A 33-year-old female patient, at 29 3/7 weeks' gestation, was admitted to our hospital on December 1st, 2021, presenting with symptoms of hyperpyrexia, abdominal pain, and diarrhea. The patient had a history of rheumatic heart disease at the age of 24, having undergone mechanical MVR and had been on warfarin therapy for an extended period. Upon admission, her temperature was recorded as 39.1°C, pulse rate at 132 beats/min, and fetal heart rate at 154 beats/min. Physical examination revealed no significant abnormalities. Blood tests showed white blood cell count of 12.39×109/L (Neutrophil: 89.3%), C-reactive protein (CRP) level of 158.0 mmol/L, procalcitonin level of 0.31ng/ml, prothrombin time (PT) of 14.7s, and international normalized ratio (INR) of 1.3 (Table 1). Electrocardiogram (ECG) analysis identified sinus tachycardia (Fig. 1a). Fetal ultrasonography from local hospital demonstrated a healthy fetus with an estimated fetal weight of 1604g. And abdominal ultrasound is normal. We initially diagnosed her with gastroenteritis and started her treatment with IV Cefuroxime 1.5g twice daily empirically. After two days of treatment, her temperature returned to normal (Fig. 2a). However, two sets of blood cultures on the third day of hospitalization revealed Streptococcus mitis infection. Consequently, we switched from IV Cefuroxime to IV Ceftriaxone 2g daily based on antimicrobial susceptibility testing. Following several days of treatment, the patient's symptoms resolved and all laboratory indicators improved. Nevertheless, she experienced mild and persistent left upper quadrant abdominal pain on December 9th. Acute fatty liver during pregnancy (AFLP), HELLP syndrome, and other pregnancy-related causes were ruled out. The second abdominal ultrasound revealed a wedge-shaped splenic lesion (3.3×1.7cm) located under the capsule of the upper pole of the spleen, suggesting a potential splenic infarction (Fig. 1c). However, the appearance of the spleen artery on vascular ultrasound was normal. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) confirmed good mechanical valve function without any vegetation findings (Fig. 1d). Based on these findings, we diagnosed her with infective endocarditis as this case fulfilled the 2023 Duke’s criteria for infective endocarditis (1 major criteria and 3 minor) (3). A multidisciplinary team, comprising experts in cardiac surgery, cardiology, obstetrics, and infectious diseases, deliberated on this case. Given the patient's pregnancy, a conservative management approach was initially implemented. This entailed sequential administration of anti-microbial, anti-coagulation, and other symptomatic treatments. The strategy aimed to administer a minimum of six weeks of antibiotics, with the warfarin dosage being continuously adjusted during hospitalization based on INR. After four days of treatment, the patient’s abdominal pain was mild.
Table 1
Laboratory results during inpatient admission.
Laboratory | Admission day | 2 weeks after RX |
WBC×109/L (4.0–10.0) | 12.39 | 8.37 |
N ×109/L (2.0–7.0) | 11.06 | 6.57 |
Hb in g/L (113.0−151.0) | 109 | 100 |
Platelets×109/L (101.0−320.0) | 121 | 253 |
CRP in mg/L (0–8.0) | 158 | 24.08 |
Creatinine in µmol/L (41.0–73.0) | 54 | |
ALT in U/L (7.0–40.0) | 29 | |
INR (0.85–1.15) | 1.3 | 1.63 |
PT in s (10.0−13.5) | 14.7 | 18.2 |
APTT in s (23.9–33.5) | 27.5 | 30.2 |
(WBC: White blood cell, N: Neutrophil, Hb: Hemoglobin, CRP: C-reactive protein, ALT: alanine transaminase, INR: internationalnormalized ratio, PT: prothrombin time, APTT: activated partial thromboplastin time) |
At 33 weeks' gestation, vaginal discharge was observed, indicating premature rupture of membranes (PROM). Consequently, warfarin was discontinued and bridging therapy with IH low-molecular-weight heparin (LMWH, Nadroparin Calcium Injection) 4100U every 12 hours was administered prior to the surgery. Other interventions included dexamethasone to facilitate fetal lung maturation, magnesium sulfate to safeguard the fetal brain nervous system, and Ritodrine to suppress uterine contractions. Given her history of a previous cesarean section and breech presentation, she underwent a second cesarean section under general anesthesia on December 29th. The intraoperative bleeding volume was approximately 400 mL, and her uterus was preserved. The newborn was subsequently transferred to the neonatology department. Post-surgery anticoagulation therapy consisted of daily warfarin 3mg and IH LMWH 4100U every 12 hours. Postpartum hemorrhage did not occur, and the hemoglobin level remained stable (Fig. 2b). And the pathological findings did not indicate the presence of intrauterine infection or any other abnormalities (Fig. 1b).
Fortunately, the abdominal ultrasonography revealed a reduced extent (2.5×1.5cm) of serositis and the blood culture was negative on the fifth day post-operation. Consequently, we deescalated the antibiotic regimen to oral Cefuroxime. The patient was eventually discharged from the hospital, but required ongoing use of warfarin and LMWH. Following a one-month follow-up, there were no recurrences of SI after the completion of antibiotic therapy. Figures 1–2 depict the laboratory indicators and imaging images obtained during the hospitalization period.