An Unusual Case of Infectious Endocarditis in Pregnancy

Background: Infectious Endocarditis during pregnancy is rare, occurring in an estimated 0.006% of pregnancies. Right sided endocarditis is most commonly associated with heart and valvular diseases, while left sided endocarditis is associated with IV drug use. Maternal mortality rates are high (33%) due to complications of heart failure and embolic events, and fetal mortality rates are noted to be between 14% and 33%.  Infectious Endocarditis presents unique challenges in patient care management, such as antibiotic treatment, timing of delivery and timing of cardiac surgery, if required.

 Case: A 30 year old, G4P1 at 26 5/7 weeks gestation was transferred to Labor and Delivery from another facility with a two week history of fever, chills, nausea, vomiting, and cough. Her medical history included, MRSA, Hepatitis C, anemia and IV drug abuse in combination with methadone use and preliminary positive blood cultures from the sending facility, as well as multiple social issues.  An echocardiogram and EKG, as well as laboratory studies, were obtained. Consults to Infectious Disease, Cardiology, and Maternal Fetal Medicine were placed and an antibiotic regime was initiated. Shortly after arrival, the patient’s respiratory status significantly declined. The Surgical Critical Care team was consulted and the patient was taken to CT scan and then transferred to the Critical Care Unit. On day three of admission, she was transferred to the OB High Risk area where her course was complicated by further febrile episodes, septic pulmonary emboli, a right sided pleural effusion requiring thoracentesis, and subsequently chest tube placement, multiple antibiotics, blood transfusions, PICC line placement and oxygen support. During week three, she was stable enough for transfer to the inpatient antenatal unit for continuing treatment with antibiotics. The patient signed herself out of the hospital on day twenty six against medical advice.

The patient returned for induction of labor at 37 weeks gestation secondary to complex antenatal course and cholestasis of pregnancy. She delivered a liveborn female and had a Bilateral Tubal Ligation complicated with a wound infection after discharge. The baby was discharged to home as a well newborn.

 Conclusion: Infectious endocarditis rarely develops during pregnancy. Treatment  requires collaboration between many disciplines and careful consideration of the effects on not only the mother, but the fetus.

Keywords: Pregnancy,  bacterial endocarditis, valvular vegetation, septic emboli