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Rapid Responses: Rapid Responses published:
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Acute rheumatic fever and pregnancy
- A.D Singh Ahuja (19 November 2007)
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Misleading advice on endocarditis prophylaxis in pregnancy
- Habib U Rehman (21 November 2007)
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Some corrections are required in this article
- E.S Prakash (23 November 2007)
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Inaccuracies and clarifications
- Kumar Satya (29 November 2007)
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Antibiotic prophylaxis
- Emily Gelson (1 December 2007)
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A.D Singh Ahuja, Senior resident PGIMER Chandigarh
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To the Editor: In the review article on the “Valvular heart disease in pregnancy”, presented by E Gelson, etal (17 Nov. issue),1 the discussants do not mention about reactivation of rheumatic fever either in the differential diagnosis nor in the secondary prophylaxis in patients with established rheumatic valvular heart disease. Although the incidence of RF has declined sharply in many developed countries, the disease remains a major problem in many developing countries with approximately one million new cases per year in India. In developing countries it accounts for 35% to 40% of cardiovascular disease- related hospital admission and is the predominant indication for cardiac surgery.2 Patients who have suffered a previous attack of RF and who develop streptococcal pharyngitis are at high risk for a recurrent attack of RF. Group A streptococcal infection need not be symptomatic to trigger a recurrence. Though the risk of recurrence of rheumatic fever tends to be highest in the first few years after the initial attack but it remains through out lifetime. Patients with increased exposure to streptococcal infections include children and adolescents; parents of young children; teachers, physicians, nurses, and allied health personnel in contact with children; military recruits; and others in crowded housing. Rheumatic heart disease, the sequel to acute rheumatic fever is an important predisposing condition for acute endocarditis. Not infrequently the clinical manifestation of recurrent rheumatic heart disease mimics that of acute endocarditis, giving rise to a diagnostic dilemma. Acute RF produces pancarditis, affecting the endocardium, myocardium, and pericardium. The diagnosis of carditis in acute RF is based on the presence of significant apical systolic and/or basal diastolic murmur(s), the presence of pericarditis, or unexplained heart failure. Prophylaxis should be initiated as soon as acute RF or rheumatic heart disease is diagnosed. Physicians must consider each individual situation when determining the appropriate duration of prophylaxis. Patients who have had rheumatic carditis are at a relatively high risk for recurrences of carditis and are likely to sustain increasingly severe cardiac involvement with each recurrence. Therefore, patients who have had rheumatic carditis should receive long-term antibiotic prophylaxis, perhaps for life. Duration of prophylaxis depends on whether residual valvular disease is present or absent. Prophylaxis should continue even after valve surgery, including prosthetic valve replacement. Patients who have had RF without carditis are at considerably less risk of cardiac involvement with a recurrence. Therefore, prophylaxis may be discontinued in these individuals after several years.3 In general, prophylaxis should continue until 5 years have elapsed since the last RF attack or age 21 years, whichever is longer. The decision to discontinue prophylaxis or reinstate it should be made after discussion with the patient of potential risks and benefits and careful consideration of the epidemiological risk factors enumerated earlier. In countries where the incidence of RF is particularly high, in special circumstances, or in certain high-risk individuals, such as patients with residual rheumatic carditis, the administration of benzathine penicillin G every 3 weeks is recommended.4 References 1. E Gelson, M Gatzoulis and M Johnson. Valvular heart disease. 2007;335;1042-1045 BMJ 2. Vijaykumar M, Narula J, Reddy KS, Kaplan EL. Incidence of rheumatic fever and prevalence of rheumatic heart disease in India. Int J Cardiol 1994;43:221–8. 3. Berrios X, del Campo E, Guzman B, et al: Discontinuing rheumatic fever prophylaxis in selected adolescents and young adults. Ann Intern Med 1993; 118:401. 4. Lue HC, Wu MH, Wang JK, et al: Long-term outcome of patients with rheumatic fever receiving benzathine penicillin G prophylaxis every three weeks versus every four weeks. J Pediatr 1994; 125:812 Competing interests: None declared |
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Habib U Rehman, Clinical assistant Professor Regina Qu
