She had an unremarkable childhood until 10 years old when she was diagnosed with moderate patent ductus arteriosus, presenting as exertional dyspnea. She was lost to follow-up until 2 years later, at 12 years old, when she was admitted at the emergency room for edema, exertional dyspnea, and orthopnea. On physical examination, she was in respiratory distress, tachypneic with alar flaring, and had bilateral crackles. She was initially treated for community-acquired pneumonia and pulmonary tuberculosis, with initial blood cultures yielding Streptococcus viridans. This was treated with Penicillin G. However, despite improvement of pneumonia, she was persistently febrile. Repeat blood cultures were positive for Pseudomonas putida. A TTE revealed multiple vegetations at the pulmonary artery and pulmonic valve. The IE was then treated with a 6-week course of intravenous meropenem. Furosemide, digoxin, and enalapril were also initiated for the heart failure. Surgery to close the PDA and remove the vegetations was offered but was not done due to the lack of consent and funds. Serial TTE done during the following year did not show a significant decrease in the size of the pulmonary artery masses. She was again lost to follow-up but continued taking furosemide, digoxin, and enalapril.
She returned to our institution for prenatal care. She discontinued taking furosemide, enalapril, and digoxin at the start of pregnancy. Given her history of a congenital heart disease, a TTE was ordered as part of the prenatal work-up. The TTE was done on her 29th week AOG, and it revealed a PDA with a computed Qp : Qs of 1.18 (see Figure 1), as well as vegetations on the pulmonic valve and pulmonary artery (see Figure 2).