What is the appropriate management for a 12‑week‑3‑day pregnant woman (gravida 7, para 1, living 5, abortus 5) with rheumatic heart disease who has undergone percutaneous mitral balloon valvotomy?

Management of Rheumatic Mitral Stenosis at 12 Weeks Gestation After Prior Valvotomy

This pregnant patient with rheumatic heart disease and prior mitral valvotomy requires immediate tertiary-care monitoring with a dedicated Heart Valve Team, optimization with beta-blockers if symptomatic, and close echocardiographic surveillance throughout pregnancy—with percutaneous balloon mitral valvotomy reserved only for refractory NYHA class III-IV heart failure after 20 weeks gestation despite maximal medical therapy. 1, 2

Immediate Management Steps

Establish Tertiary-Care Monitoring

• Transfer to or establish care at a tertiary center with a dedicated Heart Valve Team (cardiologists, cardiac surgeons, anesthesiologists, high-risk obstetricians) for all pregnant patients with severe valve stenosis, regardless of current symptom status. 1
• This multidisciplinary team must be in place now at 12 weeks, not deferred until symptoms develop. 1

Baseline Echocardiographic Assessment

• Obtain comprehensive transthoracic echocardiography immediately to determine current mitral valve area, mean gradient, pulmonary artery pressure, and degree of any mitral regurgitation. 1
• Document whether the prior valvotomy resulted in favorable anatomy (mitral valve area >1.5 cm²) or if restenosis has occurred (mitral valve area ≤1.5 cm²). 1
• Assess for leaflet calcification, mobility, subvalvular fusion, and commissural calcification to determine suitability for repeat intervention if needed. 1, 2

Rheumatic Fever Prophylaxis

• Continue penicillin prophylaxis if the patient has a history of acute rheumatic fever and carditis, as indicated in the non-pregnant state. 1

Medical Management Algorithm

If Asymptomatic or Mild Symptoms (NYHA Class I-II)

• Beta-blocker therapy is reasonable for rate control if tachycardia develops or to prevent tachycardia during pregnancy. 1, 2
• Use cardioselective agents (metoprolol or atenolol preferred over propranolol) to avoid potential deleterious effects of epinephrine blockade on myometrial activity. 1
• Add diuretics judiciously only if pulmonary congestion develops, avoiding vigorous volume depletion to protect uteroplacental perfusion. 1, 2
• Bed rest may provide additional symptomatic benefit if mild symptoms emerge. 1, 2

Medications to Absolutely Avoid

• ACE inhibitors and ARBs are contraindicated throughout pregnancy due to fetal renal dysplasia, oligohydramnios, growth retardation, and skeletal abnormalities. 1, 2

If Severe Symptoms Develop (NYHA Class III-IV)

• Optimize medical therapy first: maximize beta-blocker dosing for heart rate control, add diuretics for pulmonary congestion, and institute bed rest. 1, 2
• Percutaneous balloon mitral commissurotomy is indicated only if:
  • Severe mitral stenosis is confirmed (mitral valve area ≤1.5 cm²), AND
  • Patient remains symptomatic with NYHA class III-IV heart failure despite optimal medical therapy, AND
  • Gestational age is ≥20 weeks (preferred timing for fetal safety), AND
  • Valve morphology is favorable (minimal calcification, good leaflet mobility, minimal subvalvular disease). 1, 2

Percutaneous Balloon Mitral Commissurotomy During Pregnancy

Timing Considerations

• Perform after 20 weeks gestation whenever possible, as this is the safest period for the fetus regarding malformation risk and premature delivery. 1, 2
• The window between 20-28 weeks appears optimal if intervention becomes necessary. 1, 2

Procedural Requirements

• Must be performed only by experienced operators with documented low complication rates in high-volume centers. 1, 2
• Mandatory backup services: immediate availability of cardiac surgery, anesthesiology, and high-risk obstetrics. 1, 2
• Radiation protection: use abdominal and pelvic shielding, minimize fluoroscopy time (<2 minutes if possible), omit hemodynamic measurements and angiography when feasible. 1, 2
• Continuous fetal monitoring throughout the procedure. 1, 2
• The Inoue balloon technique is advantageous because it keeps procedure time short. 2, 3

