A 31-year-old nulligravida woman comes to the office for preconception counseling after a murmur was found on her routine physical examination. Her lifestyle is sedentary, and she reports shortness of breath on moderate exertion. She emigrated from Brazil at age 25. The patient does not use tobacco or alcohol. She was married 6 months ago and is planning to have a child "very soon." Blood pressure is 112/72 mm Hg, and pulse is 67/min and regular. BMI is 29 kg/m². Transthoracic echocardiogram reveals mitral leaflet restriction with an estimated mitral valve area of 1.2 cm² (normal: 4-6). The mitral leaflets and subvalvular apparatus are not significantly thickened, and there is minimal calcification. There is minimal mitral regurgitation. The rest of the examination is unremarkable. Which of the following is the best recommendation for this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec25c8_d891_bf97_bc81_7df5769a8c59_MD0003_00 The hemodynamic changes of pregnancy involve an increase in blood volume and up to a 50% increase in cardiac output by the second trimester. These changes can be poorly tolerated in the setting of valvular disease, placing both the mother and unborn infant at substantial risk of morbidity and mortality. Stenotic valvular disease is generally more poorly tolerated than regurgitant valvular disease. Mitral stenosis usually occurs due to rheumatic heart disease and is a common cause of pregnancy-related complications that include: Decompensated heart failure with elevated left atrial pressure and pulmonary edema Atrial fibrillation (due to left atrial stretching) Increased risk of left atrial thromboembolism (due to stagnant left atrial blood flow and the underlying hypercoagulable state of pregnancy) This patient has severe mitral stenosis (valve area ≤1.5 cm²) with associated symptoms (eg, dyspnea on exertion). Symptomatic mitral stenosis is among the highest-risk cardiac conditions during pregnancy and is a contraindication to taking pregnancy to term; therefore, valve repair (eg, percutaneous mitral intervention) should be performed prior to pregnancy whenever possible. ² Although less common than mitral stenosis in women of childbearing age, symptomatic aortic stenosis is also one of the highest-risk cardiac conditions during pregnancy and should be surgically corrected prior to pregnancy. (Choice A) Lifelong avoidance of pregnancy is recommended in patients with a highest-risk condition that is not amenable to correction, often including pulmonary arterial hypertension and symptomatic heart failure with left ventricular ejection fraction <30%. (Choices C and D) Percutaneous mitral balloon valvotomy is minimally invasive and is the preferred surgical intervention for mitral stenosis. Open mitral valve repair or replacement is pursued when the valve is not amenable to percutaneous intervention (eg, valvotomy would cause severe mitral regurgitation). However, interventions should happen prior to pregnancy. (Choice E) Beta blockers slow heart rate to increase left ventricular filling time and reduce left atrial pressure and may be used to manage relatively mild mitral stenosis during pregnancy. Medical management is also often appropriate for other relatively lower-risk valvular diseases (eg, mitral regurgitation, aortic regurgitation) during pregnancy; however, it is inadequate to prevent complications for symptomatic mitral stenosis, and surgical repair is needed. Educational objective: The increase in blood volume and cardiac output associated with pregnancy can be poorly tolerated in the setting of valvular disease. Symptomatic mitral stenosis is among the highest-risk conditions during pregnancy; therefore, surgical repair, preferably with percutaneous intervention, should be performed prior to pregnancy. References: Pregnancy complicated by valvular disease: an update. (http://www.ncbi.nlm.nih.gov/pubmed/24904015)

A 31-Year-Old Nulligravida Woman Comes to the Office for Preconception