A 35-Year-Old Pregnant Woman Presents With Progressive Dyspnea and Palpitations
A 12-lead electrocardiogram reveals atrial fibrillation with a rapid ventricular rate.
Answer: C. Titrate her beta-blockers and start her on warfarin with a goal INR of 2 to 3
Anticoagulation is a class I indication in pregnant patients with mitral stenosis (MS) and AF. Pregnancy is a prothrombotic state that further exacerbates the underlying elevated risk for thromboembolism associated with both MS and AF.1 Patients should be started on warfarin and bridged to unfractionated heparin prior to delivery. Warfarin dose in the first trimester should not exceed 5 mg.1
Option A is incorrect because in patient like this with favorable valve morphology, percutaneous mitral balloon valvuloplasty is the preferred intervention, not surgical mitral valve repair or replacement. The fetal mortality rate for surgical valve repair surgery is 30% to 40% with a maternal mortality rate of up to 9%.1
Option D is also incorrect because in pregnancy medical therapy should be attempted before pursuing an intervention. Most women can get through delivery with medical therapy and close monitoring alone. Valvuloplasty should be reserved for patients with symptoms that are refractory to medical therapy, and surgical mitral valve repair or replacement for patients who are not candidates for percutaneous valvuloplasty with refractory New York Heart Association class IV symptoms.1 There is no indication for TEE and cardioversion at this time since the patient responded well to beta-blockers and is currently hemodynamically stable. Starting anticoagulation would be the preferred next step.
Nishimura RA, Otto CM, Bonow RO, et al; for the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):e57-e185.