Infective endocarditis in pregnant women without intravenous drug use: a multicentre retrospective case series

Abstract

Objectives To describe the clinical features and outcomes of infective endocarditis (IE) in pregnant women who do not inject drugs. Methods A multinational retrospective study was performed at 14 hospitals. All definite IE episodes between January 2000 and April 2021 were included. The main outcomes were maternal mortality and pregnancy-related complications. Results Twenty-five episodes of IE were included. Median age at IE diagnosis was 33.2 years (IQR 28.3–36.6) and median gestational age was 30 weeks (IQR 16–32). Thirteen (52%) patients had no previously known heart disease. Sixteen (64%) were native IE, 7 (28%) prosthetic and 2 (8%) cardiac implantable electronic device IE. The most common aetiologies were streptococci (n = 10, 40%), staphylococci (n = 5, 20%), HACEK group (n = 3, 12%) and Enterococcus faecalis (n = 3, 12%). Twenty (80%) patients presented at least one IE complication; the most common were heart failure (n = 13, 52%) and symptomatic embolism other than stroke (n = 4, 16%). Twenty-one (84%) patients had surgery indication and surgery was performed when indicated in 19 (90%). There was one maternal death and 16 (64%) patients presented pregnancy-related complications (11 patients ≥1 complication): 3 pregnancy losses, 9 urgent Caesarean sections, 2 emergency Caesarean sections, 1 fetal death, and 11 preterm births. Two patients presented a relapse during a median follow-up of 3.1 years (IQR 0.6–7.4). Conclusions Strict medical surveillance of pregnant women with IE is required and must involve a multidisciplinary team including obstetricians and neonatologists. Furthermore, the potential risk of IE during pregnancy should never be underestimated in women with previously known underlying heart disease.

ESC guidelines 2023 on the management of endocarditis

“…Infective endocarditis in pregnancy is a rare but extremely serious condition with high maternal and foetal morbidity and mortality, and is estimated to complicate ∼1 in 100 000 pregnancies. [797][798][799] Maternal mortality approaches 18%, with most deaths relating to HF or an embolic event, while pre-term birth is reported at 55.7% and foetal mortality at 29%. 800 Recurrent infective complications can occur in up to 27% of women post-partum.…”

“…800,[804][805][806][807] The gravity of the condition requires the inclusion of gynaecologists, obstetricians, and neonatologists in the Endocarditis Team in any suspected cases, and a diagnosis and treatment plan should be formulated without delay, as this is key to saving the lives of mothers and infants. 799,808,809 Management can be challenging, especially when the pregnant patient warrants a cardiac operation under CPB. Although this poses a considerable risk to the foetus, urgent surgery when indicated should not be delayed.…”

“…Although this poses a considerable risk to the foetus, urgent surgery when indicated should not be delayed. 799,810 12.10. Infective endocarditis in immunocompromised patients…”