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"orthopnea" and is a sign of
heart or lung disease. Awaken-
ing at night short of breath with
relief on sitting up is called
"paroxysmal nocturnal dyspnea"
and is a fairly specific sign of
heart disease.
Rheumatic fever often dam-
ages the valves of the heart,
causing them to malfunction. In
Geraldine's case the mitral
valve leaflets became adherent
to one another, leaving only a
small opening through which
blood could flow. Because of the
resistance to flow caused by the
small opening, pressure rises in
the left atrium in an effort to get
the blood across narrowed mi-
tral valve.
This increased pressure is
transmitted back to the lungs,
causing them to stiffen at first.
Later the increased pressure
forces fluid out of the capillar-
ies into the lung tissue, causing
congestion and interfering with
oxygen exchange. The condition
also leads to high blood pressure
in the lungs, something we call
"pulmonary hypertension."
Further work-up, including a
cardiac echocardiogram, con-
firmed these diagnoses.
During pregnancy, total body
fluid increases, including the
amount of fluid in the circulat-
ing blood volume. The heart
must work harder to supply the
needs of the mother and the de-
veloping fetus. This workload
peaks between the third and
sixth months of pregnancy.
Geraldine's mitral stenosis did
not allow her heart to compen-
sate for the increased workload
her pregnancy required.
I reviewed options for man-
agement with Geraldine and
her husband. Terminating the
pregnancy was one option that
neither she or her husband
wanted to consider. Heart sur-
gery to open the mitral valve
presented a risk to the fetus as
well as the mother; they pre-
ferred to avoid that, as well.
Opening the valve with a bal-
loon catheter - balloon valvulo-
plasty - was an option to
consider, but the X-ray needed
to do the procedure presented
an unknown risk to the fetus.
They finally decided on a tri-
al of medical therapy, using
medicines that were unlikely to
harm the fetus but might get
her through the pregnancy,
leaving corrective measures un-
til after delivery.
Fortunately, she responded
favorably to careful treatment
with diuretics, which kept the
level of body fluid down and re-
lieved some of the load on her
heart and circulation. After de-
livering a healthy baby girl,
Geraldine's symptoms reverted
to her pre-pregnancy status. She
could lie flat comfortably and
was not awakening at night
short of breath anymore. ❑
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