Pregnancy with Doubly Committed Subarterial Ventricular Septal Defect: Management Challenges and Delayed Maternal Risk Stratification

Introduction: Congenital heart disease is a leading cause of maternal morbidity and mortality during pregnancy, with ventricular septal defect (VSD) being one of the congenital anomalies that can lead to severe complications, especially if not managed continuously. The doubly committed subarterial (DCSA) subtype is particularly challenging in pregnancy due to risk of pulmonary hypertension and heart failure. Case Presentation: A 29-year-old woman, G1P0A0, was referred at 38– 39 weeks of pregnancy with a diagnosis of VSD-DCSA subtype. The patient had progressive dyspnea since the seventh month of pregnancy and had a history of VSD since the age of 10, with treatment discontinued at age 15. Antenatal care was initially conducted by a midwife and referral to an obstetrician occurred after the onset of dyspnea. The patient received treatment from a cardiologist at District Hospital and was subsequently referred to Tertiary Hospital. Ultrasound examination revealed small gestational. NT-pro BNP was 194 pg/mL. Echocardiography confirmed a VSD-DCSA subtype and a high probability of pulmonary hypertension. Management: The patient received bisoprolol 2.5 mg daily, furosemide 40 mg daily, and sildenafil 20 mg three times daily. The baby was delivered via cesarean section (CS) in with Apgar scores of 7 and 8 at 1 and 5 minutes. The patient was discharged in a stable condition. Outcome: Postpartum follow-up showed stable hemodynamics and no dyspnea. The patient was referred for cardiology follow-up and long-acting reversible contraception. Conclusion: Early maternal risk stratification and multidisciplinary care are essential to minimize complications in women with VSD. This case highlights the challenges of delayed referral and the importance of monitoring from the preconception through the postpartum period. The patient remained hemodynamically stable despite delayed referral, likely due to preserved cardiac function and timely medical intervention. A multidisciplinary approach involving obstetricians and cardiologists is essential to minimize risks to both mother and baby. Keywords: ventricular septal defect, pulmonary hypertension, antenatal care