Pregnancy in women with mitral stenosis
- Samuel C Siu, MD, SM, MBA
Samuel C Siu, MD, SM, MBA
- Professor of Medicine
- Schulich School of Medicine and Dentistry, University of Western Ontario
- Adjunct Professor of Medicine, Obstetrics, and Gynecology
- University of Toronto
- Section Editors
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation; Valvular Disease
- Professor of Medicine
- University of Washington
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
Mitral stenosis (MS) encountered in women of childbearing age is nearly always rheumatic in origin. Maternal and perinatal complications during pregnancy in women with MS reflect the unfavorable interaction between the normal cardiovascular changes of pregnancy and the stenotic mitral valve. (See "Maternal adaptations to pregnancy: Cardiovascular and hemodynamic changes".)
This topic will review the evaluation and management of women with mitral stenosis during pregnancy. Management of other types of heart disease during pregnancy, including those with MS who have undergone valve replacement, is discussed separately. (See "Acquired heart disease and pregnancy" and "Pregnancy in women with congenital heart disease: Specific lesions" and "Pregnancy in women with congenital heart disease: General principles" and "Management of pregnant women with prosthetic heart valves".)
Prevalence — Women with heart disease comprise approximately 1 percent of the obstetric population seen in large volume centers in developed countries. In the United States and Canada, women with rheumatic heart disease, of which MS is the most common manifestation, comprise <25 percent of the pregnant women with heart disease [1,2]. Similarly, among 1321 women with heart disease included in an European Registry on Pregnancy and Cardiac disease (ROPAC), 334 had valve disease, of which 79 (6 percent) had mitral stenosis . In contrast, MS is a common condition in pregnant women with heart disease in other areas of the world where rheumatic heart disease is prevalent. For example, rheumatic heart disease was the underlying cause in 56 to 88 percent of women in three studies from centers from Brazil, Turkey, and Senegal reporting on a total of 1194 pregnancies in women with heart disease [4-6]. (See "Natural history, screening, and management of rheumatic heart disease", section on 'Mitral stenosis'.)
IMPACT OF CARDIOVASCULAR CHANGES IN PREGNANCY IN WOMEN WITH MITRAL STENOSIS
In mitral stenosis (MS), the stenotic mitral valve restricts diastolic left ventricular filling, resulting in an elevated transmitral gradient and left atrial pressure that are further increased by the physiologic hypervolemia and increased heart rate during pregnancy, thereby increasing the risk of pulmonary congestion or pulmonary edema (figure 1). The risk of pulmonary congestion remains during labor and delivery, as a result of uterine contraction during labor, and with the autotransfusion of venous return from the lower extremities as the emptied uterus is no longer impeding venous return. Increased atrial irritability and hypercoagulability associated with pregnancy, when combined with increased left atrial pressure, increase the risk of atrial fibrillation and left atrial thrombus formation. (See "Maternal adaptations to pregnancy: Cardiovascular and hemodynamic changes" and "Deep vein thrombosis in pregnancy: Epidemiology, pathogenesis, and diagnosis".)
RELATIONSHIP BETWEEN SEVERITY OF MS AND IMPACT OF PREGNANCY
There is a direct relationship between the severity of mitral stenosis (MS) and the risk of maternal and/or fetal complications [7-9]. (See "Pathophysiology and natural history of mitral stenosis" and "Echocardiographic evaluation of the mitral valve".) There is an incremental increase in the frequency of maternal and fetal complications with increasing severity of MS (table 1). While those with moderate or severe stenosis represent the higher risk group, elevated event rates are seen in those with even mild MS, reflecting the effects of the 30 to 50 percent increase in cardiac output superimposed on a mildly stenotic valve . History of cardiac complications (including pulmonary edema, arrhythmias, transient ischemic attacks, or stroke) prior to pregnancy and poor baseline maternal functional class are additional risk factors for maternal cardiac complications during pregnancy [1,9]. In the presence of obstetric risk factors (including extremes of maternal age, smoking), the presence of maternal MS confers a risk of perinatal complications .
