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Aortic Fungal Infective Endocarditis During Pregnancy
Abstract Number: S 54
Abstract Type: Case Report/Case Series
Introduction: Infective endocarditis (IE) is a rare complication during pregnancy with an incidence of 0.006% and a mortality rate as high as 33% (maternal) and 29% (fetal) (1,2). The leading causes of mortality are destruction of the valves leading to heart failure and embolism from the vegetations (2).
Case: A 23 year old G1P0 at 30 5/7 weeks gestation with a history of intravenous drug abuse on methadone, hepatitis C, and bipolar disorder presented at an outside hospital with severe right groin pain. She also had night sweats for a month and was taking ampicillin for a dental abscess. An ultrasound showed a right profunda artery thrombus, and enoxaparin was started. IE was diagnosed by echocardiogram, with 0.8cm x 1.0cm mobile aortic valve vegetation and mild to moderate aortic insufficiency (AI). The patient was transferred to our CTICU for aortic valve replacement (AVR). She received betamethasone for fetal lung maturation and magnesium for neuroprotection. Two blood cultures were positive for Candida; she was started on amphotericin B. Brain MRI revealed a 2mm anterior communicating artery aneurysm that was either idiopathic or mycotic. She was hemodynamically stable.
During a multidisciplinary meeting between MFM, cardiothoracic surgery and obstetric anesthesiology (OA), the decision was made that the maternal risk of embolism outweighed the fetal benefit of prolonging the pregnancy. The plan was to stop anticoagulation 12 hours prior to a CS and then perform the AVR ~24 hours after the CS. Heated discussions ensued between MFM, OA, and nursing about where the CS should be done, and it was agreed that the CS would be done in our main operating room. Due to her fungemia, the decision was made to utilize general anesthesia. An arterial line was placed, and a rapid sequence induction was performed using 150mg propofol, 120mg succinylcholine, and 100mcg remifentanil. Anesthesia was maintained with sevoflurane, nitrous oxide and opioids. The cardiac anesthesia team and cardiothoracic surgeons remained on standby, but the patient had no intraoperative complications and was extubated immediately postoperatively. She had a successful and uneventful AVR 24 hrs later.
Conclusion: There is no consensus on the best management of pregnant patients with IE in need of CS and AVR. Depending on the gestational age, AVR could precede CS, CS could precede AVR, or they can be done simultaneously. This patient had IE, moderate AI, fungemia, and a possible mycotic aneurysm. Her CS was done in our main OR, which is closer to adult ICUs but farther from the NICU. When a labor floor is geographically far from main ORs and ICUs, there are logistical difficulties in caring for complex parturients and neonates, especially involving staffing.
1. Kaoutzanis, C. Gen Thorac Card Surg, 2012
2. Vincelj, J. Int J Card, 2008