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, whereas left-sided endocarditis is associated with intravenous (IV) drug use. Maternal mortality rates are high (33%) due to complications of heart failure and embolic events, and fetal mortality rates are 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.
A 30-year-old G4P1 at 26 5/7 weeks gestation was transferred to labor and delivery from another facility with a 2-week history of fever, chills, nausea, vomiting, and cough. Her medical history included, methicillin-resistant Staphylococcus aureus, Hepatitis C, anemia, and IV drug abuse in combination with methadone use, preliminary positive blood cultures, and multiple social issues. An echocardiogram, electrocardiogram, and 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 for a computed tomography scan and then transferred to the critical care unit. On day 3 of admission, she was transferred to the obstetric 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, peripherally inserted central catheter line placement and oxygen support. During week 3, 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 26 against medical advice.
The patient returned for induction of labor at 37-week gestation secondary to complex antenatal course and cholestasis of pregnancy. She delivered a live born female infant and had a bilateral tubal ligation complicated by a wound infection after discharge. The infant was discharged to home as a well newborn.
Infectious endocarditis rarely develops during pregnancy. Treatment requires collaboration between many disciplines and careful consideration of the effects on the mother and fetus.