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Is Pregnancy Associated with Severe Dengue? A Review of Data from the Rio de Janeiro Surveillance Information System

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Dengue is a reportable disease in Brazil; however, pregnancy has been included in the application form of the Brazilian notification information system only after 2006. To estimate the severity of maternal dengue infection, the available data that were compiled from January 2007 to December 2008 by the official surveillance information system of the city of Rio de Janeiro were reviewed. During the study period, 151,604 cases of suspected dengue infection were reported. Five hundred sixty-one women in their reproductive age (15-49 years) presented with dengue infection; 99 (18.1%) pregnant and 447 (81.9%) non-pregnant women were analyzed. Dengue cases were categorized using the 1997 WHO classification system, and DHF/DSS were considered severe disease. The Mann-Whitney test was used to compare maternal age, according to gestational period, and severity of disease. A chi-square test was utilized to evaluate the differences in the proportion of dengue severity between pregnant and non-pregnant women. Univariate analysis was performed to compare outcome variables (severe dengue and non-severe dengue) and explanatory variables (pregnancy, gestational age and trimester) using the Wald test. A multivariate analysis was performed to assess the independence of statistically significant variables in the univariate analysis. A p-value<0.05 was considered statistically significant. A higher percentage of severe dengue infection among pregnant women was found, p = 0.0001. Final analysis demonstrated that pregnant women are 3.4 times more prone to developing severe dengue (OR: 3.38; CI: 2.10-5.42). Mortality among pregnant women was superior to non-pregnant women. Pregnant women have an increased risk of developing severe dengue infection and dying of dengue.
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Is Pregnancy Associated with Severe Dengue? A Review
of Data from the Rio de Janeiro Surveillance Information
System
Carolina Romero Machado
1
, Elizabeth Stankiewicz Machado
2
*, Roger Denis Rohloff
3
, Marina Azevedo
4
,
Dayse Pereira Campos
1
, Robson Bruniera de Oliveira
1
, Patrı
´cia Brasil
1
1Instituto de Pesquisa Clı
´nica Evandro Chagas, Fiocruz, Rio de Janeiro, Rio de Janeiro, Brasil, 2Servic¸o de Doenc¸ as Infecciosas e Parasita
´rias, Hospital Universita
´rio
Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brasil, 3Maternidade Municipal Fernando Magalha
˜es, Rio de Janeiro, Rio de Janeiro, Brasil,
4Secretaria Municipal de Sau
´de e Defesa Civil do Rio de Janeiro SMSDC-RJ, Rio de Janeiro, Rio de Janeiro, Brasil
Abstract
Background:
Dengue is a reportable disease in Brazil; however, pregnancy has been included in the application form of the
Brazilian notification information system only after 2006. To estimate the severity of maternal dengue infection, the
available data that were compiled from January 2007 to December 2008 by the official surveillance information system of
the city of Rio de Janeiro were reviewed.
Methods and Principal Findings:
During the study period, 151,604 cases of suspected dengue infection were reported. Five
hundred sixty-one women in their reproductive age (15–49 years) presented with dengue infection; 99 (18.1%) pregnant
and 447 (81.9%) non-pregnant women were analyzed. Dengue cases were categorized using the 1997 WHO classification
system, and DHF/DSS were considered severe disease. The Mann-Whitney test was used to compare maternal age,
according to gestational period, and severity of disease. A chi-square test was utilized to evaluate the differences in the
proportion of dengue severity between pregnant and non-pregnant women. Univariate analysis was performed to compare
outcome variables (severe dengue and non-severe dengue) and explanatory variables (pregnancy, gestational age and
trimester) using the Wald test. A multivariate analysis was performed to assess the independence of statistically significant
variables in the univariate analysis. A p-value,0.05 was considered statistically significant.
A higher percentage of severe dengue infection among pregnant women was found, p= 0.0001. Final analysis
demonstrated that pregnant women are 3.4 times more prone to developing severe dengue (OR: 3.38; CI: 2.10–5.42).
Mortality among pregnant women was superior to non-pregnant women.
Conclusion:
Pregnant women have an increased risk of developing severe dengue infection and dying of dengue.
