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    Case Reflection Pregnant Woman With Mitral Valve Prolapse: William Ray Cassidy 08/268114/KU/12814

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    A 30-year-old pregnant woman with a history of mitral valve prolapse presented for evaluation. Mitral valve prolapse is a common condition that affects 2-6% of the population and is usually benign, with a complication rate of less than 2% per year. Echocardiography is used to diagnose mitral valve prolapse by identifying billowing of the mitral valve leaflets into the left atrium during systole. For symptomatic patients, beta-blockers like bisoprolol can help relieve palpitations while posing minimal risk to the fetus. Pregnancy does not typically pose additional risks for women with mitral valve prolapse alone. Careful drug selection is important when treatment is

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    Case Reflection Pregnant Woman With Mitral Valve Prolapse: William Ray Cassidy 08/268114/KU/12814

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    A 30-year-old pregnant woman with a history of mitral valve prolapse presented for evaluation. Mitral valve prolapse is a common condition that affects 2-6% of the population and is usually benign, with a complication rate of less than 2% per year. Echocardiography is used to diagnose mitral valve prolapse by identifying billowing of the mitral valve leaflets into the left atrium during systole. For symptomatic patients, beta-blockers like bisoprolol can help relieve palpitations while posing minimal risk to the fetus. Pregnancy does not typically pose additional risks for women with mitral valve prolapse alone. Careful drug selection is important when treatment is

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    A 30-year-old pregnant woman with a history of mitral valve prolapse presented for evaluation. Mitral valve prolapse is a common condition that affects 2-6% of the population and is usually benign, with a complication rate of less than 2% per year. Echocardiography is used to diagnose mitral valve prolapse by identifying billowing of the mitral valve leaflets into the left atrium during systole. For symptomatic patients, beta-blockers like bisoprolol can help relieve palpitations while posing minimal risk to the fetus. Pregnancy does not typically pose additional risks for women with mitral valve prolapse alone. Careful drug selection is important when treatment is

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    26 views7 pages

    Case Reflection Pregnant Woman With Mitral Valve Prolapse: William Ray Cassidy 08/268114/KU/12814

    Uploaded by

    WilliamRayCassidy
    A 30-year-old pregnant woman with a history of mitral valve prolapse presented for evaluation. Mitral valve prolapse is a common condition that affects 2-6% of the population and is usually benign, with a complication rate of less than 2% per year. Echocardiography is used to diagnose mitral valve prolapse by identifying billowing of the mitral valve leaflets into the left atrium during systole. For symptomatic patients, beta-blockers like bisoprolol can help relieve palpitations while posing minimal risk to the fetus. Pregnancy does not typically pose additional risks for women with mitral valve prolapse alone. Careful drug selection is important when treatment is

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    CASE REFLECTION

    Pregnant Woman with Mitral Valve Prolapse

    William Ray Cassidy


    08/268114/KU/12814

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

    Department of Obstetric and Gynecology


    Faculty of Medicine Gadjah Mada University
    RSUP Dr Sardjito
    2013
    0

    Case
    A 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.
    Becauseits clinical manifestations areextremely variable, MVP maybedifficult to
    recognize.Theabnormalcomponentsofthemitralvalveapparatusarepossiblesitesfor
    endocarditis, and severe mitral regurgitation can result from endocarditis, ruptured
    chordae,orboth. 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. Itisthemostcommonformofvalvularheartdisease,occurringin3to6
    percent of the population, it is also the most frequent cause of significant mitral
    regurgitationandthemostcommonsubstrateformitralvalveendocarditisintheUnited
    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.

    Strategies and Evidence


    Diagnosis
    MVPisdefinedasthesystolicbillowingofoneorbothmitralleafletsintothe
    leftatrium,withorwithoutmitralregurgitation.ThediagnosisofMVPisoftenmadeby
    cardiacauscultationinasymptomaticpatients orbyechocardiographyperformedfor
    anotherreason.Themostfrequentpresentingcomplaintispalpitations,theusualsource
    being premature ventricular beats. Patients with MVP also frequently report chest
    discomfort.Thischestpainisatypical,itrarelyresemblesclassicanginapectoris.
    The mid-systolic click, often accompanied by a late systolic murmur, is the
    auscultatory hallmark of mitral valve prolapse. Itiscausedbythesuddentensingofthe
    mitralvalveapparatusastheleafletsbillowintotheleftatriumduringsystole.Multiple
    systolicclicksmaybegeneratedbydifferentportionsofthemitralleafletsprolapsingat
    differenttimesduringsystole.

    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.Inmoststudies,MVPhasacomplicationrateofless
    than2percentperyear.

    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
    3

    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 1 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.

    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.

    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, 31473197
    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, 24512496
    Bouknight, D P and Orourke, R A. Current Management of Mitral Valve Prolapse. Am
    Fam Physician. 2000 Jun 1;61(11):3343-3350

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