A pregnant woman with known rheumatic mitral stenosis (valve area 0.9 cm², mean gradient 15 mmHg) becomes symptomatic with pulmonary edema at 24 weeks. She is in NYHA Class III. According to modified WHO (mWHO) risk classification for pregnancy, her cardiac risk class is:

• A mWHO Class II (small increased risk, close monitoring needed)
• B mWHO Class III (significantly increased risk, specialist cardiac care throughout)
• C mWHO Class IV (extremely high risk, pregnancy not recommended) ✓
• D mWHO Class II-III (moderate increased risk)

Explanation

Modified WHO (mWHO) classification of cardiovascular risk in pregnancy: Class IV includes conditions where pregnancy carries extremely high risk of maternal mortality or severe morbidity and termination should be discussed — this includes severe mitral stenosis (MVA < 1.0 cm²), symptomatic severe aortic stenosis, Marfan syndrome with aorta > 45 mm, systemic ventricular ejection fraction < 30%, peripartum cardiomyopathy with residual dysfunction, and pulmonary arterial hypertension. Severe MS with MVA 0.9 cm² and pulmonary edema (NYHA III) is an mWHO Class IV condition. ESC 2018 Guidelines on cardiovascular diseases in pregnancy endorse this classification.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.