Infective Endocarditis in Pregnancy: A Contemporary Cohort

Malamo E. Countouris; Amy L. Marino; Megan Raymond; Alisse Hauspurg; Kathryn L. Berlacher

doi:10.1055/a-1877-5763

American Journal of Perinatology, Table of Contents

Am J Perinatol 2024; 41(S 01): e230-e235
DOI: 10.1055/a-1877-5763

Original Article

Infective Endocarditis in Pregnancy: A Contemporary Cohort

Malamo E. Countouris

¹University of Pittsburgh Medical Center, Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania

,

Amy L. Marino

¹University of Pittsburgh Medical Center, Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania

,

Megan Raymond

²Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania

,

Alisse Hauspurg

³Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Pittsburgh Medical Center University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

,

Kathryn L. Berlacher

¹University of Pittsburgh Medical Center, Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania

› Author Affiliations

Abstract

Objective Pregnancy-related infective endocarditis (IE) caries a high risk of morbidity and mortality. With increasing intravenous drug abuse (IVDA) amid the opioid epidemic, the risk factor profile may be shifting. In this case series, we aimed to describe risk factors and outcomes for peripartum IE in a contemporary cohort.

Study Design We identified patients with IE diagnosed during pregnancy or up to 6 weeks' postpartum from 2015 through 2018 at a single tertiary care center. We abstracted detailed medical history and clinical outcome measures from the electronic medical record. The diagnosis of IE was supported by the modified Duke Criteria.

Results Nine patients had peripartum IE: eight (89%) with a history of IVDA, one with an indwelling central venous catheter (11%), and one with prior IE (11%). None had preexisting congenital or valvular heart disease. Six (67%) had comorbid hepatitis C. Eight cases (89%) had gram-positive cocci with vegetations involving the tricuspid valve (56%) and both mitral and tricuspid valves (22%). Major complications included shock (33%), mechanical ventilation (44%), septic emboli (67%), and noncardiac abscesses (33%). Two patients underwent valve surgery, and there were two cases of postpartum maternal mortality (22%), one from septic shock and one from intracerebral hemorrhage. While four patients (44%) delivered preterm (average gestational age 35 weeks), most delivered vaginally (89%) with only one requiring an emergent caesarean section. There was no fetal mortality, although three newborns (43%) required admission to the neonatal intensive care unit. Two patients were initiated on medication-assisted treatment for opioid use disorder. Consultants included infectious disease, cardiology, cardiac surgery, maternal-fetal medicine, and psychiatry.

Conclusion These findings confirm that IVDA is a growing risk factor for pregnancy-related IE. Peripartum IE carries a high risk of complications, including maternal mortality, and warrants management with a multidisciplinary care team at a tertiary center.

Key Points

Intravenous drug use was the most common risk factor for IE in pregnancy.
IE in pregnancy carries a high morbidity and mortality with complications including septic emboli, septic shock, and need for mechanical ventilation.
A multidisciplinary team approach can assure the best possible maternal and fetal outcomes.

Keywords

infective endocarditis - valvular disease - pregnancy - peripartum - intravenous drug use - opioid use disorder

