Caesarean Delivery for Severe Mitral Stenosis in Resource-Limited Settings: A Case Report

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Raquel, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6190220/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Low-income countries have a growing number of mothers presenting during pregnancy with uncorrected symptomatic moderate to severe stenotic mitral valve disease. The presence of uncorrected disease is due to limited resources in diagnostic and treatment services. The risk of poor maternal and foetal outcomes in mothers with heart disease is higher in low-income countries especially in stenotic disease of the mitral and aortic valves. Vaginal delivery in severe mitral stenosis is categorised as high risk for acute decompensation triggered by valsalva and therefore requires multidisciplinary resources with expertise comprised of skilled cardiologists, obstetricians, neonatologist and anaesthesiologist in an experienced hospital to mitigate these risks. These resources are hard to come by in a single hospital in low-income countries. These risks associated with limited resources reduce the benefits of a high-risk vaginal delivery necessitating individualised assessment such as the revised cardiac risk index for cesarean delivery. Case presentation: We received a 44-year-old peasant mother in her first trimester with symptoms of heart failure and subsequent assessment confirmed severe mitral stenosis. She declined our recommendations for abortion and was lost to follow up. She returned during her third trimester after decompensation due to atrial fibrillation with rapid ventricular response. The tachycardia was then controlled, and a multidisciplinary case discussion opted for cesarean delivery after symptom control which proceeded successfully without any immediate or late complications. Conclusion: This case highlights the challenges faced in trying to conduct high-risk vaginal delivery in resource constrained settings. Such a scenario reduces the potential benefits from these recommendations in the absence of maximal medical resources. We demonstrate the options available in areas with limited resources where a cesarean section offers a controlled environment which alleviates valsalva as a trigger for acute decomposition. This is because the revised cardiac risk index for her cesarean delivery is categorised as moderate risk which can be conducted in a resource-limited setting. Caesarean delivery Severe mitral stenosis Resource-limited setting Pregnant mothers Figures Figure 1 Figure 2 Figure 3 Background In pregnancy mitral stenosis is almost always due to Rheumatic Heart Disease (RHD) [ 1 ]. Uganda has a high prevalence of RHD with few cardiac specialist and resources resulting in diagnosis usually confirmed late [ 2 ]. Risks associated with severe mitral stenosis necessitate early termination of pregnancy to be discussed [ 3 ]. If a mother is opposed to this option the recommended mode of delivery is vaginal with assisted second stage in a setting with maximal medical resources [ 4 ]. This recommendation is based on the low mortality of 0–3% associated with cardiovascular diseases in pregnancy in western countries [ 3 ]. However, in low-income settings the maternal death in women with heart disease is much higher at 34% [ 5 ]. For this reason generalisation of management approaches is not realistic because vaginal delivery is poorly tolerated in mitral stenosis [ 6 ]. To the best of our knowledge there are a few cases reported on cesarean delivery in patients with severe mitral stenosis in resource-limited settings. Therefore, we present a 44-year gravida diagnosed with severe mitral stenosis who declined medical abortion and was successfully followed up and delivered by elective cesarean in the third trimester. Learning Objectives To understand that recommendations from the Task Force on the Management of Cardiovascular Diseases during Pregnancy regarding delivery of mothers with symptomatic severe mitral stenosis may not be generalisable, especially to resource-limited settings. To recognise that conducting a high-risk vaginal delivery in severe mitral stenosis requires maximal medical resources which are virtually absent in resource-limited settings. To highlight the need for individualised assessment, using the revised cardiac risk index in consideration of cesarean delivery for mild to moderate surgical risk cases in resource limited areas. Case presentation We present a 44-year-old mother in her first trimester presenting in the antenatal clinic with features suspicious for heart failure for two weeks. Internal medicine was consulted on this gravida five, para four, plus-zero in her 12th week of gestation. She had complaints of easy fatiguability while