We do the sorting. You do the medicine.
Cardiac14 / 22

Severe mitral stenosis in labour27-year-old woman, 70 kg, 39 weeks, second pregnancy, in early labour

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Symptoms appear once the mitral area is under 1.5 cm²; severe MS is a WHO class IV lesion.
  • Faster heart rates shorten filling and raise left atrial and pulmonary pressures.
  • Early epidural, arterial line, second stage without Valsalva.
  • Delivery autotransfusion can flood her lungs; ICU or HDU for 24–72 hours.

The patient

27-year-old woman, 70 kg, 39 weeks, second pregnancy, in early labour; assisted vaginal delivery planned. Severe rheumatic mitral stenosis: valve area 0.9 cm², PA systolic 55 mmHg; breathless lying flat. Drugs: metoprolol; no anticoagulant. Vitals: BP 112/70, HR 102 sinus, SpO2 95%, RR 22.

The examiner asks

Answer aloud, then press Show.

  1. Consider

    What are your concerns?

    Show the answerHide the answer
    • A 27-year-old at term with severe rheumatic MS and pulmonary hypertension, now in labour. Patient
    • Pregnancy raises her blood volume and heart rate; labour pain and delivery autotransfusion load her further.
    • Area 0.9 cm² is severe; this lesion is WHO class IV in pregnancy. Disease
    • At 102 beats she has little diastolic time to fill her LV.
    • Orthopnoea and PA systolic 55 show she is already congested.

  2. Prepare

    How do you prepare?

    Show the answerHide the answer
    • Cardio-obstetric team with obstetric and cardiac anaesthetists together. (Disease)
    • Delivery in a centre with cardiology and cardiac surgery, including ECMO.
    • She continues metoprolol for rate control.
    • Arterial line before epidural top-ups; left uterine displacement throughout.
    • If prophylactic enoxaparin is started, epidural placement waits 12 hours after a dose.

  3. Plan

    What is your analgesia and delivery plan?

    Show the answerHide the answer
    • Early epidural, titrated slowly, so pain doesn't drive her heart rate. Disease
    • No single-shot spinal; a titrated epidural is the safer choice for her.
    • Hypotension: phenylephrine 100–150 mcg, not ephedrine, which speeds the heart.
    • Top up for the second stage and avoid pushing; assisted delivery.
    • Oxytocin 1–3 IU slowly; avoid carboprost, which raises PVR, and methylergonovine, which vasoconstricts.
    • ICU or HDU for 24–72 hours; delivery autotransfusion can overload her. After surgery

  4. Crisis

    In painful labour before the epidural works, HR is 138, SpO2 91%, RR 32. What do you do?

    Show the answerHide the answer
    • Her tachycardia is causing lung congestion; sit her up, give oxygen. (Crisis)
    • Get the epidural working to remove her pain drive.
    • Metoprolol 2.5–5 mg IV over 2 minutes, up to three doses, to slow her.
    • ECG for AF; new unstable AF needs synchronised cardioversion.
    • Fetal monitoring continues; obstetrician informed.

  5. Crisis

    Minutes after delivery she is breathless, SpO2 86%, with crackles, BP 150/92, HR 124. What do you do?

    Show the answerHide the answer
    • Acute pulmonary oedema from the autotransfusion after delivery. Crisis
    • Sit up, 100% oxygen and a loop diuretic.
    • Slow her heart with metoprolol to lengthen LV filling.
    • CPAP; intubate if she tires, avoiding hypoxia and hypercarbia.
    • ICU with arterial monitoring and early cardiology review. After surgery

Fatal mistakes

  • Single-shot spinal anaesthesia for her.
  • Ephedrine or other drugs that drive tachycardia.
  • A rapid oxytocin bolus.
  • A large fluid preload before the block.

Checked against: 2025 ESC Guidelines for the management of cardiovascular disease and pregnancy · Valvular Heart Disease in Pregnancy (2024) · Stoelting 8e · Barash 9e

Report a problem with this case

Mark Got it only if you said every point. Again brings the case back tomorrow; Got it brings it back in 3, then 7, 14 and 30 days.

All Cardiac casesBack to today