Discussion
In this case, a 31-year-old female with no history of smoking, and
substance abuse and two prior cesarean sections presented with recurrent
high-grade fever, chills, rigors, and mild vaginal bleeding following a
medical termination of pregnancy at 16 weeks gestation with diagnosis of
incomplete septic abortionDespite initial treatment, her symptoms
persisted, leading to her presentation at our center. Blood cultures
were positive for methicillin-resistant Staphylococcus aureus (MRSA),
and echocardiography revealed vegetation on the tricuspid valve,
suggesting IE secondary to septicemia. IE is a life-threatening
infection of the heart’s endocardial surface, often affecting those with
underlying heart conditions or prosthetic valves (7). Diagnosis relies
on the modified Duke criteria, which incorporate clinical,
microbiological, and echocardiographic findings. Common causative
organisms include Staphylococcus aureus, viridans Streptococcus, and
enterococci (8). The incidence of IE is increasing due to more frequent
cardiac interventions and an aging population with comorbidities.
Septic abortion remains a significant cause of maternal mortality and
morbidity in developing countries. Studies have reported incidence rates
ranging from 6.6% to 8.2% of all abortions. Most cases result from
induced abortions, often performed by unqualified individuals. Mortality
rates from septic abortion range from 6% to 15.4% (11,12). Common
complications include peritonitis, septicaemia, renal failure, and
septic shock (13). IE is a rare but potentially severe complication of
septic abortion, particularly affecting the right side of the heart.
Cases have been reported involving various pathogens, including
Escherichia coli and Staphylococcus aureus (9). IE following septic
abortion can lead to life-threatening systemic complications, such as
septic arthritis, reactive arthritis, and pulmonary septic embolization
(10). The infection can spread from the pelvic veins to the right heart,
with Staphylococcus aureus being a common causative organism. Diagnosis
typically involves clinical presentation, echocardiography, and blood
cultures (9). Herein, our case presented with the history of fever and
mild bleeding with the history of septic abortion for which we suspected
IE because of septic abortion which was further confirmed by detailed
history, examination and investigation. Blood culture was done which
revealed the presence of methicillin resistant staphylococcus aureus.
Echocardiography plays a crucial role in diagnosis, revealing
vegetations on affected valves (6). Echocardiography of our case
revealed vegetation on the tricuspid valve leaflet of 2.5 cm.
Dilation and curettage appear to have been important factors in the
development of right-sided IE because the infection can enter the venous
system through the pelvic veins following a gynaecological procedure and
then travel to the right side of the heart. This infection can also
occur a few days after the procedure in a person who is otherwise
healthy and does not have a known risk factor for right-sided IE,
increasing the likelihood that cause, and effect are related. The
American Heart Association does not advise antibiotic prophylaxis for
women having surgical abortions, however, in the event if congenital
heart disease, prior IE, or valvular heart disease are present (9, 14).
Our case underwent conventional dilatation and curettage method manual
evacuation of retained products of conception following medical
termination of pregnancy by mifepristone. Early diagnosis and treatment
are crucial, often requiring multispecialty consultation due to
potential systemic complications (6). Prophylactic antibiotics and
adherence to sterile techniques during procedures can help prevent IE
(9). National Institute for Health and Care Excellence abortion care
guidance recommends offering antibiotic prophylaxis (3-day course of
oral doxycycline) to women having a surgical abortion (15). However, our
case was not given prophylactic antibiotics following manual evacuation
of retained products of conception. Treatment typically involves
intravenous antibiotics, with surgical intervention sometimes necessary
(6).
This case highlights the importance of the recent history of obstetric
and gynaecological procedure in a patient presenting with the feature of
endocarditis. This involves detailed history taking including past
medical history, clinical examination and appropriate investigations.
This facilitates prompt diagnosis and aid in necessary treatment.