CASE REFLECTION

Pregnant Woman with Mitral Valve Prolapse

William Ray Cassidy08/268114/KU/12814

Instructor:Prof. dr. Djaswadi Dasuki, MPH, Ph.D, SpOG(K)

Department of Obstetric and GynecologyFaculty of Medicine Gadjah Mada University

RSUP Dr Sardjito2013

CaseA 30 years old woman (G2P1A0) came to outpatient clinic in RSUP Dr Sardjito

to check her pregnancy, with EGA 29 weeks. She came with diagnosis of mitral valve prolapse, diagnosed 1 year ago in the same hospital (after her first delivery). Her only symptom was episodes of palpitations, exaggerated by physical or emotional stress. She received bisoprolol 2,5 mg, taken only when she felt the palpitation. The patient underwent 4D USG for research purposes, with result revealing normal fetus.

How should we evaluate and manage pregnant women with mitral valve prolapse?

Clinical Problem

Mitral valve prolapse (MVP) occurs in an estimated 15 million Americans. Because its clinical manifestations are extremely variable, MVP may be difficult to recognize. The abnormal components of the mitral valve apparatus are possible sites for endocarditis, and severe mitral regurgitation can result from endocarditis, ruptured chordae, or both. Valvular heart disease in young women is most commonly due to rheumatic heart disease, congenital abnormalities, or endocarditis and may increase the maternal and fetal risks associated with pregnancy. The likelihood of an adverse outcome is related to the type and severity of maternal valvular disease and the resulting abnormalities of functional capacity, left ventricular function, and pulmonary pressure.

Although the prevalence of mitral valve prolapse was once thought to be as high as 15 percent in the general population, more recent studies using new echocardiographic criteria for diagnosis have suggested a prevalence of approximately 2.4 percent. It is the most common form of valvular heart disease, occurring in 3 to 6 percent of the population, it is also the most frequent cause of significant mitral regurgitation and the most common substrate for mitral valve endocarditis in the United States. Mitral valve prolapse possess low risk to both the mother and fetus, but left ventricular dysfunction associated with mitral regurgitation is unlikely to improve after surgery and will increase maternal risk during pregnancy.

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Strategies and Evidence

DiagnosisMVP is defined as the systolic billowing of one or both mitral leaflets into the

left atrium, with or without mitral regurgitation. The diagnosis of MVP is often made by cardiac auscultation in asymptomatic patients or by echocardiography performed for another reason. The most frequent presenting complaint is palpitations, the usual source being premature ventricular beats. Patients with MVP also frequently report chest discomfort. This chest pain is atypical, it rarely resembles classic angina pectoris.

The mid-systolic click, often accompanied by a late systolic murmur, is the auscultatory hallmark of mitral valve prolapse. It is caused by the sudden tensing of the mitral valve apparatus as the leaflets billow into the left atrium during systole. Multiple systolic clicks may be generated by different portions of the mitral leaflets prolapsing at different times during systole.

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All patients with signs or symptoms of mitral valve prolapse should have an initial echocardiograph. Serial echocardiography is usually not necessary unless mitral regurgitation is present.

Management and Discussion

Patients should be reminded of the low incidence of serious complications associated with mitral valve prolapse, and physicians should attempt to allay fears of serious underlying heart disease. In most studies, MVP has a complication rate of less than 2 percent per year.

Normal pregnancy is associated with an increase of 30 to 50 percent in blood volume and a corresponding increase in cardiac output. These increases begin during the first trimester, with the levels peak by 20 to 24 weeks of pregnancy and then are either sustained until term or decrease. The heart rate increases by 10 to 20 beats per minute, the stroke volume increases, and there is a substantial reduction in systemic vascular resistance, with decreases in blood pressure.

During labor, cardiac output increases, the blood pressure increases with uterine contractions. Immediately after delivery, the cardiac filling pressure may increase dramatically due to the decompression of the vena cava and the return of uterine blood

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into the systemic circulation. The cardiovascular adaptations associated with pregnancy regress by approximately six weeks after delivery.

Murmurs develop in nearly all women during pregnancy. These murmurs are usually soft, midsystolic, and heard along the left sternal border. Their intensity may increase during pregnancy as cardiac output increases. Minor degrees of atrioventricular valve regurgitation are normal. Left-sided regurgitant valve lesions carry a lower pregnancy risk than stenotic valve lesions because the decreased systemic vascular resistance reduces regurgitant volume. Severe regurgitation with LV dysfunction is poorly tolerated, as is acute severe regurgitation. No increased risk of obstetric complications has been reported. In symptomatic regurgitation the risk of offspring complications is increased.

Drugs used in management of MVP are mostly symptomatic. The most commonly used are beta-blockers, which can relieve the palpitation episodes. The benefit in using beta-blockers outweighs the possible risks for the fetus. Bisoprolol as selective β1 adrenergic antagonist is preferred in this patient as it will not cause unwanted effects such as bronchoconstriction. In severe regurgitation in which surgical intervention is performed, mechanical valves carry the risk of valve thrombosis which is increased during pregnancy. In a large review, this risk was 3.9% with OACs throughout pregnancy, 9.2% when UFH was used in the first trimester and OACs in the second and third trimester, and 33% with UFH throughout pregnancy. All anticoagulation regimens carry an increased risk of miscarriage and of haemorrhagic complications, including retroplacental bleeding leading to premature birth and fetal death.

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Areas of Uncertainty Evidence is still lacking in guidelines for management of pregnant patients with MVP or MR, and their effects and outcome after treatment in obstetric cases.

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Conclusion

MVP is common in women, it has benign prognosis and only carry small chance of serious complications. Thus, it is necessary to educate the patient on the prognosis and risks of complications of MVP as it the disease itself will not cause serious negative effects on labor and delivery. However, drug therapy must be chosen carefully, only if the benefits outweigh the risks to both the mother and the fetus.

Reference

Reimold, S C and Rutherford, J D. Valvular Hear Disease in Pregnancy. N Engl J Med 2003;349:52-9.

ESC Guidelines on the management of cardiovascular diseases during pregnancy. The Task Force on the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). European Heart Journal (2011) 32, 3147–3197

Shipton, B and Wahba H. Valvular Heart Disease: Review and Update. Am Fam Physician 2001;63:2201-8

Guidelines on the management of valvular heart disease (version 2012) The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal (2012) 33, 2451–2496

Bouknight, D P and O’rourke, R A. Current Management of Mitral Valve Prolapse. Am Fam Physician. 2000 Jun 1;61(11):3343-3350

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