Heart Disease In Pregnancy Research Articles

Concordance Between Obstetric Anatomic Ultrasound and Fetal Echocardiography in Detecting Congenital Heart Disease in High-risk Pregnancies.

To evaluate the concordance between second-trimester anatomic ultrasound and fetal echocardiography in detecting minor and critical congenital heart disease in pregnancies meeting American Heart Association criteria. We conducted a retrospective cohort study of pregnancies in which a second-trimester fetal anatomic ultrasound examination (18-26 weeks) and fetal echocardiography were performed between 2012 and 2018 at our institution based on American Heart Association recommendations. Anatomic ultrasound studies were interpreted by maternal-fetal medicine specialists and fetal echocardiographic studies by pediatric cardiologists. Our primary outcome was the proportion of critical congenital heart disease (CCHD) cases not detected by anatomic ultrasound but detected by fetal echocardiography. The secondary outcome was the proportion of total congenital heart disease cases missed by anatomic ultrasound but detected by fetal echocardiography. Neonatal medical records were reviewed for all pregnancies when obtained and available. Overall, 722 studies met inclusion criteria. Anatomic ultrasound and fetal echocardiography were in agreement in detecting cardiac abnormalities in 681(96.1%) studies (κ=0.803; P < .001). The most common diagnosis not identified by anatomic ultrasound was a ventricular septal defect, accounting for 9 of 12 (75%) missed congenital heart defects. Of 664 studies with normal cardiac findings on the anatomic ultrasound examinations, no additional instances of CCHD were detected by fetal echocardiography. No unanticipated instances of CCHD were diagnosed postnatally. With current American Heart Association screening guidelines, automatic fetal echocardiography in the setting of normal detailed anatomic ultrasound findings provided limited benefit in detecting congenital heart defects that would warrant immediate postnatal interventions. More selective use of automatic fetal echocardiography in at-risk pregnancies should be explored.

Ischemic Heart Disease in Pregnancy.

The reported incidence of ischemic heart disease in pregnancy is 2.8 to 6.2 per 100,000 pregnancies. Although additional factors, such as maternal diabetes, obesity, and hypertension, are risk factors for ischemic heart disease, pregnancy itself more than doubles the risk for acute myocardial infarction. Given the increasing clinical importance of ischemic heart disease during pregnancy, this article addresses underlying pathophysiology, risk stratification, screening, and diagnosis of ischemic heart disease, as well as recommendations for management of acute myocardial infarction during pregnancy and the early postpartum period.

Cardiovascular Contribution to Maternal Mortality.

The United States is the only industrialized nation with an increasing maternal mortality. Many factors contribute to this worrisome US trend; among them, social and demographic factors, and congenital and acquired cardiac conditions. Cardiovascular disease is the leading cause of maternal mortality, and adverse outcomes related to cardiovascular disease disproportionately affect black and Hispanic mothers. This article addresses knowledge gaps related to the treatment of heart disease in pregnancy, initiatives to address these gaps, and guidelines and best practices surrounding the care of women affected by cardiovascular disease and their babies affected by cardiovascular disease.

Risk factors for cardiac, obstetric, and neonatal complications in patients with heart disease during pregnancy.

Heart disease in pregnancy can cause clinical deterioration and maternal-fetal death. It is essential to evaluate risk factors related to complications. This was a observational, analytical retrospective cohort study with a non-probabilistic convenience sample of pregnant women with congenital or acquired heart disease, corrected or not, or arrhythmias requiring urgent intervention. Patients with mild or moderate valvular regurgitation, mild valvular stenosis, patients without echocardiography or without delivery information were excluded from the study. The outcome was a composite of cardiac, obstetric, and neonatal events. Univariate and multivariate analyzes were performed with logistic regression model and discriminatory capacity with area under the curve and independent analysis of the modified World Health Organization (mWHO) risk classification (mWHO). A total of 104 patients with an average age of 25 ± 6.5 years presented cardiac events in 13.5%, obstetric in 14.42%, and neonatal in 28.85%. The univariate analysis found an association with New York Heart Association functional status, hypertensive disorders of pregnancy, cesarean delivery, gestational age < 27 weeks, hypoxemia, and mWHO risk. In multivariate only cesarean delivery (odds ratio [OR], 2.68; 95% confidence interval [CI], 1.05-6.86) and gestational age at delivery (OR, 0.39; 95% CI, 0.22-0.67) maintain association with outcomes. The area under the curve for the mWHO risk is 0.75. There is a high rate of adverse events in patients with heart disease during pregnancy. Gestational age and cesarean delivery behaved as predictors of adverse maternal-fetal outcomes. The mWHO risk classification had an acceptable prediction of adverse outcomes.

