Tonsillitis during pregnancy is an acute infectious inflammation of the palatine, lingual tonsils, lymphadenoid tissues on the back wall of the pharynx and in the larynx that occurred during the gestational period. It is manifested by hyperthermia, severe intoxication syndrome, sore throat, enlargement and soreness of submandibular, rarely cervical lymph nodes. It is diagnosed by pharyngoscopy, a back-up smear from the oropharynx. Cephalosporins, macrolides, beta-lactam penicillins, NSAIDs, antiseptic solutions are used for treatment. With a severe purulent-destructive process, it is possible to open abscesses and perform abscessonzillectomy.
ICD 10
J03 J35.
General information
Acute tonsillitis is the third most common infectious disease of the upper respiratory tract (after influenza and SARS), diagnosed during pregnancy. Since the pathogen affects the tissues of not only the tonsils, but also the pharynx, recently the term acute tonsillopharyngitis has been used to describe the disease. Since 82% of patients have beta-hemolytic streptococcus of group A, previously only streptococcal acute tonsillitis was called angina. Currently, the understanding of the etiology of the disease is expanded. Angina is more often observed in pregnant women under the age of 30-35 years in the second half of gestation. A more severe course of inflammation is noted in the 3rd trimester of pregnancy. The peak incidence of bacterial forms of acute tonsillitis occurs in early spring, viral — in the autumn-winter period.
Causes
Acute tonsillitis in pregnant women belongs to the category of anthroponotic infections with a predominantly airborne transmission mechanism. It develops as a result of infection of the lymphoid formations of the pharyngeal ring with pathogenic and conditionally pathogenic microflora. The rapid occurrence of the inflammatory process and deeper destruction of tissues is facilitated by a natural decrease in immunity during gestation, which prevents rejection of a genetically alien fetus. The causative agents of tonsillitis during pregnancy are the same infectious agents as outside the gestational period:
- Bacteria. In more than 80% of patients, acute tonsillitis during pregnancy is caused by beta-hemolytic streptococcus of group A. Less often, the causative agents of the disease are streptococci of other groups, staphylococci, pneumococci, meningococci, gonococci, klebsiella, typhoid and hemophilic bacilli, anaerobes, Vincent’s spirochete in association with spindle bacillus.
- Viruses. In recent years, the prevalence of angina of viral origin has been increasing. Inflammation of the tonsils in pregnant women can be a complication of adenovirus, enterovirus, herpetic ARVI. In some patients with low immunity, secondary colonization of the epithelium by bacterial flora occurs against the background of primary viral damage to lymphoid tissue.
In sporadic cases, angina occurs due to infection with chlamydia and mycoplasmas. In some women, associations of cocci with candida are sown from the separated tonsils. Hypothermia, insufficient nutrition, stay of pregnant women in dusty and polluted rooms with a large number of employees or visitors, the presence of caries and chronic gum diseases become predisposing factors to the disease of acute tonsillitis.
Pathogenesis
The source of infection is usually bacterial carriers, patients with acute tonsillopharyngitis, sometimes convalescents. The causative agent of the disease is more often transmitted by airborne droplets, less often by household contact through contaminated dishes or alimentary with water and food. The starting point of the development of tonsillitis during pregnancy is the ingestion of a microorganism on the epithelium of the oropharyngeal lymphoid ring. Due to the presence of M-protein, which suppresses local immunity, lipoteichoic acid, which has an affinity for the epithelium of the tonsils, and other pathogenicity factors, infectious agents are fixed to the mucosa and begin to multiply actively, releasing exo- and endotoxins.
In response to the damaging effect of bacteria, viruses, fungi, a local inflammatory reaction occurs: due to increased capillary permeability, the lymphoid tissue swells and is infiltrated by neutrophils. Subsequently, under the action of macrophage proteases, lymphoid follicles melt, pus forms. In severe cases, not only the epithelial layer is destroyed, but also the stroma of the tonsils. Rejection of necrotic areas is accompanied by the formation of bleeding defects, which subsequently epithelize. As a result of the spread of infection along the lymphatic pathways, regional lymph nodes are affected, and the entry of microorganisms from the septic focus into the systemic bloodstream contributes to their spread throughout the body, the development of general intoxication and a multi-organ reaction.
