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
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