Effect of Nursing Care Guideline on Nurses Knowledge and practice about Pregnant Women Suffering from Heart disease

Background: Heart disease in pregnancy is still a major problem worldwide, particularly in developing countries. The presence of heart disease increases the risk of maternal and fetal complication. Aim of the present study is to evaluate the effect of nursing care guidelines for pregnant women suffering from heart disease on nurses‟ knowledge and practice. Research design: A Quasi experimental design was used in carrying out this study. Setting at Beni-suef general Hospital & Beni-suef University hospital at (gynecological ward (Inpatient: high-risk ward) & outpatient clinic. Sample: A convenient sample of a total 40 maternity nurses was included in the study. Tools: Two tools were utilized for data collection. I- A structured interviewing questionnaire sheet, which includes two parts; part 1 socio-demographic characteristic. Part 2: Assessment of nurses‟ knowledge regarding heart disease during pregnancy which includes definition, causes, risk factors, etc. II- A standard observational checklist to assess nurses‟ practices regarding heart diseases during pregnancy. Results of the current study revealed a statistically significant improvement in nurses' knowledge and practice related to care of pregnant women suffering from heart disease at the post test and follow up. Conclusion: implementation of nursing care guideline enhance nurses‟ knowledge& practices regarding care of pregnant women suffering from heart diseases, so study mainly recommended that the educational program for nursing care of pregnant women suffering from heart disease should be conducted periodically for nursing staff in obstetrics and gynecology department

Acute Coronary Syndrome and Ischemic Heart Disease in Pregnancy: Data From the EURObservational Research Programme-European Society of Cardiology Registry of Pregnancy and Cardiac Disease.

BackgroundThe prevalence of ischemic heart disease (IHD) in women of child‐bearing age is rising. Data on pregnancies however are scarce. The objective is to describe the pregnancy outcomes in these women.Methods and ResultsThe European Society of Cardiology‐EURObservational Research Programme ROPAC (Registry of Pregnancy and Cardiac Disease) is a prospective registry in which data on pregnancies in women with heart disease were collected from 138 centers in 53 countries. Pregnant women with preexistent and pregnancy‐onset IHD were included. Primary end point were maternal cardiac events. Secondary end points were obstetric and fetal complications. There were 117 women with IHD, of which 104 had preexisting IHD. Median age was 35.5 years and 17.1% of women were smoking. There was no maternal mortality, heart failure occurred in 5 pregnancies (4.8%). Of the 104 women with preexisting IHD, 11 women suffered from acute coronary syndrome during pregnancy. ST‐segment‒elevation myocardial infarction were more common than non‒ST‐segment‒elevation myocardial infarction, and atherosclerosis was the most common etiology. Women who had undergone revascularization before pregnancy did not have less events than women who had not. There were 13 women with pregnancy‐onset IHD, in whom non‒ST‐segment‒elevation myocardial infarction was the most common. Smoking during pregnancy was associated with acute coronary syndrome. Caesarean section was the primary mode of delivery (55.8% in preexisting IHD, 84.6% in pregnancy‐onset IHD) and there were high rates of preterm births (20.2% and 38.5%, respectively).ConclusionsWomen with IHD tolerate pregnancy relatively well, however there is a high rate of ischemic events and these women should therefore be considered moderate‐ to high‐risk. Ongoing cigarette smoking is associated with acute coronary syndrome during pregnancy.

Correlation Between Risk or Severity of Heart Failure and Outcome of Pregnancy.