Classification
The systematization of clinical forms of angina during gestation is based on the features of the course and the nature of morphological changes in lymphoid tissue. In general, the classification reflects the stages of the development of the infectious and inflammatory process, although it partially takes into account the etiological factor. Specialists in the field of otorhinolaryngology, obstetrics and gynecology distinguish the following variants of acute tonsillitis diagnosed during pregnancy:
- Catarrhal angina. A relatively infrequent variant of tonsillar inflammation with predominantly local symptoms, moderate intoxication, and the absence of pus. With sufficient reactivity and timely therapy, catarrhal angina may not turn into purulent forms. It often has a viral origin.
- Purulent angina. Depending on the prevalence of inflammation, it can be follicular with spot pustules, lacunar with foci of plaque, fibrinous with involvement in inflammation of the entire amygdala and transition to adjacent tissues. Usually, during pregnancy, one of the purulent forms of acute tonsillitis is detected.
Relatively rarely, phlegmonous angina with purulent melting of a part of the amygdala and ulcerative-necrotic fusospirochetosis of Simanovsky-Plaut-Vincent occur at the stage of gestation. Taking into account the specificity of the clinical picture, acute tonsillopharyngitis of herpetic origin is distinguished as a separate variant of the disease, in which bubbles with reddish contents form on the mucous membrane of the tonsils and oropharynx.
Symptoms of tonsillitis during pregnancy
Usually, the disease develops acutely for several hours to 2 days from the moment of infection. At the initial stages of tonsillopharyngitis, the body temperature of a pregnant woman rises to 38-40 ° C, chills, headache, muscle and joint pain, back pain occur, with severe course — loss of appetite, nausea, vomiting, abdominal pain. The woman feels pronounced weakness, weakness. Against the background of intoxication, a sore throat appears, which increases when swallowing, talking, can radiate into the ear. In the future, the submandibular lymph nodes become compacted, increase to 1-2 cm in diameter, and become painful. There is an unpleasant smell from the mouth, the voice sounds hoarse.
Complications
In the acute period, as well as outside of gestation, angina in a pregnant woman can be complicated by acute laryngitis, acute cervical lymphadenitis, otitis media, paratonsillitis, and the formation of a pharyngeal abscess. With the contact spread of the pathogen, mediastinitis, meningitis may occur. Massive dissemination of microorganisms against the background of reduced immunity leads to the development of sepsis and infectious-toxic shock. 2-4 weeks after streptococcal angina, a woman may develop symptoms of acute glomerulonephritis, acute rheumatic fever, rheumocarditis caused by an autoimmune reaction of the body.
Specific complications of early pregnancy are increased toxicosis, with severe intoxication and hyperthermia — spontaneous miscarriage. In 2-3 trimesters, there may be a violation of placental blood flow and fetal hypoxia, placental abruption, premature birth. A number of infectious agents that cause angina are able to penetrate the fetoplacental barrier, causing intrauterine infection of the child. Significant damage to fetal tissues can lead to developmental abnormalities, pregnancy fading, and increased perinatal mortality rates. In patients who have suffered acute tonsillitis, weakness of labor activity is more often observed.
Diagnostics
In most cases, the diagnosis of tonsillitis during pregnancy is not particularly difficult. An infectious lesion of the tonsils is usually indicated by their hyperemia, swelling, detection of white follicles with a diameter of 2-3 mm, yellowish-white discharge. In the necrotic form, deep defects of lymphoid tissue up to 2 cm in size with a bumpy bottom are observed, formed after rejection of dark gray necrotic areas. Rarely diagnosed herpetic angina is characterized by the appearance of reddish bubbles on the mucous membrane of the oropharynx. The recommended methods of examination are:
- Examination of the pharynx. Pharyngoscopy performed by otorhinolaryngol using special tools allows you to more accurately determine the condition of the pharyngeal mucosa. The study assessed the nature and prevalence of pathological changes in lymphoid tissue.
