J. EDWARD IIALL, M.D., AND ROBERT CHARLES (From
and at hTcw
IN PREGNANCY” KNAPP, of
M.D., BROOKLYN, Tiniocrsity
N. Y. l’ork.
EART disease has become one of the most important causes of maternal mortality since toxemia, hemorrhage. and infection have been treated more successfully. Mitral commissurotc)Jl~y, by rclicving pulmonary hypcrtension and thus decreasing the danger of congestive heart failure, may be of great value 1.0 certain pregnant cardiac patients. An increase in maternal and fetal salvage can be expected if the cases arc selected properly. In recent years t.here has been much discussion in the literature concerning the value of cardiac surgery during the pregnant state. Some investigators believe that pregnancy may increase the risk of commissurotomy. Hamiltonlo is of the opinion that operation should be avoided during pregRurwrl15 does not advocate mit,ral valve nancy except in rare circumstances. surgery during the pregnant state. He believes that, with few exceptions, the patients who are in congestive heart failure can be brought to term and delivered normally with careful medical control. Furthermore, he believes that mitral valve surgery frequently reactivates the rheumatic disease, which is extremely undesirable during pregnancy. He therefore advocates mitral valve surgery, where indicatecl, after the postpartum period. Glover’ believes that commissurotomy is not advisable during pregnancy except in patients in Classes 3 and 4. He believes that patients in Classes 1 and 2 can be safely carried through pregnancy and delivered under strict medical regimen. Commissurotomy in these cases may be consiclcrcd at a later date. On the other hand, Abramson and Tenneyl are of t,hc opinion that under certain circumstances it is advisable to recommend mitral valve surgery during pregnancy. If a woman with mitral stenosis has had progressive disability before her pregnancy to a degree sufficient for operation to have been advisecl, it is proper to recommend operation during the first four months of pregnancy. The risk of operation at this time is less than if valvulotomy were done later in pregnancy because of the worsening of the cardiac state. Mendelson” believes that the 5 per cent mortality associated with valvulotomy is no higher than that associated with the operation in the nonpregnant state. Some believe that the benefits from valvulotomy will not occur during pregnancy since the hemodynamic burden of pregnancy may develop before adequate benefits from the operation materialize. It is the opinion of most investigators that coillmissurotomy is best done in the first trimester when the cardiac load is less and when the patient can be so improved by surgery that she can safely go through the remainder of the *Presented
at a meeting of the Brooklyn
Society, Oct. 19, 1955.
Volume 72 Number F
pregnancy. Therefore, as a rule it is contraindicated after the thirty-second week and should be carefully weighed from t,he sixteenth to the thirty-second week. MendelsorP reported upon 16 patients from the Lying-In Hospital who became pregnant subsequent to valvulotomy and all went through pregnant) without cardiac difficulty. One patient had multiple fibromyomas and aborted at the fourth month. There was no other recorded fetal mortality. He also reported upon 40 patients who underwent valvulotomy at varying times ant<‘ partum from the second to the thirty-sixth week of gestation. All but 2 survived ; one of these had irreversible pulmonary vascular changes. Abortio-tl had to be performed in another patient following operation because of sevc~ca mitral insufficiency. The remaining 37 patients did well. Glover and his associates7 reported 5 commissurotomit~s performed during pregnancy. They reported that all these patients withstood t,he operation wt~ll ant1 all 5 showed marked functional improvcmc~nt.
Report of Cases CASE 1.-M. K., No. 50836, a 26-year-old white housewife, para i, gravida i, first She was hospitalized for developed symptoms of rheumatic fever at the age of 10 years. 3 years and spent another year in bed at home. Two years later she was hospitalized for 8 months because of another attack. Precordial pain, palpitation, and mild exert,ional dyspnea developed and she was admitted to the medical service of the Kings County Hospital on Feb. 20, 1954. The pertinent cardiac findings were a regular sinus rhythm, thrill at the apex, Grade II diastolic and Grade III systolic murmur at t,he apex. M, was lot111 and snapping and P, was greater than A,. There was cardiac enlargement and laborator? studies helped to establish a diagnosis of mitral stenosis anI1 milt1 mitral insufficiene?-. A mitral commissurotomy was performed on March 11. 1954, antI the patient matte an uneventful recovery.
The patient was first seen in the obstetrical clinic on Dec. 17, 1954, at which time she was 5 months pregnant. She was admitted to the hospital on Jan. 20, 1955, because of some dyspnea and placed on bed rest ancl digitalizetl. She was delivered of a ::,llO gram living infant by breech extraction under cyclopropane anesthesia on April II, 195.5. She had an uneventful postpartum course and all follow-up examinations have shown normal cardiac findings. CASE 2.--J. B., No. 52913, a 24-year-old Negro woman, para i, gravida i, was firrt admitted to the Kings County Hospital in December, 1949, because of fever, epistarix, and polyarthritis. She was discharged after 5 daps and was readmitted Ott,. 20, 1953, with a diagnosis of severe mitral stenosis and mild mitral insufficiency. After a thorough workup, a mitral commissurotomy was performed on Sov. 23, 1953. Seven days post operation, the patient developed signs and symptoms suggestive of acute perit,onitis but She was discharged in good condition laparotomy failed to disclose any abnormality. and was seen in the prenatal clinic on March 3, 1955. when she was 2 months pregnant. She was placed on Serpasil,” digitalis, and a and was admitted for cardiac rva,luation. for low-salt diet, and discharged to the clinic. On Sept. 22, 1955, she was readmitted cardiac survey and was delivered by low segment cesarean section, under Spinal XIICS. The indication for the section wa% thesia, of a living infant who weighed 2,480 grams. The postoperative course was uneventful. arnnionitis and primary uterine inertia. CASE
told she 25 years.
