Case Report: Shared decision-making in severe rheumatic mitral stenosis complicating pregnancy

Severe rheumatic mitral stenosis (MS) is one of the highest-risk valvular lesions in pregnancy, and it becomes particularly hard to manage when the valve is unsuitable for percutaneous balloon mitral valvuloplasty (PBMV) and the patient declines termination. We describe a 20-year-old primigravida who presented at 23.5 weeks of gestation with progressive dyspnea, having deteriorated from New York Heart Association (NYHA) class I to class III. Multimodality echocardiography confirmed severe rheumatic MS, with a valve area of 0.5 cm² by two-dimensional planimetry and 0.572 cm² by three-dimensional transesophageal planimetry, a mean transmitral gradient of 15 mmHg, and a Wilkins score of 13, together with severe left atrial dilatation and pulmonary hypertension. PBMV was not feasible. After a shared decision-making process that respected the patient's refusal of termination, a multidisciplinary cardio-obstetric team provided a medical bridge aimed at fetal viability. Acute pulmonary edema at 28.1 weeks led to cesarean delivery of a 940 g neonate, and the patient underwent uncomplicated mechanical mitral valve replacement two weeks postpartum. The case shows how shared decision-making, multidisciplinary care, and the timing of surgery after delivery can be combined to protect both mother and child.