Late Presentation of Rheumatic Heart Disease during Pregnancy: A common occurrence in the NT

Abstract

Rheumatic heart disease remains an undertreated and underdiagnosed entity in Australia. As 98% of acute rheumatic fever and rheumatic heart disease occurs in the Indigenous population and as females represent two thirds of rheumatic heart disease, our most vulnerable population suffers from this disease the most. This is a disease of the socially disadvantaged: social, cultural, physical barriers exist between this population and appropriate prevention, diagnoses and management. We present here 6 years of data, equating to 60 females, diagnosed with rheumatic heart disease during pregnancy. Approximately one third with moderate to severe valvular disease and 20% pulmonary hypertension. This is not uncommon in the Northern Territory. The majority of these cases were diagnosed before admission for birth, however a small number were only diagnosed perinatally. The majority of these cases were able to be managed through normal vaginal delivery or elective lower segment caesarean section without fatal complications. A small number of attempted vaginal deliveries resulted in emergency. We observe the changing physiology within pregnancy trimesters and stages of delivery and the impact this has on valvular gradients and pulmonary hypertension, including the incredible and unexpected physiological reserve many of these females display. We also discuss the various methodology of diagnosis, the medical and social management of such females, including the anaesthetic approach to vaginal delivery or lower segment caesarean section.