Febrile Condition in 23-Year Old Pregnant Woman

Abstract

A 23-year-old woman in her 29th gestation week of pregnancy was admitted in Obstetrics and Gynaecology Department with symptoms of fever, dyspnea and shortness of breath. The blood test examinations showed significant leukocytosis and elevated c-reactive protein levels. Transthoracic(TT) echocardiography was performed showing severe mitral valve regurgitation with posterior cusp destruction confirming the diagnosis of infective endocarditis. The condition of the patient significantly deteriorated, and she was urgently transferred to the Cardiovascular Surgery Department for an emergent surgical treatment. She was admitted in the Intensive Care Unit with clinical signs of severe septic shock and severe left heart insufficiency. A consultation of gynaecologist was performed and fetal death in utero from fetal ultrasonography was diagnosed. A decision for an emergent simultaneous operation was taken. During the anesthesia induction the patient developed severe circulatory shock needing a cardiopulmonary resuscitation which restored the spontaneous circulation after one minute. At first, before heparinization sectio parva was performed confirming the diagnosis of fetal death. During the cardiac operation after the cardiopulmonary bypass(CPB) institution, mitral valve replacement and inspection of the tricuspid valve was performed. The CPB was discontinued with three catecholamine support. In the postoperative period she was febrile with severe multiple organ system failure(MOSF) manifestation, generalized single tonic-clonic seizure and in the following hours three seizures with focal onset(muscle contractions in the right facial half) were observed. On the postoperative day(POD) 2 she developed clinical signs of blue discoloration of the distal phalanx of the left foot. Doppler ultrasound examination showed subtle pulsations on the left dorsal pedal artery. Ultrahemofiltration with antiseptic filter was performed for cytokine removal. In the following days the condition of the patient improved. She was extubated on POD 4, transferred to the post-operative department on POD 7 and discharged on POD 23. Despite advances in medicine, the treatment of the infective endocarditis is associated with high mortality and complication rates. Multidisciplinary collaboration is crucial for achieving the best outcome.