A 31-year-old G2P1 with bicuspid aortic stenosis reaches 26 weeks. She has NYHA Class III dyspnoea despite bed rest, beta blocker therapy, and diuretics. Echocardiography shows a valve area of 0.8 cm squared with a mean gradient of 45 mmHg and LVEF 55 percent. The fetus is viable and in stable condition. The MOST appropriate intervention is:

• A Urgent caesarean delivery
• B Percutaneous balloon aortic valvuloplasty ✓
• C Surgical aortic valve replacement with continuation of pregnancy
• D Increase diuretic dose and defer all intervention until delivery

Explanation

In symptomatic severe aortic stenosis refractory to medical therapy before fetal viability or lung maturity, percutaneous balloon aortic valvuloplasty is the accepted temporising intervention because it avoids cardiopulmonary bypass, which carries a high fetal loss rate. Urgent caesarean at 26 weeks exposes an extremely premature fetus to major morbidity, and open surgery with bypass is associated with substantial fetal mortality. Escalating diuretics alone will not relieve a fixed gradient.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.