Obstetric anaesthesia in rheumatic heart disease – a unique perspective from the Top End

Abstract

Rheumatic heart disease (RHD) is a complex manifestation of social inequity. It is a life-long burden and, in Australia, affects predominantly young First Nations Australians. It is endemic in the Northern Territory (NT), with a rate of disease 26 times higher than the rest of Australia.1 Despite intensive primary and secondary prevention, it is not a disease of the past, with episodes of acute rheumatic fever (ARF) continuing to increase in the NT. Of those suffering an episode of ARF, 50% will develop rheumatic heart disease within 10 years, of which one-third will be severe. With episodes of ARF occurring almost exclusively in children, this translates to the majority of subsequent heart disease occurring in those aged 15-44. Females are consistently overrepresented in this population leading to a disproportionate burden of disease in women of childbearing age. As the tertiary referral centre in the Northern Territory, the Royal Darwin Hospital is in the unique situation of managing a relatively high volume of obstetric patients with rheumatic heart disease, often from the most remote locations in Australia. Up to 2-3% of First Nations women who become pregnant in the NT have some form of RHD, and many have had previous valve interventions. This presents not only the challenge of managing valvular heart disease in pregnancy and the peripartum period, but also in a way that addresses different concepts of health and the additional complexities of distance, language, and culture.