performing house chores with shortness of breath on light exertion, orthopnea and dry cough which gradually worsened over two weeks. No hemoptysis or palpitations. Resting relieved her symptoms. This was her index admission due to these symptoms. No prior diagnosis of heart disease. No history of hypertension or diabetes. She was unable to remember prior recurrent sore throat or joint pains. She doesn't smoke or drink alcohol. Her previous pregnancies were uneventful and all delivered vaginally. Her last born was 4 years of age. On examination, she was in moderate respiratory distress. No; pallor, jaundice, lymphadenopathies or cyanosis. She had mild bipedal oedema. Her vital signs were Blood Pressure of 105/70 mmHg, Pulse rate of 115, Pulse oxygen saturation of 96%, Temperature of 36.9 0 c. Cardiovascular examination revealed a regularly regular, normal volume, non-collapsing and synchronous radial pulse. No elevated Jugular venous Pressure. The point of maximal impulse was in the fifth intercostal space mid clavicular line with a tapping character, no thrills or heaves palpable. Her first and second heart sounds were of normal intensity with a low pitched continuous systolic murmur at the apex radiating to the axilla. Additionally, a mid-diastolic soft murmur was also heard with rumbling nature. She had no pericardial rub, no carotid bruit. Dorsalis pedis pulses were present with normal volume. She had no osler’s nodes, janeway lesions, or splinter haemorrhages. In her respiratory examination, she had a respiratory rate of 26 cycles per minute and few bi-basal fine crackles. The abdomen revealed signs of a gravid uterus with a fundal height estimated at 14 weeks and no hepatomegaly. The rest of the examination findings were unremarkable. A point of focus screening echocardiography done at the bedside showed (Fig. 1), thickened mitral valve leaflets with hockey stick appearance (Blue arrow). An electrocardiography showed sinus tachycardia. Access to comprehensive echocardiography was not readily available. Based on the above findings the management team started IV furosemide 40mg BD for 3/7, then switched to oral furosemide 60mg BD. Oral Bisoprolol 2.5mg OD was initiated on day 3/7 of admission when the chest was free of crackles; and increased to 5mg a week later at discharge. We scheduled her for review and comprehensive echocardiographic assessment in one week’s time. We advised her on risks associated with mitral stenosis in pregnancy and jointly with the obstetric team recommended that she terminates the gestation and start Benzathine penicillin G prophylaxis. However, she got lost to follow up returning in the 34th week of her pregnancy because she was avoiding termination of her pregnancy. At this time, she was re-admitted with palpitations in addition to exacerbation of the previous symptoms because she had defaulted on her medication a month prior. Her assessment revealed an irregularly irregular pulse and electrocardiography subsequently confirmed atrial fibrillation (Fig. 2). A comprehensive echocardiography (Fig. 3) revealed good systolic function with severe mitral valve stenosis of 0.85cm 2 and 0.72cm 2 by pressure half time and planimetry respectively, moderate mitral regurgitation (vena contracta of 0.5cm), mild tricuspid regurgitation (Pressure gradient of 7mmHg), Inferior vena cava of 1.8cm and a severely dilated left atrium. We then initiated Low molecular weight heparin, diuretics, bisoprolol and dexamethasone. A multidisciplinary team case discussion comprised of Internal medicine, Obstetrics & gynaecology, Anesthesia, critical care and paediatric departments jointly agreed on delivery by caesarean to avoid decompensation during vaginal delivery. A successful caesarean was done under spinal anaesthesia with tubal ligation following consent to the above recommendations. A live baby girl was born with a birth weight of 2.7 Kg with APGAR Score of 10/10. No immediate complications were noted. She was discharged in the second week of puerperium. She was monitored and reviewed serially in the outpatient department for six months and did relatively well post-delivery though still unable to afford fees for corrective valve surgery because the more than mild mitral regurgitation made balloon mitral valvuloplasty unsuitable. Discussion Severe mitral stenosis in pregnancy possess an extremely high risk of maternal mortality or severe morbidity [ 3 ]. Conducting a high risk vaginal delivery with assisted second stage in a patient with severe mitral stenosis in a setting without maximal resources can potentially result into complications. Guidelines by the European society of cardiology (ESC) recommends that nearly all gravidas with cardiac disease, vaginal delivery is preferred to cesarean delivery since vaginal delivery