REVIEW
Pregnancy and Postpartum Infective Endocarditis: A Systematic Review Kalie Y. Kebed, MD; Kalkidan Bishu, MD; Raed I. Al Adham, MBBS; Larry M. Baddour, MD; Heidi M. Connolly, MD; Muhammad R. Sohail, MD; James M. Steckelberg, MD; Walter R. Wilson, MD; Mohammad H. Murad, MD, MPH; and Nandan S. Anavekar, MBBCh Abstract The objective of this review was to describe the clinical characteristics, risk factors, and outcomes of infective endocarditis (IE) in pregnancy and the postpartum period. We conducted a systematic review of Ovid MEDLINE, Ovid Embase, Web of Science, and Scopus from January 1, 1988, through October 31, 2012. Included studies reported on women who met the modified Duke criteria for the diagnosis of IE and were pregnant or postpartum. We included 72 studies that described 90 cases of peripartum IE, mostly affecting native valves (92%). Risk factors associated with IE included intravenous drug use (14%), congenital heart disease (12%), and rheumatic heart disease (12%). The most common pathogens were streptococcal (43%) and staphylococcal (26%) species. Septic pulmonary, central, and other systemic emboli were common complications. Of the 51 pregnancies, there were 41 (80%) deliveries with survival to discharge, 7 (14%) fetal deaths, 1 (2%) medical termination of pregnancy, and 2 (4%) with unknown status. Maternal mortality was 11%. Infective endocarditis is a rare, life-threatening infection in pregnancy. Risk factors are changing with a marked decrease in rheumatic heart disease and an increase in intravenous drug use. The cases reported in the literature were commonly due to streptococcal organisms, involved the right-sided valves, and were associated with intravenous drug use. ª 2014 Mayo Foundation for Medical Education and Research
I
nfective endocarditis (IE) has been difficult to study in randomized controlled trials because of its low incidence and the absence of uniformity in presentation, risk factors, and microbial organisms involved. Our understanding of IE in pregnancy is further limited by an extremely low reported incidence.1 Despite a low incidence, maternal mortality is reportedly 33%,2 prompting the need to better define this syndrome and improve its outcomes. Furthermore, the management of IE in pregnancy poses a unique and difficult challenge in balancing both maternal and fetal outcomes. To help understand IE in pregnancy and the postpartum period, we conducted a systematic review of maternal risk factors, microorganisms involved, and maternal and fetal outcomes among reported cases in the literature. This is an initial attempt, based on the available literature, to understand IE in pregnancy and the postpartum period. METHODS This systematic review of the literature is reported in accordance with recommendations
n
Mayo Clin Proc. 2014;89(8):1143-1152
of Preferred Reporting Items for Systematic Reviews and Meta-Analyses.3 Data Sources and Searches An Ovid MEDLINE, Ovid Embase, Web of Science, and Scopus search from January 1, 1988, through October 31, 2012, was performed. The search terms were endocarditis OR endocarditis, bacterial AND ex pregnancy OR ex pregnancy complications. We used the explode function to include the embedded subheadings within the primary search term. Results were limited to human subjects and English language. An expert reference librarian developed the search strategy.
From the Department of Internal Medicine (K.Y.K.) and Department of Cardiovascular Diseases (K.B., H.M.C., N.S.A.), Mayo Clinic, Rochester, MN; Department of Internal Medicine, St. Joseph’s Hospital, Phoenix, AZ (R.I.A.A.); Department of Infectious Diseases (L.M.B., M.R.S., J.M.S., W.R.W.) and Division of Preventive Medicine (M.H.M.), Mayo Clinic, Rochester, MN.
