Advanced Rheumatic Heart Disease Complicated by Pregnancy, Mitral Valve Disease, Pulmonary Hypertension, and Left Atrial Thrombus: A Multidisciplinary Case Report from Resource-Limited Settings.

INTRODUCTION: Rheumatic heart disease (RHD) remains a leading cause of cardiovascular morbidity and mortality among pregnant women in resource-limited settings. Pregnancy induces significant hemodynamic changes that can decompensate pre-existing valvular heart disease, leading to life-threatening complications for both mother and fetus.

CASE PRESENTATION: A 27-year-old pregnant woman (gravida 6, para 5) at approximately 34-38 weeks presented with progressive shortness of breath, palpitations. Based on the modified World Health Organization (mWHO) classification, she was categorized as Class IV (extremely high risk) bilateral lower limb swelling, cough, fatigue, and reduced appetite. Cardiovascular examination revealed a systolic murmur, loud S1 and S2, with bilateral basal crepitations on respiratory examination. Echocardiography demonstrated an enlarged left atrium (5 cm), moderate mitral stenosis, mild mitral regurgitation, with fixed mitral valve leaflets, pulmonary hypertension, poor right ventricular function, a large left atrial thrombus, Labor occurred spontaneously while on low-molecular-weight heparin (LMWH). Mild pericardial effusion, and preserved left ventricular ejection fraction (58%). Laboratory investigations showed elevated CRP (48.8 mg/L), thrombocytopenia (platelets 99 ×109/L), mild coagulation abnormalities (INR 1.5), and urinalysis findings consistent with hematuria and proteinuria. Electrocardiography revealed sinus tachycardia, left atrial enlargement, right ventricular hypertrophy pattern, incomplete right bundle branch block, and prolonged QTc interval. The patient received multidisciplinary care including furosemide, metoprolol, and enoxaparin. She delivered a 2.1 kg neonate with good Apgar scores.

DISCUSSION: This case illustrates the severe maternal and fetal risks associated with advanced RHD during pregnancy. The presence of a large left atrial thrombus in a pregnant woman poses significant thromboembolic and hemodynamic risks. Multidisciplinary management involving cardiology, obstetrics, anesthesia, and intensive care is essential for optimizing outcomes.

CONCLUSION: This case highlights the critical importance of early recognition, strict adherence to CARE guidelines and multidisciplinary management, and the need for preventive strategies including primary prevention of rheumatic fever and secondary prophylaxis for RHD in resource-limited settings.