Urgent Mitral Commissurotomy During Labor in Critical Rheumatic Mitral Stenosis

A 32-year-old woman with critical rheumatic mitral stenosis presented at 39 weeks of gestation in early labor with ruptured membranes, having missed a percutaneous mitral commissurotomy planned for the second trimester. She was hemodynamically stable, with clear lungs and an oxygen saturation of 95% on room air, but reported dyspnea at rest corresponding to New York Heart Association class IV despite uninterrupted medical therapy. Echocardiography showed a mitral valve area of 0.55 cm², a mean transmitral gradient of 17 mm Hg, pulmonary artery systolic pressure of 58 mm Hg, a Wilkins score of 9 driven mainly by subvalvular thickening, and dense left atrial spontaneous echo contrast without thrombus. With the cervix dilated to 2 cm, a multidisciplinary team performed urgent Inoue-balloon commissurotomy two hours after admission. Mitral valve area increased to 1.60 cm², the mean gradient decreased to 6 mm Hg, the mean left atrial pressure fell from 37 to 26 mm Hg, and mitral regurgitation remained minimal. Spontaneous vaginal delivery of a term newborn followed approximately nine hours later, with Apgar scores of 8 at one minute and 10 at five minutes. No immediate maternal, obstetric, neonatal, or procedural complication occurred. This case illustrates individualized multidisciplinary sequencing of valve intervention and delivery when critical mitral stenosis is encountered after labor has already begun.