A 28-year-old woman with known rheumatic mitral stenosis (MVA 1.0 cm², NYHA Class II) is at 24 weeks gestation. Her echocardiogram shows moderate mitral stenosis with mean gradient 10 mmHg and pulmonary artery systolic pressure of 42 mmHg. The best management approach is:

• A Immediate surgical mitral valve replacement as valve area is critically low
• B Continue medical management with beta-blocker and diuretic; plan elective cesarean at 37 weeks
• C Emergency cesarean delivery at 24 weeks to relieve hemodynamic stress on the heart
• D Percutaneous balloon mitral valvuloplasty (PBMV) under echo guidance with lead shielding as hemodynamics are worsening ✓

Explanation

Percutaneous balloon mitral valvuloplasty (PBMV/PTMC) is the intervention of choice for significant mitral stenosis in pregnancy (MVA <1.5 cm² with class II-IV symptoms) that is unresponsive to medical therapy. It can be safely performed in the second trimester (ideally after 16 weeks to minimize fetal radiation exposure) using fluoroscopy with lead shielding or increasingly under echo guidance alone. Operative risk is much lower than open cardiac surgery in pregnancy. Medical management (beta-blockade to slow heart rate and diuretics for pulmonary congestion) is the first step, but MVA 1.0 cm² with rising PA pressures indicates hemodynamic compromise requiring intervention. Surgical valve replacement carries 25-30% fetal loss risk and is reserved for PBMV failure.

Reference: Williams Obstetrics, 26th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.