Infective endocarditis in pregnancy

Infective endocarditis during pregnancy is an inflammatory disease caused by various infectious agents, which is characterized by damage to the heart valves and/or parietal endocardium and bacteremia. The causative agents of infective endocarditis during pregnancy, localizing on the valve flaps and/or parietal endocardium, cause the appearance of growths (vegetations) consisting of fibrin, platelets, leukocytes, other inflammatory elements, immune complexes, which become a source of embolism.

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What causes infective endocarditis during pregnancy?

Etiology. The most common causative agents of infective endocarditis during pregnancy are Streptococcus viridans (up to 70%), Staphylococcus epidermidis or Staphylococcus aureus, enterococci; less commonly, the disease is caused by gram-negative bacteria (salmonella, Escherichia coli, Pseudomonas aeruginosa, Klebsiella), other microbial flora and fungi (Candida, Histoplasma, Aspergillus, Blastomyces).

In the pathogenesis of infective endocarditis during pregnancy, transient bacteremia is of the utmost importance, occurring during any operations on infected tissues, dental interventions, endoscopy with biopsy, curettage of the uterine cavity, obstetric interventions (caesarean section, forceps, manual entry into the uterine cavity, etc.), urological manipulations. The source of bacteremia can also be endogenous foci of infection, including altered tissues of the valves and parietal endocardium.

Infection developing on the valves and the tissues damaged by it cause immune disorders in the body, as a result of which many organs and systems are affected (nephritis, arthritis, vasculitis, hepatitis, etc.). Another mechanism of damage to many organs is embolism with the subsequent development of infarctions (kidneys, spleen, lungs, brain).

Symptoms of infective endocarditis during pregnancy

There are two clinical forms of infective endocarditis during pregnancy: subacute (protracted) and acute. Subacute endocarditis is much more common.

Infective endocarditis in pregnant women is very severe and can lead to maternal death. Even with adequate and timely treatment, infective endocarditis is often accompanied by severe complications (heart failure, embolism with infarctions of various organs, purulent pericarditis, intracardiac abscesses, septic aneurysms of the cerebral arteries, abdominal aorta, etc.); in the absence of treatment for infective endocarditis, it usually leads to death. In 10-15% of patients, infective endocarditis recurs during pregnancy.

Symptoms of infective endocarditis during pregnancy vary. They include hectic fever with chills; sweating, especially at night; anorexia; arthralgia; skin manifestations (hemorrhages, petechial rash, Osler's nodes); petechiae on the conjunctiva (Libman's symptom), oral mucosa and palate; enlarged spleen; kidney damage (focal or diffuse glomerulonephritis); lungs (infarction, pneumonia, pulmonary vasculitis); central nervous system (cerebral vascular embolism, brain abscess, septic aneurysms, meningitis, encephalitis, etc.); significant increase in ESR and hypochromic anemia.

The main symptom of infective endocarditis during pregnancy is heart damage in the form of the appearance or change in the nature of murmurs, depending on the location of the endocarditis and the presence of a previous defect, manifestations of myocarditis, pericarditis, heart failure.

Classification

• Process activity: active, inactive.
• Endocarditis of natural valves:
  • primary, arising as a primary disease of previously intact valves (often found in injection drug addicts);
  • secondary, developing against the background of previous heart pathology (acquired heart defects, congenital heart defects, after heart surgery, cardiomyopathy, trauma, foreign bodies).
• Prosthetic valve endocarditis.
• Localization: aortic valve, mitral valve, tricuspid valve, pulmonary valve, endocardium of the atria or ventricles.
• Exciter.
• Stage of valve disease; stage of heart failure.
• Complications.

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List of diagnostic tests

• Complete blood count (increased ESR, anemia, leukocytosis) and urine analysis (hematuria):
  • blood cultures for sterility (positive blood culture);
• ECG (rhythm and conduction disturbances);
• Echocardiography (presence of vegetation, appearance of valve insufficiency, signs of systolic dysfunction);
• chest x-ray (enlargement of the corresponding parts of the heart);
• consultation with a cardiac surgeon.

Diagnosis of infective endocarditis during pregnancy

Diagnosis is based mainly on characteristic clinical data, detection of the pathogen in the blood and vegetation on the valves (with conventional or transesophageal echocardiography). Blood sampling for sowing should be done three times during the day and from different veins. The sowing result may be negative in case of fungal endocarditis, as well as after 1-2 weeks (sometimes 2-3 days) of antibacterial therapy.

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Pregnancy management tactics

The presence of infective endocarditis is an indication for termination of pregnancy regardless of the term. However, termination of pregnancy should never be an emergency. Both artificial abortion and any intervention at a late term (intra-amniotic injection, cesarean section) can be performed only against the background of adequate antibacterial therapy and only after normalization of body temperature (in rare cases after a significant decrease in fever) and a stable improvement in the patient's condition.

Delivery of patients with infective endocarditis should be performed through the natural birth canal, ending with the application of obstetric forceps. Antibacterial therapy is continued during labor. Infective endocarditis during pregnancy is one of those diseases that are considered a contraindication to cesarean section. Therefore, abdominal delivery should be resorted to only for absolute (vital) indications on the part of the mother (central placenta previa, threat of uterine rupture, etc.).

Treatment of infective endocarditis during pregnancy involves prolonged use of high doses of antibiotics; anticoagulants, detoxifying and symptomatic agents, and sometimes glucocorticoids are also used.

Surgical treatment is carried out:

• in case of ineffectiveness of drug therapy, in case of endocarditis of artificial valves, in case of relapses of the disease;
• in complications of IE (destruction, perforation, rupture of valve cusps, chord ruptures, intracardiac abscesses, septic aneurysm of the sinus of Valsalva, recurrent embolisms, purulent pericarditis, valve obstruction by large vegetations).

Principles of antibiotic therapy for infective endocarditis during pregnancy

Treatment should be started as early as possible (immediately upon diagnosis), initially prescribing drugs empirically. The optimal combination for empirical therapy is penicillin antibiotics + gentaminin or cephalosporin. After receiving the results of blood cultures, the prescribed antibiotics can be replaced.

Initial therapy should be intravenous and massive (high doses of antibiotics).

Antibacterial therapy should be long-term - at least 4 weeks with a good effect. In some cases (damage to the artificial valve, mitral valve, two or more valves, prolonged course of the disease at the beginning of treatment) the use of antibiotics should be continued for up to 6 weeks or even longer

If there is no obvious clinical improvement within 3 days, antibiotics should be replaced. With effective therapy, antibiotics should be replaced every 3 weeks.

How to prevent infective endocarditis during pregnancy?

Prevention of infective endocarditis should be carried out during childbirth (regardless of the method and complications) or artificial termination of pregnancy in patients with artificial heart valves, complicated childbirth or cesarean section in patients with acquired and congenital heart defects, cardiomyopathy, Marfan syndrome, myxomatous degeneration of the mitral valve.

For prevention, use: ampicillin 2 g + gentamicin 1.5 mg/kg intravenously or intramuscularly 30-60 minutes before delivery or termination of pregnancy and 8 hours after.