generally poses less cardiac risk [ 3 ]. This recommendation combines all cardiac lesions resulting in a low mortality of 1.9% compared with risks associated with caesarean delivery [ 7 ]. We thought this is not generalisable to gravidas with uncorrected symptomatic severe mitral stenosis. This is because majority of patients in the studies referenced for the recommendations either received preconception or during pregnancy intervention such as balloon valvuloplasty (BMV) or valve surgery. Among these studies, the European Registry on Pregnancy and Cardiac (ROPAC) disease demonstrates impacts of uncorrected severe mitral stenosis [ 7 ]. This study enrolled 2966 participants. Of these, 390 mothers had RHD and 30 mothers were found to have severe mitral stenosis. Amongst these, fourteen (14) were uncorrected which is representative of our scenario of which three (3) died, thus a case fatality of 3/14 (21.4%). This is an alarming number. In Sub Saharan Africa a study from Dakar in Senegal is more representative of our resource limited setting. In this study RHD was found in 46 mothers of which thirty-two 32/46 (69.9%) had uncorrected mitral stenosis. Seventeen (17) maternal deaths were registered in this study where almost all 15/17 individuals had severe mitral stenosis resulting in a case fatality of 15/32 (46.8%) [ 5 ],. This figure is more than twice that seen in the ROPAC study above. The ESC adopted findings from ROPAC data for high risk scenarios such as severe pulmonary arterial hypertension (PAH) and Eisenmenger’s to recommend cesarean delivery [ 3 ]. This is because it offers an opportunity of a controlled environment and avoids the risk of undergoing unplanned prolonged labour in high risk settings [ 8 ]. Our patient clinically had no indication for cesarean delivery but her vaginal delivery is categorised as a “ high risk ” delivery [ 9 ]. The team available for her care lacked a cardiologist and had less than optimal equipment to manage the potential risks associated with acute heart failure decompensation. The joint team decided on an individualised approach for cesarean delivery, given that the patient’s revised cardiac risk index was classified as “ moderate ” [ 10 ]. The team concluded that the procedure could be safely performed with the resources available at the regional referral hospital. Conclusion Hemodynamic changes during labor in high-risk mothers, such as those with severe mitral stenosis, are linked to rapid elevation of filling pressures. This can lead to acute pulmonary oedema, which carries significant morbidity and mortality risks. In resource-limited settings, the benefits of attempting a high-risk vaginal delivery are reduced due to suboptimal conditions. For mothers with uncorrected severe mitral stenosis, an individualised approach—such as performing a cesarean delivery deemed mild to moderate risk according to the revised cardiac risk index—can be a more feasible and safer option. Abbreviations RHD - Rheumatic Heart Disease ESC - European society of cardiology ROPAC - European Registry on Pregnancy and Cardiac diseases Declarations Ethics approval and consent to participate: Applied for at The Mbarara University of Science and Technology – Research Ethics Committee (MUST – REC) Consent for publication: We acquired written informed consent from the patient. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: No funding is associated with the content of this work. Acknowledgements: Heads of department in Internal medicine, Obstetrics and Gynaecology, Anaesthesia and Critical care, and Uganda Heart Institute Rheumatic Heart Disease registry. Author Contribution ER: Wrote the main Manuscript text and led the multidisciplinary case discussion that led to the individualised management.OB: Identified the patient and initiated the initial consultation and subsequent follow up and participated in the delivery of the patient. OMA: Participated in the obstetric aspects of the multidisciplinary case presentation and management of the patient. MGK: Participated in the obstetric aspects of the multidisciplinary case preparation and management of the patient. LN: Participated in the anaesthesia aspects of the multidisciplinary case presentation and management of the patient. BA: Participated in the obstetric aspects of the multidisciplinary case presentation and management of the patient. BAEL: Was the faculty that guided the students in the organization of the case and editing from the time of case identification through the multidisciplinary discussion to guidance on publication. References OLSON, L.J., et al. Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. in Mayo Clinic Proceedings. 1987. Elsevier. Lwabi, P., et al., The Uganda Heart Association: Developing cardiovascular care for the 45 million population is the objective of the Uganda Heart Association. 