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A case of infective endocarditis, during pregnancy: should we keep the fetus?/Bir gebelik donemi enfektif endokardit vakasi: fetusu korumali miyiz?

Incidence of infective endocarditis during pregnancy is reported to be 0.006% (1). Among those patients, 22% have a history of valve disease, and etiology is variable among others (2).

A 27-year old female patient in the 14th week of pregnancy began to have palpitations, pain in left shoulder, and became orthopneic. Echocardiogram demonstrated severe mitral stenosis (MS), moderate aortic regurgitation (AR) and mild aortic stenosis. Two days after her admission, she developed dyspnea, tachycardia and refractory hypotension. The repeat echocardiogram revealed echodense structures over the mitral valve, consistent with vegetations. Blood tests were insignificant except elevated leukocyte count (18.6 [10.sup.9]/L), high erythrocyte sedimentation rate (72 mm/h). Therefore, infective endocarditis was considered to be complicating her valve disease. The patient was intubated and medical treatment including diuretics, digitals and broad-spectrum antibiotics was initiated. After two days, the patient was hemodynamically stable, and she underwent surgery for aortic and mitral valve replacement with St Jude[R] mechanical heart valve prosthesis. During the operation, a high flow (2.5 lt/min.[m.sup.2]), high pressure (mean 60mmHg), and non-pulsatile perfusion with moderate hypothermia was achieved. Anesthesia protocol included a hypnotic (propofol, Diprivan[R]), a narcotic (fentanyl, Fentanyl Citrate[R]), a muscle relaxant (vecuronium bromide, Norcuron[R]) and an inhalation anesthetic (isoflurane, Forane[R]). Intravenous tocolytic (ritodrin, Prepar[R]) and antiepileptic (phenytoin, Epdantoin[R]) drugs were also administered during surgery to prevent a preterm labor. Adrenaline was not used during or after surgery because of its vasoconstrictive effects over placental vessels.

The fetal ultrasonography after the operation showed a live fetus in 16th week of gestation. The patient was hemodynamically stable after the operation, and continued to receive antibiotic and low molecular weight heparin therapy. On discharge at 20th postoperative day, the patient was free of any symptoms, with a live fetus in the 19th week of gestation.

Infective endocarditis during pregnancy carries a high mortality risk, both for the mother and for the fetus. However, over the last three decades, successful medical and surgical management has helped in lowering mortality rates in those groups of patients. There are previous case reports of cesarean sections in the 29th and 36th weeks of pregnancies in mothers with infective endocarditis with live fetuses weighing 1400 and 2530 grams, respectively. The mothers underwent heart surgery a few days after cesarean delivery (3, 4). In a pregnant patient, the ideal time for cardiac surgery is between 13th and 28th gestational weeks. In pregnant patients during cardiac surgery, maternal mortality rate is reported between 1% and 5%, with an average of 2.5% in the literature. This rate does not differ from non-pregnant women undergoing cardiac surgery. Fetal loss or preterm labor might also occur during surgery, and perioperative administration of adrenaline, dopamine or furosemide might cause reduced placental perfusion and increased fetal loss (5).

The decision to keep the fetus orto terminate the pregnancy should be given by a team of obstetricians, cardiac surgeons and the patient. The patient should also be informed about the advantages and disadvantages of mechanical and tissue valves to be able to make a choice between them.

doi: 10.5152/akd.2010.076

References

(1.) Montoya M E, Karnath BM, Ahmad M. Endocarditis during pregnancy. South Med J 2003; 96:1156-7.

(2.) Wijesinghe N, Sebastian C, McAlister HE Devlin GP Outcome of pregnancy complicated by infective endocarditis; a review of published literature over the last three decades. Heart Lung Circ 2007; 16: S-77.

(3.) Shimada K, Nakazawa S, Ishikawa N, Haga M, Takahashi Y, Kanazawa H.Successful surgical treatment for infective endocarditis during pregnancy. Gen Thorac Cardiovasc Surg 2007; 55: 428-30.

(4.) Vincelj J, Sokol I, Pevec 0, Sutlic Z. Infective endocarditis of aortic valve during pregnancy: a case report. Int J Cardiol 2008; 126:10-2.

(5.) Takano Y, Matsuyama H, Fujita A, Kobayashi A, Kawamura M. A case of urgent aortic valve replacement for infective endocarditis in pregnancy. Masui 2003; 52: 1086-8.

Address for Correspondence/Yazisma adresi: Dr. Nezihi Kucukarslan GATA Askeri Hastanesi Kalp ve Damar Cerrahisi Anabilim Dalr, 06018 Etlik, Ankara, Turkey Phone: +90 312 304 52 71 Fax: +90 312 304 52 00 E-mail: nkucukarslan@gata.edu.tr

Adem Guler, Mehmed A. Sahin, Nezihi Kucukarslan, Mustafa Kurkluoglu, Ata Kirilmaz [1], Harun Tatar

Department of Cardiovascular Surgery, GATA Military Medical Hospital, Ankara

[1] Division of Cardiology, GATA Haydarpasa Military Training Hospital, Istanbul, Turkey
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Article Details
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Title Annotation:Letters to the Editor/Editore Mektuplar
Author:Guler, Adem; Sahin, Mehmed A.; Kucukarslan, Nezihi; Kurkluoglu, Mustafa; Kirilmaz, Ata; Tatar, Harun
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Letter to the editor
Date:Jun 1, 2010
Words:729
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