- Sowing a smear from the pharynx on the microflora. The determination of the pathogen facilitates the differential diagnosis of angina with other infectious processes. In the course of a microbiological study, the sensitivity of the microorganism to antibacterial drugs is established.
- Blood testing. The indicators of the general blood test correspond to the signs of an acute infectious process. Usually, an increase in the number of leukocytes is determined, mainly due to neutrophils, a shift in the leukocyte formula to the left, a moderate increase in ESR. RIF, ELISA, and PCR diagnostics are recommended as additional methods for detecting an infectious agent in complex clinical cases.
Angina during gestation is differentiated with influenza, acute respiratory viral infections, diphtheria, scarlet fever, lesions of lymphoid formations, pharyngeal mucosa and lymph nodes in infectious mononucleosis, listeriosis, syphilis, tuberculosis, tularemia, typhoid fever, neoplasia, hematological diseases. According to the indications, a pregnant woman, in addition to an obstetrician-gynecologist and ENT specialist, is advised by an infectious disease specialist, venereologist, phthisiologist, hematologist, oncologist, oncohematologist.
Treatment of tonsillitis during pregnancy
In case of catarrhal, follicular, lacunar, fibrinous inflammation and absence of obstetric complications, outpatient management of the patient is recommended. Hospitalization is indicated for severe phlegmonous or atypical course of acute tonsillitis, ulcerative necrotic form of the disease, signs of intrauterine fetal damage, threat of termination of pregnancy. During the period of hyperthermia and the first days of convalescence, a woman is shown bed rest, the use of a large amount of warm liquid (water, weak tea, broth of rosehip, compotes of fresh berries and dried fruits).
The basis of drug treatment of bacterial angina is etiotropic systemic antibiotic therapy, taking into account the sensitivity of the pathogen and the possible effect of the drug on the fetus, supplemented with symptomatic means. Pregnant women with acute tonsillitis may be prescribed the following groups of drugs:
- Antibacterial agents. Most antibiotics recommended for the treatment of angina are prohibited during pregnancy due to their fetotoxicity. During gestation and lactation, the use of certain cephalosporins, natural and semi-synthetic macrolides, broad-spectrum beta-lactam penicillins is allowed. Antibiotics are not used for viral sore throats.
- Antipyretic drugs. They are prescribed only when the temperature rises to 39 ° C or more. The drugs of choice during pregnancy are antipyretics from the group of anilides, the use of which is permissible at all terms. In 1-2 trimesters, it is possible to use derivatives of phenylacetic and propionic acids. In addition to lowering the temperature, NSAIDs have a moderate analgesic effect.
- Disinfectant solutions. Regular gargling with nitrofuran, phenolic, cationic antiseptics of local action is recommended for the rehabilitation of the throat. Some pharmaceutical antiseptic drugs are effective not only against bacteria, but also viruses and fungi. Decoctions of medicinal herbs (eucalyptus, chamomile, sage) can become an alternative to pharmacological solutions.
To reduce sore throat, pregnant women are shown steam and hardware inhalations. It is possible to perform special ENT procedures – treatment of the posterior wall of the pharynx and tonsils with medications, physiotherapy treatment on the Tonsillor apparatus. With purulent melting of lymphoid tissue and abscessing, an autopsy of a paratonsillar abscess, abscessonzillectomy is performed.
Prognosis and prevention
Against the background of adequate antibiotic therapy, the symptoms of the disease are completely stopped within 7-10 days, catarrhal angina is cured in 3-5 days. More serious is the prognosis of destructive forms of angina. Preventive measures during pregnancy are aimed at limiting contacts with possible carriers of the pathogen — limiting the time spent in public places, especially during the off-season, wearing a medical mask when contacting people during SARS epidemics, visiting a dentist and an otorhinolaryngologist for timely sanitation of foci of infection in the oral cavity.
Strengthening immunity, reducing the level of physical exertion and psychological stress play a non-specific role in preventing the disease. To prevent late complications of angina that can worsen the course of pregnancy, active medical supervision is recommended during the first month after the infection with the appointment of general blood and urine tests, ECG at 1 and 3 weeks.
