Infectious endocarditis in pregnancy

Infectious endocarditis in pregnancy is an inflammatory disease caused by various infectious agents, which are characterized by damage to the heart valves and / or parietal endocardium and bacteremia. Pathogens of infectious endocarditis in pregnancy, localized on valve flaps and / or parietal endocardium, cause proliferation (vegetation) consisting of fibrin, platelets, leukocytes, other elements of inflammation, immune complexes that become the source of embolism.

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What causes infectious endocarditis in pregnancy?

Etiology. The causative agents of infective endocarditis in pregnancy are most often Streptococcus viridans (up to 70%), staphylococcus epidermal or golden, enterococci; less often the disease is caused by gram-negative bacteria (Salmonella, Escherichia coli, Pseudomonas aeruginosa, Klebsiella), other microbial flora and fungi (candida, histoplasm, aspergillus, blastomycetes).

In the pathogenesis of infective endocarditis in pregnancy, transient bacteremia is of paramount importance, arising during any operations on infected tissues, dental interventions, endoscopy with biopsy, scraping of the uterus cavity, obstetric interventions (caesarean section, forceps, manual entry into the uterus cavity, etc.). , urological manipulation. The source of bacteremia can be endogenous foci of infection, including altered valve tissues and parietal endocardium.

Infection that develops on the valves and damaged tissues cause immune disorders in the body, which affects many organs and systems (jade, arthritis, vasculitis, hepatitis, etc.). Another mechanism of destruction of many organs are embolisms with the further development of infarcts (kidneys, spleen, lungs, brain).

Symptoms of infective endocarditis in pregnancy

There are two clinical forms of infective endocarditis in pregnancy: subacute (prolonged) and acute. Subacute endocarditis occurs much more often.

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

Symptoms of infective endocarditis during pregnancy are diverse. Includes hectic fever with chills; sweating, especially at night; anorexia; arthralgia; skin manifestations (hemorrhages, petechial rash, Osler nodules); petechiae on conjunctiva (Libmann's symptom), mucous membrane of mouth and palate; enlarged spleen; renal damage (focal or diffuse glomerulonephritis); lungs (heart attack, pneumonia, pulmonary vasculitis); central nervous system (cerebral vascular embolism, brain abscess, septic aneurysm, meningitis, encephalitis, etc.); a significant increase in ESR and hypochromic anemia.

The main sign of infective endocarditis in pregnancy is heart damage in the form of the appearance or change in the nature of the noise, which depends on the localization of endocarditis and the presence of a previous defect, manifestations of myocarditis, pericarditis, and CH.

Classification

• Process activity: active, inactive.
• Endocarditis of natural valves:
  • primary, arising as a primary disease of pre-intact valves (often found in injecting drug users);
  • secondary, developing against the background of the previous pathology of the heart (acquired heart defects, congenital heart defects, after heart operations, cardiomyopathy, trauma, foreign bodies).
• Endocarditis of the prosthetic valve.
• Localization; aortic valve, mitral valve, tricuspid clap-pan, pulmonary artery valve, endocardium of the atria or ventricles.
• Exciter.
• The stage of valvular disease; stage CH.
• Complications.

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List of diagnostic studies

• General analysis of blood (increased ESR, anemia, leukocytosis) and urine (hematuria):
  • blood cultures for sterility (positive blood culture);
• ECG (rhythm and conduction disorder);
• Echocardiogram (presence of vegetation, appearance of valve insufficiency, signs of systolic dysfunction);
• chest X-ray (increase in the corresponding parts of the heart);
• consultation of a cardiosurgeon.

Diagnosis of infective endocarditis in pregnancy

Diagnosis is based mainly on the characteristic clinical data, the detection of the causative agent in the blood and vegetation on the valves (with normal or bypass echocardiography). Blood sampling for sowing should be done thrice during the day and from different veins. The result of inoculation can be negative in fungal endocarditis, and also after 1-2 weeks. (sometimes 2-3 days) of antibacterial therapy.

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Tactics of management of pregnancy

The presence of infective endocarditis is an indication for the interruption of pregnancy irrespective of the term. However, termination of a pregnancy should never be an emergency. Both artificial abortion and any intervention in the late term (intraamnial administration, caesarean section) can be carried out only against the background of adequate antibiotic therapy and only after the normalization of body temperature (in rare cases after a significant reduction in fever) and a steady improvement in the patient's condition.

The delivery of patients with infective endocarditis should be carried out through the natural birth canal, ending with the operation of imposing obstetric forceps. During childbirth, antibiotic therapy continues. Infectious endocarditis in pregnancy is one of those diseases that are considered as a contraindication to cesarean section. Therefore, abdominal delivery should be resorted only to absolute (vital) indications from the mother (central placenta previa, threat of rupture of the uterus, etc.).

Treatment of infective endocarditis during pregnancy provides for the continued use of high doses of antibiotics; also used anticoagulants, detoxification and symptomatic agents, sometimes glucocorticoids.

Surgical treatment is carried out:

• with ineffectiveness of drug therapy, with endocarditis of artificial valves, with relapses of the disease;
• with complications of IE (destruction, perforation, valve flaps, ruptured chords, intracardiac abscesses, septic aneurysm of the sinus of the Valsalva, recurrent embolism, purulent pericarditis, valve obstruction in large vegetation).

Principles of antibiotic therapy for infective endocarditis in pregnancy

To begin treatment it is necessary as soon as possible (at once at an establishment of the diagnosis), appointing at first preparations empirically. The optimal combination for empirical therapy is the antibiotics of the penicillin group + gentaminin or cephalosporin. After receiving the results of blood cultures, it is possible to replace the prescribed antibiotics.

Start therapy should be intravenous and massive (large doses of antibiotics).

Antibiotic therapy should be continuous - at least 4 weeks. With 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 up to 6 weeks and even longer

In the absence of a clear clinical improvement over the course of 3 days, antibiotics should be replaced. With effective therapy, the replacement of antibiotics should be done every 3 weeks.

How to prevent infective endocarditis during pregnancy?

Prophylaxis of infective endocarditis should be performed at delivery (regardless of the method and complications) or artificial termination of pregnancy in patients with artificial heart valves, complicated delivery or caesarean section in patients with acquired and congenital heart defects, cardiomyopathy, Marfan syndrome, myxomatous degeneration of the mitral valve.

For prophylaxis use: Ampicillin 2 g + gentamicin 1.5 mg / kg intravenously or intramuscularly for 30-60 minutes before the delivery or termination of pregnancy and 8 hours after them.