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.