Citation: Machado CR, Machado ES, Rohloff RD, Azevedo M, Campos DP, et al. (2013) Is Pregnancy Associated with Severe Dengue? A Review of Data from the
Rio de Janeiro Surveillance Information System. PLoS Negl Trop Dis 7(5): e2217. doi:10.1371/journal.pntd.0002217
Editor: Scott B. Halstead, Pediatric Dengue Vaccine Initiative, United States of America
Received January 4, 2012; Accepted April 1, 2013; Published May 9, 2013
Copyright: ß2013 Machado et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: The authors have indicated that no funding was received for this work.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: emachado@infolink.com.br
Introduction
Since the reintroduction of DENV-1 in 1986 in RJ, dengue
has become a major public health problem in Brazil [1]. The
occurrence of dengue fever (DF) and dengue hemorrhagic fever
(DHF) has increased over the past several years in Brazil, in
part due to the rapid spread and simultaneous circulation of
the DENV-1, DENV-2, DENV-3 [1]. In 2008, over 600,000
cases of DF and 4,455 cases of DHF were reported in Brazil,
with 40% and 42%, respectively, occurring in the state of RJ
[2,3].
A surveillance information system of reportable diseases,
SINAN, was implemented in Brazil in the early 1980s [4], and
since then, dengue has been a compulsory reportable disease.
However, pregnancy was a reportable item on the form only after
2006.
Globally, there are increasing reports of dengue during
adulthood, increasing the risk for dengue during pregnancy. In
the literature only approximately 400 cases of dengue during
pregnancy have been reported, primarily describing the maternal
and fetal outcomes [5,6]. If diseases such as malaria and cholera
are more severe during pregnancy, would dengue also be more
severe? During the 2007/2008 epidemic in the city of RJ, the
highest rate of laboratory-positive dengue samples was among
those in the age group under 15 years, followed by those 15–29
years; 99% of all births during this period occurred in mothers
aged 15–49 years [7].
To estimate the severity of maternal dengue, the available data
provided by SINAN related to the epidemic period of January 1,
2007, through December 31, 2008, in the city of RJ, were
reviewed. Laboratory-confirmed dengue cases in reproductive-age
women (15–49 years) were included. Mortality and severity of the
PLOS Neglected Tropical Diseases | www.plosntds.org 1 May 2013 | Volume 7 | Issue 5 | e2217
disease were compared between pregnant and non-pregnant
women.
Methods
Data source (SINAN form)
A suspected dengue case is routinely reported to SINAN within
24 hours of attendance in a healthcare unit, using a standardized
form [8]. When the laboratory results are available, the form is
completed by a health staff member who reviews the chart
information and adds the final dengue classification, usually after a
period of no more than 3 months. Suspected cases are reported
from all healthcare facilities in RJ.
The SINAN form includes information on basic demogra-
phy, laboratory data, hospitalization and outcomes (death or
cure). Dengue cases are classified according to the WHO
1997 [9], adapted by the Brazilian Ministry of Health to
include the category of dengue with complications [10] for the
cases that do not fulfill all three criteria for DHF. Laboratory
confirmed cases were considered when either virus isolation,
PCR testing, paired IgM or IgG testing or single IgM test was
positive.
Pregnancy is categorized in the SINAN form according to
trimester: 1
st
trimester (up to 14 weeks of gestation), 2
nd
trimester
(14–28 weeks), 3
rd
trimester (after 28 weeks) or unidentified
gestational age.
Study population
Eligibility criteria. childbearing-age women with complete-
ness information about pregnancy, dengue classification and
laboratory confirmation.
During 2007–2008, of 151,604 suspected dengue cases reported
to SINAN in RJ, 76,990 occurred in women. Those with age less
than 15 years or over 49 years (n = 17,985) were excluded,
resulting in 50,005 suspected dengue cases in reproductive-age
women. Laboratory dengue confirmation corresponded to 3,972
cases. Of these, 546 were eligible.
The mean population of reproductive-age women in the city of
RJ in the period was 1,700,036: 83,332 pregnant and 1,616,704
non-pregnant women [7].
To estimate dengue-mortality and fatality rates, it was assumed
the ratio of 5% [7] pregnancy among childbearing-age women,
corresponding to 199 pregnant and 3773 non-pregnant infected
women.
Deaths due to dengue occurred in 3 pregnant women and 28 in
non-pregnant women.
Dengue classification
Patients were categorized according to the WHO 1997
classification system as DF, DHF or DSS [10]. Dengue
classification of patients (n = 117) categorized in the SINAN form
as ‘dengue with complications’ were reviewed. If patients had
evidence of plasma leakage they were categorized as having DHF/
DSS and thus considered as severe cases. Otherwise, patients were
categorized as having DF.
