Valvular Heart Disease — Pregnancy Management

Pregnancy imposes substantial cardiovascular stress including 30-50% blood volume expansion, 25-50% increase in cardiac output, decreased systemic vascular resistance and tachycardia, which can decompensate moderate-to-severe valvular heart disease (VHD). Most poorly tolerated lesions are severe mitral stenosis, severe aortic stenosis, severe pulmonary hypertension, mechanical prosthetic valves, and severe LV dysfunction (mWHO Class III-IV).

Pre-conception counseling is essential, applying the modified WHO classification (mWHO I-IV) to estimate maternal risk. Class IV (severe pulmonary hypertension, severe LV dysfunction, severe symptomatic mitral or aortic stenosis, Marfan with aorta > 45 mm) generally contraindicates pregnancy. Echocardiography, CMR, exercise testing and genetic counseling guide decision-making. Multidisciplinary Pregnancy Heart Team coordinates obstetric, cardiology, anesthesia and genetics input.

Management strategies include valvuloplasty (percutaneous balloon mitral commissurotomy in severe symptomatic mitral stenosis) preferably mid-trimester, beta-blocker tolerated mitral stenosis with rate control, careful diuresis for heart failure, and anticoagulation strategy for mechanical prosthetic valves balancing thromboembolic and teratogenic risks (warfarin if dose ≤5 mg, otherwise LMWH first trimester then warfarin, switching to UFH or LMWH near delivery). Vaginal delivery with epidural and assisted second stage preferred; cesarean reserved for obstetric indications, severe aortopathy or oral anticoagulation at delivery.