Pregnancy in patients with mitral valve prolapse

217

hr. J. Gynaecol. Obsrer., 1985, 23: 217-221

International

Federation of Gynaecology & Obstetrics

PREGNANCY IN PATIENTS WITH MITRAL VALVE PROLAPSE

LAWRENCE C.H. TANG, STEVEN Y.W. CHAN, VIVIAN C.W. WONG and HO-KEI MA Deparrmenr

of Obsrerrics and Gynaecology,

University of Hong Kong. Hong Kong (Hong Kong)

(Received September 9th, 1984) (Accepted January 23rd, 1985)

Abstract Tang LCH, Chan SY W Wong VCW, Ma HK. (Department of Obstetrics and Gynaecology, University of Hong Kong, Hong Kong). Pregnancy in patients with mitral valve prolapse. Int J Gynaecol Obstet 23: 217-221, 1985 The obstetrical performances and outcomes of 37 pregnancies in women with mitral valve prolapse between 19 79 and 1982 are reviewed. Thirteen patients were diagnosed before pregnancy and 24 patients were detected at antenatal examinations. Three ended in cesarean sections for obstetrical complications and 34 in uneventful vaginal deliveries at term. No cardiac complications occurred in these patients. There was no maternal mortality. Thirty-six babies were born without congenital abnormalities. One baby was hydropic due to haemoglobinopathy and died. Prophylactic antibiotics is recommended in selected cases. Early detection and treatment of cardiac arrhythmias is mandatory.

Keywords: Mitral valve; Mitral valve prolapse; Maternal medical in pregnancy.

complication;

Heart disease

Introduction Idiopathic or primary mitral valve prolapse is diagnosed if clinical evidence of prolapse of the posterior leaflet of the mitral valve is detected in the absence of any other heart disease 0020-7292/85/$03.30 0 1985 International

Federation of Gynaecology & Obstetrics Published and Printed in Ireland

or specific congenital syndrome such as ischaemit heart disease, rheumatic heart disease, hypertrophic obstructive cardiomyopathy. congenital cardiac defect (e.g. ostium secumdum-type atria1 septal defect), muscular dystrophy and certain connective tissue and musculoskeletal disease with involvement of the mitral valvular apparatus (e.g. Marfan syndrome, Ehlers-Danlos syndrome and [ I,18 I. osteogenesis imperfecta) It is probably the most common valvular disease in adults [9]. Most studies reported a prevalence of as high as 6% in the general population [26,29,30] and a slight female preponderance was observed [6,241. Circumstantial evidence supports a developmental abnormality of connective tissue with myxomatous transformation in the redundant leaflet as the pathogenesis. Family studies have suggested a dominant autosomal pattern of inheritance [ 14,33,35]. Majority of patients are asymptomatic and are discovered incidentally to have mitral valve prolapse [ 31. A significant proportion of these patients have anthropometrically distinct habitus with narrower anteroposterior chest diameters, pectus excavatum. scoliosis, longer arm spans and high metacarpal index [ 28.341. Symptomatology is diverse and includes atypical chest pain [ 21, palpitation [ 15,361, syncope [ 71, fatigue and dyspnoea [ 131, and neurotic symptoms [40]. The auscultatory hallmark of mitral valve prolapse is the nonejection systolic click(s) which is a snapping. crisp, high-pitched mid-late systolic extraInr J Gvnaecol Obsrer 23

218

Tang et al.

sound with or without systolic murmur. The most typical electrocardiographic abnormality consists of flattened or frankly inverted T waves in the inferolateral leads (II, III, aVF) [ 231. The diagnostic criteria of mitral valve prolapse with M-mode echocardiogram are the presence of pansystolic prolapse greater than 3 mm, midsystolic bucking of the mitral leaflets or localized mitral prolapse [ 181. Hemodynamic studies usually reveal no abnormality except in the presence of severe mitral regurgitation. The prognosis in this condition is generally benign. Rare reports of sudden death [ 25,321, infective endocarditis [5,22], spontaneous rupture of chordae tendinae [ 161, progressive mitral regurgitation [ 171 and platelet embolism leading to transient ischaemit attacks [ 2 11 or visual disturbances [ 391 were documented. Management of asymptomatic patients requires reassurance. Betablockers such as propanolol are effective in patients with arrhythmias [3 11, chest pain and palpitation. As most studies observed a predominate of mitral valve prolapse in young women of reproductive age, the present study is undertaken to determine the obstetric performance and outcome of these patients. Materials and methods During the 4-year period from January 1979 to December 1982, 37 patients with mitral valve prolapse were delivered at the Department of Obstetrics and Gynaecology, Tsan Y uk Hospital, Hong Kong. The diagnosis was made clinically and confirmed by echocardiography. The patients’ age, parity, height, prepregnant body weight, body weight at term, gestational age, blood pressure at 32 weeks and term were recorded. Information concerning the prenatal course, labor, delivery, puerperium and the neonates were obtained. The occurrence of cardiac complications such as arrhythmias, endocarditis and congestive heart failure were specifically sought for. A control group of 282 normal subjects who had delivered during the same period was Int J Gynaecol Obstet 23

selected at random for comparison. Statistical analysis was performed by chi-square test and Student’s &-test. Results Diagnosis