Study Selection Inclusion criteria were (1) published retrospective and prospective studies, (2) endocarditis defined by the modified Duke criteria for the diagnosis of endocarditis,4 (3) among women aged 12 years or older, and (4) during pregnancy or the 6-month postpartum period. A 6-month postpartum period was chosen given
Mayo Clin Proc. n August 2014;89(8):1143-1152 n http://dx.doi.org/10.1016/j.mayocp.2014.04.024 www.mayoclinicproceedings.org n ª 2014 Mayo Foundation for Medical Education and Research
1143
MAYO CLINIC PROCEEDINGS
ARTICLE HIGHLIGHTS n
n
n
n
Infective endocarditis (IE) remains a highly morbid condition in the pregnant population, incurring both maternal and fetal risk, that requires a high index of suspicion and a multidisciplinary team in the management of complicated presentations. Maternal and fetal mortality rate ranges between 10% and 15% in our review of the available literature, which, although high, is lower than that previously reported. As noted in the nonpregnant population, we describe an increase in the reported cases of IE related to intravenous drug use. The major limitation of our review is the reporting bias. Not all cases of pregnancy-related IE are published. There are no large, prospective randomized trials to study IE in the pregnant population, nor will there be in the future, highlighting the need for multicenter prospectively driven registries to improve our understanding of this illness.
the indolent symptoms and delayed presentation of IE as previously used in the IE literature.5,6 The modified Duke criteria, published in 2000, were applied to all our cases, including those published from 1988 to 2000. Abstracts were screened to identify studies that mentioned cases of endocarditis in pregnant women. Studies thus identified were obtained in full text to assess whether they met all inclusion criteria. Screening and data extraction were performed by K.K. and K.B. Any disagreement between the reviewers was resolved by consensus. Data Extraction and Quality Assessment Cases were reviewed for maternal risk factors as well as maternal and fetal outcomes. Risk factors included native valve predisposition (degenerative valve disease), prosthetic heart valves, intracardiac devices (pacemaker, defibrillator), congenital heart disease, history of endocarditis, intravenous drug use, and chronic intravenous access. Maternal outcomes included mortality, embolic phenomena, and surgical interventions. Fetal outcomes included mortality, gestational age at birth, birth weight, and Apgar scores. Specific valve location and type (prosthetic vs native), cultured organism, and antimicrobial and adjunctive treatment were also recorded. 1144
Mayo Clin Proc.
n
To assess the quality of the included studies, which were individual case reports, we used the World Health Organization’s tool to evaluate associations reported in case reports.7 This tool focuses on the adequacy of outcome and exposure ascertainment and possible causality. Data Synthesis and Analyses The agreement between the reviewers on the selection of abstracts and full-text articles was assessed using Cohen k.8 Categorical variables of interest were summarized by totaling across the different case reports and reported as proportions with 95% CIs. Continuous variables were similarly averaged across all case reports and presented as mean SD (median, range). Data were insufficient to conduct meta-analysis. RESULTS The search yielded 476 abstracts. Of these, 92 met abstract screening criteria and the full text was reviewed. There was a high level of agreement between the 2 reviewers for the abstracts and full-text articles, k¼0.95 and k¼1.0, respectively. There were 72 articles that met inclusion criteria, representing 90 cases of pregnancy or postpartum IE.9-80 A total of 20 articles were excluded: 15 articles for not meeting the modified Duke criteria,81-95 4 for being review articles or editorials,96-99 and 1 for being an article describing a nonpregnant patient100 (see Figure 1). Using the World Health Organization’s tool to evaluate associations in case reports7 in all cases, the diagnosis was based on echocardiography and repeated blood cultures or surgical pathology, making the diagnosis reliable/valid. Demographic and Clinical Characteristics There were 90 identified cases of IE in pregnancy or the postpartum period, with baseline characteristics and valvular involvement summarized in Table 1. Of the 51 patients who were pregnant, infection affected native valves in 50 (98.0%; 95% CI, 88.7%-100.0%), with the most commonly affected being the mitral in 21 (41.1%; 95% CI, 28.5%-54.9%) patients. Additional IE valve involvement for pregnant patients is summarized in Table 2. Of the 39 patients who were postpartum or postabortion, the median time between delivery or abortion and diagnosis
August 2014;89(8):1143-1152
n
http://dx.doi.org/10.1016/j.mayocp.2014.04.024 www.mayoclinicproceedings.org
PREGNANCY AND POSTPARTUM INFECTIVE ENDOCARDITIS
Identification
Records identified through database searching
Screening
476 Potentially relevant abstracts identified 384 Cases excluded on the basis of title and abstract
Eligibility
92 Full-text articles assessed for eligibility
Included
72 Reports of peripartum IE (90 patients)
20 Cases excluded for not meeting inclusion criteria 15 Modified Duke criteria not met 4 Review articles/editorials 1 Nonpregnant/postpartum patient
FIGURE 1. Selection flow chart demonstrating abstract and article screening. IE ¼ infective endocarditis.