2019, Oxford University Press. Regitz-Zagrosek, V., et al., 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy: the task force for the management of cardiovascular diseases during pregnancy of the European Society of Cardiology (ESC). 2018. 39(34): p. 3165-3241. Obstetricians, A.C.o. and G.J.O. Gynecol, ACOG practice bulletin no. 212: pregnancy and heart disease. 2019. 133(5): p. e320-e356. Diao, M., et al., Pregnancy in women with heart disease in sub-Saharan Africa. 2011. 104(6-7): p. 370-374. Nanna, M. and K.J.J.o.t.A.H.A. Stergiopoulos, Pregnancy complicated by valvular heart disease: an update. 2014. 3(3): p. e000712. Van Hagen, I.M., et al., Pregnancy in women with a mechanical heart valve: data of the European Society of Cardiology Registry of Pregnancy and Cardiac Disease (ROPAC). 2015. 132(2): p. 132-142. Weiss, B.M., et al., Pregnant patient with primary pulmonary hypertension: inhaled pulmonary vasodilators and epidural anesthesia for cesarean delivery. 2000. 92(4): p. 1191-1191. Endorsed by the European Society of Gynecology , t.A.f.E.P.C., et al., 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). 2011. 32(24): p. 3147-3197. Lee, T.H., et al., Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. 1999. 100(10): p. 1043-1049. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6190220","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":493623519,"identity":"b9751a72-3544-4c92-a645-401ed9334e6b","order_by":0,"name":"Elijah Rutahaba","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYLACxgaGBAb2BlI0gLXwHACyE0jSIpFApBZ+6TPmD37usMvjn/k6TfLnDwZ5/gYe4xf4tEj25Rg29p5JLpa4nbtNmieBwXDGAR4zC3xaDM7wGDbwtjEnNoC0AB3GuIGBx8wAnxZ7oJbGv231ifNvnt0m+SOBwZ6gFgMeHsNm3rbDiRtu8G6TADosEajF+AE+LRJn2Apny7YdLzY8k7vZmidNInnGYbYyfDoY+HuYN3x821adJ3f87MabP2xsbPvbmzd/wKsH3VYGBmYGNglStIABM0m2jIJRMApGwbAHAG9GSFnEbc9zAAAAAElFTkSuQmCC","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":true,"prefix":"","firstName":"Elijah","middleName":"","lastName":"Rutahaba","suffix":""},{"id":493623520,"identity":"eee78d69-ee15-40d6-894e-15da5634f244","order_by":1,"name":"Onesmus Byamukama","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Onesmus","middleName":"","lastName":"Byamukama","suffix":""},{"id":493623521,"identity":"87590866-f220-48f1-a45f-b9039273e163","order_by":2,"name":"Onesmus M Ahabwe","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Onesmus","middleName":"M","lastName":"Ahabwe","suffix":""},{"id":493623522,"identity":"2b8d7255-fe32-45a1-8568-1a394eadd164","order_by":3,"name":"Martinez G.K. Raquel","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Martinez","middleName":"G.K.","lastName":"Raquel","suffix":""},{"id":493623523,"identity":"fe0f48df-7e37-49e3-a8b0-c4583f582838","order_by":4,"name":"Lazia Najjuma","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Lazia","middleName":"","lastName":"Najjuma","suffix":""},{"id":493623524,"identity":"a37c9da7-4b65-4614-b71a-e5f8e5c0b2cd","order_by":5,"name":"Brenda Ainomugisha","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Brenda","middleName":"","lastName":"Ainomugisha","suffix":""},{"id":493623525,"identity":"08ba4c22-06e8-493a-84fe-8e65a535df49","order_by":6,"name":"Boniface. A.E Lumori","email":"","orcid":"","institution":"Mbarara University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Boniface.","middleName":"A.E","lastName":"Lumori","suffix":""}],"badges":[],"createdAt":"2025-03-09 19:38:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6190220/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6190220/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88310927,"identity":"8ef64d85-a000-4228-8616-f17c3e91e91e","added_by":"auto","created_at":"2025-08-05 06:54:19","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":47691,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA: \u003c/strong\u003eBlue arrow showing thickend mitral valve leaftlet tips with anterior mitral valve\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6190220/v1/99f01b5c2df8f61902beb8a6.jpg"},{"id":88310928,"identity":"696cc9d5-0d38-4a1f-ba05-0e1504578855","added_by":"auto","created_at":"2025-08-05 06:54:19","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":71444,"visible":true,"origin":"","legend":"\u003cp\u003eAn electrocardiogram showing atrial fibrilation with controled rates.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6190220/v1/9372d9b64030e886286002de.jpg"},{"id":88310930,"identity":"c4f4a35b-9970-44d3-9d72-11e12c3b37ec","added_by":"auto","created_at":"2025-08-05 06:54:19","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":93312,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA: \u003c/strong\u003eShowing dilated left atrium of 5.5cm. \u003cstrong\u003eB: \u003c/strong\u003eShowing severe mitral valve stenosis by planimetry approximating 0.72cm\u003csup\u003e2\u003c/sup\u003e. \u003cstrong\u003eC: \u003c/strong\u003eShowing mild tricuspid regurgitation. \u003cstrong\u003eD: \u003c/strong\u003eShowing moderate mitral regurgitation.