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Multidisciplinary planning for a parturient with bacterial endocarditis and septic emboli
Abstract Number: 257
Abstract Type: Case Report/Case Series
INTRODUCTION: Bacterial endocarditis in pregnancy is rare. In the most recent systematic literature review, only 68 cases of bacterial endocarditis in a parturient were reported from 1965-20021. The incidence has been noted to be between 1:8,000 and 1:16,0002, with a fetal mortality rate of 14% and maternal mortality rate from 22-35%1,2.
The course of the disease ranges from effective medical management with few sequelae, to acute heart failure requiring valve replacement and serious systemic insults such as stroke, ruptured mycotic aneurysm or arrhythmia. We present such a case and highlight the issues that arose while formulating our anesthetic plan.
CASE: Our patient presented at 25 weeks gestation with one week of "fireworks" in the eyes, fever, and left hand weakness. Streptococcus mitis grew on blood culture. The echo showed MVP with mild MR, and mitral vegetation with annular abscess. By MRI she had a right middle cerebral artery infarct, with no hemorrhage. She was considered at risk for mycotic aneurysm in light of the septic emboli, but it was ruled out by angiogram. After 10 days she returned to the hospital with persistent visual symptoms, left arm weakness, and new onset right foot and left great toe pain. She was found to have increased vegetation size per echo and new septic emboli in the lower extremities. All her symptoms improved when antibiotic therapy changed. Throughout her course the fetus has remained stable. She completed a six-week course of penicillin and showed a 50% decrease in the vegetation size and no abscess. At 34 weeks gestation, conservative management continues.
DISCUSSION: Successful management of a parturient with bacterial endocarditis requires a multidisciplinary team with a commitment to constant dialogue. Cardiac integrity and the need for surgical intervention is an obvious consideration in such a case, but there are also neurologic, fetal and obstetrical issues that must be addressed among medical services.
Our patient met the criteria for elective cardiac surgery (vegetation >10mm, annular abscess), but there were neurologic concerns in proceeding with full heparinization (risk of further embolic stroke, hemorrhagic stroke and mycotic aneurysm). We discussed the effects of CPB on the fetus. The plan formulated by our group also took into account the obstetrical team as they considered the feasibility of vaginal versus operative delivery.
Lastly, our anesthesia care team had to entertain anesthetic options for a parturient with conservatively managed disease. This approach required close follow up, including serial echos and continued neurologic observation. To date our patient has responded well to medical management, with negative follow-up blood cultures and no new septic emboli, so a neuraxial anesthetic remains a good option for delivery.
1) Campuzano, Arch Gynecol 2003
2) Cox, J Reprod Med 1988