Artikel 36 – Dengue Infection as One of The Reason of Maternity Death in Indonesia.


I read in Kompas (the biggest newspaper in terms of readers in Indonesia) in these recent few days. If I look at the article of the rate of maternity death, in the big picture then rate of maternity death is concluded as 14.630 cases per year. This estimation is derived from the number of alive child birth of 4 million lives per year and the rate of maternity death is 359/100.000 of child birth. On the other hand I say that the rate of people death that has been caused by Dengue infection (T.Mudwal in article of the benefit of how to diagnose dengue infection based on combination of WHO 2009 criteria and T.Mudwal theory in the site of , then we will get the result of 120.000 cases per year (1/20 % from 240 million people of Indonesia). If we estimates from 120.000 people above 1 percent of them is pregnant women, then Dengue infection has contributed to 1200 death of them each year. We estimate 1 percent itself is the lowest estimation. Because WHO themselves estimate the rate of death in Dengue infection ranged between 1-20 percent from poppulation depending on the treatment.

The reason of death in pregnant women is such as these :

1. The obstetricians still will choose to make an operation only if platelet is above 50.000 (because it’s the knowledge that’s stated by the literature). On the other hand I say that if thrombocytopenia itself is caused by Dengue infection then those platelets are the impotent platelets. Platelet which has been bonded by immune complex can be counted as normal in laboratory. But its function as a plug in bleeding is not maximum. I say all thrombocytopenia in hyperendemic dengue area, including Indonesia, should be determined to be caused by Dengue infection until it can be proven otherwise. Because of that an operation can’t be done until it can  be proven that thrombocytopenia is not being caused by Dengue infection. Included in these matter is what being called as HELLP syndrome and Evan syndrome. The increase of SGOT,SGPT,LDH, haemolytic anemia and thrombocytopenia are some things that are very common to occur in Dengue infection.

2. Almost all obstetricians and doctors still use the WHO 1997 benchmark to diagnose Dengue infection. So then in platelet that’s not yet to reach 100.000/mm3 is not considered as DHF. They should be using WHO 2009 criteria to diagnose Dengue infection. The result of this neglection, the periodical examination of platelet and the giving of adequate liquid in patient will be negated too.

3. Not using T.Mudwal theory to predict the possibility of Dengue infection in patient who is not haveing having cold. Whereas T.Mudwal predicts there will be Dengue infection occured in the patient if Ht/Hb>3x, limphocyte count <20%, monocyte count <3%, platelet <170.000, Hb for 40 years old patient >14 gr%, Hb for 60 years old patient >15gr%, Ht for 40 years old patient >42%, Ht for 60 years old patient >45% (the iceberg phenomenon of Dengue in barely and no sickness phase).

If we applied this, obstetrics will think firsthand before doing cito sectio caesaria even if the platelet is counted as normal. There will be different result if we don’t applied this theory, the neglection of adequate liquid and the periodical platelet examination whereas all of them will be resulted in the increaseing rate of maternity death.

4. The neglection to give high dose of corticosteroid in patients who has been diagnosed to suffer Dengue infection based on Who 1997 or 2009 criteria. WHO has not yet recommending corticosteroid to patient with Dengue infection. Although according to us in theory, the strongest pathophysiology and pathogenesis from the occurance of Dengue infection is the hypersensitivity type 3 theory (look at my site,, in article no.18, Again Let’s Discuss About DHF Pathogenesis and Pathophysiology (the effect of rapid spread of immune complexes vs the effect of Dengue virus). And if it will be acknowledged then the giving of high dose corticosteroid should be done.

Based on those reasons I strongly believe that the maternity death rate will never be reduced if what we have been stated above are neglected. Indonesia is one country that’s very sensitive towards Dengue virus and the country that’s very worse in terms of ecosystem regulation. Other than that the moral of obstetrician still has to be kept in good condition, what it means is the life of a mother should be put as the first priority rather than saving the baby’s life.

Case Report

Name : Mrs. Mela S

RM : 650748

Resume :

Patient G1POA0, 28 years old, aterm pregnancy at 40-41 weeks (partus estimation, March 14th 2012). Come to obstetrician ER 18th of March 2012 at 7 PM with the diagnosis of kala 1 latent phase and severe preeclampsia (hypertension +, proteinuria ++++, shock -). Patient was starting to excreting fluid and blood since 6 am at March 18th 2012. Hypertension history could only be detected when the pregnancy had entered the 9th month already. Vital signs when entering obstetrician ER, T: 180/120, pulse : 79x/minute, RR: 22x/minute, t: 36,2o C, the patient was on the compose mentis state. When treated, the patient got severe preeclampsia treatment protocol combined with oxytocin (infused through 2 ways, right hand : dextrose 5% + oxytocin, left hand : Ringer Lactate + MgSO4 40%). At March 19th 2012, the patient was decided to undergo sectio caesarea operation room, because the partus didn’t have any progress, there’s no infant pulse report that had been submitted when the patient went to the operation room. Vital signs which were examined before SC (8 am, March 19th 2012) tension :190/100, pulse : 86 x/ minute, RR : 22x/minute, t : 37,3o C, infant heart rate : 142x/minute. Vital signs which was examined just before the operation begun right in the operation room, tension : 190/110, pulse : 99x/minute, t:36,5o C. The operation had been started since 10.30 am until 11.30 am. Patient was submitted to ICU from operation room at March 19th 2012 at 3 pm with the tension of 130/80 ; pulse : 150x/minute, RR :28x/minute ; t: 36,5o C and in the comatose state. The infant was born alive.