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6190220/v1/7819bbd80770667c89726752.jpg"},{"id":104776740,"identity":"1fb1d14a-af12-4813-a742-108bbc738e3d","added_by":"auto","created_at":"2026-03-17 06:57:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":649940,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6190220/v1/fbe670cc-3eec-405b-9874-8924e9f05d6a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eCaesarean Delivery for Severe Mitral Stenosis in Resource-Limited Settings: A Case Report\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eIn pregnancy mitral stenosis is almost always due to Rheumatic Heart Disease (RHD) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Uganda has a high prevalence of RHD with few cardiac specialist and resources resulting in diagnosis usually confirmed late [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Risks associated with severe mitral stenosis necessitate early termination of pregnancy to be discussed [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. If a mother is opposed to this option the recommended mode of delivery is vaginal with assisted second stage in a setting with \u003cb\u003emaximal medical resources\u003c/b\u003e [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This recommendation is based on the low mortality of 0–3% associated with cardiovascular diseases in pregnancy in western countries [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, in low-income settings the maternal death in women with heart disease is much higher at 34% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. For this reason generalisation of management approaches is not realistic because vaginal delivery is poorly tolerated in mitral stenosis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. To the best of our knowledge there are a few cases reported on cesarean delivery in patients with severe mitral stenosis in resource-limited settings. Therefore, we present a 44-year gravida diagnosed with severe mitral stenosis who declined medical abortion and was successfully followed up and delivered by elective cesarean in the third trimester.\u003c/p\u003e\n\n\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Learning Objectives","content":"\u003cul\u003e\u003cli\u003e\u003cp\u003eTo understand that recommendations from the Task Force on the Management of Cardiovascular Diseases during Pregnancy regarding delivery of mothers with symptomatic severe mitral stenosis may not be generalisable, especially to resource-limited settings.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTo recognise that conducting a high-risk vaginal delivery in severe mitral stenosis requires maximal medical resources which are virtually absent in resource-limited settings.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTo highlight the need for individualised assessment, using the revised cardiac risk index in consideration of cesarean delivery for mild to moderate surgical risk cases in resource limited areas.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e"},{"header":"Case presentation","content":"\u003cp\u003eWe present a 44-year-old mother in her first trimester presenting in the antenatal clinic with features suspicious for heart failure for two weeks. Internal medicine was consulted on this gravida five, para four, plus-zero in her 12th week of gestation. She had complaints of easy fatiguability while performing house chores with shortness of breath on light exertion, orthopnea and dry cough which gradually worsened over two weeks. No hemoptysis or palpitations. Resting relieved her symptoms. This was her index admission due to these symptoms. No prior diagnosis of heart disease. No history of hypertension or diabetes. She was unable to remember prior recurrent sore throat or joint pains. She doesn't smoke or drink alcohol. Her previous pregnancies were uneventful and all delivered vaginally. Her last born was 4 years of age. On examination, she was in moderate respiratory distress. No; pallor, jaundice, lymphadenopathies or cyanosis. She had mild bipedal oedema. Her vital signs were Blood Pressure of 105/70 mmHg, Pulse rate of 115, Pulse oxygen saturation of 96%, Temperature of 36.9\u003csup\u003e0\u003c/sup\u003ec. Cardiovascular examination revealed a regularly regular, normal volume, non-collapsing and synchronous radial pulse. No elevated Jugular venous Pressure. The point of maximal impulse was in the fifth intercostal space mid clavicular line with a tapping character, no thrills