Case Study 13 – Pregnancy Dengue Clinical Management [26-year-old] Acknowledgements

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)
G1P0 at 35 weeks, booked at 32 weeks,
LMP: 29.6.05, EDD: 5.4.06
History
Fever x 1 day
Chills & rigors
Frequency
No body ache, headache, abdominal
pain, diarrhoea, vomiting, bleeding
Physical examination:
BP:150/90
HR: 140/min
Temp: 39.4°C
PA: 34/52 gravid uterus, cephalic
Others: unremarkable
FBC:
Hb
HCT
WBC
Plt
9.4
0.29
13.8
238
Urine
Protein
1+
Ketone
3+
WBC
35
RBC
24
Bacteria +
Leucocyte esterase +
Diagnosis:
1. Pregnancy-induced hypertension
2. Urinary tract infection
Case study 13 - Pregnancy
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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
Temperature:
38.2°C
Developed vomiting, poor appetite
Blood pressure:
136/70
Pulse rate:
116/min
Changed to IV cefuroxime 750mg tid
Developed shortness of breath and
desaturated to 86% on room air
Repeated vomiting and cough since
evening
No abdominal pain
Temperature:
38.6°C
Blood pressure:
148/78
Pulse rate:
124/min
Respiratory rate: 22
SaO2: 98% on 10L/min O2
RS: crepitations heard up to mid-zone
mainly on the left side
I/O: 4100ml/1500ml for Day 2
Case study 13 - Pregnancy
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DAY 3: Medical review at 04:00
Mildly dehydrated
Temperature:
38.8°C
Blood pressure:
120/90
Pulse rate:
120
Respiratory rate: 36/min
Tachypnoeic
Mild bilateral pitting edema
JVP not elevated
RS: Crepitations over left lung
No calf swelling
Chest X-ray:
Opacities over left mid-zone
and lower zone
ECG: sinus tachycardia,
T inversion in lead III
1. What are the possible reasons
to account for her desaturation?
Pneumonia
Pulmonary embolism
Fluid overload
2. What investigations should be
done?
FBC
Septic workout
ABG
D-dimer
CXR
ECG
Spiral CT thorax
ECHO
Case study 13 - Pregnancy
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PROGRESS
ABG:
PH
PCO2
PO2
HCO3
BE
SaO2
INR
APTT
TT
D-Dimer
Na
K
Urea
Creat
Uric acid
7.44
21
97
14
-8
97%
Spiral CT scan:
WhatNoisfilling
the defect
diagnosis?
noted within the main
pulmonary vessels and segmental branches
Bilateral pleural effusion with atelectasis of the
adjacent lung
1.1 Dengue haemorrhagic fever
54.4
2
3
3
Day
17.9
Fever
08:36
14:57
22:44
positive
Thrombocytopenia
HB
9.1
9.2
9.5
135 of leakage:
Evidence
HCT
0.29
0.28
0.30
3.3
pleural
effusionWBC
clinically
and radiologically
12.5
8.2
8.8
1.8
HCT65has increasedPLT
(from baseline
0.29
to 0.32)
198
146
126
269
Case study 13 - Pregnancy
4
15:17
10.4
0.32
10.7
99
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DAY 5
03:55
Blood pressure: 170/110
Pulse rate:
96/min
Nifedipine 10mg stat
14:30
Developed generalized
maculopapular rash
Fever settled
Petechiae noted over right
upper limb
Blood pressure: 120/60
Pulse rate:
94/min
Day
3
22:44
4
15:17
HB
HCT
WBC
PLT
TCO2
9.5
0.30
8.8
126
20.5
10.4
0.32
10.7
99
22.5
5
07:19
>48hrs
11.2
0.35
9.4
43
18.1
Dengue IgM & IgG: negative (D4)
Management:
500ml NS infusion over 2 hours
Maintenance: 4 pint NS/24hrs (83 ml/hr)
Change to IVI ceftriaxone
Case study 13 - Pregnancy
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DISCUSSION
3. Does
Why negative
is there acute
breathlessness
during
the febrile
phase
1.
dengue
IgG/IgM results
exclude
the diagnosis
dengue?
ofofdengue
infection on Day 4 of illness?
NoVascular permeability gradually increases and usually
reaches its peak during the critical phase of dengue;
Dengue
IgM
becomes
positiveplasma
only from
Day 5usually
of illness.
hence,
clinically
significant
leakage
will
be observed during critical phase.
However,
largetest
volumes
oral fluid
intake the
coupled
2. What
diagnostic
can beofdone
to confirm
diagnosis
with large
volumes
fluid during the
of dengue
infection
in of
theintravenous
early phase?
febrile phase could result in an excessive increase in
Dengue
NS-1 Ag hydrostatic pressure and aggravate
intravascular
plasma leakage
with excessive
fluid
extravasated
Polymerase
chain reaction
(PCR) for
dengue
virus into
the pulmonary interstitial space.
