A 27-year-old woman presents at 26 weeks gestation in pulmonary oedema. She recently moved to the UK from Pakistan but was previously well. An echocardiogram showed mitral valve disease. The MV area is 1.0 cm2 , mean gradient is 25 mmHg, and PHT is 220 ms.
What is the most appropriate treatment?
A. Deliver the baby by Caesarean section and arrange balloon mitral valvuloplastyIf the patient is already in pulmonary oedema this will continue to worsen through pregnancy, so diuretics etc. will only be a temporary relief. The outcome for a fetus delivered at 26 weeks is poor and therefore delivery is not desirable at this gestation. The treatment of choice is balloon mitral valvuloplasty by a skilled operator. Balloon mitral valvuloplasty is highly effective in pregnancy and safe. If there is severe mitral regurgitation at the end of the procedure this will be much better tolerated in progressing pregnancy than severe mitral stenosis. Note that the increased preload of pregnancy needs to be taken into account when assessing mitral stenosis. Peak and mean gradients will be extremely elevated because of the increase in preload. Cardiothoracic surgery is not the treatment of choice as cardiopulmonary bypass is associated with a 50% risk of fetal mortality. Rheumatic heart disease in pregnancy is common in developing countries and is increasing in the UK because of increased immigration.