A fatal case of subacute bacterial endocarditis in pregnancy. A review of this condition in pregnancy including the incidence, diagnosis and treatment

Bacterial endocarditis complicating pregnancy: case report and systematic review of the literature

INTRODUCTION

Infectious endocarditis is a rare life-threatening complication of pregnancy. We report a pregnancy complicated by a 3.5-cm infected vegetation of the tricuspid valve initially presenting as unilateral hip pain as well as systematic review of this entity.

SOURCES

A MEDLINE review of the English language literature from 1965 to present using the search terms 'endocarditis', 'pregnancy' and 'infection' as well as review of references was performed.

RESULTS

Sixty-eight cases of infectious endocarditis complicating pregnancy were identified. The calculated maternal and fetal mortality rates were 22.1% and 14.7% respectively.

CONCLUSIONS

With persistent symptomatic lesions, delivery should be considered without regard to measures of fetal lung maturity because of high fetal mortality rates.

Infective endocarditis in obstetric and gynecologic practice

Infective endocarditis is an important but uncommon complication in obstetric or gynecologic practice; we found only 124 cases reported in English and selected European papers during the last 40 years. The majority of cases (74%) were caused by streptococci; viridans streptococci predominated, while enterococci and group B streptococci were uncommon except after abortion. The overall mortality rate was 29%, while the mortality rate for the fetus when the mother developed infective endocarditis was 23%. The incidence of endocarditis in this setting is low and seems to be decreasing. Therefore, the risk-benefit ratio may not favor routine use of prophylaxis for endocarditis. We conclude that antibiotics need not be given for prevention of endocarditis before most common obstetric and gynecologic procedures. These include uncomplicated vaginal deliveries, uncomplicated spontaneous or induced abortions, dilatation and curettage, insertion or removal of intrauterine contraceptive devices (in the absence of pelvic infection), and biopsies of the cervix. For patients in whom both the underlying heart lesion and the obstetric or gynecologic procedure seem to pose significant risk for endocarditis, prophylaxis should be given. Two parenteral regimens for patients at highest risk are recommended: ampicillin plus gentamicin or vancomycin plus gentamicin. For lower-risk situations, one oral regimen is suggested: amoxicillin.