Abstract Background The Indigenous population of Australia has one of the highest prevalence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) globally. RHD is more common in females and the incidence peaks in the 3rd to 4th decade of life, corresponding with child-bearing age. It is the number one cause of cardiac complications in pregnancy globally. Signs and symptoms of normal pregnancy may overlap with those of cardiac pathology. Significant valvular disease can complicate pregnancy and delivery. Current practice sees pregnant women referred for echocardiography if there are signs or symptoms of possible cardiac pathology or a history of RHD. Aim To assess the current practice of echocardiography in pregnant women in a region with a high prevalence of rheumatic heart disease. Method A retrospective study of all echocardiograms requested for an indication relating to pregnancy over a three-year period were reviewed in the Northern Territory of Australia. Data collected included patient demographics, echocardiography indication, history of RHD, ARF or other cardiac disease, echocardiographic parameters, location of delivery, peri-partum morbidity and mortality. Results The total number of patients reviewed were 257. The 158 Indigenous Australian women had a mean age of 25 years and the 99 non-indigenous women had a mean age of 30 years. The Indigenous women had a higher rate of abnormal echocardiograms, 36.1% compared with 9.1% for non-indigenous women. Table 1 outlines echocardiography indications and outcomes. Indigenous women had extremely high rates of ARF or RHD representing 37% of echocardiography referrals, with 17.1% (27/158) having moderate or severe valve lesions. 5 cases (3.2%) had a history of prior valve surgery. 10 (6.3%) Indigenous patients required transfer to a tertiary centre with valve intervention services available for delivery. There was one maternal death, one post-partum stroke and one foetal death in utero. Echocardiogram indications and outcomes Incidental murmur Cardiac symptoms Other cardiac disease History of RHD and/or ARF Normal study Rheumatic heart disease Congenital heart disease Other heart disease Indigenous (n=158) 60 (38%) 15 (9.4%) 24 (15%) 59 (37.3%) 101 (63.9%) 47 (29.7%) 7 (4.4%) 3 (1.9%) Non-indigenous (n=99) 44 (44.4%) 24 (24.2%) 31 (31.3%) 0 90 (91%) 2 (2%) 3 (3%) 4 (4%) Conclusion In the Top End of Australia, Indigenous patients have a very high rate of abnormal echocardiograms during pregnancy compared with their non-indigenous counterparts, mainly as a result of RHD. Data suggests that pregnant Indigenous women are being under serviced by the current medical model and referral practices. Guidelines are urgently needed in relation to echocardiography and pregnancy in populations that are burdened by RHD.