Ludwig Angina in Pregnancy: Treatment Outcome in 12 Patients and Review of Literature

Abstract

Ludwig angina is a rare but severe life-threatening cellulitis, classically of odontogenic origin, characterized by an extensive and a rapidly progressive inflammation of subcutaneous tissue of the face and severe systemic toxicity. Its prognosis is potentially worse in pregnancy given the higher vulnerability of both mother and fetus to infection and to the consequences of therapies. Early diagnosis and timely treatment are of paramount importance in the prognosis of this condition but could be however challenging as it is infrequently observed in current daily practice. Moreover, literature dealing with Ludwig's angina in pregnancy is scarce, consisting mostly in isolated case reports from developed countries. The aim of this article was to improve awareness on Ludwig angina in pregnancy through a report of experience in 12 patients and a literature review on the diagnosis and treatment of this clinical entity. To this end, medical records of 12 patients with Ludwig angina in pregnancy were analysed retrospectively and the diagnosis and treatment approaches discussed through a literature review. Age of pregnancy ranged from 27 to 37 weeks. In all the patients, the cellulitis origin was a carious molar of the mandible. The infection spread extended to the neck (4 patients), the thorax (3 patients) and the temporal fossa (2 patients). One patient presented with necrotizing fasciitis extending from the submandibular and submental regions to the thorax. Bacteriological examination of pus which was possible and successful in 4 patients only, showed staphylococcus aureus (2 patients) staphylococcus SP (1 patient) and staphylococcus epidermidis (1 patient). Death occurred in 2 mothers and in 7 fetus giving mortality rates of 16.7% and 58.3% respectively. Direct causes of death in mothers were sepsis shock and air way compromise. In 6 out of the 7 mothers who had dead fetus, the infection extended beyond the mouth floor. Oral health care providers should be aware for proper treatment of dental infections. They should also be alert for early recognition and multidisciplinary treatment of Ludwig angina in pregnancy in collaboration with obstetricians, specialists of intensive care and infectious diseases.