BackgroundThe incidence of heart failure in pregnancy increases by 1–4% every year and causes 9% of maternal mortality worldwide. Determinant factors, characteristics, and risk factors influence the incidence of heart disease in pregnancy, so the early detection of determinant factors can reduce the incidence of heart disease in pregnancy. This study aimed to find the relationship between determinant factors of maternal and fetal outcomes with the severity of heart disease in pregnancy.MethodsThis was an observational cross-sectional analytical study. We used 342 cases of heart disease in pregnancy that were recorded in medical records at Dr. Hasan Sadikin Hospital, Bandung, Indonesia, from January 2014 to December 2018. The data were grouped based on the severity of heart disease according to the New York Heart Association (NYHA) classification. The relationship of maternal determinant factors with the severity of heart disease was analyzed based on the NYHA classification.ResultsMaternal occupation was significantly associated with a higher risk of NYHA class III–IV heart disease. Most of the patients with NYHA class III-IV were housewives. The severity of heart disease was also influenced by severe preeclampsia (p<0.05) as a risk factor. Maternal outcome with heart disease of severity NYHA class III–IV was worse than with NYHA class I–II. The risk of maternal death was higher, and the mother’s length of stay in hospital and her need for monitoring were also increased. There were no significant differences in the outcome of the fetus, but the incidence of fetal mortality increased in patients with heart disease severity III–IV.ConclusionMaternal determinant factors did not correlate with the severity of heart disease in pregnancy. Maternal outcomes were worse with increasing severity of heart disease. Fetal mortality was correlated with severity of heart disease but other outcomes were not affected.

A case of rheumatic heart disease diagnosed in the third trimester

Migration from areas with a high incidence of rheumatic heart disease has led to an increase in pregnancy complicated by rheumatic heart disease in high-income countries. We present a case of rheumatic heart disease diagnosed in a 33-year-old G2P0010 French-speaking Congolese woman at 32 weeks gestation. She was initially hospitalized with respiratory syncytial virus (RSV) bronchiolitis at 24 weeks gestation and established care in our clinic. Mitral valve stenosis was identified at 32 weeks gestation after she presented with severe edema and was hospitalized for acute on chronic heart failure complicated by urosepsis and cellulitis. She was managed in the cardiovascular intensive care unit with a subsequent emergent cesarean delivery at 33 weeks gestation for nonreassuring fetal status. Postoperatively, pulmonary artery pressures were 40 mm Hg and left ventricular ejection fraction was 35%. Her condition stabilized and she was discharged home with outpatient cardiology management on postoperative day 10 with baby in the NICU. This case illustrates the importance of a high threshold of suspicion for women at risk for complications of heart disease in pregnancy. A triad of cardiovascular risk screening, patient education and multidisciplinary team planning with maternal-fetal medicine, cardiology, and anesthesiology has been shown to optimize outcomes in women with known cardiovascular disease.

Managing Heart Disease in Pregnancy

Cardiac disease is an important cause of mortality in pregnancy. It has the potential to remain undiagnosed and may present with cardiovascular decompensation during pregnancy, at the time of delivery, or immediately postpartum. It can have long-term implications to the life of the affected women and their families. This review summarises the current knowledge of the incidence, prevalence, and management of pregnancy-related cardiovascular disease in women presenting preconceptionally or during pregnancy.

Medical and surgical complications in pregnancy and obstetric labour complications in the Japan Environment and Children’s Study (JECS) cohort: a birth cohort study

This study aimed to describe the distribution of pregnancies with medical and obstetric complications based on the Japan Environment and Children’s Study (JECS). We evaluated the distribution of the history of obstetric/gynaecological diseases, the history of obstetric labour complications, pregnancy with medical and surgical complications, and obstetric labour complications in participants in the JECS. Of 100,818 pregnant women with medical record entries after delivery, 15,305 (15.2%) had medical and surgical complications in pregnancy and 46,756 (46.4%) experienced obstetric labour complications. The proportion of pregnancies with heart disease, kidney disease and hepatitis was 0.3%, 0.3% and 0.1%, respectively. Gestational diabetes was diagnosed in 2715 (2.7%) women. The proportion of women with mild and severe gestational hypertension was 2.3% and 1%, respectively. The JECS is the largest birth cohort in Japan. These data will provide useful, basic information for perinatal care in Japan. IMPACT STATEMENT What is already known on this subject? Epidemiological studies have suggested that pre-existing diseases and complications of pregnancy, such as heart disease in pregnancy, gestational hypertension and gestational diabetes, may have implications for pregnancy outcomes, as well as for children’s health and development. What the results of this study add? We evaluated the distribution of the history of obstetric/gynaecological diseases, the history of obstetric labour complications, medical and surgical complications in pregnancy, and obstetric labour complications using data from the Japan Environment and Children’s Study (JECS). What the implications are of these findings for clinical practice and/or further research? The JECS is the largest birth cohort in Japan. Our data will provide useful, basic information for perinatal care in Japan.