was 3.5 weeks (range, 0-26 weeks). Only 3 cases were diagnosed after 6 weeks (17, 21, and 26 weeks). Risk Factors The most commonly identified risk factors were intravenous drug use in 13 (14.4%; 95% CI, 8.5%-23.3%), congenital heart disease in 11 (12.2%; 95% CI, 6.8%-20.7%), and rheumatic heart disease in 11 (12.2%; 95% CI, 6.8%20.7%) patients. From 1988 to 2000, there were 8 patients with a history of rheumatic heart disease compared with only 3 patients from 2001 to 2012. There were 5 (5.6%; 95% CI, 1.8%-12.5%) patients with prior IE. Risk factors are summarized in Figure 2. Microbiology The most commonly identified pathogens were streptococcal and staphylococcal species in 39 (43.3%; 95% CI, 33.6%-53.6%) and 23 (25.6%; 95% CI, 17.6%-35.5%) cases, respectively. There were 8 (8.9%) culture-negative and 3 (3.3%) polymicrobial IE cases. The additional microbiology is listed in Table 3. Mayo Clin Proc. n August 2014;89(8):1143-1152 www.mayoclinicproceedings.org
n
Left-sided cases (43 single left-sided valve cases and 6 left-sided multivalvular cases) were more likely to be streptococcal species than staphylococcal species: 27 (55.1%; 95% CI, 41.3%68.2%) vs 4 (8.2%; 95% CI, 2.7%-19.7%). Conversely, right-sided cases (30 single rightsided valve cases and 3 right-sided intracardiac abscess cases) were more likely to be staphylococcal species than streptococcal species: 17 (51.5%; 95% CI, 35.2%-67.5%) vs 10 (30.3%; 95% CI, 17.3%-47.5%). Treatment Most of the cases (69 [76.7%]; 95% CI, 66.9%84.3%) described the antimicrobials used. Of these 69, 56 used multidrug regimens. It was commonplace for addition or replacement of antibiotics as the clinical status of the patient changed. Surgical intervention was performed in 48 (53.3%, 95% CI, 43.1%-63.3%) patients. There were 7 antenatal operations. The procedures included aortic valve/root replacement in 19 (21.1%; 95% CI, 13.9%-30.7%), mitral valve replacement in 14 (15.6%; 95% CI,
http://dx.doi.org/10.1016/j.mayocp.2014.04.024
1145
MAYO CLINIC PROCEEDINGS
TABLE 1. Demographic and Clinical Characteristics of Patients With Infective Endocarditis Characteristic
n (%)
(95% CI)
Age (y), mean SD Gestational age at diagnosis (wk), mean SD Pregnant Postabortion Postpartum Valve involvement Native valve Prosthetic valve Intracardiac Left sided, single Aortic Mitral Right sided, single Pulmonary Tricuspid Multivalvular Left sided Right sided Both sides Not stated
88 48
27.75.8
51 (56.7) 14 (15.6) 25 (27.8)
26.38.5 (46.4%-66.4%) (9.4%-24.6%) (19.5%-37.8%)
83 4 3 43 16 27 30 7 23 11 6 0 5 3
(84.6%-96.4%) (1.4%-11.2%) (0.7%-9.8%) (37.8%-58.0%) (11.1%-27.1%) (21.5%-40.2%) (24.4%-43.6%) (3.6%-15.4%) (17.6%-35.5%) (6.8%-20.7%) (2.8%-14.1%) (0%-4.9%) (2.1%-12.7%) (0.7%-9.8%)
(92.2) (4.4) (3.3) (47.8) (17.8) (30) (33.3) (7.8) (25.6) (12.2) (6.7) (0) (5.6) (3.3)
9.4%-24.6%), and valve debridement in 7 (7.8%, 95% CI, 3.6%-15.4%) patients. Outcomes The major end point was mortality and morbidity from embolic events. There were 10 (11.1%; 95% CI, 6.0%-19.4%) maternal deaths. Maternal mortality was 11.5% (95% CI, 5.0%-23.3%) and
TABLE 2. Demographics and Clinical Characteristics of Pregnant Patients With Infective Endocarditis Characteristic
n (%)
(95% CI)
Age (y), mean SD Gestational age at diagnosis (wk), mean SD Valve involvement Native valve Prosthetic valve Intracardiac Left sided, single Aortic Mitral Right sided, single Pulmonary Tricuspid Multivalvular Left sided Right sided Both sides Not stated
51 48
27.65.4 26.38.5
1146
50 1 3 30 9 21 10 3 7 6 4 0 2 2
(98) (2) (5.9) (58.8) (17.7) (41.4) (19.6) (5.9) (13.7) (11.8) (7.8) (0) (3.9) (3.9)
(88.7%-100.0%) (0.0%-11.3%) (1.4%-16.5%) (45.2%-71.3%) (9.3%-30.5%) (28.5%-54.9%) (10.8%-32.7%) (1.4%-16.5%) (6.5%-26.0%) (5.1%-23.8%) (2.6%-19.0%) (0%-8.4%) (0.3%-14.0%) (0.3%-14.0%)
Mayo Clin Proc.