Statistical analysis
The Mann-Whitney Utest was used to test the difference
between the mean age of pregnant and non-pregnant women and
the difference between the mean age of pregnant women by
dengue classification (DF and DHF/DSS).
A chi-square test was used to evaluate the differences in the
proportion of dengue severity between pregnant and non-pregnant
women. A p-value of ,0.05 was considered significant in all
statistical tests.
A univariate analysis was performed using DHF/DSS (depen-
dent variable) and pregnancy, maternal age (as a continuous
variable) and trimester (independent variables) using the Wald test.
Multiple logistic regression analysis was used to determine whether
statistically significant variables were independently associated
with dengue severity. Variables with a p-value,0.05 in the
univariate analysis were included in the multivariate analysis.
Finally, the residuals of the fitted model were analyzed. With this
modeling, the odds ratio and their respective confidence intervals
(95%) were obtained. All statistical analyses of data were
performed using Rsoftware, version 2.11.1.
Ethics statement
Our study was reviewed and approved by the Ethical
Committee of the Municipal Secretary of the City of Rio de
Janeiro: ComiteˆdeE
´tica em Pesquisa da Secretaria Municipal de
Sau´de e Defesa Civil. Protocolo de pesquisa: 51/08. CAAE:
0122.1.314.000-08 e 0130.1.314.000-08. Inform consent was not
obtained because the data were analyzed anonymously.
Results
The incidence of laboratory confirmed dengue among women
in reproductive age was 234/100,000 inhabitants/2y, with similar
rates between pregnant (238/100,000) and non-pregnant women
(233/100,000). Mortality of dengue was 3,6/100,000 inhabitants/
2y among pregnant women and 1,7/100,000 inhabitants/2y
among non-pregnant women. Case fatality rate was 7,4 and 1,5%
respectively.
Data on 546 eligible reproductive-age women who had
confirmed cases of dengue were analyzed: 99 (18.1%) were
pregnant and 447 (81.9%) were not (table 1). The mean (6
standard deviation) maternal age was significantly different:
26.368.5 years in pregnant women compared with 31.5610.7
years in non-pregnant women (p,0.05). No significant difference
Author Summary
Dengue represents a major worldwide public health
problem. According to the WHO, up to 50 million dengue
infections occur each year. The occurrence of dengue fever
and dengue hemorrhagic fever has increased in Brazil, in
part due to the simultaneous circulation of DENV-1, DENV-
2 and DENV-3. Although a primary infection with one
serotype confers a partial or transient immunity against
other serotypes, any subsequent infections harbor the risk
of increased morbidity/mortality. Several case reports have
been published regarding maternal and fetal outcomes
from dengue infection, but it is still inconclusive if
pregnancy is associated with severity. To estimate the
severity of maternal dengue infection, available data that
were compiled from 2007 to 2008 by the official
surveillance information system of the city of Rio de
Janeiro were reviewed. The cases of dengue were analyzed
using the 1997 WHO classification. Pregnant women were
3.4 times more prone to developing severe dengue than
non-pregnant women. Mortality among pregnant women
was superior to non-pregnant women. The increased risk
of severe outcomes in pregnant women merits further
attention to effective public health and medical interven-
tions that will aid in avoiding morbidity/fatalities within
this population.
Dengue Infection Severity among Pregnant Women
PLOS Neglected Tropical Diseases | www.plosntds.org 2 May 2013 | Volume 7 | Issue 5 | e2217
was observed in the mean age between pregnant women with
DHF/DSS (25.568.2) and DF (26.968.5).
Most cases were classified as DF (n = 417, 76.4%), 123 as DHF
(22.5%) and 6 as DSS (1.1%). A higher proportion of pregnant
women than non-pregnant women had DHF/DSS (table 1).
Hospitalization information available for 186 (34.1%) patients
occurred in 61 (34.1%) pregnant women, and in 118 (65.9%) non-
pregnant women. The proportion of severe dengue among
hospitalized women was similar: 73.8% and 66.9% for pregnant
and non-pregnant women, respectively.
Information on death was available for 395 (72.3%) of the
eligible cases: three pregnant and five non-pregnant women died
(table 1). Shock syndrome (n = 3) and cavity effusion (n =2) were
associated with deaths. The cause of death was unknown in three
patients.
