DENGUE INFECTION IN

PREGNANCY AND ITS IMPACT

ON THE PLACENTA
Christiane Fernandes Ribeiroa,*, Va nia Glo ria Silami Lopesb, Patricia Brasilc,
Andrea Rodrigues Cordovil Piresd, Roger Rohloff e, Rita Maria Ribeiro Nogueiraf

International Journal of Infectious Diseases 55 (2017) 109112

introduction
The occurrence of dengue infection in pregnancy has been reported in the
literature since 1948.
A recent systematic review reported several cases of antenatal
complications associated with dengue, including miscarriage, stillbirth, and
premature deliveries.
In addition, maternal death due to dengue infection in pregnancy has been
reported in Brazil.2,3 In 2013, seven cases of vertical transmission were
reported and confirmed by serology, RT-PCR, and immunohistochemistry.4
This study describes the fetal outcomes and the histopatholog- ical and
immunohistochemical findings in placenta samples and retained products of
conception in pregnant women with confirmed dengue infection.
Materials and methods
It is a descriptive study of fetal outcome and pathological alterations from 24
pregnant women with laboratory-confirmed dengue.

Nineteen placentas and five ovular remnants were examined.

Pregnant women with seropositivity to HIV infection, hepatitis B, syphilis,

toxoplasmosis, or rubella; preeclampsia and gestational diabetes were
excluded.
Placental weight and disk measurements and some of
the characteristics of the fetal membranes, including :

color and transparency

The distribution and size of the chorionic

vessels were evaluated in the fetus.

The color and appearance of the placental

lobes and tissue sections

The color and thickness of the funicular

vessels.

Whartons jelly were evaluated in the

umbilical cord and the abnormalities
recorded.
 After examination, the placental tissues
were excised, and seven sections were
obtained:
from the umbilical cord, two cross-sections at opposite
ends and a longitudinal section in the median region;

from the membrane, a cross-section of the membrane roll;

from the placental disk, a sample of the cord

insertion site and a sample from the middle and
outer disks as well as of any other sites considered
relevant.
All of the tissues sections were stained with hematoxylin-
eosin (HE).

The fetal membranes, umbilical cord, chorionic plate, villi,

intervillous space, and decidua basalis were examined under a
light microscope.
 Result
Damage to the fetus occurred as miscarriage in 5
cases (20,8%),

The average gestational
fetal death in 2 cases (8,3%),
age at delivery was 38 3
weeks, and the average
birth weight was 2,881 prematurity in 3 cases (12,5%),
543 g.

7 symptomatic new- borns (29%).

Two newborns developed dengue shock syndrome

(DSS) and were discharged without sequelae
* Elapsed period between the onset of symptoms and childbirth
** Premature.
*** CAPILLARY LEAK SYNDROME IN THE MOTHER: hemoconcentration, hypotension, shock, pleural effusion or ascites
**** HYPOXIA: EDEMA OF THE VILLOUS STROMA, PRE-INFARCTION AREAS (INCREASE IN THE NUMBER OF SYNCYTIAL KNOTS AND REDUCED
INTERVILLOUS SPACE), OR CHORANGIOSIS.
***** IHC: Immunohistochemistry.
****** PPA: Preterm placental abruption.
FIGURE 1 (Light microscopic findings and immunostaining.)
A. Loss of trophoblastic epithelium
( ) and inflammatory infiltrate
in villous stroma ( ) HE 40X (case
13);
B. Immunostaining in villous
stroma cells 20 X (case 13);
C. Proliferation and congestion of
intravilliary vessels ( ) and
villous stroma edema ( ) HE
40X (case 18);
D. Immunostaining in villous stroma
cells 40 X (case 18);
E. Fibrin deposit in villi ( ),
proliferation and villous vascular
congestion ( ) HE 20X (case 10);
F, Immunostaining in villous stroma
cells and trophoblast 20X (case 10).
Figure 2 (Immunostaining in placental tissue)

A-Negative control in liver tissue 20 X;

B- Negative control in placental tissue 20 X;
C- Positive control in liver tissue;
D- Immunostaining in decidual cells 20 X (case 10);
E- Immunostaining in villous stroma cells 40 X (case 17);
F- Immunostaining in trophoblast 20X (case 13).
The light microscopic findings were The
shown in Figure 1. No changes were
observed in the umbilical cord
immunohistochemical
suggestive of maternal blood-borne analysis in 24 samples:
infections, even during the vertical In two cases the
transmission of type 2 virus confirmed in immunostaining was
cases No. 06,09,13, and 24 in newborns negative.
and case No. 23 in the fetus.

In 10 cases (41,6%) with

Staining was observed in the positive immunostaining,
following placental cells: decidual a correspondence was
cells trophoblasts, and villous observed between the
stroma cells (Figure 2). All staining area with histological
was cytoplasmic. changes and the
immunostained area.
DISCUSSION
In this study, two possible
mechanisms of fetal and
neonatal morbidity were Of the 17 newborns, 14
proposed: the presence of newborns were at term and
hemodynamic changes three were premature
during pregnancy that could corroborating the results of
affect the placenta and previous studies on the
cause fetal hypoxia, or the association between dengue
direct effect of infection on virus infection and
the fetus. increased prematurity.
Pathological changes, related to Two of the six patients
hypoxia, were observed: edema
of the villous stroma, pre-
with sickled erythrocytes
infarction areas, chorangiosis, in the intervillous space
and infarcted areas. evolved to DSS and died.
These findings underline the Accordingly, sickle cell
importance of the
hemodynamic changes disease has been
experienced by pregnant reported to be a risk
women during dengue virus factor for severe dengue.
infection.
CONCLUSION

The hemodynamic changes experienced

by the mother due to capillary leak
syndrome as well as the vertical
transmission of the virus would be
responsible to neonatal and fetal
higher morbidity.
The placenta proved to be an organ
that reflects well the inflammatory
response, virus presence and the
maternal hemo- dynamic alterations.
The positive immunostaining
in placental samples in 92%
(22 cases) opens a new
perspective for the diagnosis
of dengue in pregnant
women, considering that
these samples are easily
available, especially when
these samples are the only
material available.
THANK YOU
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