n
10.5% (3.6%-24.7%) in the pregnant and postpartum states, respectively. Mortality appeared higher in left-sided IE at 14.3% (95% CI, 6.8%27.0%) than in right-sided IE (6.1%, 95% CI, 0.7%-20.6%). Septic pulmonary emboli were common complications in 21 (23.3%; 95% CI, 15.7%-33.1%) patients. Central nervous system septic emboli occurred in 11 (12.2%; 95% CI, 6.8%-20.7%) patients, all with left-sided IE. Other embolic complications were seen in 7 (7.8%; 95% CI, 3.6%-15.4%) patients. None of the cases reported chronic antiplatelet or statin use. One case used therapeutic aspirin.61 Of the 51 patients who were pregnant at the time of IE diagnosis, there were 41 (80.4%; 95% CI, 67.4%-89.2%) deliveries with survival to discharge, 7 (13.7%; 95% CI, 6.5%-26.0%) fetal deaths, 1 (2.0%; 95% CI,
Pregnancy and Postpartum Infective Endocarditis: A Systematic Review Kalie Y. Kebed, MD; Kalkidan Bishu, MD; Raed I. Al Adham, MBBS; Larry M. Baddour, MD; Heidi M. Connolly, MD; Muhammad R. Sohail, MD; James M. Steckelberg, MD; Walter R. Wilson, MD; Mohammad H. Murad, MD, MPH; and Nandan S. Anavekar, MBBCh Abstract The objective of this review was to describe the clinical characteristics, risk factors, and outcomes of infective endocarditis (IE) in pregnancy and the postpartum period. We conducted a systematic review of Ovid MEDLINE, Ovid Embase, Web of Science, and Scopus from January 1, 1988, through October 31, 2012. Included studies reported on women who met the modified Duke criteria for the diagnosis of IE and were pregnant or postpartum. We included 72 studies that described 90 cases of peripartum IE, mostly affecting native valves (92%). Risk factors associated with IE included intravenous drug use (14%), congenital heart disease (12%), and rheumatic heart disease (12%). The most common pathogens were streptococcal (43%) and staphylococcal (26%) species. Septic pulmonary, central, and other systemic emboli were common complications. Of the 51 pregnancies, there were 41 (80%) deliveries with survival to discharge, 7 (14%) fetal deaths, 1 (2%) medical termination of pregnancy, and 2 (4%) with unknown status. Maternal mortality was 11%. Infective endocarditis is a rare, life-threatening infection in pregnancy. Risk factors are changing with a marked decrease in rheumatic heart disease and an increase in intravenous drug use. The cases reported in the literature were commonly due to streptococcal organisms, involved the right-sided valves, and were associated with intravenous drug use. ª 2014 Mayo Foundation for Medical Education and Research
I
nfective endocarditis (IE) has been difficult to study in randomized controlled trials because of its low incidence and the absence of uniformity in presentation, risk factors, and microbial organisms involved. Our understanding of IE in pregnancy is further limited by an extremely low reported incidence.1 Despite a low incidence, maternal mortality is reportedly 33%,2 prompting the need to better define this syndrome and improve its outcomes. Furthermore, the management of IE in pregnancy poses a unique and difficult challenge in balancing both maternal and fetal outcomes. To help understand IE in pregnancy and the postpartum period, we conducted a systematic review of maternal risk factors, microorganisms involved, and maternal and fetal outcomes among reported cases in the literature. This is an initial attempt, based on the available literature, to understand IE in pregnancy and the postpartum period. METHODS This systematic review of the literature is reported in accordance with recommendations
n
Mayo Clin Proc. 2014;89(8):1143-1152
of Preferred Reporting Items for Systematic Reviews and Meta-Analyses.3 Data Sources and Searches An Ovid MEDLINE, Ovid Embase, Web of Science, and Scopus search from January 1, 1988, through October 31, 2012, was performed. The search terms were endocarditis OR endocarditis, bacterial AND ex pregnancy OR ex pregnancy complications. We used the explode function to include the embedded subheadings within the primary search term. Results were limited to human subjects and English language. An expert reference librarian developed the search strategy.