In the present study, mitral valve prolapse was diagnosed in 13 patients before conception and the diagnoses were made during antenatal examinations and subsequently confirmed by echocardiography in 24 patients (64.9%). Clinical data

The patient profiles including age, parity, height, prepregnant weight, body weight at term and gestational maturity were similar in the study and control groups (Table I). An tenatal course

The blood pressures at 32 weeks, at term and l-h postdelivery were not different between the study and control groups. The incidence of pregnancy-induced hypertension was also not different between the two groups (Table II). Labor and mode of delivery No difference was observed in the duration

of labor between the study (5.9 + 3.6 h) and the control (5.8 + 3.6 h) groups. Thirty-four patients were delivered vaginally at term. Three cesarean sections were performed; two because of no progress of labor and one for foetal distress (Table III).

Table 1.

Patient profiles.

Age (Year) Primiparity (%) Height (cm) Prepregnant weight (kg) Weight at term (kg) Gestational maturity (weeks)

Study CN=37) Mean t S.D.

Control (IV = 282) Mean !I SD.

24.8 + 3.6 30 (81.1%) 157.4 C 6.0 45.4 + 5.1 56.1 C5.6 39.5 + 2.7

26.3 + 4.9 201 (71.6%) 140.6 C 17.1 49.8 -+7.7 59.6 C 7.8 37.8 + 3.4

Pregnancy and mitral valve prolapse Table IL Blood pressures at 32 weeks, at term and l-h postdelivery in patients with mitral valve prolapse and in control group. Blood pressure (mmHg)

At 32 weeks Systolic Diatolic At term Systolic Diatolic At l-h postdelivery Systolic Diatolic

Study (N = 37) Mean + SD.

Control (N = 282) Mean _+SD.

117.6 t 12.3 72.0 & 9.2

116.0 + 12.8 73.1 f 8.6

123.4 + 12.3 80.0 + 9.7

120.4 + 11.7 79.8 t 9.5

118.4 f 11.0

120.1 ? 11.8

78.1 + 8.4

78.0 t 9.4

Ma temal complications There was no maternal mortality. No cardiac complications such as arrhythmias, endocarditis and congestive heart failure were recorded. No patients required beta-blocker therapy. All except three patients received prophylactic antibiotics. These three were multiparous patients who had short labor (less than 2 h) and delivered before antibiotics could be started.

Table IIL Obstetrical performances and outcomesinpatients with mitral valve prolapse and in control group. Study (N=37)

Antepartum Pregnancy-induced hypertension Intrapartum Premature delivery Meconium-stained liquor Ceserean sections Neonatal Low birth weight Apgar score at 5 min (<6) Major anomaly Perinatal mortality

Control (N = 282)

No.

%

No.

%

6

16.2

29

10.2

0 3

0 8.1

2 17

0.7 6.0

3

8.1

32

11.3

5 2

13.5 5.4

49 17

17.4 6.0

1 1

2.7 2.7

5 6

1.8 2.1

219

Foetal outcome The average birth weight was 3024 g for infants of the patients with mitral valve prolapse and 2980 g for those of the controls. No statistically significant difference was observed. The numbers of infants with low birth weight (less than 2500 g) and neonatal asphyxiation were not different in the two groups. Hydrops foetalis (hemoglobin Barts) was the only major anomaly in the study group and this was also the cause of the perinatal mortality (Table III). Discussion The present study confirms the reassuring results of a previous report on the lack of increased risk for obstetric complications or fetal distress among pregnancies in women with mitral valve prolapse [ 271. Our observations suggest that this group of cardiac patients can tolerate the hemodynamic changes in pregnancy and their physiological responses to pregnancy are similar to those of their normal counterparts. The findings that patients were diagnosed at the antenatal clinic stress the importance of a thorough cardiovascular examination for pregnant women [4,8,38 I. The non-invasive nature of echocardiographic assessment has improved the accuracy of diagnosis of valvular lesions [ 121. A full knowledge of the cardiac status in pregnancy will alert the obstetricians to initiate necessary preventive measures. Devereux et al. (1982) [ 101 reported an association of mitral valve prolapse with low body-weight and low blood pressure [ 10,l 1, 19 I. They suggested a possible beneficial effect of lower body-weight on other cardiovascular risk factors. It was our initial idea to study if such an association exists in our group of pregnant patients with mitral valve prolapse. If this observation is confirmed, we would expect a lower incidence of pregnancy-induced hypertension in this group of patients. However, no such associations were observed in the present study population (Table I). The incidence of pregnancy-induced hypertension was not lower and there was no difference in Int J Gynaecol Obstet 23