Virus isolation
Case study 13 - Pregnancy
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DAY 5
21:45
Temperature:
37.2°C
Blood pressure:
118/74
Pulse rate:
108/min
Urine output:
~70ml/hr
Increase IVD to 110ml/hr NS
23:30
Temperature:
37.0°C
Blood pressure:
132/78
Pulse rate:
98/min
CTG reduced variability
Decision:
Not to provoke delivery
Avoid LSCS
Increase IVD to 125ml/hr NS
Transfuse 4 units platelet
concentrate
4
5
5
5
15:17
07:19
19:38
HB
10.4
11.2
13.1
23:23
14.2
HCT
0.32
0.35
0.41
0.43
WBC
10.7
9.4
8.2
10.1
PLT
99
43
15
14
TCO2
22.5
18.1
14.9
16.6
Day
What is the risk of delivery at this stage?
Risk of bleeding is very high whether it is a
spontaneous or LSCS delivery.
Case study 13 - Pregnancy
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DAY 6
08:30
Fetal bradycardia
USS: No fetal heart beat
Day
13:45
Blood pressure:
160/120 X 3
08:40
Nifedipine SR 20mg bd
Hb
Day
HCT
Blood pressure: 122/90
Pulse
106/min
15:30 rate:
500ml
AfebrileNS over 1 hour +
maintenance
Blood
pressure: 125ml/hr
140/110 NS
Pulse rate:
120/min
11:20
Another 500ml NS bolus
Continue maintenance 125ml/hr
HCT:
0.46 NS
Changepressure:
antibiotics to
Tazosin
Blood
150/105
Pulse rate:
108/min
16:00
500ml NS infusion over 1 hour
Transfer
ICU for125ml/hr
BIPAP
Maintenance
NS
Referred to ICU
6
6
6
7
09:31
14:05
18:44
01:03
>96h
15.2
6
0.47
14:05
19.0
15.4
14
0.46
8.3
15.2
9
15.0
15.4
16.3
5
6
6
0.46
0.46
0.49
06:25 09:31
23:23
WBC
19.0
15.2
25.5
Hb
14.2
14.4
15.0
Plt
8
9
HCT
0.43
0.44
0.468
TCO2
15.1
12.8
WBC
10.1
10.9
19.0
Plt
14
15
8
TCO2
14.3
15.1
19:17 16.6
Blood pressure:
140/90
Pulse rate:
92/min
Urine output: 40ml/hr
Transfuse 4 units platelet concentrate
Case study 13 - Pregnancy
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DAY 7
08:00
HCT improving and stabilizing
Still acidotic
Bilirubin rising, WBC rising
IUD
Continue maintenance
09:45
6 units platelet transfusion
11:15
In established labour (os: 4cm)
Alerted blood bank on blood/blood
products
14:10
High flow mask
Reduce fluid regime to 1L/24hrs
06:11
11:57
16:11
20:16
HB
HCT
14.9
0.46
14.4
0.44
13.2
0.41
10.7
0.33
WBC
40.0
42
41.2
39.9
PLT
TCO2
11
9.2
20
clot
28
13.2
Day 7
16:35
Contraction 3:10 lasting 30 seconds
Membrane bulging
Blood transfusion
(4 units platelet + 2 units FFP with frusemide
10 mg bolus)
IVI oxytocin
Delivered at 17:30
No active bleeding post-delivery
Case study 13 - Pregnancy
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DAYS 8, 9
20:00
Febrile with chills and rigors
Tachycardic
08:00
Deterioration in mental state, more
HCT
improved to 0.32
obtunded
No
focal neurological
deficit
WBC:
3.0
Plt:
30
Diagnosis:
Became more depressed/
Transfusion
reaction?
withdrawn
Sepsis?
Intracranial bleed?
Day
Day 8
06:39
HB
HB
HCT
HCT
WBC
WBC
PLT
TCO2PLT
TCO2
10.6
0.32
3.0
30
21.5
8
13:07
20:11
9
20:11
06:30
9.8
6.0
0.30
0.18
27.6
34
34
6021.5
25.2
6.0
9.0
0.18
0.28
34
17.5
60
53
25.2
27.5
18:00
22:00
Excessive
blood clots (PV loss ~400ml) Diagnosis: Eclampsia?
Developed generalized
tonic–clonic
Transfusion
of
packed
cells, FFP and platelets was planned
seizure while preparing her for
unitspacked
packedcells
cells transfusion
FFPelective
and platelets
intubation
were given promptly but3 not
Change to IVI meropenem
CT-scan: noinserted
intracranial
Cervagem
PVbleed
IV Mg sulfate bolus
HB:oxytocin
6 bolus
IV
HCT:
Plt:
0.18
60
Case study 13 - Pregnancy
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DAY 10
Extubated
Regained conscious level
FBC continues to improve
Discharged on Day 18
Case study 13 - Pregnancy
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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
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