From the Department of Internal Medicine (K.Y.K.) and Department of Cardiovascular Diseases (K.B., H.M.C., N.S.A.), Mayo Clinic, Rochester, MN; Department of Internal Medicine, St. Joseph’s Hospital, Phoenix, AZ (R.I.A.A.); Department of Infectious Diseases (L.M.B., M.R.S., J.M.S., W.R.W.) and Division of Preventive Medicine (M.H.M.), Mayo Clinic, Rochester, MN.
Study Selection Inclusion criteria were (1) published retrospective and prospective studies, (2) endocarditis defined by the modified Duke criteria for the diagnosis of endocarditis,4 (3) among women aged 12 years or older, and (4) during pregnancy or the 6-month postpartum period. A 6-month postpartum period was chosen given
Mayo Clin Proc. n August 2014;89(8):1143-1152 n http://dx.doi.org/10.1016/j.mayocp.2014.04.024 www.mayoclinicproceedings.org n ª 2014 Mayo Foundation for Medical Education and Research
1143
MAYO CLINIC PROCEEDINGS
ARTICLE HIGHLIGHTS n
n
n
n
Infective endocarditis (IE) remains a highly morbid condition in the pregnant population, incurring both maternal and fetal risk, that requires a high index of suspicion and a multidisciplinary team in the management of complicated presentations. Maternal and fetal mortality rate ranges between 10% and 15% in our review of the available literature, which, although high, is lower than that previously reported. As noted in the nonpregnant population, we describe an increase in the reported cases of IE related to intravenous drug use. The major limitation of our review is the reporting bias. Not all cases of pregnancy-related IE are published. There are no large, prospective randomized trials to study IE in the pregnant population, nor will there be in the future, highlighting the need for multicenter prospectively driven registries to improve our understanding of this illness.
the indolent symptoms and delayed presentation of IE as previously used in the IE literature.5,6 The modified Duke criteria, published in 2000, were applied to all our cases, including those published from 1988 to 2000. Abstracts were screened to identify studies that mentioned cases of endocarditis in pregnant women. Studies thus identified were obtained in full text to assess whether they met all inclusion criteria. Screening and data extraction were performed by K.K. and K.B. Any disagreement between the reviewers was resolved by consensus. Data Extraction and Quality Assessment Cases were reviewed for maternal risk factors as well as maternal and fetal outcomes. Risk factors included native valve predisposition (degenerative valve disease), prosthetic heart valves, intracardiac devices (pacemaker, defibrillator), congenital heart disease, history of endocarditis, intravenous drug use, and chronic intravenous access. Maternal outcomes included mortality, embolic phenomena, and surgical interventions. Fetal outcomes included mortality, gestational age at birth, birth weight, and Apgar scores. Specific valve location and type (prosthetic vs native), cultured organism, and antimicrobial and adjunctive treatment were also recorded. 1144
Mayo Clin Proc.