220 Tang et al.

the birth weights of the newborns as compared with the control group. In our series, there was no cardiac complication observed. This is not surprising because of the benign course of disease in patients with mitral valve prolapse. For the management of antenatal care of pregnant women with mitral valve prolapse, no extra precautions are necessary except for prophylactic antibiotics in selected cases. Early detection and treatment of cardiac arrhythmias are the other aspect of concern to the obstetricians. Although prophylactic antibiotics were used in most of our patients, most authorities are of the opinion that prophylaxis should be given for complicated delivery and for patients with mitral regurgitation [ 37 1. Aqueous crystalline penicillin or ampicillin plus gentamicin are given in the regime as recommended by American Heart Association for the prevention of endocarditis [ 201. Spontaneous vaginal route should be the aim of mode of delivery. Abdominal delivery should be indicated by coexisting obstetrical complications only. The fetal outcome would be expected to be favourable in uncomplicated cases. Breast feeding should not be discouraged. Hormonal contraception is not contraindicated; although the use of intra-uterine device is controversial. In view of the suggestions of a familial incidence and an autosomal dominant inheritance, prospective studies of the relatives and follow-up studies of the newborn with echocardiography may produce interesting results. In conclusion, pregnancy in patients with mitral valve prolapse usually follow a benign and uneventful course. The obstetrical performance is not affected by the valvular lesion and the fetal outcomes are favourable. Although controversy regarding the efficacy of prophylactic antibiotics requires further evaluation, its use is recommended in selected cases. Acknowledgment

The authors would like to thank the physicians and cardiologists in the Department of Int J Gynaecol Obsret 23

Medicine, University of Hong Kong involved in the medical management of these patients. References 1 Barlow JB, Pocock WA: Mitral valve prolapse,the specific billowing mitral leaflet syndrome, or an insjgnlticant nonejection systolic click. Am Heart 3 97: 227,1979. 2 Beton DC, Brear SC, Edwards JD, Leonard JC: Mitral valve prolapse: an assessment of clinical features, associated conditions and prognosis. Q J Med 52: 150,1983. 3 Brown OR, Kloster FE, DeMots H: Incidence of mitral valve prolapsein the asymptomatic normal. Circulation (suppl II) II: 17, 1975. 4 Burrow GN, Ferris TF: Medical Complications During Pregnancy. W.B. Saunders Company, Philadelphia, 1982. 5 Clemens JD, Horwitz RI, Jaffe CC, Feinstein AR, Stanton BF: A controlled evaluation of the risk of bacterial endocarditis in persons with mitral valve prolapse. N Engl J Med 307: 776,1982. 6 Davies MJ, Moore BP, Bralmbridge MV: The floppy mitral valve. Study of incidence, pathology, and complications in surgical, necropsy, and forensic material. Br Heart J 40: 468,1978. 7 DeMaria AN, Amsterdam EA, Viimara LA, Neumann A, Mason DT: Arrhythmias in the mitral valve prolapse syndrome. Prevalence, nature and frequency. Ann Intern Med 84: 655,1976. 8 de Swiet M: Medical Disorders in Obstetric Practice. Blackwell Scientific Publications Ltd., Oxford, 1984. 9 Devereux RB, Perloff JK, Reichek N, Josephson ME: Mitral valve prolapse. Circulation 54: 3,1976. 10 Devereux RB, Brown WT, Lutas EM, Kramer-Fox R, Laragh JH: Association of mitral valve prolapse with low body weight and low blood pressure. Lancet ii: 192,1982. 11 Devereux RB, Brown WT Lutas EM, Kramer-Fox R, Laragh JH: Mitral valve prolapse and blood pressure. Lancet i: 366.1983. 12 Elkayam U, Gleicher N: Cardiac Problems in Pregnancy: Diagnosisand Management of Maternal and Fetal Disease. Alan R. Liss, Inc., New York, 1983. 13 Fontana ME, Pence HL, Leighton RF, Wooley CF: The varying clinical spectrum of the systolic click - late systolic murmur syndrome. Circulation 41: 807.1970. 14 Fortuin NJ, Strahan NV, Come PC, Humphries JO, Murphy EA: Inheritance of the mitral valve prolapse syndrome. Clin Res 25: 470A, 1977. 15 Gooch AS, Vicencis F, Maranhao V, Goldberg H: Arrhythmias and left ventricular asynergy in the prolapsing mitral leaflet syndrome. Am J Cardiol29: 611,1972. 16 Goodman D, Kimbiris D, Llnhart JW: Chordae tendineae rupture complicating the systolic click - late systolic murmur syndrome. Am J Cardiol33: 681,1974. 17 Guy FC McDonald RPR, Fraser DB, Smith ER: Mitral valve prolapse as a cause of hemodynamlcally important mitral regurgitation. Can J Surg 23: 166,198O.

