Perhaps this is largest study investigated maternal and perinatal outcomes of dengue during pregnancy. The main findings of this study were the poor maternal and perinatal outcomes due to dengue mainly maternal deaths (21.7%) and preterm deliveries (24.3%). We recently reported a high maternal mortality in different regions of Sudan due to various infectious diseases [
19,
20] for example four (4.9%) out of 42 and 25% of the sixteen women died due to visceral leishmaniasis and viral hepatitis, respectively [
17,
21]. However, in Sudan, as in many sub-Saharan countries, the frequency rates of miscarriage, preterm labor, and congenital abnormalities in the general population are unknown. In Malaysia, out of 16 patients with dengue, there were three cases of maternal death, 50.0% of the women had preterm deliveries and three babies required intensive care [
9]. Previously, it have been reported that maternal clinical dengue may be associated with pregnancy complications, including maternal mortality, preterm delivery, fetal death, low birth weight, neonatal admissions, fetal anomalies, and miscarriage [
7‐
14]. These reports should be compared with ours cautiously, because in this setting we might have observed the severe form of the disease. In contrast to other Asiatic countries, dengue is not endemic in Sudan and epidemics occur from time to another, which explains the lack of immunity in the population and the severity of the disease. Hyperendemic conditions are associated with an increased probability of secondary infections and occurrence of virulent strains. Despite these trends, little research has been conducted to examine the impact of the severity of maternal dengue infection. This is an important factor to assess because viral titers are thought to vary by severity of infection, and pathogenesis associated with poor pregnancy outcomes can be caused by either the direct effect of the virus or the body's response to high titers [
22‐
24]. On the other hand there were no any significant differences in pregnancy outcome comparing dengue IgM-positive with IgM-negative women, perhaps in mild or asymptomatic dengue in pregnant women [
25]. However, our study was a hospital-based one which might not reflect what was at the community level.
In the current study, 5 (6.4%) patients had vaginal bleeding and 8 (10.2%) patients delivered by caesarean delivery. The risk of maternal haemorrhage was reported before when caesarean section was carried out on patient with dengue fever [
14]. Furthermore, difficulties in maintaining haemostasis during the caesarean section were observed too [
14]. Deliveries were sometimes pathological, so the risk of haemorrhage has to be assessed and precautions should be taken both for natural delivery and caesarean section. Generally in tropics the situations sometimes are not clear and many infections/toxicity may mimic the obstetrical emergency for example we recently observed association between antepartum haemorrhage and snake bite [
26].The impact of dengue on pregnancy is not fully understood. Studies in the literature are limited and case studies were too small to draw conclusions.