Expected Outcomes

• Success rates of 95-100% have been reported in pregnant patients with favorable valve morphology. 4, 5, 6, 3
• Mitral valve area typically increases from ~0.9 cm² to 1.7-2.0 cm². 5, 6, 3
• Immediate symptomatic improvement by at least one NYHA class occurs in >80% of patients. 5, 6, 3

Procedural Risks

• 5% risk of severe traumatic mitral regurgitation requiring emergency mitral valve replacement under cardiopulmonary bypass, which carries 30-40% fetal mortality and up to 9% maternal mortality. 1, 2
• Low risk of cardiac tamponade or embolic events. 2

Management if Valve Morphology is Unfavorable

When Balloon Valvotomy is Too High-Risk

• If severe leaflet calcification, thickening, immobility, extensive subvalvular fusion, or commissural calcification is present, percutaneous balloon commissurotomy carries unacceptable risk. 1, 2
• Mitral valve replacement is reasonable only for refractory NYHA class IV heart failure unresponsive to maximal medical therapy. 1, 2
• Open heart surgery during pregnancy carries 30-40% fetal mortality and up to 9% maternal mortality. 1, 2
• If surgery becomes necessary, use high pump flows, normothermic perfusion, shortest possible cardiopulmonary bypass time, and continuous fetal monitoring. 1, 2

Ongoing Surveillance Throughout Pregnancy

Clinical Monitoring

• Obtain history, physical examination, chest X-ray, and ECG at regular intervals (frequency determined by symptom status and severity of stenosis). 1
• Monitor for development of atrial fibrillation, which significantly increases stroke risk and requires immediate anticoagulation. 1

Echocardiographic Follow-Up

• Repeat echocardiography if symptoms worsen to assess for restenosis, worsening mitral regurgitation, or rising pulmonary artery pressures. 1
• Exercise hemodynamics may be indicated if there is discrepancy between clinical symptoms and resting echocardiographic findings. 1

Delivery Planning

Anesthetic Considerations

• Regional anesthesia (slow, titrated epidural) is preferred over single-shot spinal to avoid catastrophic hypotension from abrupt sympathetic blockade. 7
• Use very low-concentration local anesthetic (0.0625-0.125% bupivacaine) if severe stenosis is present. 7
• Avoid single-shot spinal anesthesia in patients with fixed cardiac output from stenosis. 7

Intrapartum Management

• Establish invasive arterial blood pressure monitoring before labor or cesarean section for beat-to-beat pressure assessment. 7
• Avoid Valsalva maneuver during second-stage labor if NYHA class III-IV or severe stenosis; use assisted delivery (forceps or vacuum). 7
• Maintain careful fluid balance and heart rate control throughout the peripartum period. 1, 7

Postpartum Monitoring

• Continue intensive hemodynamic monitoring for at least 24-48 hours postpartum because autotransfusion of 500-1000 mL from uterine involution can precipitate heart failure. 7, 8
• This is the highest-risk period for cardiac decompensation. 7, 8

Critical Pitfalls to Avoid

1. Do not perform balloon valvotomy before 20 weeks gestation unless there is life-threatening maternal deterioration. 1, 2
2. Do not perform the procedure in centers lacking immediate cardiac surgical backup. 1, 2
3. Do not assume adequate medical therapy without first optimizing beta-blocker dosing and appropriate diuretic use. 1, 2
4. Do not use methylergonovine for postpartum uterine atony (causes marked vasoconstriction and hypertension); use slow IV oxytocin (<2 U/min) instead. 7
5. Do not discharge the patient within 24 hours of delivery without intensive monitoring for delayed heart failure. 7, 8
6. Do not use ACE inhibitors or ARBs at any point during pregnancy. 1, 2

Prognosis and Long-Term Outcomes

• At mean follow-up of 44 months after balloon valvotomy during pregnancy, event-free survival is approximately 54%, indicating that many patients will eventually require repeat intervention. 6
• Fetal outcomes are excellent when procedures are performed in experienced centers, with 88% of newborns having normal weight and normal growth and development at long-term follow-up. 6
• Preterm delivery occurs in approximately 13% of cases. 6