Full Text

References

References
1 Kadri AN, Wilner B, Hernandez AV. et al. Geographic trends, patient characteristics, and outcomes of infective endocarditis associated with drug abuse in the United States from 2002 to 2016. J Am Heart Assoc 2019; 8 (19) e012969
2 Montoya ME, Karnath BM, Ahmad M. Endocarditis during pregnancy. South Med J 2003; 96 (11) 1156-1157
3 Connolly C, O'Donoghue K, Doran H, McCarthy FP. Infective endocarditis in pregnancy: case report and review of the literature. Obstet Med 2015; 8 (02) 102-104
4 Kebed KY, Bishu K, Al Adham RI. et al. Pregnancy and postpartum infective endocarditis: a systematic review. Mayo Clin Proc 2014; 89 (08) 1143-1152
5 Ward H, Hickman RC. Bacterial endocarditis in pregnancy. Aust N Z J Obstet Gynaecol 1971; 11 (03) 189-191
6 Driscoll AK, Ely DM. Effects of changes in maternal age distribution and maternal age-specific infant mortality rates on infant mortality trends: United States, 2000-2017. Natl Vital Stat Rep 2020; 69 (05) 1-18
7 American College of Obstetricians and Gynecologists' Presidential Task Force on Pregnancy and Heart Disease and Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 212: pregnancy and heart disease. Obstet Gynecol 2019; 133 (05) e320-e356
8 Li JS, Sexton DJ, Mick N. et al. Proposed modifications to the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis 2000; 30 (04) 633-638
9 Bonet M, Nogueira Pileggi V, Rijken MJ. et al. Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation. Reprod Health 2017; 14 (01) 67
10 Kuijpers JM, Koolbergen DR, Groenink M. et al. Incidence, risk factors, and predictors of infective endocarditis in adult congenital heart disease: focus on the use of prosthetic material. Eur Heart J 2017; 38 (26) 2048-2056
11 Bor DH, Woolhandler S, Nardin R, Brusch J, Himmelstein DU. Infective endocarditis in the U.S., 1998-2009: a nationwide study. PLoS One 2013; 8 (03) e60033
12 Hill EE, Herijgers P, Claus P, Vanderschueren S, Herregods MC, Peetermans WE. Infective endocarditis: changing epidemiology and predictors of 6-month mortality: a prospective cohort study. Eur Heart J 2007; 28 (02) 196-203
13 Chu VH, Cabell CH, Benjamin Jr DK. et al. Early predictors of in-hospital death in infective endocarditis. Circulation 2004; 109 (14) 1745-1749
14 Wong CY, Zhu W, Aurigemma GP. et al. Infective endocarditis among persons aged 18-64 years living with human immunodeficiency virus, hepatitis C infection, or opioid use disorder, United States, 2007-2017. Clin Infect Dis 2021; 72 (10) 1767-1781
15 Task Force on the Management of Cardiovascular Diseases During Pregnancy of the European Society of Cardiology. Expert consensus document on management of cardiovascular diseases during pregnancy. Eur Heart J 2003; 24 (08) 761-781
16 Prasad M, Jones M. Medical complications of opioid use disorder in pregnancy. Semin Perinatol 2019; 43 (03) 162-167
17 Hensley MK, Bauer ME, Admon LK, Prescott HC. Incidence of maternal sepsis and sepsis-related maternal deaths in the United States. JAMA 2019; 322 (09) 890-892
18 Parry AJ, Westaby S. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg 1996; 61 (06) 1865-1869
19 John AS, Gurley F, Schaff HV. et al. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg 2011; 91 (04) 1191-1196
20 Botea R, Porterie J, Marcheix B, Breleur F-O, Lavie-Badie Y. Infective endocarditis in a third trimester pregnant woman: team work is the best option. JACC Case Rep 2020; 2 (04) 521-525
21 Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J. et al; ESC Scientific Document Group. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018; 39 (34) 3165-3241
22 Chirillo F, Scotton P, Rocco F, Rigoli R, Polesel E, Olivari Z. Management of patients with infective endocarditis by a multidisciplinary team approach: an operative protocol. J Cardiovasc Med (Hagerstown) 2013; 14 (09) 659-668
23 Fanucchi LC, Walsh SL, Thornton AC, Lofwall MR. Integrated outpatient treatment of opioid use disorder and injection-related infections: a description of a new care model. Prev Med 2019; 128: 105760
24 Fanucchi LC, Walsh SL, Thornton AC, Nuzzo PA, Lofwall MR. Outpatient parenteral antimicrobial therapy plus buprenorphine for opioid use disorder and severe injection-related infections. Clin Infect Dis 2020; 70 (06) 1226-1229