Rheumatic heart disease in pregnancy: Profile of women admitted to a Western Australian tertiary obstetric hospital.

This retrospective study assessed maternal and perinatal outcomes for women with rheumatic heart disease (RHD) admitted to the largest tertiary obstetric hospital in Western Australia from 2009 to 2016. Of 54 women identified, 75.9% were Indigenous, 59.3% lived in rural areas and 40.7% had severe RHD. Heart failure developed in 10% who gave birth. Indigenous women were younger, had higher gravidity (P=0.0305), were more likely to receive secondary prophylaxis (P=0.0041) and have sub-optimal antenatal clinic attendance (P=0.0078). There were no maternal deaths and two perinatal deaths (4.0%), reflecting vigilance in the obstetric management of women with RHD in Western Australia.

Acquired heart disease in pregnancy - need for a greater focus.

Cardiovascular conditions are now the leading cause of maternal death in both the US (Petersen EE et al MMWR Morb Mortality Wkly Rep 2019; 68:762-765) and the UK (Knight M et al Saving Lives, Improving Mothers' Care 2019, NPEU:Oxford). The majority of women die from acquired heart conditions, and more than half of women who die are not known to have cardiac disease prior to pregnancy. In the US, deaths from cardiomyopathy cause a proportionately higher number of pregnancy-related deaths amongst black women compared to white women. Disparities in overall maternal mortality by ethnic group have also been identified in the UK.

The high prevalence and impact of rheumatic heart disease in pregnancy in First Nations populations in a high-income setting: a prospective cohort study.

To describe the epidemiology of rheumatic heart disease (RHD) in pregnancy in Australia and New Zealand (A&NZ). Prospective population-based study. Hospital-based maternity units throughout A&NZ. Pregnant women with RHD with a birth outcome of ≥20weeks of gestation between January 2013 and December 2014. We identified eligible women using the Australasian Maternity Outcomes Surveillance System (AMOSS). De-identified antenatal, perinatal and postnatal data were collected and analysed. Prevalence of RHD in pregnancy. Perinatal morbidity and mortality. There were 311 pregnancies associated with women with RHD (4.3/10000 women giving birth, 95% CI 3.9-4.8). In Australia, 78% were Aboriginal or Torres Strait Islander (60.4/10000, 95% CI 50.7-70.0), while in New Zealand 90% were Māori or Pasifika (27.2/10000, 95% CI 22.0-32.3). One woman (0.3%) died and one in ten was admitted to coronary or intensive care units postpartum. There were 314 births with seven stillbirths (22.3/1000 births) and two neonatal deaths (6.5/1000 births). Sixty-six (21%) live-born babies were preterm and one in three was admitted to neonatal intensive care or special care units. Rheumatic heart disease in pregnancy persists in disadvantaged First Nations populations in A&NZ. It is associated with significant cardiac and perinatal morbidity. Preconception planning and counselling and RHD screening in at-risk pregnant women are essential for good maternal and baby outcomes. Rheumatic heart disease in pregnancy persists in First Nations people in Australia and New Zealand and is associated with major cardiac and perinatal morbidity.

Hyperthyroid heart disease in pregnancy: Retrospective analysis of a case series and review of the literature.

BACKGROUNDHyperthyroidism in pregnancy may pose a great threat to maternal and fetal health. The risk of hyperthyroid heart disease (HHD), even heart failure, is significantly elevated in pregnant women.AIMTo investigate the clinical characteristics, prognosis, and therapy of HHD in pregnant women.METHODSWe searched the patient registry data at West China Second University Hospital of Sichuan University in Chengdu, China, following the approval by the Ethics Committee. We retrospectively analyzed the clinical characteristics of pregnant women diagnosed with HHD. The medical records of women with HHD during pregnancy from January 2012 to December 2017 were obtained from the electronic medical records system. All the included patients were followed in outpatient clinics and by telephone interviews until October 2018.RESULTSA total of 155 patients were diagnosed with thyrotoxicosis, of whom six were diagnosed with HHD. Three of them had regular antenatal care. Two patients were complicated with acute heart failure attacks, and one of them had a stillbirth. Both of these patients had a long history of Graves’ disease with poor treatment compliance. Treatments of precipitating factors such as the control of infection could relieve the symptoms and prolong gestation for a better prognosis. Hyperthyroid heart failure could be controlled with aggressive diuretics and management of the coexisting complications. Intense monitoring and timely anti-heart failure treatment were crucial in patients with severe cardiac damage. Our findings indicated the importance of regular antenatal care and treatment adherence in patients with hyperthyroidism.CONCLUSIONThe timely and accurate diagnosis of HHD and the implementation of effective management are important for a better prognosis in pregnant women with HHD. Improvement in patients’ awareness of thyrotoxicosis is needed.

