It was prepared only for self preparation

1. DR. MASHFIQUL HASAN
28 November 2012

2.  Directly related to the severity of the mitral
stenosis

3.  Pregnancy is associated with a 30 to 50
percent increase in cardiac output and a 40 to
50 percent increase in maternal blood volume
over baseline values.
 The cardiac output gradually increases
through the first trimester and reaches a peak
at approximately 20 to 24 weeks of gestation;
the high output state is then maintained
throughout the remainder of pregnancy

4.  The resting transmitral gradient increases by
the square of the cardiac output.
 In general, the patient’s symptomatic status
during pregnancy will increase by about one
NYHA class

5.  During active labor, additional increases in
cardiac output and stroke volume occur with
each uterine contraction (additional 50 percent)
 Following delivery, there is an abrupt increase in
preload, resulting from the autotransfusion of
uterine blood into the systemic circulation and
to aortal caval decompression in the absence of
a gravid uterus.
 The increase in cardiac output can persist up to
six weeks postpartum and can continue to
exaggerate the adverse hemodynamic effects of
MS

6.  Women with MS should be evaluated before
pregnancy to determine the need for
prophylactic percutaneous mitral balloon
valvotomy (PMBV) or surgical intervention

7.  Mild to moderate MS
 can almost always be managed with judicious use
of diuretics and beta blockade
 Though diuretics are safe during pregnancy,
care must be taken to avoid hypovolemia
 A beta blocker should be tried, beginning
with very low doses. A cardioselective drug
may be preferred

8.  Who fail medical management should
undergo PMBV at experienced centers
 In developing regions where PMBV may not
be available, surgical closed
commissurotomy has been successfully
performed in pregnant women
 The preferred time for PMBV is in the 22 to 26
week gestational window that minimizes the
radiation risks to the developing fetus

9.  If a pregnant woman becomes hemodynamically
unstable with AF, electrical cardioversion is both safe
and effective.
 If an antiarrhythmic drug is needed to maintain sinus
rhythm because of poorly tolerated symptoms with AF,
quinidine and procainamide are the drugs of choice
 Beta blockers are preferred for control of the
ventricular rate.
 Anticoagulation should be continued during
pregnancy.
 Warfarin is typically avoided in the first trimester
because of its known teratogenic effects, particularly
between the sixth and ninth weeks

10.  For women with severe mitral stenosis or
symptoms of heart failure at the time of
labor, invasive hemodynamic monitoring with
a right heart catheter is appropriate

11.  Routine endocarditis prophylaxis is
not necessary for either cesarean or vaginal
delivery
 However, continuation of antibiotics for
secondary prophylaxis of rheumatic fever is
recommended