Pregnancy and mitral valve prokzpse

18 Jeresaty RM: Mitral Valve Prolapse. Raven Press, New York, 1979. 19 Kagan A: Mitral valve prolapse and blood pressure. Lancet ii.- 1408,1982. 20 Kaplan EL: American Heart Association Committee Report Prevention of bacterial endocarditis. Circulation 56: 139a 1977. 21 Kostuk WJ, Boughner DR, Barnett HJM, Silver MD: Stroke: a complication of mitral-leaflet prolapse? Lancet ii: 313,1977. 22 Lachman AS, Bramwell-Jones DM, Lakier JB,Pocock WA, Barlow JB: Infective endocarditis in the billowing mitral leaflet syndrome. Br Heart J 37: 326, 1975. 23 Lobstein HP, Horowitz LD, Curry CC, Mullins CE: Electrocardiographic abnormalities in the mitral clickmurmur syndrome. N Engl J Med 289: 127, 1973. 24 Markiewicz W, Stoner J, London E, Hunt SA, Popp RL: Mitral valve prolapse in one hundred presumably healthy young females. Circulation 53: 464,1976. 25 Marshall CE, Shappell SD: Sudden death and the balIoning posterior leaflet syndrome. Arch Path01 98: 134, 1974. 26 Procacci PM, Savran SV, Schreiter SL. Bryson AL: Prevalence of clinical mitral-valve prolapse in 1169 young women. N Engl J Med 294. 1086, 1976. 27 Rayburn WF, Fontana ME: Mitral valve prolapse and pregnancy. Am J Obstet Gynecol141: 9,198l. 28 Salomon J, Shah PM, Heinie RA: Thoracic skeletal abnormalities in idiopathic mitral valve prolapse. Am J Cardiol 36: 32,197s. 29 Savage DD, Garrison RJ, Devereux RB et al.: The Framingham study. Am Heart J 106: 571,1983. 30 Savage DD, Devereux RB, Garrison RJ et al.: Mitral valve prolapse in the general population. 2. Clinical features the Framingham study. Am Heart J 106: 577, 1983. 31 Savage DD, Levy D, Garrison RJ et al.: Mitral valve prolapse in the general population. 3. Dysrhythmias: the Framingham study. Am Heart J 106: 582.1983.

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32 Shappell SD, Marshall CE, Brown RE, Bruce TA: Sudden death and the familial occurrence of mid-systolic click, late systolic murmur syndrome. Circulation 48: 1128, 1973. 33 Scheele W, Allen HN, Kraus R, Rubin PC: Familial prevalence and genetic transmission of mitral valve prolapse. Circulation 54 (suppl III): III-1 11, 1976. 34 Schutte JE Gaffney FA, Blend L, Blomqvist CG: Distinctive anthropometric characteristics of women with mitral valve prolapse. Am J Med 71: 533, 1981. 35 Shell WE, Walton JA, Clifford ME, Willis PW: The familial occurrence of the syndrome of mid&e systolic click and late systolic murmur. Circulation 39: 327. 1969. 36 Sloman G, Wong M, Walker J: Arrhythmias on exercise in patients with abnormalities of the posterior leaflet of the mitral valve. Am Heart J 83: 312, 1972. 37 Sugure D, Blake S. Troy P, MacDonald D: Antibiotics prophylaxis against Infective endocarditis after normal delivery. Br Heart J 44: 499.1980. 38 Szekeiy P, Snaith L: Heart Disease and Pregnancy. Churchill Livingstone, Edinburgh, 1974. 39 Wilson LA, Keeling PWN, Malcolm AD, Russell RWR, Webb-Peploe MM: Visual complications of mitral valve prolapse. Br Med J ii: 86,1977. 40 Wooley CF: Where are the diseases yesteryear? Da Costa’ syndrome, soldiers’ heart, the effort syndrome, neurocirculatory asthenia - and the mitral valve prolapse syndrome. Circulation 53: 749,1976.

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for reprints:

LawrenceC.H.Tang Department of Obstetrics and Gynaecology University of Hong Kong Queen Mary HospitaI Hong Kong

Int J Gynaecol Obstet 23