Chronic heart disease in pregnancy: exploring Marfan syndrome

Coronary heart disease is the biggest killer in the UK, causing more than a quarter of deaths in 2018 ( British Heart Foundation, 2018 ). Congenital defects are the most common cause of heart disease in pregnancy ( Wylie and Bryce, 2016 ). This article will discuss Marfan syndrome and the impact this has on pregnancy and childbirth. Current literature and research will be appraised and discussed to explore mode of delivery during the second stage of labour and calculate the most appropriate method of delivery. Additionally, this article will address how the midwife can support women with Marfan syndrome during the pregnancy booking, antenatal period and intrapartum period without labelling them, and discuss how this may be achieved in relation to the uncertainty reduction communication theory.

Maternal Mortality in the United States and the HOPE Registry.

Maternal mortality in the United States is highest among all developed nations and continues to rise. The leading cause of morbidity and mortality during pregnancy and the postpartum period is cardiovascular disease. While there are large European and Canadian studies exploring the care and outcomes of moms with heart disease in pregnancy, there are no large prospective studies to guide the care of this growing group of patients in the US. We review the current approach to the management of patients with heart disease in pregnancy and the gaps in knowledge thereof. Currently, antenatal management and delivery planning are highly variable for patients with heart disease in pregnancy and maternal risk models' application to the US patient population is limited by their derivation from an international cohort of patients and their focus on patients with congenital heart disease. As the need for interdisciplinary care between cardiologists and obstetricians becomes evident, and as broad research efforts within this space are very much needed, we propose a research collaborative called the Heart Outcomes in Pregnancy: Expectations (HOPE) for Mom and Baby Registry. The HOPE Registry aims to address key clinical questions surrounding the preconception period, antenatal care, delivery planning and outcomes, and long-term postpartum care and outcomes of these unique patients. We have made progress in recent years by recognizing the clinical need to address and standardize the management of patients with heart disease in pregnancy. We now must initiate and propel US-based cardio-obstetrics research to address key gaps in knowledge and variability in the care of patients with heart disease in pregnancy.

Standardizing clinical care measures of rheumatic heart disease in pregnancy: A qualitative synthesis

Rheumatic heart disease (RHD) is a preventable cardiac condition that escalates risk in pregnancy. Models of care informed by evidence-based clinical guidelines are essential to optimal health outcomes. There are no published reviews that systematically explore approaches to care provision for pregnant women with RHD and examine reported measures. The review objective was to improve understanding of how attributes of care for these women are reported and how they align with guidelines. A search of 13 databases was supported by hand-searching. Papers that met inclusion criteria were appraised using CASP/JBI checklists. A content analysis of extracted data from the findings sections of included papers was undertaken, informed by attributes of quality care identified previously from existing guidelines. The 43 included studies were predominantly conducted in tertiary care centers of low-income and middle-income countries. Cardiac guidelines were referred to in 25 of 43 studies. Poorer outcomes were associated with higher risk scores (detailed in 36 of 41 quantitative studies). Indicators associated with increased risk include anticoagulation during pregnancy (28 of 41 reported) and late booking (gestation documented in 15 of 41 studies). Limited access to cardiac interventions was discussed (19 of 43) in the context of poorer outcomes. Conversely, early assessment and access to regular multidisciplinary care were emphasized in promoting optimal outcomes for women and their babies. Despite often complex care requirements in challenging environments, pregnancy provides an opportunity to strengthen health system responses and address whole-of-life health for women with RHD. A standard set of core indicators is proposed to more accurately benchmark care pathways, outcomes, and burden.

