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C a s e R e p o r t
Singapore Med J
2007; 48(10) : e281
Dengue haemorrhagic fever
complicated by eclampsia
Tagore S, Yim C F, Kwek K
A 28-year-old primigravida presented
A 28-year-old primigravida presented at 36 weeks at 36 weeks of gestation with a one-week
with irregular contractions, fever with myalgia, history of fever with myalgia. Diagnosis
and dysuria of one-week duration. Her obstetrical of dengue fever was made based on viral
history included an earlier admission at 35 weeks with polymerase chain reaction. She progressed
threatened preterm labour, for which she had been to dengue shock syndrome by day nine
treated with tocolysis, dexamethasone and and subsequently recovered. She delivered
was well at discharge. Apart from this, her a healthy male baby by the vaginal route,
antenatal follow-up was otherwise uneventful. On but within 24 hours of delivery, had an
examination, she was febrile (38.4°C), had a pulse eclamptic seizure, which was controlled
rate of 105/min, and blood pressure of 122/65 mmHg. with intravenous magnesium sulphate.
Vaginal examination revealed a closed cervix. Mother and the baby were well at
Cardiotocograph (CTG) was reactive and showed discharge and on the follow-up visit at
irregular contractions.three months.
She was admitted to the labour ward and was
started on intravenous ampicillin and gentamicin.
Keywords: dengue haemorrhagic fever,
Symptomatic and supportive treatment was initiated, dengue shock syndrome, eclampsia, pregnancy
and the diagnosis of dengue fever was subsequently complication
confirmed by polymerase chain reaction (PCR).
Singapore Med J 2007; 48(10):e281–e283
Her blood and urine cultures were negative. Platelet
count was 258,000/uL. Her temperature rose to a
maximum of 38.8°C and she was closely monitored
The global prevalence of dengue infection has grown with daily full blood counts, urea, electrolyte and Division of
dramatically in recent decades. It remains a major
liver function tests. On the fifth day of her admission, Gynaecology,
concern in public health, mainly in tropical and her platelet level dropped to 21,000/uL and her KK Women’s and
subtropical areas of the world. It is caused by four blood pressure fell to 74/47 mmHg, without evidence 100 Bukit Timah
dengue virus serotypes of the genus Flavivirus, and
of active bleeding. A diagnosis of dengue shock syndrome Singapore 229899
transmitted by Aedes aegypti
mosquitoes. Infection was made, and she was transferred to the intensive care provides immunity against the infecting viral
unit for monitoring. Platelet count dropped further to MD, MRCOG
serotype, but not against the other serotypes. Clinical
15,000/uL, and prothrombin time was prolonged.
features of dengue fever vary according to the age
On day eight, she had vaginal bleeding of Department of
of the patient. Infants and children may have a
approximately 200 ml. Her abdomen was soft, non- Medicine
non-specific febrile illness with rash, whereas adults tender, and her os cervix was 2 cm dilated and partially Kwek K, MBBS,
may have either a mild febrile syndrome or severe effaced. CTG was satisfactory. Normal vaginal MMed, MRCOG,disease with abrupt onset of high fever, headache,
delivery was planned as there was no obstetrical Head
muscle and joint pains, and a skin rash. The major indication for surgical intervention. Her full blood complications include dengue haemorrhagic fever
count showed a haemoglobin level of 8.0 g/L, and Women’s Anaesthesia
and dengue shock syndrome, with rare manifestations prothrombin time/partial thromboplastin time Yim CF, MBBS,
of encephalopathy and cardiomyopathy.(1) Pre- (PT/PTT) values were prolonged. She was MMedeclampsia is a mutisystem disorder and may
transfused with platelets and fresh frozen
cause thrombocytopenia, encephalopathy and plasma. By day nine, her platelet count improved to Correspondence to:
cardiomyopathy. Concomitant dengue fever during 41,000/L and no further bleeding was noted. A total Tel: (65) 6293 4044pregnancy may give rise to a clinical dilemma in
of nine units of platelets, eleven units of fresh frozen Email: shephul@
terms of diagnosis and the timing of delivery.
plasma and one unit of packed red blood cells were yahoo.com
Singapore Med J
2007; 48(10) : e282
transfused during this time. Two days later she went management was continued in the absence of into spontaneous labour and had normal vaginal maternal or foetal compromise. She had an uneventful delivery. A baby boy weighing 2,560 g, was born with vaginal delivery on day 11 after the acute phase an apgar score of nine at one and five minutes. She of dengue and increasing trend of platelet count. remained apyrexial, haemodynamically stable and Dengue PCR of the baby was negative. was transferred to general ward.
