Infective endocarditis is uncommon during pregnancy and the puerperium. During a 7 -year period, the incidence of endocarditis at Parkland Hospital approximated 1 in 16,000 births, and two of seven women died (Cox, 1988). Matenal and fetal mortality rates range from 25 to 35 percent (Habib, 2015; Seaworth, 1986). In a systematic review of infective endocarditis during pregnancy, risk factors were intravenous drug use (14 percent), congenital heart disease (12 percent), and rheumatic heart disease (12 percent) (Kebed, 2014). he most common pathogens were streptococcal (43 percent) and staphylococcal (26 percent) species. Among 51 pregnancies, the maternal mortality rate was 11 percent.
For years, patients with heart valve problems were given peri procedural antibiotics for endocarditis prophylaxis. Currently, however, recommendations are more stringent. The American Heart Association recommends prophylaxis for dental procedures in those with: (1) a prosthetic valve or prosthetic material used in a valve repair, (2) prior endocarditis, (3) unrepaired cyanotic heart defect or repaired lesion with residual defect at prosthetic sites, and (4) valvulopathy ater heart transplantation (Nishimura, 2017). The American College of Obstetricians and Gynecologists (2016) does not recommend endocarditis prophylaxis for either vaginal or cesarean delivery in the absence of pelvic infection except with the lesions cited above. Women at highest risk for endocarditis are those with cyanotic cardiac disease, prosthetic valves, or both. When indicated, and for women not already receiving intrapartum antimicrobial therapy for another indication that would also provide coverage against endocarditis, prophylactic regimens are shown in Table 49-8. hese are administered as close to 30 to 60 minutes before the anticipated delivery time as is feasible.
Both preexisting and new-onset cardiac arrhythmias are often encountered during pregnancy, labor, delivery, and the puerperium Qoglar, 2014; Knotts, 2014). In a study of73 women with a history of supraventricular tachycardia (ST) , paroxysmal atrial flutter or fibrillation, or ventricular tachycardia, recurrence rates during pregnancy were 50, 52, and 27 percent, respectively (Silversides, 2006). The mechanism(s) responsible for the higher incidence of arrhythmias during pregnancy are
TABLE 49-8. Antibiotic Prophylaxis for Infective Endocarditis in High-Risk Patients
American College of Obstetricians and Gynecologist (2016)
Standard (IV): ampicillin 2 9 or cefazolin or ceftriaxone 1 9 Penicillin-allergic (IV): cefazolin or ceftriaxone 1 9 or clindamycin 600 mg Oral: amoxicillin 2 9
American Heart Association/European Society of Cardiology (Karchmer, 201n5)a
Standard: amoxicillin 2 9 PO or ampicillin 2 9 IV or 1M Penicillin-allergic: clarithromycin or azithromycin 500 mg PO; cephalexin 2 gnPO; clindamycin 600 mg PO, IV, or 1M; or cefazolin or ceftriaxone 1 9 IV or 1M 1M = intramuscularly; IV = intravenously.
aCefazolin r ceftriaxone given 30 minutes and all others given 1 hour prior to procedure.