Maternal mortality risk factor in pregnancy with heart disease at Dr. Soetomo General Hospital, Surabaya, Indonesia

Objectives: This research want to identify some factors that increasing risk of maternal death in pregnant woman with heart disease. Materials and Methods: This study was a retrospective analytic study with cross sectional design, with total sampling 92 patient with heart disease in pregnancy at maternity room Dr. Soetomo hospital, Surabaya, during periode January until December 2017. Results: Prevalency of pregnancy with heart disease in dr. Soetomo hospital about 0,5% with mortality that caused by heart disease 14% from all maternal death. Factors that increase risk of maternal death are non adequate antenatal visit number (OR 1,7;CI 95%), delay of detecting heart disease (OR 2,5;CI 95%), complication such as severe pulmonal hypertension (OR 61,4;CI 95%), Eisenmenger syndrome (OR 2,9;CI 95%), Decompensatio Cordis Functional Class IV (OR 1,2;CI 95%), and Thrombo-embolism (OR 9;CI 95%). Conclusion: Mortality rate in pregnancy with heart disease is 14% of all maternal mortality. Risk of maternal death increased by non adequate antenatal visit and delay in heart disease detection, and also medical complications. Detection of heart disease since before pregnant with pre-conceptional councelling and a good managed multidisciplinary antenatal care supposed to decrease morbidity and mortality.

Maternal mortality risk factor in pregnancy with heart disease at Dr. Soetomo General Hospital, Surabaya, Indonesia

Objectives: This research want to identify some factors that increasing risk of maternal death in pregnant woman with heart disease.Materials and Methods: This study was a retrospective analytic study with cross sectional design, with total sampling 92 patient with heart disease in pregnancy at maternity room Dr. Soetomo hospital, Surabaya, during periode January until December 2017.Results: Prevalency of pregnancy with heart disease in dr. Soetomo hospital about 0,5% with mortality that caused by heart disease 14% from all maternal death. Factors that increase risk of maternal death are non adequate antenatal visit number (OR 1,7;CI 95%), delay of detecting heart disease (OR 2,5;CI 95%), complication such as severe pulmonal hypertension (OR 61,4;CI 95%), Eisenmenger syndrome (OR 2,9;CI 95%), Decompensatio Cordis Functional Class IV (OR 1,2;CI 95%), and Thrombo-embolism (OR 9;CI 95%).Conclusion: Mortality rate in pregnancy with heart disease is 14% of all maternal mortality. Risk of maternal death increased by non adequate antenatal visit and delay in heart disease detection, and also medical complications. Detection of heart disease since before pregnant with pre-conceptional councelling and a good managed multidisciplinary antenatal care supposed to decrease morbidity and mortality.

Epidemiology of Rheumatic Heart Disease in Pregnancy in ANZ

Background: Rheumatic heart disease (RHD) in pregnancy is associated with significant maternal morbidity and mortality. We describe the epidemiology of RHD in pregnancy in Australia and New Zealand (ANZ). Methods: A population-based cohort study of pregnant women with RHD recruited 2013-14 through the hospital-based Australasian Maternity Outcomes Surveillance System. Findings: There were 311 cases of RHD in pregnancy - 266 (86%) identified as First Nations. Prevalence was highest in Aboriginal women in the NT (2.22%). MR was present in 269 cases (86%), MS in 116 (37%). Fifty (16%) cases had a prior cardiac intervention - 13 valve replacement, 22 repair, 15 PBMV. Fourteen percent of cases had a cardiac visit before 14 weeks, 9% between 14–19 weeks, 42% ≥ 20 weeks. A third of cases did not visit a cardiac specialist. Forty-five (15%) cases had no echocardiogram during pregnancy/postpartum; 39 (13%) were diagnosed with RHD during pregnancy/postpartum. There was one maternal death (case fatality rate = 0·3%). 32% were admitted to intensive/higher care units during pregnancy and 19% postpartum. 314 babies were born with seven stillbirths (22·3/1,000), three to women taking anticoagulants, and two neonatal deaths (6·5/1,000). Twenty-one percent of neonates were preterm, 19% had low birthweights. Conclusion: In ANZ, RHD in pregnancy persists among First Nations populations. It remains a disease of inequity. Despite significant cardiac and perinatal morbidity, high quality tertiary health care minimised mortality. There is a need to build upon care provided in pregnancy so as to provide long-term chronic disease management for women with RHD.