A higher prevalence of DHF/DSS that increased with gestation
age was observed (table 2). Pregnant women were 3.4 times more
likely to have DHF/DSS, primarily in the last trimester; OR 3.38;
CI 2.1–5.42 (table 3).
Discussion
This study suggests that dengue during pregnancy can increase
maternal mortality, as previously reported [11]. It also suggests
that pregnancy is associated with DHF/DSS and that the
susceptibility to severe disease increases with pregnancy age.
Severe dengue has been associated with maternal deaths, with
fatality rates ranging from 2.9%–22% [5–6,11–13]. The maternal
dengue fatality in this study was 7.4%. The differences in dengue
fatality in pregnant women likely result from differences in the
designs and in the heterogeneity of the studies sample sizes.
Additionally, it may represent different regional management of
dengue in pregnant women.
More than half of pregnant women were hospitalized and it
was twice the rate of hospitalization for non-pregnant women,
since it was a recommendation of Rio de Janeiro’s healthcare
authorities to prevent dengue complications in this group.
Moreover, the proportion of DHF could still be underestimated
as the identification of plasma leakage syndrome through the
hemoconcentration or hypoproteinemia may be compromised
from the seventh to the 32rd week of gestation, by the
physiological increase of intravascular volume of this period
[14].
The reasons for the association of DHF/DSS with pregnancy
were not assessed in this study. The amount of vascular leakage
during early versus late pregnancy may have different effects on
the clinical presentation and on the perceived severity level. The
higher risk for developing severe disease in the 2
nd
and 3
rd
trimesters should be confirmed by prospective studies as the
selection bias related to admission because of risk of preterm
delivery cannot be excluded.
The non-laboratory confirmed dengue cases were not analyzed
to avoid a detection bias, and the confusion of dengue with
pregnancy complications, such as HELLP syndrome.
The findings of the study are based on a retrospective review of
routinely collected data, with laboratory confirmed dengue, which
Table 1. Mean age, dengue classification, hospitalization and
death in pregnant and non-pregnant women of reproductive
age.
Women of reproductive age
Pregnant (N = 99) Non-pregnant (N = 447)
Age (years)
Mean age (6SD) 26.3 (8.5) 31.5 (10.7)
Missing 1 (0.2%) 0
Dengue criteria
(WHO 1997)
Dengue fever 53 (53.5%) 364 (77.4%)
DHF 45 (45.5%) 78 (17.5%)
DSS 1 (1.0%) 5 (5.0%)
Hospitalization
Yes 61 (61.6%) 118 (26.4%)
No 3 (3.0%) 4 (0.9%)
Missing response 35 (35.4%) 325 (72.7%)
Death
Yes 3 (3.0%) 5 (1.1%)
No 78 (78.8%) 309 (69.1%)
Missing response 18 (18.2%) 133 (29.8%)
doi:10.1371/journal.pntd.0002217.t001
Table 2. Distribution according to the trimester of pregnant
women.
Dengue criteria (WHO 1997)
Dengue fever DHF/DSS
n(%) n(%)
Pregnant 53 (53.5) 46 (46.5)
First trimester 17 (32,0) 7 (15.2)
Second trimester 11 (20,8) 14 (30,4)
Third trimester 14 (26.4) 23 (50.0)
Trimester unknown 11 (20.8) 2 (4.4)
doi:10.1371/journal.pntd.0002217.t002
Table 3. Univariate and multivariate analyses.
DHF/DSS
OR (CI)
p-value
Univariate analysis
Pregnancy 3.80 (2.40–6.04) ,0.001
Age (15–49 years) 0.97 (0.95–0.98) ,0.001
Trimester
First trimester 1
Second trimester 3.10 (0.97–10.6) 0.06
Third trimester 3.98 (1.36–12.65) 0.01
Multivariate analysis
Pregnancy 3.38 (2.1–5.42) ,0.001
Age (15–49 years) 0.97 (0.95–0.99) 0.03
Trimester
First trimester 1
Second trimester 3.02 (0.94–10.37) 0.06
Third trimester 3.94 (1.33–12.69) 0.01
doi:10.1371/journal.pntd.0002217.t003
Dengue Infection Severity among Pregnant Women
PLOS Neglected Tropical Diseases | www.plosntds.org 3 May 2013 | Volume 7 | Issue 5 | e2217
introduces some limitations such as bias resulted from incomplete
data and possible misclassification. Although pregnant women
were more likely to be hospitalized for fever and illness in general
compared to their non-pregnant counterparts, it would be
expected a lower frequency of severity among this group as
pregnant women had a preventive hospitalization.
