Severe Mitral Stenosis in Term Pregnancy Presenting During Labor in a Resource-Limited Setting: A Case Report from Borama, Awdal Region of Somalia

Background: Mitral stenosis (MS), primarily from rheumatic heart disease (RHD), is a significant cause of maternal morbidity and mortality, especially in low- and middle-income countries (LMICs). Pregnancy places considerable stress on the cardiovascular system, often revealing or worsening existing cardiac issues. Diagnosing severe MS in pregnant women with acute heart failure is particularly difficult in resource-limited settings lacking specialized diagnostic modalities. Here, we report a case of severe undiagnosed MS presenting in active labor. Case Presentation: We present a 28-year-old multiparous woman (gravida 4, para 3) at 39 weeks of gestation, who arrived at Al-Rahma Specialist Hospital in Borama, Awdal region of Somalia, in active labor with acute dyspnea, orthopnea, hypoxia (SpO2 88%), and tachycardia (110 bpm). Initially suspected of having pre-eclampsia, further investigation using bedside echocardiography revealed severe rheumatic mitral stenosis (mitral valve area 0.9 cm 2 , mean gradient 15 mmHg, pulmonary artery systolic pressure ≈45 mmHg), a dilated left atrium, but preserved left ventricular function. Due to a lack of interventional cardiology facilities, management focused on medical stabilization with oxygen, intravenous furosemide, and therapeutic low molecular weight heparin. Despite her severe condition, she had an uncomplicated spontaneous vaginal delivery of a healthy infant, with significant symptom improvement postpartum. Conclusion: This case highlights the need for a high suspicion of severe mitral stenosis in pregnant women presenting with respiratory distress, even without typical pre-eclampsia signs. It underscores the importance of clinical judgment and echocardiography for timely diagnosis in LMICs. Favorable outcomes can be achieved through effective medical management and multidisciplinary collaboration, pointing to the urgent need for improved cardiac care infrastructure and comprehensive postpartum counseling in LMICs. Plain Language Summary: In pregnant women presenting with acute pulmonary edema or respiratory distress, particularly with normal blood pressure, a high index of suspicion for underlying cardiac etiologies—including valvular heart disease like mitral stenosis—is paramount.Transthoracic echocardiography, even basic studies, is an invaluable and often indispensable tool for accurate diagnosis and guiding management strategies for cardiac conditions in pregnancy, especially in resource-limited settings.In settings where definitive surgical or interventional options are unavailable, meticulous supportive medical management, careful hemodynamic monitoring, and multidisciplinary team planning for delivery can still lead to favorable maternal and fetal outcomes.