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Journal of Obstrectic Anaesthesia and Critical Care
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LETTER TO EDITOR
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 128-130

Implications of active infective endocarditis with pregnancy and its management


1 Department of Anaesthesia and Critical Care, Command Hospital (SC) Pune, Maharashtra, India
2 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission31-Jan-2021
Date of Acceptance08-Mar-2021
Date of Web Publication01-Oct-2021

Correspondence Address:
Dr. Deepak Dwivedi
Department of Anaesthesia and Critical Care, Command Hospital (SC) Pune – 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JOACC.JOACC_10_21

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How to cite this article:
Bhatia P, Dwivedi D, Gautam AR, Singh S. Implications of active infective endocarditis with pregnancy and its management. J Obstet Anaesth Crit Care 2021;11:128-30

How to cite this URL:
Bhatia P, Dwivedi D, Gautam AR, Singh S. Implications of active infective endocarditis with pregnancy and its management. J Obstet Anaesth Crit Care [serial online] 2021 [cited 2021 Nov 28];11:128-30. Available from: https://www.joacc.com/text.asp?2021/11/2/128/327400



Dear Editor,

Infective endocarditis during pregnancy increases the mortality for both mother (33%) and fetus (29%). High degree of suspicion arises during pregnancy with the presence of preexisting rheumatic heart disease, unexplained fever, and murmur.[1] Most deaths are being related to heart failure or an embolic event, instances of intracranial bleed are not uncommon.[2] Outcomes may improve at higher referral centers equipped with facilities of echocardiography, neonatology, and intensive care for managing high-risk pregnancy.

A 24-year-old G1P1L0 lady, a diagnosed case of rheumatic heart disease at the age of 10 years treated with Inj Penicillin till 15 years of age, presented as an unbooked antenatal case (ANC) at 32 weeks, period of gestation with fever and dyspnea on exertion. 2D–echo showed severe mitral regurgitation with moderate mitral stenosis, mild pulmonary arterial hypertension with the ejection fraction of 60%. Two mobile masses likely vegetation of 10 mm length were seen attached to anterior mitral leaflet and posterior mitral leaflet [Figure 1]. Patient was diagnosed as a case of active infective endocarditis and was empirically started on antibiotics and fetal monitoring ensued. During the hospital stay she developed two episodes of generalized tonic clonic seizures followed by an acute intraparenchymal bleed at right frontal lobe, likely due to ruptured mycotic aneurysm and was managed conservatively with favorable biophysical profile. The findings were confirmed on non-contrast CT brain [Figure 2]. Other causes of intracranial hemorrhage like, preeclampsia/eclampsia, arteriovenous malformation, coagulopathy, cerebral venous thrombosis was ruled out.[3]
Figure 1: 2D Echocardiography, Parasternal long axis view showing the vegetations present over mitral valve leaflets

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Figure 2: Non-Contrast CT head showing subdural hematoma in RT frontoparietal convexity, intracranial hemorrhage in Rt frontal lobe with mass effect

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Obstetricians involving the neonatologist, anesthesiologist, and the cardiologist took the decision in favor of the termination of the pregnancy following the administration of the steroids for the fetal lung maturity.

A written informed consent was obtained from the patient after explaining the risks and benefits involved in the operation. In operating room (OR), two wide bores 18-gauge cannula were secured. Under local anesthesia, right radial artery was cannulated for invasive blood pressure monitoring. Standard balanced general anesthesia (GA) was administered using rapid sequence intubation with Inj Etomidate 0.2 mg/kg, succinylcholine 2 mg/kg, followed by, fentanyl 2 μg/kg, atracurium 0.5 mg/kg and was maintained on oxygen with sevoflurane. The intraoperative period was uneventful. Perioperative intermittent transthoracic echocardiography was done for cardiovascular monitoring including vegetations. Sinus rhythm was maintained, and hypoxemia was avoided throughout the intraoperative period. The patient was extubated successfully with GCS 15/15 and a healthy female baby weighing 1.9 kg was born and shifted to NICU. Patient was discharged after 10 days and was referred to cardiac center.

Pregnancy associated with pyrexia of unknown origin with heart murmur should have a high degree of suspicion of active IE.[1] Although rare, it is either a complication of a pre-existing cardiac lesion as seen in our case or resultant of intravenous drug abuse. Active IE is life threatening, the risk of embolic episodes increases in cases having vegetations longer than 10 mm.[4] Role of echocardiography cannot be negated in such clinical situations where it has played a key role in the diagnosis of IE as well as predicting the embolic risks. Habib et al. has proposed an algorithm in which on clinical suspicion of IE, non-invasive transthoracic echocardiography (TTE) should be done initially and if there are positive findings, trans esophageal echocardiography (TEE) should be performed to map the vegetations and diagnose the perivalvular involvement.[5] Perioperatively due to unavailability of the TEE in OR we utilized expertise of the cardiologist with intermittent TTE to assess and quantify the pulmonary pressures, discerning the vegetation on the valve as well as the left ventricular function.

Recommendations of European society of cardiology suggest early surgery in cases with severe heart failure, recurrent embolic episodes and persisting infection despite antibiotic treatment.[4] Clinical management of ANC with IE, the vital issue is to safeguard both, maternal and fetal lives. Initial treatment is medical to minimize the risk and reduce maternal and fetal morbidity, however, medical management of refractory cases are only amenable to corrective cardiac surgery.

Vaginal delivery can be attempted in patients with mild MS, and in patients with moderate or severe MS in New York Heart Association (NYHA) Class I-II without pulmonary hypertension. Cesarean section is considered in patients with moderate to severe MS with NYHA Class III-IV symptoms, or who have pulmonary hypertension despite medical therapy and in patients when percutaneous mitral valvuloplasty cannot be performed or has failed. Our index case had moderate MS, mild PAH with NYHA Class III symptoms with fresh intracranial bleed, therefore patient underwent caesarean section under GA.

Multidisciplinary approach with inclusion of echocardiography and meticulous preoperative assessment and planning of anesthesia improves the maternal and fetal outcomes.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wajih Ullah M, Lakhani S, Sham S, Ashraf F, Siddiq W, Siddiqui T. Subacute infective endocarditis of aortic valve during pregnancy. Cureus 2018;10:e2748.  Back to cited text no. 1
    
2.
Yuan SM, Wang GF. Cerebral mycotic aneurysm as a consequence of infective endocarditis: A literature review. Cor et Vasa 2017;59:e257-65.  Back to cited text no. 2
    
3.
Ascanio LC, Maragkos GA, Young BC, Boone MD, Kasper EM. Spontaneous intracranial hemorrhage in pregnancy: A systematic review of the literature. Neurocrit Care 2019;30:5-15.  Back to cited text no. 3
    
4.
Habib G. Management of infective endocarditis. Heart 2006;92:124-30.  Back to cited text no. 4
    
5.
Habib G, Badano L, Tribouilloy C, Vilacosta I, Zamorano JL, Galderisi M, et al. Recommendations for the practice of echocardiography in infective endocarditis. Eur J Echocardiogr 2010;11:202-19.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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