Laboratory report,

18/3/2012 (pre op) → urine : protein ++++

Laboratory exsamination  19/3/2012 (pre op)


Parameter Result Normal
Hemoglobin 11,7 L :14-18 / P: 12-16
Leukocyte 11.000 5000-10000
Platelet 128.000 150.000-450000
Erythrocyte 4,1 L: 4,6-6,2/ P:4,2-5,4
Hematocrit 36 L :40-54/P : 37-47
Basophil 0 0-1%
Eusinophil 0 1-4%
Band Neutrophil 0 3-5%
Segment Neutrophil 76 35-70%
Limphocyte 17 20-40%
Monocyte 7 2-10%
Blood Type O/+


Laboratory examination  (post-op)


Parameter Result Normal
Hemoglobin 6,4 L:14-18/ P:12-16
Leukocyte 21.800 5000-10000
Platelet 66.000 150.000-450.000
Erythrocyte 2,2 L:4,6-6,2 / P: 4,2-5,4
Hematocrit 21 L: 40-54/ P:37-47
Basophil 0 0-1%
Eusinophil 0 1-4%
Band Neutrophil 0 3-5%
Segment Neutrophil 75 35-70%
Lymphocyte 22 20-40%
Monocyte 3 2-10%



Was Cito Operation In This Patient Correct ???

There were 2 things that make the cito operation in this patient was not the best option. The tension of the patient which was very high and the thrombocytopenia in patient. It was very obvious about the need to consult with an internist to lower the blood pressure in this patient. Even when the blood pressure was in the normal state and the patient was capable to do the operation (systolic is ≤ 150 mmHg and diastolic is ≤90 mmHg) the possibility of severe bleeding in this patient is still can happening because of thrombocytopenia. It’s true that in the text book it’s clearly stated that the operation can be done if platelet is >100.000/mm3 or even when it dropped to >75.000/mm3 but this can only be done if thrombocytopenia itself is not caused by Dengue fever or suspected because of Dengue infection. In Dengue infection, immune complex (Dengue virus+antibody) which has bonded with platelet can be counted as normal by laboratory analyst. But the platelet which had been counted as normal itself don’t have the same functionality as normal platelet because it had been bonded by immune complex. So that those platelets can’t do the normal functionality such as blood clotting or making plug as good as before. And for Indonesia, patient with thrombocytopenia will always be considered as having the possibility of Dengue infection until proven otherwise. This situation happens because Indonesia is a country with the highest rate of Dengue endemic in the whole world.

Platelet which had been counted as 128.000 in this patient, maybe only have the strength equivalent of 20.000 platelets to make the platelet plug. It was clearly obvious that we need a normal rate of both APTT and PT and it should be examined 1 hour before the operation. The examination of activated Partial Thromboplastin Time, Prothrombin Time, Clotting Time, Bleeding Time > 1 hour before the operation is considered as invalid. Because in the patient with Dengue infection, platelet can raise and drop at a very rapid rate according the frequency of patient to have platelet antibody which is sometimes positive or negative can change rapidly. On the other hand, the disturbance in the hepar functionality is frequently happen in the patient with Dengue virus infection. And in this patient GOT/GPT was 142/65 (March 19th 2012, pre op). Fever can possibly do not happen in the patient which has been infected with Dengue virus even if thrombocytopenia occurred in this patient. This is caused by the fever itself which is caused by the amount of arachidonic acid that’s being secreted by hypothalamus. If the wreckage in circulatory system is only minimal then TNF and IL1 that stimulate hypothalamus will be minimal too, so that fever won’t happen. Immune complex that‘s been destructed in circulation can further make DIC process easier. The severe bleeding and severe thrombocytopenia in the patient after operation and patient fell in shock state was clearly the result of Dengue infection. Because before operation was done, there was no severe bleeding in patient. Thrombocytopenia which meant as the bad quality of platelet before operation itself that had been causing severe bleeding in patient post operation. Calcium rate was never increase (even when he’s having maximum correction) further strengthening the happening of Dengue infection and DIC that had been followed by secondary infection from bacterial.


All patients with pregnancy and thrombocytopenia (<150.000/mm3) must not be operated before consulting with internist. Keep in mind that in pregnant women with thrombocytopenia whether she is having a fever or not, whether she is having a positive or negative Dengue blood, Calcium rate, APTT, PT, CT, BT, GOT, GPT, total Billirubin, whole urine sample should always be checked.

Filed under Artikel 36 - Dengue Infection as One of The Reason of Maternity Death in Indonesia. : Comments (0) : Jan 14th, 2014