As all the uncompleted data about death were attributed to non-
pregnant women, the mortality rate among pregnant women
might still be underestimated.
SINAN has also been used in Brazil to conduct studies on
dengue [15]. Although citywide surveillance system of information
has no specific clinical plasma leakage signs data and may be
incomplete, it is a population-base registry from which maternal
dengue severity could be inferred by the access to dengue
classification. Further longitudinal studies are needed to confirm
these findings and to determine on how these two subgroups
presents clinically and how their presentations differ.
Supporting Information
Checklist S1 STROBE Checklist.
(DOC)
Author Contributions
Conceived and designed the experiments: PB . Performed the experiments:
CRM ESM PB. Analyzed the data: CRM ESM RBdO PB RDR.
Contributed reagents/materials/analysis tools: RBdO DPC MA. Wrote
the paper: CRM ESM PB RDR.
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Dengue Infection Severity among Pregnant Women
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... Studies from Brazil have highlighted a rise in severe dengue cases among pregnant women, particularly in the second and third trimesters, with higher mortality rates compared to non-pregnant women (9,10). Similarly, research has indicated increased risks of maternal and fetal complications such as obstetric hemorrhage, thrombocytopenia, and anemia (11,12). This study aims to evaluate the maternal and fetal outcomes of dengue fever in pregnancy, conducted as a cross-sectional analysis at Hajiani Hospital and Bilawal Medical College Teaching (CDF) Hospital in Hyderabad over two years from January 1, 2020, to December 31, 2021. ...
... Thrombocytopenia, obstetric hemorrhage, and anemia were prevalent complications, consistent with existing literature The maternal mortality rate of 13.4% was notably high, highlighting the severe impact of dengue fever on pregnant women. This is comparable to other studies that reported high maternal mortality rates in similar settings (11,12). The high rate of complications such as thrombocytopenia (90.3%) and obstetric hemorrhage (71.1%) underscores the need for timely and effective medical interventions to manage these conditions. ...
... Previous studies have similarly reported increased risks of adverse fetal outcomes, including low birth weight, stillbirth, and preterm delivery, in pregnancies complicated by dengue fever (10,13,14). The findings of this study are consistent with research from Brazil and other dengue-endemic regions, where dengue infection during pregnancy has been associated with significant maternal and fetal morbidity and mortality (11,12). The study's strengths include its comprehensive data collection and the use of standardized laboratory tests to diagnose dengue fever, which enhances the reliability of the findings. ...
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... Small studies have suggested that pregnant women seem to be more likely to present more severe forms of dengue infection than the general population [90,91]. In the study of Machado et al. in Brazil (January 2007 to December 2008), pregnant women had an increased risk of developing severe dengue infection and dying of dengue [90]. ...
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... The literature has shown that pregnant women are at greater risk of progressing to more severe forms of the disease and death. (27) In Brazil, a retrospective evaluation showed that the rate of maternal deaths from dengue between 2007-2015 was four times higher among pregnant women with dengue, with a worse prognosis when occurring in the third trimester of pregnancy. (9) Another evaluation of maternal mortality by dengue between 2007 and 2012 showed an increase in this rate by statistically significant values when comparing the first 10 days of the disease to deaths occurring after 10 days, indicating that women in the pregnancy-puerperal cycle need differentiated care and attention in the acute phase of the disease. ...
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Dengue fever is considered the most prolific vector-borne disease in the world, with its transmission rate increasing more than eight times in the last two decades. While most cases present mild to moderate symptoms, 5% of patients can develop severe disease. Although the mechanisms are yet not fully comprehended, immune-mediated activation leading to excessive cytokine expression is suggested as a cause of the two main findings in critical patients: increased vascular permeability that may shock and thrombocytopenia, and coagulopathy that can induce hemorrhage. The risk factors of severe disease include previous infection by a different serotype, specific genotypes associated with more efficient replication, certain genetic polymorphisms, and comorbidities such as diabetes, obesity, and cardiovascular disease. The World Health Organization recommends careful monitoring and prompt hospitalization of patients with warning signs or propensity for severe disease to reduce mortality. This review aims to update the diagnosis and management of patients with severe dengue in the intensive care unit.