or heaves palpable. Her first and second heart sounds were of normal intensity with a low pitched continuous systolic murmur at the apex radiating to the axilla. Additionally, a mid-diastolic soft murmur was also heard with rumbling nature. She had no pericardial rub, no carotid bruit. Dorsalis pedis pulses were present with normal volume. She had no osler’s nodes, janeway lesions, or splinter haemorrhages. In her respiratory examination, she had a respiratory rate of 26 cycles per minute and few bi-basal fine crackles. The abdomen revealed signs of a gravid uterus with a fundal height estimated at 14 weeks and no hepatomegaly. The rest of the examination findings were unremarkable. A point of focus screening echocardiography done at the bedside showed (Fig.\u0026nbsp;1), thickened mitral valve leaflets with hockey stick appearance (Blue arrow). An electrocardiography showed sinus tachycardia. Access to comprehensive echocardiography was not readily available. Based on the above findings the management team started IV furosemide 40mg BD for 3/7, then switched to oral furosemide 60mg BD. Oral Bisoprolol 2.5mg OD was initiated on day 3/7 of admission when the chest was free of crackles; and increased to 5mg a week later at discharge. We scheduled her for review and comprehensive echocardiographic assessment in one week’s time. We advised her on risks associated with mitral stenosis in pregnancy and jointly with the obstetric team recommended that she terminates the gestation and start Benzathine penicillin G prophylaxis. However, she got lost to follow up returning in the 34th week of her pregnancy because she was avoiding termination of her pregnancy. At this time, she was re-admitted with palpitations in addition to exacerbation of the previous symptoms because she had defaulted on her medication a month prior. Her assessment revealed an irregularly irregular pulse and electrocardiography subsequently confirmed atrial fibrillation (Fig.\u0026nbsp;2). A comprehensive echocardiography (Fig.\u0026nbsp;3) revealed good systolic function with severe mitral valve stenosis of 0.85cm\u003csup\u003e2\u003c/sup\u003e and 0.72cm\u003csup\u003e2\u003c/sup\u003e by pressure half time and planimetry respectively, moderate mitral regurgitation (vena contracta of 0.5cm), mild tricuspid regurgitation (Pressure gradient of 7mmHg), Inferior vena cava of 1.8cm and a severely dilated left atrium. We then initiated Low molecular weight heparin, diuretics, bisoprolol and dexamethasone. A multidisciplinary team case discussion comprised of Internal medicine, Obstetrics \u0026amp; gynaecology, Anesthesia, critical care and paediatric departments jointly agreed on delivery by caesarean to avoid decompensation during vaginal delivery. A successful caesarean was done under spinal anaesthesia with tubal ligation following consent to the above recommendations. A live baby girl was born with a birth weight of 2.7 Kg with APGAR Score of 10/10. No immediate complications were noted. She was discharged in the second week of puerperium. She was monitored and reviewed serially in the outpatient department for six months and did relatively well post-delivery though still unable to afford fees for corrective valve surgery because the more than mild mitral regurgitation made balloon mitral valvuloplasty unsuitable.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSevere mitral stenosis in pregnancy possess an extremely high risk of maternal mortality or severe morbidity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Conducting a high risk vaginal delivery with assisted second stage in a patient with severe mitral stenosis in a setting without maximal resources can potentially result into complications. Guidelines by the European society of cardiology (ESC) recommends that \u003cb\u003enearly all gravidas\u003c/b\u003e with cardiac disease, vaginal delivery is preferred to cesarean delivery since vaginal delivery generally poses less cardiac risk [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This recommendation combines all cardiac lesions resulting in a low mortality of 1.9% compared with risks associated with caesarean delivery [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. We thought this is not generalisable to gravidas with uncorrected symptomatic severe mitral stenosis. This is because majority of patients in the studies referenced for the recommendations either received preconception or during pregnancy intervention such as balloon valvuloplasty (BMV) or valve surgery. Among these studies, the European Registry on Pregnancy and Cardiac (ROPAC) disease demonstrates impacts of uncorrected severe mitral stenosis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This study enrolled 2966 participants. Of these, 390 mothers had RHD and 