# Complex decision-making in pregnancy-associated infective endocarditis: a case series

## TL;DR

This paper presents two cases of infective endocarditis during pregnancy, highlighting the complex decisions needed to manage both maternal and fetal health.

## Contribution

The paper provides insights into the unique challenges and decision-making processes in managing pregnancy-associated infective endocarditis.

## Key findings

- Two pregnant patients with infective endocarditis required surgical valve replacement during the second trimester.
- Management involved multidisciplinary decisions balancing maternal and fetal risks, including timing of surgery and anticoagulation.
- Both patients delivered at term without complications despite complex interventions.

## Abstract

Although infective endocarditis during pregnancy is rare, it carries significant morbidity and mortality for both mother and foetus. While professional societies provide recommendations for the treatment of infective endocarditis, there are no specific guidelines for the management of pregnancy-associated infective endocarditis. In this report, we present two cases of infective endocarditis presenting during the second trimester of pregnancy that required surgical intervention, focusing on the unique considerations when caring for pregnant individuals.

Two patients in the second trimester of pregnancy presented with fevers and malaise. Both were found to have positive blood cultures and mitral valve vegetations, leading to diagnoses of mitral valve endocarditis. Their hospital courses were complicated by embolic strokes, and one patient required transcatheter embolization of a mycotic aneurysm. Both patients underwent surgical valve replacements with bioprosthetic valves. Ultimately, both patients delivered at term without complication.

In addition to the standard management of infective endocarditis, pregnancy-associated infective endocarditis requires multidisciplinary collaboration regarding the relative timing of cardiac surgery and delivery, the use of intraoperative foetal monitoring, and the choice of valve replacement and anticoagulation. Each of these decisions requires balancing the risk of morbidity and mortality to the patient, the risk of neonatal prematurity and associated complications and disability, and the risk of foetal death during cardiopulmonary bypass. We discuss our teams’ decision-making processes with a focus on the relevant considerations for each of these challenging decisions.