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

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.