Pulmonic Stenosis Differential Diagnoses

Updated: Dec 22, 2014
  • Author: Xiushui (Mike) Ren, MD; Chief Editor: Richard A Lange, MD, MBA  more...
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DDx

Diagnostic Considerations

Other conditions to be considered in patients with suspected pulmonic stenosis include the following:

  • Congenital heart abnormality (see Causes)

  • Rheumatic valvular heart disease

  • Carcinoid heart disease

Pulmonic stenosis in pregnancy

Valvular heart disease, including PS, should warrant follow-up care by a high-risk obstetrics team. The hemodynamic changes in pregnancy—which include increase in 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 decrease in venous return that is more marked in the third trimester—can exacerbate the symptoms of PS.

In general, pregnancy is tolerated well by individuals who have asymptomatic PS before conception, 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 click, and a diminished or absent P2. ECG and echocardiographic evaluation are essential in confirming clinical suspicion. Fetal echocardiography is indicated in patients with PS or tetralogy of Fallot.

Treatment in pregnancy

Avoidance of vigorous exercise is recommended, especially during the second half of pregnancy in patients with moderate-to-severe gradients.

Balloon valvuloplasty is recommended in nonpregnant patients when the gradient across the right ventricular outflow track is greater than 50 mm Hg at rest or when the patient is symptomatic.

If severe 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 of symptoms.

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 generally is not recommended for cesarean delivery and is considered optional in women with PS that is associated with complex congenital heart disease.

See AHA Guidelines on prevention of Infective Endocarditis.

Pulmonic stenosis in athletes

Athletes with mild PS gradients (ie, < 50 mm Hg) have no activity limitations.

Those with more severe PS can participate in low-intensity competitive sports; their treatment should be directed by the criteria discussed in Treatment.

Differential Diagnoses