Diagnostic Considerations
Other conditions to be considered in patients with suspected pulmonic stenosis (pulmonary stenosis) (PS) include the following:
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Associated or different congenital heart abnormalities (see Etiology)
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Rheumatic valvular heart disease
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Carcinoid heart disease
Pulmonic stenosis in pregnancy
Valvular heart disease, including PS, warrants follow-up care by a high-risk obstetrics team. The hemodynamic changes in pregnancy are significant and include relative anemia due to increased plasma volume proportionally greater than red blood cell volume, increase in cardiac stroke volume, decrease in systemic vascular resistance, decrease in pulmonary vascular resistance with a drop in pulmonary pressures and, finally, decrease in venous return that is more marked in the third trimester. Pregnancy, in the already symptomatic woman with severe PS, can worsen symptoms. However, pregnancy is generally well tolerated in asymptomatic women with PS, even if the degree of stenosis is severe.
When symptoms are referable to PS, they are similar to those of individuals who are not pregnant and symptomatic. The symptoms of healthy pregnancy can resemble those of PS, including exertional fatigue, dyspnea, orthopnea, presyncope, and, rarely, frank syncope. Palpitations due to arrhythmias have been noted to be more common in those with PS.
Mild PS produces a murmur similar to that of the benign flow murmur of pregnancy, which typically increases in intensity as the stroke volume is augmented. During the physical examination, this murmur can be distinguished from the flow murmur of pregnancy by noting a prominent jugular venous a wave, an RV lift, a systolic thrill over the pulmonic area, a pulmonic ejection sound (in doming PS), and a diminished or absent P2. Electrocardiographic (ECG) and echocardiographic evaluation are essential in confirming clinical suspicion. Fetal echocardiography is indicated in patients with PS or tetralogy of Fallot.
Treatment of PS during pregnancy
Balloon valvuloplasty is recommended in nonpregnant, asymptomatic patients with a peak instantaneous gradient >60 mmHg or mean Doppler gradient >40 mmHg (provided there is less than moderate pulmonary regurgitation). In the presence of symptoms, balloon valvuloplasty is indicated for a peak instantaneous gradinet of >50 mmHg or mean gradient >30 mmHg (with the same caveat of less than moderate pulmonary regurgitation).
If severe symptomatic PS is detected during pregnancy, percutaneous balloon valvuloplasty to relieve the obstruction usually can be accomplished safely, obviating the need to terminate the pregnancy.
Arrhythmias are treated according to the severity and etiology.
Considerations for labor and delivery
Patients who are asymptomatic during pregnancy generally tolerate labor and delivery well.
For more severe valvular disease, a high-risk obstetrics team along with a cardiology consultation may be required to manage deliveries.
Antibiotic prophylaxis is not indicated for women with isolated valvular PS.
See the American Heart Association (AHA) and/or American College of Cardiology (ACC) guidelines on:
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Prevention of infective endocarditis in childhood (2015 update)
Differential Diagnoses
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Pulmonic Stenosis. Echocardiogram of a patient with severe pulmonic stenosis. This image shows a parasternal short-axis view of the thickened pulmonary valve.
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Pulmonic Stenosis. Echocardiogram of a patient with severe pulmonic stenosis. This image shows a Doppler scan of the peak velocity (5.2 m/s) and gradients (peak 109 mmHg, mean 65 mmHg) across the valve.
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Pulmonic Stenosis. Echocardiogram of a patient with severe pulmonic stenosis. This image shows moderately severe pulmonary insufficiency (orange color flow) is also present.
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Pulmonic Stenosis. This is an echocardiogram of a patient with severe pulmonic stenosis. The first segment shows the parasternal short-axis view of the thickened pulmonary valve. The second segment shows the presence of moderate pulmonary insufficiency (orange color flow). AV = aortic valve; PA = pulmonary artery; PI = pulmonary insufficiency; PV = pulmonary valve.