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Introducción: las infecciones por dengue y chikungunya son transmitidas por el vector Aedes aegypti y pueden afectar a la mujer embarazada y al producto de su gestación. Objetivo: identificar si las infecciones por dengue y chikungunya durante el embarazo son factores asociados a la presencia de complicaciones obstétricas, en Colima, México. Material y métodos: se incluyeron 45 pacientes con complicaciones obstétricas y 90 sin complicaciones. Su selección fue por muestreo bietápico. Se recolectaron datos sociodemográficos, antropométricos, ginecoobstétricos y de complicaciones obstétricas. Se calcularon estadísticos descriptivos, pruebas de significación no paramétricas y estimaciones de riesgo crudas y ajustadas (razón de momios [RM] e intervalos de confianza al 95% [IC 95%]). Resumen 2 Resultados: de 135 pacientes incluidas, 15 tuvieron diagnóstico de dengue y 20 de chikungunya. Hubo complicaciones obstétricas en 60% de pacientes infectadas con chikungunya, en 46.7% con dengue y en 26% de no infectadas (p = 0.007). La infección por chikungunya (RM ajustada = 1.6) y el antecedente de aborto y cesárea (RM ajustada = 2.2) fueron factores de riesgo independientes que estuvieron asociados a la presencia de complicaciones. El dengue tuvo una RM ajustada = 1.3 sin una diferencia estadísticamente significativa. Conclusiones: la infección por chikungunya y el antecedente de aborto y cesárea son factores de riesgo asociados a complicaciones obstétricas. Su detección oportuna es prioritaria como estrategia preventiva.
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Climate change is known to have profound impacts on global mental health and worsen gender-specific mental health disparities. These impacts must be better understood as the current body of literature and evidence at this nexus is still nascent. This chapter will first review the existing evidence for the biological, cultural, and socioeconomic factors at the intersection of climate-sensitive and gender- and sex-based mental health disparities across the life span. We will subsequently review evidence for climate change adaptation and mitigation measures that can promote and protect the mental health of women and sexual and gender minorities (SGMs). Major gaps in gender analysis and research related to how climate change impacts mental health exist globally, but they are particularly prominent in low- and middle-income countries (LMICs). Even more glaring gaps exist in research investigating climate-sensitive mental health impacts on SGMs. Promoting mental health and neurodevelopment in women and girls, particularly during perinatal periods as well as childhood and adolescence, are linked to far-reaching social, economic, health, and policy outcomes for communities globally.
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Objective Severe dengue is a significant health problem in Latin America, with children being the most affected. Understanding risk factors for severe dengue is crucial for enhancing patient care. Therefore, this study aims to systematically review the literature to identify the risk factors associated with severe dengue in Latin America through systematic review and meta‐analysis. Methods PubMed, SciELO, LILACS and EMBASE databases were used to search for eligible scientific articles for the review. The outcomes considered were symptoms of severe dengue, hospitalisation and death. The Joanna Briggs Institute Critical Appraisal Checklist was used to assess the quality of the studies. Data analysis was performed using STATA v 13.0 software. The degree of heterogeneity between studies was quantified using the I² measure, and statistically significant results were defined as those with p values <0.05. Results Of the 1876 articles screened, 47 articles were included in the systematic review and 45 articles were analysed through meta‐analysis. Identified risk factors associated with severe dengue included secondary dengue infection, female sex, white or Caucasian ethnicity and specific signs and symptoms such as headache, myalgia and/or arthralgia, vomiting/nausea, abdominal pain or tenderness, diarrhoea, prostration, lethargy, fatigue or similar. For the death outcome, respiratory symptoms and age <18 years were identified as risk factors. On the other hand, in women, the diagnosis of positive tourniquet test, platelet count <100,000 per μL and symptoms of capillary fragility were associated with a lower probability of death. These data highlight the importance of early screening of patients, to identify possible haemorrhagic signs and reduce deaths from dengue. This study has limitations, including possible publication bias, heterogeneity of results and study design biases. Conclusion These findings are significant for shaping strategies, management approaches and identifying high‐risk groups, which will help establish future guidelines.
