Contemporary management of infective endocarditis in pregnancy

ABSTRACT

Introduction

Infective endocarditis (IE) during pregnancy is a rare condition that is associated with a high level of morbidity and mortality. The epidemiology, diagnosis, treatment, and prognosis have changed significantly in the last two decades. The declining incidence of rheumatic heart disease, improved life expectancy with congenital heart disease, advances in cardiac surgery and cardiac devices, rise in resistant microorganisms, complications of the opioid epidemic, and increasing maternal age are some of the many factors contributing to these changes.

Areas Covered

This article explores existing literature on the topic including case reports, case series, registry data, and clinical guidelines. The focus of this article is the evolving epidemiology, predisposing factors and preventative measures, clinical presentation, investigation, management, and potential complications of IE in pregnancy.

Expert Opinion

Robust prospective data on the management of IE in pregnancy is lacking, and obtaining these data will be very challenging. It is imperative that international registries are used to provide data on best clinical practices and inform future clinical guidelines. Multimodal imaging should be incorporated in the investigation of complicated cases. A multidisciplinary approach to the management of this rare and life-threatening condition is essential to ensure the best outcomes for both the mother and the fetus.

KEYWORDS:

• Congenital heart disease
• infective endocarditis
• pregnancy
• review
• valve

Article highlights

• Infective endocarditis (IE) in pregnancy has an estimated incidence of 1 per 100,000 pregnancies. This increases to 1 per 1,000 in patients with congenital heart disease and 3-12 per 1,000 in patients with prosthetic valves.

• Due to the highly variable clinical presentation of IE in pregnancy, a high index of suspicion and low threshold for investigation are essential in high-risk groups such as patients with congenital heart disease and intravenous drug users.

• The European Society of Cardiology clinical guidelines now include multimodal imaging findings in the modified Duke’s criteria for the diagnosis of IE.

• Empirical antimicrobial guidelines are outlined in this article. Antimicrobial regimens should be modified for local epidemiology, antimicrobial susceptibility patterns from identified pathogens, and the potential fetotoxic effects of the antimicrobials.

• Urgent cardiothoracic surgery is mandatory in cardiogenic shock or refractory heart failure due to acute regurgitation. Widely accepted indications for surgery include valve dehiscence, cardiac abscess, refractory heart failure, fungal IE, and embolic events while on appropriate antimicrobial therapy.

• Currently, maternal mortality is estimated at 11–13%, and fetal mortality at 14–29%. Patients with complicated IE or negative prognostic markers should be referred early to a tertiary center with surgical facilities and involvement of an endocarditis team including internal medicine physicians, cardiologists, cardiothoracic surgeons, clinical microbiologists or infectious diseases specialists, cardiac anesthetists, cardiac nurses, obstetricians, and midwives.

Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.