n
To assess the quality of the included studies, which were individual case reports, we used the World Health Organization’s tool to evaluate associations reported in case reports.7 This tool focuses on the adequacy of outcome and exposure ascertainment and possible causality. Data Synthesis and Analyses The agreement between the reviewers on the selection of abstracts and full-text articles was assessed using Cohen k.8 Categorical variables of interest were summarized by totaling across the different case reports and reported as proportions with 95% CIs. Continuous variables were similarly averaged across all case reports and presented as mean SD (median, range). Data were insufficient to conduct meta-analysis. RESULTS The search yielded 476 abstracts. Of these, 92 met abstract screening criteria and the full text was reviewed. There was a high level of agreement between the 2 reviewers for the abstracts and full-text articles, k¼0.95 and k¼1.0, respectively. There were 72 articles that met inclusion criteria, representing 90 cases of pregnancy or postpartum IE.9-80 A total of 20 articles were excluded: 15 articles for not meeting the modified Duke criteria,81-95 4 for being review articles or editorials,96-99 and 1 for being an article describing a nonpregnant patient100 (see Figure 1). Using the World Health Organization’s tool to evaluate associations in case reports7 in all cases, the diagnosis was based on echocardiography and repeated blood cultures or surgical pathology, making the diagnosis reliable/valid. Demographic and Clinical Characteristics There were 90 identified cases of IE in pregnancy or the postpartum period, with baseline characteristics and valvular involvement summarized in Table 1. Of the 51 patients who were pregnant, infection affected native valves in 50 (98.0%; 95% CI, 88.7%-100.0%), with the most commonly affected being the mitral in 21 (41.1%; 95% CI, 28.5%-54.9%) patients. Additional IE valve involvement for pregnant patients is summarized in Table 2. Of the 39 patients who were postpartum or postabortion, the median time between delivery or abortion and diagnosis
August 2014;89(8):1143-1152
n
http://dx.doi.org/10.1016/j.mayocp.2014.04.024 www.mayoclinicproceedings.org
PREGNANCY AND POSTPARTUM INFECTIVE ENDOCARDITIS
Identification
Records identified through database searching
Screening
476 Potentially relevant abstracts identified 384 Cases excluded on the basis of title and abstract
Eligibility
92 Full-text articles assessed for eligibility
Included
72 Reports of peripartum IE (90 patients)
20 Cases excluded for not meeting inclusion criteria 15 Modified Duke criteria not met 4 Review articles/editorials 1 Nonpregnant/postpartum patient
FIGURE 1. Selection flow chart demonstrating abstract and article screening. IE ¼ infective endocarditis.
was 3.5 weeks (range, 0-26 weeks). Only 3 cases were diagnosed after 6 weeks (17, 21, and 26 weeks). Risk Factors The most commonly identified risk factors were intravenous drug use in 13 (14.4%; 95% CI, 8.5%-23.3%), congenital heart disease in 11 (12.2%; 95% CI, 6.8%-20.7%), and rheumatic heart disease in 11 (12.2%; 95% CI, 6.8%20.7%) patients. From 1988 to 2000, there were 8 patients with a history of rheumatic heart disease compared with only 3 patients from 2001 to 2012. There were 5 (5.6%; 95% CI, 1.8%-12.5%) patients with prior IE. Risk factors are summarized in Figure 2. Microbiology The most commonly identified pathogens were streptococcal and staphylococcal species in 39 (43.3%; 95% CI, 33.6%-53.6%) and 23 (25.6%; 95% CI, 17.6%-35.5%) cases, respectively. There were 8 (8.9%) culture-negative and 3 (3.3%) polymicrobial IE cases. The additional microbiology is listed in Table 3. Mayo Clin Proc. n August 2014;89(8):1143-1152 www.mayoclinicproceedings.org
