Severe Mitral Stenosis Complicating Pregnancy Management Challenges: A Case Report and Literature Review

Abstract

Background: Mitral stenosis (MS) during pregnancy remains a high-risk valvular condition because gestational increases in blood volume, heart rate and cardiac output can intensify transmitral obstruction and precipitate decompensation. Aims: This case report describes the management of very severe MS identified late in pregnancy and complicated by atrial fibrillation, left atrial thrombus, severe pulmonary hypertension and preterm delivery. Presentation of Case: A 43-year-old woman, gravida 5 para 2, was admitted at 27 weeks of gestation for exertional dyspnoea. Echocardiography revealed very severe MS (mitral valve area 0.6 cm², mean gradient 18 mmHg), a severely dilated left atrium (area 34 cm²), new-onset atrial fibrillation, a fresh left atrial thrombus (15×15 mm), and pulmonary arterial systolic pressure of 60 mmHg. Despite anticoagulation, the patient delivered prematurely at 28 weeks. The postpartum course was complicated by acute pulmonary oedema, and percutaneous mitral commissurotomy (PMC) was performed after thrombus resolution. Discussion: Haemodynamic changes of pregnancy dramatically worsen severe MS. Transoesophageal echocardiography (TEE) is indispensable for excluding left atrial thrombus before PMC. Anticoagulation, rate control, and a multidisciplinary approach are the cornerstones of management. Conclusion: PMC remains the treatment of choice for symptomatic severe MS in pregnancy when medical therapy fails, provided left atrial thrombus is excluded or resolved. Preconception counselling should be promoted in rheumatic disease-endemic regions.