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Dear Sir Gelson et al give extremely misleading advice in their article on the management of valvular heart disease in pregnancy (1).Their recommendation of considering antibiotic prophylaxis for all valvular lesions irrespective of delivery mode is incorrect. The reference they have quoted to support this advice actually states the exact opposite. The ACC/AHA guidelines for the management of patients with valvular heart disease "does not recommend routine antibiotic prophylaxis in patients with valvular heart disease undergoing uncomplicated vaginal delivery or caesarean section unless infection is suspected (2)." Indeed the revised guidelines of the American Heart Association do not recommend administration of antibiotics solely to prevent endocarditis for patients who undergo a genitourinary or gastrointestinal tract procedure. Moreover, it emphasises the restriction of prophylaxis for only those patients with the highest risk of adverse outcome (3). These patients are those with prosthetic cardiac valve, patients with a history of previous infective endocarditis, patients with cyanotic congenital and cardiac transplant recipients who develop cardiac valvulopathy. The current guidelines go as far as recommending no prophylaxis even for mitral valve prolapse, the most common underlying condition that predisposes to acquisition of infective endocarditis. (1) Gelson E, Gatzoulis M, Johnson M. valvular heart disease. BMJ 2007;335:1042-5. (2) ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the american College of cardiology/American Heart association task force on practice guidelines (Committee on management of patients with valvular heart disease). J Am Coll Cardiol 1998;32:1486-588. (3) Prevention of Infective Endocarditis. Guidelines From the American Heart Association: A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116:1736-1754. Competing interests: None declared |
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E.S Prakash, Senior Lecturer School of Medicine, Asian Institute of Medicine, Science & Technology, 08100 Bedong, Kedah, Malaysia
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p. 1045 (print version), Line 8 in the Scenario Box: Is beta blocker the drug used? Box 1 & line 1 of p. 1043 (print version) "New York Health Association" must read New York Heart Association. Competing interests: None declared |
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Kumar Satya, Medical Resident Norwalk, US 06850
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The article about Valvular heart Disease in Pregnancy was informative. I seek 2 clarifications, though: 1. 'Thromboprophylaxis with unfractionated heparin is indicated during bed rest and in the presence of atrial arrhythmia, particularly if the left atrium is dilated': I assume the prophylaxis during bed rest is from Venous Thrombosis. Is unfractionated heparin known to be better than low molecular weight heparin? I am not sure what prophylaxis the article refers to in the second part of the statement - the one regarding atrial arrhythmia and dilated LA. Please guide me to the right reference if there is evidence for prevention of cerebral embolism by prophylactic doses of unfractionated heparin in this setting. 2. The recommendations regarding endocarditis prophylaxis have already been alluded to in an earlier letter. In fact, the reference cited in the article is a bit out of date as the AHA has published new guidelines regarding antibiotic prophylaxis and very few conditions now qualify for antibiotics - information all physicians must arm themselves with at the earliest to prevent misuse and overuse of antimicrobials. Competing interests: None declared |
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Emily Gelson, Research Fellow sw10 9nh
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Dear Sir, We would like to thank Professor Rehman for his comments. However our advice that 'antibiotic prophylaxis should be considered for all valvular lesions irrespective of delivery mode' is not misleading. The rationale for antibiotic prophylaxis in patients with valvular heart disease is that endocarditis develops from bacteremia in patients with abnormal heart valves. Early studies indicated a low likelihood for bacteremia associated with uncomplicated vaginal or abdominal deliveries (1). However, recent reports have indicated higher rates of bacteremia, with a 14% bacteremia rate detected after intra-partum cesearean section (2), positive blood cultures detected in 19% of women during delivery (3) and a 5% bacteremia rate reported postpartum (4). Although rare, bacterial endocarditis during pregnancy caries a 22% maternal mortality rate (4). Due to these recent data indicating a high risk of bacteremia even after uncomplicated delivery, the relative low risk and cost of therapy, and the potential devastating effect of endocarditis, antibiotic prophylaxis should be considered for all valvular lesions irrespective of delivery mode. Indeed in many institutions it is routine. (1) Sugrue D, Blake S, Troy P, MacDonald D. Antibiotic prophylaxis against infective endocarditis after normal delivery is it necessary? British Heart Journal 1980;44:499-502 (2) Boggess KA, Watts DH, Hillier SL, Krohn NA, Benedetti TJ, Eschenbach DA. Bacteremia shortly after placenta separation during caesarean delivery. Obstet Gynecol 1996;87:779-784 (3) Petanovic M, Zagar Z. The significance of asymptomatic bacteremia for the newborn. Acta Obstet Gynecol Scand 2001;80:813-817 (4) Furman B, Shohan-Vardi I, Bashire A, Erez O, Mazor M. Clinical significance and outcome of pre-labor rupture of membranes population- based study. Eur J Obstet Gynecol Reprod Biol 2000;92:209-216 (5) Campuzano K, Roque H, Bolnick A, Leo MV, Campbell WA. Bacterial endocarditis complicating pregnancy: case report and systematic review of the literature. Arch Gynecol Obstet 2003;268(4): 251-255 Competing interests: None declared |
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