3.-F. I,., No. 71717, a 37.year-old white housewife, para ii, gravida ii, was first had valvular heart disease during a routine physical examination at the age of At the age of 30, she was delivered of a living infant following an uneventful
pregnancy and delivery. She developed exertional dyspnea, cough, and orthopnea 17 lla!s post pa&urn. She was placetl on digitalis ant1 followed in t.he cardiac clinic. On Nov. IO, 1954, she was seen in the prenatal clinic because she was 2 months pregnant. She was admitted to the hospital one month later because of hemoptgsis anI1 marked dyspnea. Following a complete workup, a mitral commissurotomy was performed on Jan. 12, 1955. The postoperative course was uneventful except for the development of a postcommissurotomy syndrome which was successfully treated. She remained in the hospital ant1 was delivered on June 26, 1955, of a living 3,030 gram female infant under saddle block anesthesia. The postpartum course was uneventful and she has been able to 110 her own housework and care for her family. CASE 4.-C. N., No. 13282, a 22.year-old white woman, para i, abortus i, gravida ii, had her first attack of rheumatic fever at the age of 6. She was hospitalized for one year and then attended a special school for cardiac patients. The cardiac symptoms in creased in severity and in 1952 at the age of 19 she was delivered of a living infant that weighed 2,240 grams following 7 months of bed rest and digitalis. Congestive heart failure developed 7 months post partum and on Nov. 18, 1952, a mitral commissurotom> was performed. Following this procedure there was marked improvement in her cardiac reserve. She was first seen in the prenatal clinic on March 34, 1955, when she was ‘8 weeks pregnant. She was admitted to the hospital, placed on bed rest, Serpasil, and a low-salt diet, and was delivered on June 6, 1955, of a living infant weighing 2,800 grams under saddle block anesthesia. Her postpartum course was uneventful. There has been no resumption of cardiac symptoms and she does her own housework ant1 cares for her two children.
Comment Although mitral valvulotomy may be of great value in the management of the pregnant patient with heart disease, it is only an adjunct. The accepted principles of treating these patients must still be employed and one must not be lulled into a false sense of security because of the benefits derived from the surgical procedure. Each patient for whom valvulotomy is to be considered must be surveyed as to cardiac status and the advisability of the operation. The major beneficial effect of mitral commissurotomy is the reduction of pulmona.ry vascular hypertension and if this is not achieved the operation is a failure. Therefore, there are definite indications and contraindications for mitral valvulotomy which have been outlined by Mendelsonll and with which we would agree. The indications mainly are based on the establishment of the diagnosis of a tight mitral stenosis. The contraindications are active rheumatic fever, subacute bacterial endocarditis, mitral insufficiency, and major involvement of the other valves. If the cases are selected with these principles in mind, one can anticipate a favorable outcome. Proper selection combined with improved surgical techniques should result in an operative mortality of 1 to 5 per cent.
Summary Four cases of rheumatic heart disease with mitral stenosis associated with pregnancy treated by mitral commissurotomy have been reported. Three of these operations were done prior to pregnancy and the fourth at the fifteenth
Vohne 7-7 Number 5
week of gestation. The results have all been favorable. It should be emphasized that this operation is only an adjunct in the treatment of the pregnant cardiac patient and does not replace the accepted principles of management of these patients. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Abramson, J., and Tenney, B.: New England J. Med. 253: 279, 1955. AM. J. OBST. & GYNEC. 67: 741,1954. Adams, J. Q.: Bigelow, W. G., and Greenwood, W. F.: AM. J. OBST. & GYNEC. 67: Brock. R. C.: Proc. Rov. Sot. Med. 45: 538.1952. Burw&l, C. S.: Bull. JLhns Hopkins Hosp.‘95: 130, 1954. J. A. M. A. 150: 1113.1952. Cooler. D. A.. and ChaDman. D. W.: Glove”r; R. P.; et al.: i. A. %f. A. 158: 895, 1955. Gorenberg, H., and Chesley, L. C.: Obst. & Gynec. 1: 15, 1953. Gorenberg, H., and Chesley, L. C.: AM. J. OBST. & GYNEC. 68: 1151, Hamilton, 13. E.: Circulation 9: 922, 1954. Mendelson, C. L.: AM. J. OBST. & GYNEC. 69: 1233, 1955.