Pre-eclampsia has been reported previously
22 hours after delivery, she developed generalised in intrapartum dengue fever.(7) In the present case,
tonic-clonic seizures. She was intubated for airway the patient developed generalised tonic-clonic maintenance and subsequently managed in the intensive seizures within 24 hours of delivery. At that point, the care unit. Her blood pressure during the episode possibility of encephalopathy (in relation to dengue) was normal but she was hyper-reflexic with clonus. was considered, but encephalopathy usually occurs Computed tomography (CT) of the brain was in the febrile stage.(8) Occasionally, it may occur as a unremarkable, except for evidence of ischaemia consequence of intracranial haemorrhage, cerebral in the parietal and bilateral frontal lobes. The oedema or anoxia, micropapillary haemorrhage or neurological working diagnosis was posterior even with release of toxic products.(9) CT of the reversible encephalopathy secondary to eclampsia. brain, done after the seizure, revealed only focal Intravenous magnesium sulphate therapy was instituted. ischaemic areas. Moreover, although the blood Platelet count was 87,000/uL and haemoglobin level pressure was normal during the episode, hyper- was 10 g/L. Serum AST (66 mmol/L) and urinary total reflexia and raised urinary proteins were present. protein (0.77 g/day) were raised, although uric acid The pathogenesis of a marginal rise in blood remained normal. Her blood pressure was elevated pressure, especially 48 hours after the eclamptic to 136/85 – 140/95 mmHg at 48 hours post-fit, and episode with other signs of eclampsia, remains was controlled with nifedipine. She recovered with unclear. The possible mechanism of the blood supportive care and the follow-up CT of the brain was pressure response as well as the eclamptic fits normal. At the three-month follow-up visit, she had may be the results of a residual post-dengue leaky no neurological deficit, and the baby was well.
vasodilatory state. Conventionally, eclampsia is diagnosed with hypertension, proteinuria and convulsions.
However, signs may be wide, ranging from severe
Dengue infection is prevalent in tropical Asia, and hypertension to even absent or minimal hypertension, it is an important differential diagnosis in patients no proteinuria and oedema.(10) In most cases, postpartum presenting with fever.(1) Early diagnosis of dengue convulsions usually occurs within 48 hours, although fever is essential, as appropriate supportive treatment in some patients, it may develop beyond 48 hours, can be initiated early.(2) The pathophysiology of requiring extensive neurological evaluation.(11-13) severe dengue fever (WHO classifies this as dengue
To our knowledge, this is the first documented case
haemorrhagic fever [DHF]) is a transient increase in of dengue fever complicated by eclampsia in pregnancy. vascular permeability resulting in plasma leakage. In As the average age of dengue infections increases, severe cases, circulation is compromised, potentially it is possible that more pregnant women will be resulting in hypovolaemic shock and even demise, exposed.(2) It is thus important for the obstetrician without appropriate management. Patients with DHF to be aware of the need for early diagnosis to initiate can also have abnormal blood coagulation, but major appropriate management.
haemorrhage is unusual except in association with
The management of dengue infection in pregnancy 1. Deen JL, Harris E, Wills B, et al. The WHO dengue classification
and case definitions: time for a reassessment. Lancet 2006;
is conservative, and intervention is needed only for
obstetrical indications.(3) Previous case series on 2. Waduge R, Malavige GN, Pradeepan M, et al . Dengue infections
during pregnancy: a case series from Sri Lanka and review of
dengue fever in pregnancy reported complications of
the literature. J Clin Virol 2006; 37:27-33.
preterm labour, abruption and severe haemorrhage 3. Phupong V. Dengue fever in pregnancy: case report. BMC during caesarean section. Foetal problems include
4. Carles G, Talarmin A, Peneau C, Bertsch M. [Dengue fever and
preterm birth, intrauterine death, and acute foetal
pregnancy. A study of 38 cases in french Guiana]. J Gynecol
distress during labour.(4) Vertical transmission has also
Obstet Biol Reprod (Paris) 2000; 29:758-62. French.
5. Witayathawornwong P. Parturient and perinatal dengue
been described.(4-6) Our patient had vaginal bleeding,
hemorrhagic fever. Southeast Asian J Trop Med Public Health 2003;
without clinical or ultrasonographical evidence of
placental abruption and was hence managed supportively 6. Janjindamai W, Pruekprasert P. Perinatal dengue infection: a case
report and review of literature. Southeast Asian J Trop Med Public
with platelet and blood transfusions. Conservative
Singapore Med J
2007; 48(10) : e283
7. Bunyavejchevin S, Tanawattanacharoen S, Taechakraichana N,
10. ACOG Committee on Practice Bulletins--Obstetrics. ACOG practice
et al. Dengue hemorrhagic fever during pregnancy: antepartum,
bulletin. Diagnosis and management of preeclampsia and eclampsia.
intrapartum and postpartum management. J Obstet Gynaecol Res
11. Mattar F, Sibai BM. Eclampsia. VIII. Risk factors for maternal
8. Chotmongkol V, Sawanyawisuth K. Case report: Dengue
morbidity. Am J Obstet Gynecol 2000; 182:307-12.
hemorrhagic fever with encephalopathy in an adult. Southeast Asian
12. Chames MC, Livingston JC, Invester TS, Barton JR, Sibai BM. Late
J Trop Med Public Health 2004; 35:160-1.
postpartum eclampsia: a preventable disease? Am J Obstet Gynecol
9. de Souza LJ, Martins AL, Paravidini PC, et al. Hemorrhagic
encephalopathy in dengue shock syndrome: a case report. Braz J Infect
13. Lubarsky SL, Barton JR, Friedman SA, et al. Late postpartum
eclampsia revisited. Obstet Gynecol 1994; 83:502-5.
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