Rheumatic heart disease (RHD) continues to be a major cause of maternal death in low- and middle-income countries (LMICs), where access to preconception counseling and coordinated cardio-obstetric care is often limited. We describe the case of a 35-year-old woman with a known history of RHD who stopped cardiac follow-up after becoming pregnant. She presented in her second trimester with worsening breathlessness and was found to have advanced valvular disease and pulmonary hypertension. Despite multidisciplinary support and medical management, her condition deteriorated. She experienced intrauterine fetal demise and later died from progressive cardiopulmonary failure. This case highlights the critical role of early risk assessment, structured care, and system-wide support in improving outcomes for high-risk pregnancies in resource-limited settings.