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The aim of this study was to explore the distribution of reproductive outcomes following dengue virus infection during pregnancy (2001-2005). An ecological epidemiological study was conducted in all counties with more than 80,000 inhabitants in Southeast Brazil. The study explored the correlation between dengue incidence rates in women 15-39 years of age and selected mortality indicators (maternal, fetal, perinatal, neonatal, early neonatal, and infant) in these counties, and Spearman correlation coefficients were calculated. A positive correlation was observed between median dengue incidence in women 15-39 years of age and median maternal mortality (r = 0.88; 95%CI: 0.51; 1.00), with a determination coefficient R² = 0.78. The correlation between dengue incidence in childbearing-age women and reproductive outcomes in Southeast Brazil suggests that dengue infection during pregnancy can negatively impact its outcome and increase maternal mortality.
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The aim of this study was to explore the distribution of reproductive outcomes following dengue virus infection during pregnancy (2001-2005). An ecological epidemiological study was conducted in all counties with more than 80,000 inhabitants in Southeast Brazil. The study explored the correlation between dengue incidence rates in women 15-39 years of age and selected mortality indicators (maternal, fetal, perinatal, neonatal, early neonatal, and infant) in these counties, and Spearman correlation coefficients were calculated. A positive correlation was observed between median dengue incidence in women 15-39 years of age and median maternal mortality (r = 0.88; 95%CI: 0.51; 1.00), with a determination coefficient R² = 0.78. The correlation between dengue incidence in childbearing-age women and reproductive outcomes in Southeast Brazil suggests that dengue infection during pregnancy can negatively impact its outcome and increase maternal mortality.
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The article describes the epidemiologic profile of dengue cases in Vitória, the capital of Espírito Santo, Brazil, from 2000 to 2009, aimed at identifying risk groups regarding the incidence and severity of the disease. Confirmed cases of dengue among city residents during ten years were classified as dengue fever, dengue hemorrhagic fever, dengue shock syndrome and dengue with complications, and analyzed according to sex, age, race-color and education. The proportion of dengue cases was highest among women aged 20 to 29 years-old and similar between whites and blacks. A gradual decrease occurred in the percentage of dengue cases in the population aged 15 years-old or more, in the historical series of 10 years, and a growing increase in individuals less than 15 years-old, showing statistical significance. The fatality rate ranged from zero to 0.3% for all forms of dengue and from 0.2% to 18.2% for severe forms. The profile of those affected by the disease in the municipality is similar to those affected in Brazil. The increasing number of cases in individuals under 15 years-old corroborates the results of recent studies in other Brazilian municipalities.
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Dengue is the most important mosquito-borne disease in Sri Lanka, leading to more than 340 deaths during the last outbreak (˜35,000 reported cases) starting in mid April 2009. The predominant dengue virus serotypes during the last few years have been DENV-2 and DENV-3. Dengue infection in pregnancy carries the risk of hemorrhage for both the mother and the newborn. Other risks include premature birth, fetal death, and vertical transmission. We report clinical and laboratory findings and outcomes in pregnant women hospitalized with dengue infection during pregnancy. Clinical, laboratory, maternal/fetal outcomes and demographic data were collected from patients with confirmed dengue infections during pregnancy treated at De Soysa Maternity Hospital, Sri Lanka from 1 May 2009 to 31 December 2009. Fifteen seropositive dengue infected pregnant women were diagnosed in the period. Multiorgan failure leading to intrauterine fetal and maternal death occurred in one case of dengue hemorrhagic fever (DHF) IV. One patient with DHF III had a miscarriage at the 24th week of gestation. Perinatal outcomes of the other cases were satisfactory. One woman developed dengue myocarditis but recovered with supportive treatments. No cases of perinatal transmission to the neonate occurred. Dengue in pregnancy requires early diagnosis and treatment. A high index of clinical suspicion is essential in any pregnant woman with fever during epidemic. Further studies are mandatory as evidence-based data in the management of dengue specific for pregnancy are sparse.
