Endocarditis during pregnancy.

Abstract: The incidence of infective Endocarditis during pregnancy has been reported to be 0.006%. The maternal mortality rate can reach 33%, with most deaths related to heart failure or an embolic event. The rate of fetal mortality can reach 29%. Heart diseases are the most important non obstetric causes of maternal death during pregnancy, accounting for 10% of maternal deaths. As many as 3% of women have a form of cardiac disease diagnosed during or in the period preceding pregnancy, with 70 to 80% of the cardiac conditions having congenital causes.

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Nazarian et al (1) first described the successful outcome in a case of a pregnant patient with bacterial Endocarditis in 1976. Their patient was a 23-year-old priming at 22 weeks' gestation, presenting with fever and respiratory distress. She reported a 4- to 5-day history of toothache, and her blood cultures were positive for group D streptococci. A diagnosis of aortic valve Endocarditis was made, and the patient underwent successful prosthetic aortic valve replacement and delivered a healthy, term infant. Bacterial Endocarditis in pregnancy is extremely rare, and is either a complication of a preexisting cardiac lesion or the result of intravenous drug use. Cox et al (2-4) describe their experience with seven women whose pregnancies were complicated by Endocarditis. Streptococcus viridian was the most commonly isolated organism (found in four of seven cases).

Discussion

A bicuspid aortic valve is the most common congenital heart lesion, occurring in 1 to 2% of the general population. (5) Calcific aortic stenosis is the most common long-term complication of the congenitally bicuspid aortic valve. (6) A fibrous ridge or raphe forms the fusion between the two components of the conjoined cusp in three-fourths of bicuspid aortic valves. (6) Dyson et al (7) reported that the most common predisposing cardiac risk factor in native valve Endocarditis is the bicuspid aortic valve, with S. viridian being the most common etiologic organism. The most commonly identified source of infection was dental disease/procedure.

[FIGURE 1 OMITTED]

Active aortic Endocarditis is a serious, life-threatening condition, and surgical treatment is usually delayed until the infection is eliminated. Aortic valve replacement in the presence of active infection leads to a high risk of reinfection. Surgical treatment must be performed emergently if shock, severe heart failure, or persistent embolic events are present. The three types of valve replacements are homograft, bioprosthetic, and mechanical. (8) A study by North et al (8) supports the use of homografts for young women in need of aortic valve replacement. In their study, the 10-year survival rate was highest for patients who received homograft valve replacement. Women with mechanical prosthetic valves require lifelong anticoagulation therapy and are at high risk for thromboembolic events. Bioprosthetic valves have a higher rate of structural degeneration than homografts. Riberi et al (9) reported a low risk of recurrent Endocarditis in their study of 24 patients who underwent aortic valve replacement for aortic Endocarditis with cryopreserved homografts.

[FIGURE 2 OMITTED]

Our case report describes an extremely rare condition, in which a pregnant patient developed bacterial Endocarditis of a congenitally bicuspid aortic valve from Enterococcus faecalis infection and underwent successful aortic valve replacement with a homograft valve. Lamas and Eykyn, (10) in their description of 50 cases of bicuspid aortic valve Endocarditis, reported only 1 case caused by infection with E. faecalis.

Close attention should be paid to any pregnant woman with an unexplained fever and a cardiac murmur. Rapid detection of Endocarditis and appropriate treatment is important in reducing the risk of both maternal and fetal mortality.

Key Points

* Endocarditis should be considered in the diagnosis of a pregnant patient with unexplained fever and heart murmur.

* Indications for valve replacement surgery include development of heart failure, embolic events, and hemodynamic instability.

* Homograft valve replacement offers the best prognosis for pregnant women in need of valve replacement.

From the Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX.

Reprint requests to Maria E. Montoya, MD, Department of Internal Medicine, University of Texas Medical Branch at Galveston, 301 University Blvd., Galveston, TX 77555-0570. Em ail: [e-mail]

Accepted March 8, 2002.

Copyright [c] 2003 by The Southern Medical Association

0038-4348/03/9611-1156

References

1. Malarian M. McCullough GH, Fielder DL. Bacterial Endocarditis in pregnancy: Successful surgical correction. J Thorac Cardiovasc Surg 1976;71:880-883.

2. Cox SM, Hankins GD, Leveno KJ, et al. Bacterial Endocarditis: A serious pregnancy complication. J Reprod Med 1988;33:671-674.

3. Payne DG, Fishburne JI Jr, Rufty AJ, et al. Bacterial Endocarditis in pregnancy. Obstet Gynecol 1982;60:247-250.

4. Gei AF, Hankins GD. Cardiac disease and pregnancy. Obstet Gynecol Clin North Am 2001;28:465-512.

5. Roberts WC. The congenitally bicuspid aortic valve: A study of 85 autopsy cases. Am J Cardiol 1970;26:72-83.

6. S abet H, Edwards WD, Tabular PHD, et al. Congenitally bicuspid aortic valves: A surgical pathology study of 542 cases (1991 through 1996) and a literature review of 2,715 additional cases. Mayo Clin Pro 1999;74:14-26.

7. Dyson C, Barnes RA, Harrison GA. Infective Endocarditis: An epidemiological review of 128 episodes. J Infect 1999;38:87-93.

8. North RA, Saddler L, Stewart AWP, et al. Long-term survival and valve-related complications in young women with cardiac valve replacements. Circulation 1999;99:2669-2676.

9. Riberi A, Claus T, Mesa na T, et al. Aortic valve or root replacement with cryopreserved homograft for active infectious Endocarditis. Cardiovasc Surg 1997;5:579-583.

10. Lamas CC, Eykyn S. Bicuspid aortic valve: A silent danger--analysis of 50 cases of infective Endocarditis. Clin Infect Is 2000;30:336-341.

RELATED ARTICLE: Case Report

A 35-year-old, gravida 4, para 3, white woman presented with a 4-day history of fever and chills and a 1-day history of left-sided hemiparesis. She was 9 weeks pregnant. Her medical history was significant for chronic hepatitis C. The patient had a history of intravenous (IV) drug abuse and reported last using IV drugs 1 year before admission. Vital signs at admission included a temperature of 37.7[degrees]C, a pulse rate of 119 beats/min, a blood pressure of 130/72 mm Hg, and a respiratory rate of 24 breaths/min. Physical examination was significant for a 2/6 systolic murmur, best heard at the right inter-costal space. The patient also had scattered inspiratory crackles. IV therapy was begun with penicillin and gentamicin. Transthoracic echocardiography showed vegetations on a bicuspid aortic valve. These findings were confirmed by transesophageal echocardiography (Fig. 1). Magnetic resonance imaging of the brain showed several small embolic infarcts of the cerebrum and cerebellum. On the third hospital day, the patient complained of left upper quadrant pain, and an abdominal ultrasound examination revealed splenic infarcts. The patient developed a rash by hospital Day 5, so antibiotic treatment was switched from penicillin to vancomycin. On

hospital Day 13, the patient complained of pain in the digits of the right hand. On hospital Day 14, she underwent homograft aortic valve replacement (Fig. 2). A fetal ultrasound examination at 23 weeks' gestation showed an absent heartbeat and fetal death.

Maria E. Montoya, MD, Bernard M. Karnath, MD, and Masood Ahmad, MD