[1]
Erkan Yıldırım, Gulhane Military Medical Academy, Department of Cardiology, Ankara, Turkey.
[2]
Murat Çelik, Gulhane Military Medical Academy, Department of Cardiology, Ankara, Turkey.
[3]
Yaşam Kemal Akpak, Ankara Mevki Military Hospital, Department of Obstetrics and Gynecology, Ankara, Turkey.
Maternal cardiac disease is a major risk factor for nonobstetric mortality and morbidity in pregnancy. Rheumatic heart disease is less common than in the past, but is still a major heart problem associated with pregnancy in developing countries. Mitral stenosis (MS) is most common rheumatic valvular lesions seen in pregnancy and is poorly tolerated. A series of cardiocirculatory changes including increase in blood volume, cardiac output, stroke volume and heart disease, decrease in blood pressure and systemic vascular resistance occur in pregnancy beginning from the early first trimester. These hemodynamic changes may provoke clinical manifestations of cardiac complications during pregnancy. The normal mitral valve orifice area is about 4–6 cm2. When the valve area is reduced <2 cm2 the classical symptoms of mitral stenosis start appearing. These symptoms include dyspnea, ortophnea, paroxysmal nocturnal dyspnea and decreased exercise capacity. Cardiac decompensation and pulmonary edema usually occur in second or third trimester as the hemodynamic burden of pregnancy is greatest. Although physical examination, assessment of functional capacity, electrocardiogram and chest X-ray may reveal many clues, echocardiography is the standard imaging modality used to assess patients with MS. The maternal cardiac complications correlate with the New York Heart Association (NYHA) functional classification and the severity of the mitral stenosis. Management depends upon the severity of disease, symptoms and time of diagnosis. The risks associated with pregnancy should be discussed with patients. In pregnancy medical treatment should be the first line of management. If symptoms persist despite optimal medical treatment invasive procedures should be considered. Multiple studies have shown that vaginal delivery under epidural anaesthesia is safe and well tolerated, unless obstetrically contraindicated. Understanding of the physiological changes in pregnancy and the pathogenesis of mitral stenosis and a multidisciplinary team approach with a cardiologist, obstetrician, and obstetric anesthesiologist in management provides decreased mortality and morbidity.
Cardiac Disease in Pregnancy, Mitral Stenosis, Valvular Heart Disease in Pregnancy
[1]
Silversides CK, Colman JM, Sermer M. Siu SC. Cardiac risk in pregnant women with rheumatic mitral stenosis. Am J Cardiol 2003; 91: 1382-5.
[2]
Elkayam U, Bitar F. Valvular heart disease and pregnancy part I: native valves. J Am Coll Cardiol 2005; 46: 223-30.
[3]
Desai DK, Adanlawo M, Naidoo DP, Moodley J. Kleinschmidt I. Mitral stenosis in pregnancy: a four-year experience at King Edward VIII Hospital, Durban, South Africa. BJOG 2000; 107: 953-8.
[4]
Warnes CA, Pregnancy and heart disease, in Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine, P. Libby, R. O. Bonow, D. L. Mann, and D.P. Zipes, Editors. 2007, WB Saunders: Philadelphia. p. 1967–1982.
[5]
Sawhney MP, Batra RB. Chlamydia trachomatis seropositivity during pregnancy. Indian J Dermatol Venereol Leprol 2003; 69: 394-5.
[6]
al Kasab SM, Sabag T, al Zaibag M, Awaad M, al Bitar I, Halim MA, Abdullah MA, Shahed M, Rajendran V. Sawyer W. Beta-adrenergic receptor blockade in the management of pregnant women with mitral stenosis. Am J Obstet Gynecol 1990; 163: 37-40.
[7]
Schaefer C, Hannemann D, Meister R, Elefant E, Paulus W, Vial T, Reuvers M, Robert-Gnansia E, Arnon J, De Santis M, Clementi M, Rodriguez-Pinilla E, Dolivo A. Merlob P. Vitamin K antagonists and pregnancy outcome. A multi-centre prospective study. Thromb Haemost 2006; 95: 949-57.
[8]
Hammerstingl C. Monitoring therapeutic anticoagulation with low molecular weight heparins: is it useful or misleading? Cardiovasc Hematol Agents Med Chem 2008; 6: 282-6.
[9]
College of Obstetricians and Gynecologists Committee on Obstetric Practice. Antibiotic prophylaxis for infective endocarditis. ACOG Committee Opinion No. 421. Washington DC, November 2008. Obstet Gynecol 2008; 112: 1193-4
[10]
Fawzy ME, Kinsara AJ, Stefadouros M, Hegazy H, Kattan H, Chaudhary A, Williams E. Al Halees Z. Long-Term outcome of mitral balloon valvotomy in pregnant women. J Heart Valve Dis 2001; 10: 153-7.
[11]
De Souza JA, Martinez EE, Jr, Ambrose JA, Alves CM, Born D, Buffolo E, Carvalho AC. Percutaneous balloon mitral valvuloplasty in comparison with open mitral valve commissurotomy for mitral stenosis during pregnancy. J Am Coll Cardiol 2001; 37: 900-903.
[12]
Sutton SW, Duncan MA, Chase VA, Marce RJ, Meyers TP, Wood RE. Cardiopulmonary bypass and mitral valve replacement during pregnancy. Perfusion 2005; 20: 359-368.
[13]
Ngan Kee WD, Shen J, Chiu AT, Lok I, Khaw KS. Combined spinal-epidural analgesia in the management of labouring parturients with mitral stenosis. Anaesth Intensive Care 1999; 27: 523-6.
[14]
Hameed A, Karaalp IS, Tummala PP, Wani OR, Canetti M, Akhter MW, Goodwin I, Zapadinsky N. Elkayam U. The effect of valvular heart disease on maternal and fetal outcome of pregnancy. J Am Coll Cardiol 2001; 37: 893-9.
