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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Mitral Valve Prolapse

ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease -- II. General Principles

Mitral Valve Disease: Stenosis and Regurgitation

[from ob-gyn-l]

At any rate, we have been told that mitral valve prolapse is really (in general, at least) a non-issue in pregnancy. None of our women developed symptoms related to it, and at least one had a homebirth.

Or Mitral valve prolapse is pretty common and often asymptomatic till pregnancy.

I'm intrigued by this statement, as we in our practice have looked after several women who had been diagnosed with mitral valve prolapse prior to pregnancy, and had to have antibiotics with dental work etc. to prevent endocarditis. I just looked after one woman with it recently, and two obstetricians that I consulted with (for a different reason, actually) said that it's absolutely not a problem in pregnancy.

My comments were from my memory of a seminar in Maternal and Fetal Cardiopathy way back in 82. MVP was all the rage back then and lots of folks were blaming all sorts of problems on it.

The lecturer (neat doc, cardiologist of LONG experience) was of the opinion that anything which occurs in such a large percent of the population can't really be considered TOO abnormal. He (if memory serves ; perhaps it doesn't) said that sometimes odd but harmless symptoms may show up in pregnancy and MVP is often the "cause". He cautioned us not too over-react to it.... Hence, I don't consider mvp much of a risk either, but do think of it when a woman reports "fluttering" or palpitations...

I know of one woman (friend, not a client) who became symptomatic in third trimester - and had valve repair a few months after birth.

Actually have two classmates with it. One asymptomatic, never been pregnant. The other has had four children, was not diagnosed until relatively recently when she started having horrible bouts of PAT (HR > 200) from which she would pass out. We all blamed it on midwifery school!! She's okay now, thank goodness, but we all used to get prepared to have to get her to push on her eyeballs or massage her carotid [GRIN] or get her to Valsalva.

We have had maybe a half a dozen clients birth with MVP. Have just ignored it since the first one where we read a lot and had her see a doc to check it out. Haven't had any of them experience tachy that I can remember without pulling charts.

We have had a few clients have anxiety attacks worsen during pregnancy. They need a lot of reassurance all times of the day and night, supportive partners, some times doc checks to let them know nothing else is going on.

I thought women with MVP need antibiotics postpartum or intrapartum. The same way they get antibiotics after dental work. comments?

I think that is "the standard of care", but the clients I had didn't even do it for all dental work.

I don't know about elsewhere, but here women are not given antibiotics in labour d/t MVP, even if they do get them for dental work. The risk of contracting endocarditis as a result of childbirth is considered to be infinitesimally low.

MVP is often first noted in pregnancy. Cardiac changes are quite the reverse of "fitting" the valve better. The LV only dilates significantly with pressure loading, which pregnancy definitely is not. Instead it is volume loading, which causes RV dilatation and left atrial enlargement, dilating the mitral ring and causing it to leak. In MVP'ers, it is much worse.

I've introduced several residents to MVP by having them listen to gravidas, where the findings are easy enough for even the young examiner. So think of it for any arrhythmia incl tachy, any panic attacks, any chest pain, and any hyperventilation.

Since you've heard it both ways I suggest you check the book. I only advise that of course when it agrees with me.

Well, now that you had me thoroughly confused, I had to go back and check with Williams Obstetrics, which states:

Pregnant women with mitral valve prolapse rarely have cardiac complications. In fact, pregnancy-induced hypervolemia may improve alignment of the mitral valve.

As well, my Blackburn and Loper (Maternal, Fetal and Neonatal Physiology) states:

The hemodynamic changes of pregnancy can reduce the clinical signs of MVP by decreasing audible murmurs (usually a late systolic murmur associated with a click), possibly by increasing the left ventricular end-diastolic volume and favorable realigning the mitral valve complex. The decrease in peripheral vascular resistance relieves the mitral insufficiency, thereby reducing the murmur. Once these parameters return to normal in the postpartum period, the auscultatory findings of MVP return. These changes are also reflected on echocardiographic studies.

The book does, however, mention that women may experience palpitations with it. And, as I e-mailed to her, I did have a friend who became quite bothered by it, but only in her forties and after four children. My client with it, BTW, had it secondary to Ehlers-Danlos Syndrome. Had no problems, other than shoulder dystocia (another story, another day...), which caused considerable tachycardia in me.

Hope you don't mind my books didn't agree with you....

I would like to hear a bit more about management of MVP in pregnancy. I don't have much experience with this. I would like to hear how people are handling this.

Over here (England) the indications for antibiotic prophylaxis are:

1. Women with mechanical valve replacements
2. Women with past history of endocarditis.

We add patients who are symptomatic with MVP and patients with mitral regurgitation.

As I understand the theory behind it, a purist would give prophylaxis to anyone with a significant MURMUR, but not simply a CLICK alone. Supposedly it's the turbulence of the blood flow which causes a relative area of low pressure that is somewhat "protected" from the body's immune system, allowing for bacteria to settle out and grow without disturbance.

In theory, I agree. But in practical terms, those in which an increased chance of SBE exists, the ?American Heart Association about January1991 recommended no prophylaxis for ob-gyn procedures unless antibiotics would be used without the diagnosis of MVP, e.g. infection, temperature elevation, prolonged labor. It is the opinion of the cardiologists in our geographic area that mitral regurgitation indicates a greater functional abnormality of the valve, increasing the likelihood of infection. Similarly, symptomatology is more likely to be related to greater functional abnormality of the valve and therefore, these two criteria will increase the risk of SBE (although the MR is considered much more of a risk than the symptom expression).

The reference is (I'm at home, but pretty sure) is a December 1990 JAMA. SBE prophylaxis really boils down to these 2 separate issues, according to the article:

1. Is the lesion one that requires prophylaxis? As I recall, MVP without a click doesn't require it, regardless of the procedure.
2. Does the procedure require it? For example, uninfected, uncomplicated vag deliveries, D and Cs, etc. do not require prophylaxis regardless of the lesion.

Ya'll--it's easy just to give the antibiotics, but I think the support exists to follow these guidelines. What do ya'll think?

What prophylactic antibiotic treatment, if any, is warranted in a laboring patient with Mitral Valve Prolapse, if she has no symptoms and no documented valvular regurgitation? Any???

Such people require no prophylaxis for any procedure, since their risk is not elevated above the normal population. Even for people at the highest risk, normal vaginal birth is not considered a bacteremia-producing procedure, so no prophylaxis is required. So this case is easy: the answer is no, from two separate perspectives.

Go to the American Heart Association's excellent Web site and check out the very latest recommendations regarding SBE prophylaxis; I loved being able to lay these on our overzealous anesthesia staff!