A pregnant woman at 30 weeks with known rheumatic mitral stenosis (valve area 1.0 cm²) develops progressive dyspnea, orthopnea, and atrial fibrillation. Echocardiography confirms moderate-to-severe MS. She is on betablockers and anticoagulation. Next best management step?

• A Diuretics, rate control for AF, and plan elective cesarean delivery at 34 weeks
• B Emergency open heart surgery with cardiopulmonary bypass for commissurotomy
• C Digoxin for rate control and plan preterm induction at 36 weeks
• D Percutaneous balloon mitral valvuloplasty (PBMV) under echocardiographic guidance ✓

Explanation

Symptomatic severe mitral stenosis (MVA ≤1.0 cm²) with pulmonary oedema or progressive symptoms despite medical therapy in pregnancy is the primary indication for intervention. PBMV (percutaneous balloon mitral valvuloplasty) is the preferred intervention — it avoids cardiopulmonary bypass (which has 20–30% fetal mortality), uses only fetal radiation shielding to minimize X-ray exposure, and achieves valve areas >1.5 cm² in experienced hands. Open cardiac surgery with CPB carries high fetal mortality and is a last resort. Medical management alone (diuretics, rate control) may temporize but not definitively treat severe, symptomatic MS.

Reference: Williams Obstetrics, 26th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.