30 mothers were found to have severe mitral stenosis. Amongst these, fourteen (14) were uncorrected which is representative of our scenario of which three (3) died, thus a case fatality of 3/14 (21.4%). This is an alarming number. In Sub Saharan Africa a study from Dakar in Senegal is more representative of our resource limited setting. In this study RHD was found in 46 mothers of which thirty-two 32/46 (69.9%) had uncorrected mitral stenosis. Seventeen (17) maternal deaths were registered in this study where almost all 15/17 individuals had severe mitral stenosis resulting in a case fatality of 15/32 (46.8%) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e],. This figure is more than twice that seen in the ROPAC study above. The ESC adopted findings from ROPAC data for high risk scenarios such as severe pulmonary arterial hypertension (PAH) and Eisenmenger\u0026rsquo;s to recommend cesarean delivery [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This is because it offers an opportunity of a controlled environment and avoids the risk of undergoing unplanned prolonged labour in high risk settings [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Our patient clinically had no indication for cesarean delivery but her vaginal delivery is categorised as a \u0026ldquo;\u003cb\u003ehigh risk\u003c/b\u003e\u0026rdquo; delivery [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The team available for her care lacked a cardiologist and had less than optimal equipment to manage the potential risks associated with acute heart failure decompensation. The joint team decided on an individualised approach for cesarean delivery, given that the patient\u0026rsquo;s revised cardiac risk index was classified as \u0026ldquo;\u003cb\u003emoderate\u003c/b\u003e\u0026rdquo; [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The team concluded that the procedure could be safely performed with the resources available at the regional referral hospital.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eHemodynamic changes during labor in high-risk mothers, such as those with severe mitral stenosis, are linked to rapid elevation of filling pressures. This can lead to acute pulmonary oedema, which carries significant morbidity and mortality risks. In resource-limited settings, the benefits of attempting a high-risk vaginal delivery are reduced due to suboptimal conditions. For mothers with uncorrected severe mitral stenosis, an individualised approach\u0026mdash;such as performing a cesarean delivery deemed mild to moderate risk according to the revised cardiac risk index\u0026mdash;can be a more feasible and safer option.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cul\u003e\n \u003cli\u003eRHD - Rheumatic Heart Disease\u003c/li\u003e\n \u003cli\u003eESC - European society of cardiology\u003c/li\u003e\n \u003cli\u003eROPAC - European Registry on Pregnancy and Cardiac diseases\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eApplied for at The Mbarara University of Science and Technology \u0026ndash; Research Ethics Committee (MUST \u0026ndash; REC)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eWe acquired written informed consent from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNo funding is associated with the content of this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eHeads of department in Internal medicine, Obstetrics and Gynaecology, Anaesthesia and Critical care, and Uganda Heart Institute Rheumatic Heart Disease registry.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eER: Wrote the main Manuscript text and led the multidisciplinary case discussion that led to the individualised management.OB: Identified the patient and initiated the initial consultation and subsequent follow up and participated in the delivery of the patient. OMA: Participated in the obstetric aspects of the multidisciplinary case presentation and management of the patient. MGK: Participated in the obstetric aspects of the multidisciplinary case preparation and management of the patient. LN: Participated in the anaesthesia aspects of the multidisciplinary case presentation and management of the patient. BA: Participated in the obstetric aspects of the multidisciplinary case presentation and management of the patient. BAEL: Was the faculty that guided the students in the organization of the case and editing from the time of case identification through the multidisciplinary discussion to guidance on publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOLSON, L.J., et al. Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. in Mayo Clinic Proceedings. 1987. Elsevier.\u003c/li\u003e\n\u003cli\u003eLwabi, P., et al., The Uganda Heart Association: Developing cardiovascular care for the 45 million population is the objective of the Uganda Heart Association. 