Mitral Valve Replacement During Pregnancy

Author Information
Sachin Pardeshi*, Mayadeo NM**, Himangi Warke***
(* Assistant Professor, ** Professor, *** Associate  Professor. Department of Obstetrics and Gynecology, Seth G.S. Medical College and K.E.M Hospital, Mumbai, India.)


Though incidence of cardiovascular diseases and pregnancy has decreased over the last few decades, the incidence of heart disease in pregnant women has been reported to range from 1 to 4% , mitral disease being the most common.[1,2] Cardiac surgeries during pregnancy is a high risk procedure with respect to fetal wellbeing, with fetal mortality ranging from 0 to 35%, averaging 19%.[3,4]
This is a case report of 23 years old primigravida with rheumatic heart disease with severe mitral stenosis. mitral regurgitation and severe pulmonary hypertension diagnosed four months prior to admission at our institute. She presented to our hospital in emergency with severe dyspnoea with hemoptysis at 36 weeks of gestation. Initially she was stabilized medically in intensive care unit, but required mitral valve replacement subsequently.


The incidence of heart disease during pregnancy  ranges from 0.4 to 4.1%,[5] During pregnancy cardiac output increases by 30-40% above normal. From 20th to 32nd weeks of gestation there is also volume expansion by 30-50% and oxygen consumption by 25-30% above non pregnant levels.
Mitral stenosis is the most common valvular lesion and may require surgical intervention when the lesion is severe enough to cause heart failure in spite of medical therapy. Surgical intervention should be considered for pregnant women with heart disease with decompensated state.

Case report

A 23 years old primigravida admitted in emergency in view of cardiac failure. Patient  was diagnosed to have rheumatic heart disease with mitral stenosis 4 months back. She  presented with dyspnoea grade III-IV for 15days, hemoptysis for 10 days, and bilateral pedal edema for 1month. On physical examination patient was orthopneic, pulse was 98 beats per minute, regular. Blood pressure was 110/70mm of Hg. Jugular venous pressure was 8cms. Bilateral ankle edema was present.
On cardiac examination, there was a mid-diastolic murmur. On respiratory system examination there were bilateral basal crepitations. Abdominal examination revealed 36 weeks’ uterus with fetal heart sounds present. On per vaginal examination the cervical os was closed. Her electrocardiogram revealed left axis deviation and right ventricular hypertrophy. 2-D Echo was suggestive of left atrial enlargement with severe mitral stenosis, severe mitral regurgitation and severe pulmonary hypertension with an ejection fraction of 60%. The mitral valve area was 0.7-0.8 cm2. An urgent cardiology opinion was taken and patient was transferred to intensive cardiac care unit. Patient was initially stabilized with injection frusemide, digoxin, and oxygen by mask. Infective endocarditis prophylaxis was given. But thereafter owing to her declining health status, a decision of emergency surgical intervention was taken and mitral valve replacement was performed on day 2 after admission. Fetal heart sounds were monitored throughout the procedure. The procedure was uneventful. The patient was monitored in intensive cardiac care unit. Patient was peri-operatively on Inj. Heparin for anticoagulation. Daily obstetric examination was done. The patient was transferred back to antenatal ward on the 11th post operative day. The patient went into active labour 15 days  post procedure. She was transferred back to cardiac ICU where she delivered vaginally a live male baby 2.480 kg. Injectable Heparin was withheld during labour. After delivery anticoagulation therapy was restarted.


Cardiac surgery in pregnancy has been reported successfully by many authors.  Fetal age and timing of the surgical procedure should be taken into account when possible on an ethical basis with regards to maternal and fetal outcome.
Surgical intervention in case of cardiac diseases during pregnancy has 90% neonatal mortality at 25weeks of gestation and decreases to below 15% at 30weeks.[6]. It is critically important to observe the response of fetal heart rate to surgical and drug therapy throughout the pregnancy. Uterine contraction, hypoxia, hypotension, low blood  flow, maternal positioning, drugs crossing fetoplacental barrier are some of the factors responsible for inducing fetal bradycardia. In individual settings, the maternofetal response may vary according to the health status at the time of the procedure and the timing of operation.
Clinical knowledge gained from such cases gives immense insight in the management of these cases, especially considering the inability to conduct clinical trials in pregnant women undergoing mitral valve replacement.


1.       Mahli A, Izdes S, Coskun D. Cardiac operations during pregnancy: review of factors influencing fetal outcome. Ann Thorac Surg 2000;69:1622-6
2.      Cardiac diseases in pregnancy. ACOG technical bulletin number 168-June 1992. Int J Gynaecol Obstet 1993;41:298-306.
3.      Parry AJ, Westaby S. Cardiopulmonary bypass during pregnancy. Ann Thorac Surg 1996;61:1865-69.
4.      Ueland K. Cardiac surgery and pregnancy. Am J Obstet Gynecol 1965;92:148-62.
5.      McFaul PB, Dorman JC, Lamki H et al. Pregnancy complicated by maternal heart disease. A review of 519 women. Br J Obstet Gynaecol 1988;95:861-67.
6.      Cooper RL, Goldenberg RL, Creasy RK et al. A multicenter study of preterm birth weight and gestational age specific neonatal mortality. Am J Obstet Gynecol 1993;168:78-84


Pardeshi S, Mayadeo NM, Warke HS.  Mitral Valve Replacement During Pregnancy. JPGO 2014 Volume 1 Number 4 Available from: