Interdisciplinary management of tricuspid valve endocarditis in pregnancy with polysubstance use: A case study and care framework

Background: Substance use disorders (SUD) in pregnancy pose critical, multifaceted risks for maternal–fetal health. Intravenous drug use (IVDU) increases the likelihood of severe complications, including infective endocarditis (IE)—often affecting the tricuspid valve—with septic embolization to the lungs and other organs, and blood-borne infections such as hepatitis C virus (HCV) and HIV. Concurrent psychosocial challenges—stigma, mistrust, and delayed care—compound medical complexity and impede engagement with treatment.

 
Methods: We describe the interdisciplinary management of a 32-year-old pregnant patient (~16 weeks’ gestation) with opioid, methamphetamine, and tobacco use disorders, presenting with methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia, tricuspid valve IE, acute renal failure (creatinine >11), pneumonia, acute hypoxic respiratory failure (AHRF), and a spinal epidural abscess. Following initial care and early discharge against medical advice from an outside hospital, she was transferred to a tertiary center for higher-level medical, obstetric, psychiatric, infectious disease, cardiology, and surgical care. Addiction treatment and psychiatric management were initiated alongside medical stabilization; structured decision-making assessments led to short-term holds and subsequent substance use and mental health commitments.

 
Results: Hospital course was complicated by a large tricuspid vegetation on transthoracic echocardiogram (TTE) and new acute systolic heart failure. An AngioVac procedure achieved partial debulking; intraoperative transesophageal echocardiogram (TEE) revealed a small patent foramen ovale (PFO). After interdisciplinary risk–benefit deliberation (maternal cardiac risk vs. transfusion needs), the patient was placed on therapeutic anticoagulation and aspirin. Severe transfusion-dependent anemia prompted hematology evaluation; workup supported anemia attributable to pregnancy and critical illness, with marked improvement in transfusion requirements post-AngioVac (to ~1 unit packed RBC/week). No active source of bleeding was identified by CT angiography and interventional radiology. Oxygen desaturation—especially nocturnal—was addressed with CPAP after inpatient sleep testing. Psychiatric care (sertraline titration for MDD/PTSD/GAD, sleep optimization) and addiction treatment (methadone for OUD) were provided; hospital heroin use was detected, visitor restrictions enacted, and harm-reduction counseling reinforced. At 23 weeks, the patient experienced preterm premature rupture of membranes (PPROM), was transferred to the antepartum unit, and delivered via cesarean section; a bicornuate uterus was noted. The neonate died on day 3 of life in the NICU. After temporary leave for funeral services, the patient returned in withdrawal, was stabilized, and discharged with outpatient substance use and mental health commitments, intensive outpatient program (IOP) follow-up, and planned residential treatment.

 
Conclusions: This case underscores the necessity of an integrated, trauma-informed, and harm-reduction–oriented model that coordinates obstetrics, infectious diseases, cardiology, cardiothoracic and orthopedic surgery, addiction medicine, psychiatry, social work, and case management. Early, sustained interdisciplinary engagement can optimize maternal cardiac outcomes, support addiction recovery, address psychosocial determinants, and structure safe discharge plans—aiming to improve outcomes for both mother and child.

Alicia K. Kilian, MD, is a Fellow Physician specializing in addiction medicine, complex medical co-management, and health policy advocacy. Her work spans hospital-based interdisciplinary care and systems-level improvement for patients with substance use disorders, including pregnant individuals with high-acuity medical needs. She has engaged in legislative advocacy and collaborates with health agencies to promote evidence-based, stigma-free care. Her clinical and scholarly interests include integrated care pathways, harm reduction, and maternal–fetal outcomes in the context of SUD.