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To investigate maternal and perinatal outcomes (maternal death, preterm delivery, low birth weight and perinatal mortality) of dengue at PortSudan and Elmawani hospitals in the eastern Sudan. This was a retrospective Cohort study where medical files of women with dengue were reviewed. There were 10820 deliveries and 78 (0.7%) pregnant women with confirmed dengue IgM serology at the mean (SD) gestational age of 29.4(8.2) weeks. While the majority of these women had dengue fever (46, 58.9%), hemorrhagic fever and dengue shock syndrome were the presentations in 18 (23.0%) and 12, (15.3%) of these women, respectively. There were 17(21.7%) maternal deaths. Fourteen (17.9%) of these 78 women had preterm deliveries and 19 (24.3%) neonates were admitted to neonatal intensive care unit. Nineteen (24.3%) women gave birth to low birth weight babies. There were seven (8.9%) perinatal deaths. Eight (10.2%) patients delivered by caesarean section due to various obstetrical indications. Thus dengue has poor maternal and perinatal outcomes in this setting. Preventive measures against dengue should be employed in the region, and more research on dengue during pregnancy is needed.
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The goals of this review were to determine the incidence of recurrent shoulder dystocia and the incidence of brachial plexus injury in such cases. A search of PubMed was conducted between 1980 and March 2009. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. The search yielded 191 publications, of which 9 provided complete data; these were used to calculate the incidence of recurrent shoulder dystocia. The rate of shoulder dystocia in the prior pregnancies was 1.64% (31,311/1,911,014). Among 10,591 known subsequent vaginal births, the rate of recurrent shoulder dystocia was 12% (OR, 8.25; 95% CI, 7.77, 8.76). Brachial plexus injury occurred significantly more often during recurrent shoulder dystocia than during the first shoulder dystocia (4% vs. 1%; OR, 3.59; 95% CI, 2.44, 5.29; or 45/1000 vs. 13/1000 births). About 12% of parturients with a history of shoulder dystocia have a recurrent dystocia in the subsequent pregnancy, a risk of about 1 in 8. Brachial plexus injury occurs in 19/1000 vaginal births during the first episode of shoulder dystocia, and in 45/1000 vaginal births after recurrent dystocia. Obstetricians & Gynecologist, Family Physicians. After completion of this educational activity, the reader will be able to compare the risk of primary versus recurrent shoulder dystocia. Formulate counseling and treatment strategies for pregnant women who have had a prior pregnancy complicated by shoulder dystocia. Assess the strength of the evidence suggesting the risk of recurrent shoulder dystocia.
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To assess the impact of dengue infection during pregnancy on birth outcomes, we conducted a systematic review of 30 published studies (19 case reports, 9 case series, and 2 comparison studies). Studies were identified by searching computerized databases using dengue and dengue hemorrhagic fever, cross-referenced with pregnancy, preterm birth or delivery, low birth weight, small-for-gestational age, spontaneous abortion, pre-eclampsia, eclampsia, or fetal death as search terms. The case reports examined showed high rates of cesarean deliveries (44.0%) and pre-eclampsia (12.0%) among women with dengue infection during pregnancy, while the case series showed elevated rates of preterm birth (16.1%) and cesarean delivery (20.4%). One comparative study found an increase in low birth weight among infants born to women with dengue infections during pregnancy, compared with infants born to noninfected women. Vertical transmission was described in 64.0% and 12.6% of women in case reports and case series (respectively), as well as in one comparative study. The authors conclude that there is a risk of vertical transmission, but whether maternal dengue infection is a significant risk factor for adverse pregnancy outcomes is inconclusive. More comparative studies are needed. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this educational activity, the participant should be better able to assess symptoms of dengue fever and locations where dengue fever occurs, describe possible perinatal complications of maternal dengue fever, and identify the limitations of available literature describing dengue fever in pregnancy.
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Problem statement: The principal aim was to evaluate the effects of dengue virus infection by dengue during pregnancy and analyze the histopathology of the placenta. Approach: A retrospective study was conducted with 13 pregnant women with dengue confirmed in the period from January-December 2002, during a widespread dengue type 3 epidemic in Rio de Janeiro. Maternal and newborn data were collected from patient files and medical records during hospitalization for research for identification of dengue IgM antibodies (PanBio, Australia). Virus isolation was performed on all fatal cases and anathomopathological studies and immunohistochemistry of the placenta were carried out in three cases. Results: Among the 13 women, 11 (84, 6%) were infected in the third quarter of pregnancy, 6 (54, 5%) of which resulting in premature birth and 4 cases (30, 7%) were classified as DHF, causing 2 deaths. Intense abdominal pain afflicted 6 patients (46, 2%) and 5 newborns presented low weight, however appropriate for the gestacional age. Conclusion: Dengue virus infection in pregnancy increases premature birth risk, especially if the infection occurs in the last quarter of pregnancy.