 20mg bd Hb 15.0 15.4 16.3 15.2
Blood pressure: 122/90 Day 5 6 6 6
HCT 0.46 0.46 0.49 0.47
Pulse
15:30 rate: 106/min 23:23 06:25 09:31 14:05
WBC 19.0 15.2 25.5 19.0
500ml
AfebrileNS over 1 hour + Hb 14.2 14.4 15.0 15.4
maintenance
Blood pressure: 125ml/hr
140/110 NS Plt
HCT 8
0.43 9
0.44 0.468 14
0.46
Pulse rate: 120/min TCO2
WBC 15.1
10.1 10.9 12.8
19.0 8.3
15.2
11:20
Another 500ml NS bolus Plt 14 15 8 9
HCT: 0.46 NS
Continue maintenance 125ml/hr TCO2 19:17 16.6 14.3 15.1
Changepressure:
Blood antibiotics to Tazosin
150/105 Blood pressure: 140/90
Pulse rate: 108/min Pulse rate: 92/min
16:00
500ml NS infusion over 1 hour Urine output: 40ml/hr
Transfer ICU for125ml/hr
Maintenance BIPAP NS Transfuse 4 units platelet concentrate
Referred to ICU

Case study 13 - Pregnancy 9 of 13

 DAY 7

08:00 Day 7 06:11 11:57 16:11 20:16

HCT improving and stabilizing HB 14.9 14.4 13.2 10.7
Still acidotic HCT 0.46 0.44 0.41 0.33
Bilirubin rising, WBC rising WBC 40.0 42 41.2 39.9
IUD
PLT 11 20 clot 28
Continue maintenance
TCO2 9.2 13.2
09:45
16:35
6 units platelet transfusion
Contraction 3:10 lasting 30 seconds
Membrane bulging
11:15
In established labour (os: 4cm) Blood transfusion
Alerted blood bank on blood/blood (4 units platelet + 2 units FFP with frusemide
products 10 mg bolus)
IVI oxytocin
14:10
High flow mask Delivered at 17:30
Reduce fluid regime to 1L/24hrs No active bleeding post-delivery

Case study 13 - Pregnancy 10 of 13

 DAYS 8, 9

20:00
Febrile with chills and rigors
Tachycardic Day 8 9
08:00 Day 8 06:39 13:07
20:11 20:11
06:30
Deterioration in mental state, more
HCT improved to 0.32
obtunded HB
HB
10.6
6.0
9.8 6.0
9.0
WBC:
No 3.0
focal neurological deficit HCT 0.32 0.30 0.18
HCT 0.18 0.28
Plt: 30 WBC 3.0 27.6 34
Diagnosis: WBC 34 17.5
Became more depressed/ PLT 30 34 60
Transfusion reaction?
withdrawn TCO2PLT 21.5 6021.5 53
25.2
Sepsis? TCO2 25.2 27.5
Intracranial bleed?
18:00
22:00
Excessive blood clots (PV loss ~400ml) Diagnosis: Eclampsia?
Developed generalized
Transfusion of packed tonic–clonic
cells, FFP and platelets was planned
seizure while preparing her for
FFPelective
and platelets were given promptly but3 not
intubation unitspacked
packedcells
cells transfusion
CT-scan: noinserted
Cervagem intracranial
PVbleed Change to IVI meropenem
HB:oxytocin
IV 6 bolus IV Mg sulfate bolus
HCT: 0.18
Plt: 60
Case study 13 - Pregnancy 11 of 13
 DAY 10

Extubated
Regained conscious level
FBC continues to improve

Discharged on Day 18

Case study 13 - Pregnancy 12 of 13

 LEARNING POINTS

Pregnancy may alter the course of dengue illness

Clinical presentation can easily be confused with other illnesses

Lower HCT level is seen at a later stage of pregnancy and may “mask”
plasma leakage. Serial HCT therefore is more important to guide us on
dengue disease progression.

Intravenous fluid administration in a well-hydrated patient during the
early phase of dengue could result in early onset of severe plasma
leakage

Dengue infection can potentially affect both the fetus as well as the
mother

Avoid LSCS or do not provoke labour during leaking phase if possible

Case study 13 - Pregnancy 13 of 13