Valvular heart disease in pregnancy is rare, but it significantly increases maternal and fetal risk. Despite an overall decline in the incidence of rheumatic heart disease in Europe and North America,1 worldwide rheumatic mitral stenosis is the most common valvular lesion in pregnancy.^w1 With changing patterns of immigration, rheumatic heart disease may well become a serious problem in the United Kingdom. Advances in cardiac medication and surgery mean that more women with congenital valvular disease survive into adulthood and reproductive maturity.

Valvular heart disease may present for the first time in pregnancy as the increasing demands on the heart lead to decompensation and cardiac failure. However, the diagnosis is not always easy as the symptoms of pregnancy (tiredness, shortness of breath, and palpitations) can mask those of deteriorating disease. Moreover, in the United Kingdom, a decline in rheumatic fever means that valvular heart disease is now rare, and doctors—particularly general practitioners and obstetricians, to whom these patients present—are less aware of and less familiar with the condition. The scenario box highlights the complexities of the management of valvular heart disease in pregnancy.