2019, Oxford University Press.\u003c/li\u003e\n\u003cli\u003eRegitz-Zagrosek, V., et al., 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy: the task force for the management of cardiovascular diseases during pregnancy of the European Society of Cardiology (ESC). 2018. 39(34): p. 3165-3241.\u003c/li\u003e\n\u003cli\u003eObstetricians, A.C.o. and G.J.O. Gynecol, ACOG practice bulletin no. 212: pregnancy and heart disease. 2019. 133(5): p. e320-e356.\u003c/li\u003e\n\u003cli\u003eDiao, M., et al., Pregnancy in women with heart disease in sub-Saharan Africa. 2011. 104(6-7): p. 370-374.\u003c/li\u003e\n\u003cli\u003eNanna, M. and K.J.J.o.t.A.H.A. Stergiopoulos, Pregnancy complicated by valvular heart disease: an update. 2014. 3(3): p. e000712.\u003c/li\u003e\n\u003cli\u003eVan Hagen, I.M., et al., Pregnancy in women with a mechanical heart valve: data of the European Society of Cardiology Registry of Pregnancy and Cardiac Disease (ROPAC). 2015. 132(2): p. 132-142.\u003c/li\u003e\n\u003cli\u003eWeiss, B.M., et al., Pregnant patient with primary pulmonary hypertension: inhaled pulmonary vasodilators and epidural anesthesia for cesarean delivery. 2000. 92(4): p. 1191-1191.\u003c/li\u003e\n\u003cli\u003eEndorsed by the European Society of Gynecology , t.A.f.E.P.C., et al., 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). 2011. 32(24): p. 3147-3197.\u003c/li\u003e\n\u003cli\u003eLee, T.H., et al., Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. 1999. 100(10): p. 1043-1049.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Caesarean delivery, Severe mitral stenosis, Resource-limited setting, Pregnant mothers","lastPublishedDoi":"10.21203/rs.3.rs-6190220/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6190220/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eLow-income countries have a growing number of mothers presenting during pregnancy with uncorrected symptomatic moderate to severe stenotic mitral valve disease. The presence of uncorrected disease is due to limited resources in diagnostic and treatment services. The risk of poor maternal and foetal outcomes in mothers with heart disease is higher in low-income countries especially in stenotic disease of the mitral and aortic valves. Vaginal delivery in severe mitral stenosis is categorised as high risk for acute decompensation triggered by valsalva and therefore requires multidisciplinary resources with expertise comprised of skilled cardiologists, obstetricians, neonatologist and anaesthesiologist in an experienced hospital to mitigate these risks. These resources are hard to come by in a single hospital in low-income countries. These risks associated with limited resources reduce the benefits of a high-risk vaginal delivery necessitating individualised assessment such as the revised cardiac risk index for cesarean delivery.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e\u003cp\u003eWe received a 44-year-old peasant mother in her first trimester with symptoms of heart failure and subsequent assessment confirmed severe mitral stenosis. She declined our recommendations for abortion and was lost to follow up. She returned during her third trimester after decompensation due to atrial fibrillation with rapid ventricular response. The tachycardia was then controlled, and a multidisciplinary case discussion opted for cesarean delivery after symptom control which proceeded successfully without any immediate or late complications.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eThis case highlights the challenges faced in trying to conduct high-risk vaginal delivery in resource constrained settings. Such a scenario reduces the potential benefits from these recommendations in the absence of maximal medical resources. We demonstrate the options available in areas with limited resources where a cesarean section offers a controlled environment which alleviates valsalva as a trigger for acute decomposition. This is because the revised cardiac risk index for her cesarean delivery is categorised as moderate risk which can be conducted in a resource-limited setting.\u003c/p\u003e","manuscriptTitle":"Caesarean Delivery for Severe Mitral Stenosis in Resource-Limited Settings: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-05 06:54:11","doi":"10.21203/rs.3.rs-6190220/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e4e0f886-c7ec-4fcf-a7ea-3bbb96f5d951","owner":[],"postedDate":"August 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-17T06:55:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-05 06:54:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6190220","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6190220","identity":"rs-6190220","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}