n
Left-sided cases (43 single left-sided valve cases and 6 left-sided multivalvular cases) were more likely to be streptococcal species than staphylococcal species: 27 (55.1%; 95% CI, 41.3%68.2%) vs 4 (8.2%; 95% CI, 2.7%-19.7%). Conversely, right-sided cases (30 single rightsided valve cases and 3 right-sided intracardiac abscess cases) were more likely to be staphylococcal species than streptococcal species: 17 (51.5%; 95% CI, 35.2%-67.5%) vs 10 (30.3%; 95% CI, 17.3%-47.5%). Treatment Most of the cases (69 [76.7%]; 95% CI, 66.9%84.3%) described the antimicrobials used. Of these 69, 56 used multidrug regimens. It was commonplace for addition or replacement of antibiotics as the clinical status of the patient changed. Surgical intervention was performed in 48 (53.3%, 95% CI, 43.1%-63.3%) patients. There were 7 antenatal operations. The procedures included aortic valve/root replacement in 19 (21.1%; 95% CI, 13.9%-30.7%), mitral valve replacement in 14 (15.6%; 95% CI,
http://dx.doi.org/10.1016/j.mayocp.2014.04.024
1145
MAYO CLINIC PROCEEDINGS
TABLE 1. Demographic and Clinical Characteristics of Patients With Infective Endocarditis Characteristic
n (%)
(95% CI)
Age (y), mean SD Gestational age at diagnosis (wk), mean SD Pregnant Postabortion Postpartum Valve involvement Native valve Prosthetic valve Intracardiac Left sided, single Aortic Mitral Right sided, single Pulmonary Tricuspid Multivalvular Left sided Right sided Both sides Not stated
88 48
27.75.8
51 (56.7) 14 (15.6) 25 (27.8)
26.38.5 (46.4%-66.4%) (9.4%-24.6%) (19.5%-37.8%)
83 4 3 43 16 27 30 7 23 11 6 0 5 3
(84.6%-96.4%) (1.4%-11.2%) (0.7%-9.8%) (37.8%-58.0%) (11.1%-27.1%) (21.5%-40.2%) (24.4%-43.6%) (3.6%-15.4%) (17.6%-35.5%) (6.8%-20.7%) (2.8%-14.1%) (0%-4.9%) (2.1%-12.7%) (0.7%-9.8%)
(92.2) (4.4) (3.3) (47.8) (17.8) (30) (33.3) (7.8) (25.6) (12.2) (6.7) (0) (5.6) (3.3)
9.4%-24.6%), and valve debridement in 7 (7.8%, 95% CI, 3.6%-15.4%) patients. Outcomes The major end point was mortality and morbidity from embolic events. There were 10 (11.1%; 95% CI, 6.0%-19.4%) maternal deaths. Maternal mortality was 11.5% (95% CI, 5.0%-23.3%) and
TABLE 2. Demographics and Clinical Characteristics of Pregnant Patients With Infective Endocarditis Characteristic
n (%)
(95% CI)
Age (y), mean SD Gestational age at diagnosis (wk), mean SD Valve involvement Native valve Prosthetic valve Intracardiac Left sided, single Aortic Mitral Right sided, single Pulmonary Tricuspid Multivalvular Left sided Right sided Both sides Not stated
51 48
27.65.4 26.38.5
1146
50 1 3 30 9 21 10 3 7 6 4 0 2 2
(98) (2) (5.9) (58.8) (17.7) (41.4) (19.6) (5.9) (13.7) (11.8) (7.8) (0) (3.9) (3.9)
(88.7%-100.0%) (0.0%-11.3%) (1.4%-16.5%) (45.2%-71.3%) (9.3%-30.5%) (28.5%-54.9%) (10.8%-32.7%) (1.4%-16.5%) (6.5%-26.0%) (5.1%-23.8%) (2.6%-19.0%) (0%-8.4%) (0.3%-14.0%) (0.3%-14.0%)
Mayo Clin Proc.
n
10.5% (3.6%-24.7%) in the pregnant and postpartum states, respectively. Mortality appeared higher in left-sided IE at 14.3% (95% CI, 6.8%27.0%) than in right-sided IE (6.1%, 95% CI, 0.7%-20.6%). Septic pulmonary emboli were common complications in 21 (23.3%; 95% CI, 15.7%-33.1%) patients. Central nervous system septic emboli occurred in 11 (12.2%; 95% CI, 6.8%-20.7%) patients, all with left-sided IE. Other embolic complications were seen in 7 (7.8%; 95% CI, 3.6%-15.4%) patients. None of the cases reported chronic antiplatelet or statin use. One case used therapeutic aspirin.61 Of the 51 patients who were pregnant at the time of IE diagnosis, there were 41 (80.4%; 95% CI, 67.4%-89.2%) deliveries with survival to discharge, 7 (13.7%; 95% CI, 6.5%-26.0%) fetal deaths, 1 (2.0%; 95% CI,