- Siu SC, Sermer M, Colman JM, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001; 104:515.
- Kuklina E, Callaghan W. Chronic heart disease and severe obstetric morbidity among hospitalisations for pregnancy in the USA: 1995-2006. BJOG 2011; 118:345.
- Roos-Hesselink JW, Ruys TP, Stein JI, et al. Outcome of pregnancy in patients with structural or ischaemic heart disease: results of a registry of the European Society of Cardiology. Eur Heart J 2013; 34:657.
- Avila WS, Rossi EG, Ramires JA, et al. Pregnancy in patients with heart disease: experience with 1,000 cases. Clin Cardiol 2003; 26:135.
- Diao M, Kane A, Ndiaye MB, et al. Pregnancy in women with heart disease in sub-Saharan Africa. Arch Cardiovasc Dis 2011; 104:370.
- Madazli R, Sal V, Cift T, et al. Pregnancy outcomes in women with heart disease. Arch Gynecol Obstet 2010; 281:29.
- Hameed A, Karaalp IS, Tummala PP, et al. The effect of valvular heart disease on maternal and fetal outcome of pregnancy. J Am Coll Cardiol 2001; 37:893.
- Leśniak-Sobelga A, Tracz W, KostKiewicz M, et al. Clinical and echocardiographic assessment of pregnant women with valvular heart diseases--maternal and fetal outcome. Int J Cardiol 2004; 94:15.
- Silversides CK, Colman JM, Sermer M, Siu SC. Cardiac risk in pregnant women with rheumatic mitral stenosis. Am J Cardiol 2003; 91:1382.
- Siu SC, Colman JM, Sorensen S, et al. Adverse neonatal and cardiac outcomes are more common in pregnant women with cardiac disease. Circulation 2002; 105:2179.
- Ruys TP, Roos-Hesselink JW, Hall R, et al. Heart failure in pregnant women with cardiac disease: data from the ROPAC. Heart 2014; 100:231.
- European Society of Gynecology (ESG), Association for European Paediatric Cardiology (AEPC), German Society for Gender Medicine (DGesGM), et al. ESC Guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). Eur Heart J 2011; 32:3147.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
- al Kasab SM, Sabag T, al Zaibag M, et al. Beta-adrenergic receptor blockade in the management of pregnant women with mitral stenosis. Am J Obstet Gynecol 1990; 163:37.
- Silversides CK, Harris L, Haberer K, et al. Recurrence rates of arrhythmias during pregnancy in women with previous tachyarrhythmia and impact on fetal and neonatal outcomes. Am J Cardiol 2006; 97:1206.
- Siu SC, Sermer M, Harrison DA, et al. Risk and predictors for pregnancy-related complications in women with heart disease. Circulation 1997; 96:2789.
- Goldszmidt E, Macarthur A, Silversides C, et al. Anesthetic management of a consecutive cohort of women with heart disease for labor and delivery. Int J Obstet Anesth 2010; 19:266.
- http://www.motherisk.org. (Accessed on January 26, 2012).
- Silversides CK, Sermer M, Siu SC. Choosing the best contraceptive method for the adult with congenital heart disease. Curr Cardiol Rep 2009; 11:298.
- IMPACT OF CARDIOVASCULAR CHANGES IN PREGNANCY IN WOMEN WITH MITRAL STENOSIS
- RELATIONSHIP BETWEEN SEVERITY OF MS AND IMPACT OF PREGNANCY
- NATURE AND FREQUENCY OF ADVERSE PREGNANCY OUTCOMES
- Maternal outcomes
- Fetal outcomes
- RISK STRATIFICATION
- CLINICAL MANAGEMENT
- Preconception counseling and management
- - Indications for preconception intervention
- SUMMARY AND RECOMMENDATIONS