Management of Severe Mitral Stenosis During Pregnancy

Abstract

A 37-year-old woman originally from Iraq was referred at 10 weeks of gestation after an abnormal result on an echocardiogram. At this time, her only symptom was intermittent palpitations. She had no recollection of previous rheumatic fever. Past obstetric history was significant for a miscarriage at 3 months of gestation a year before the current pregnancy. On examination, heart rate was 98 bpm and irregular, and blood pressure was 100/60 mm Hg. There was no jugular venous distension. Auscultation revealed a variable first heart sound, a normal second heart sound, and an opening snap with a short second heart sound to opening snap interval. A grade 3/6 diastolic rumble was heard best at the apex. The results of the remainder of the physical examination were normal. Investigations performed included an ECG (Figure 1), which showed atrial fibrillation at an average rate of 98 bpm with no evidence of right or left ventricular enlargement. An echocardiogram showed features typical of severe rheumatic mitral stenosis (MS) (Figure 2, Movies I and II in the online-only Data Supplement, and Table). Laboratory investigation results were normal. The patient was started on systemic anticoagulation (Dalteparin) and metoprolol, and was referred to the perinatology service for assessment and follow-up for the duration of pregnancy. Figure 1. Twelve-lead ECG on initial presentation showing atrial fibrillation at a rate of 98 bpm. Figure 2. Parasternal long-axis view without ( A ) and with ( B ) color Doppler assessment showing typical features of …