Rheumatic Heart Disease In Pregnancy Research Articles

A Retrospective Study to Evaluate the Maternal and Fetal Outcome in Patients of Heart Disease in Pregnancy at a Tertiary Rural Hospital

Background: Heart disease(HD) in pregnancy remains an important cause of maternal, fetal morbidity and mortality especially in a developing country like India, where incidence of cardiac disease that complicates pregnancy is between 1% to 4% & Rheumatic heart disease (RHD) still remains the most common type of heart disease complicating pregnancy due to Poor socioeconomic condition. Methods: This is a retrospective observational study carried out in Department of Obstetrics and Gynaecology at S.M.B.T. Institute of medical sciences, Dhamangaon during the period of 24 months to assess the maternal and fetal outcome on patients of heart disease with pregnancy. Result: Among the 3182 patients delivered in the study 35 had cardiac disease with prevalence of 1.1%, all patients were booked and diagnosed with heart disease during ANC checkup. Rheumatic Heart disease (70%) was the commonest form of heart disease with MS with MR predominating (22%). NYHA grade 2 patients (41%) were maximum with Anemia as the associated complicating factor.4 patients with severe MS required balloon mitral valvotomy (BMV) of them 1 patient went into pulmonary edema. There was no maternal mortality. 2 patients underwent medical termination of pregnancy (MTP) for cardiac reason and there was 1 neonatal mortality. Conclusion: RHD is still the commonest heart disease in pregnancy; BMV can be performed in third trimester on patients with severe MS reducing intra and postpartum complications. Giving good and timely antenatal, Intranatal and postnatal care at a tertiary care hospital with good cardiac, obstetric & Neonatal care setup reduces maternal and fetal morbidity in patients of heart disease with pregnancy. Keywords: Rheumatic heart disease in pregnancy, Congenital heart disease in pregnancy, Balloon Mitral Valvotomy in pregnancy

Study on impact of Rheumatic Heart Disease in Pregnancy

Study on impact of Rheumatic Heart Disease in Pregnancy

Obstetric outcome in patients with rheumatic heart disease: experience in a tertiary hospital

Aims: To determine the clinical outcome of rheumatic heart disease in pregnancy.
 Methods: Retrospective cross-sectional descriptive study from April 2019 to April 2021 in Nobel Medical College, Biratnagar, Nepal. Feto-maternal variables were taken for their health status. Data presented in table with frequency.
 Results: Out of 13013 deliveries in a year, 49 had cardiac disease (0.37%) and 38 had rheumatic heart disease (0.29%) over 28 weeks of gestation; 95% (n=36) had mitral valve involvement; 12 were primigravida and 7 preterm at the time of delivery. Half of them underwent caesarean section for various indications. Most common maternal complications were cardiac failure, cardiac arrythmia, admission to ICU, obstetric complications, including maternal mortality in 5.2% (n=2) cases. Low birth was in 29% (n=11) of cases, and 34% (n=13) of them needed NICU care at the time of delivery. There was history of rheumatic fever in 9 cases (24%).
 Conclusions: Rheumatic heart disease is the commonest diagnosis among heart disease in pregnancy and adverse event can be minimized by multidisciplinary intervention

Caring for Pregnant Women with Rheumatic Heart Disease: A Qualitative Study of Health Service Provider Perspectives.

Background:Rheumatic heart disease (RHD) persists in low-middle-income countries and in high-income countries where there are health inequities. RHD in pregnancy (RHD-P) is associated with poorer maternal and perinatal outcomes. Our study examines models of care for women with RHD-P from the perspectives of health care providers.Methods:A descriptive qualitative study exploring Australian health professionals’ perspectives of care pathways for women with RHD-P. Thematic analysis of semi-structured interviews with nineteen participants from maternal health and other clinical and non-clinical domains related to RHD-P.Results:A constellation of factors challenged the provision of integrated women-centred care, related to health systems, workforces and culture. Themes that impacted on the provision of quality woman-centred care included conduits of care – helping to break down silos of information, processes and access; ‘layers on layers’ – reflecting the complexity of care issues; and shared understandings – factors that contributed to improved understandings of disease and informed decision-making.Conclusions:Pregnancy for women with RHD provides an opportunity to strengthen health system responses, improve care pathways and address whole-of-life health. To respond effectively, structural and cultural changes are required including enhanced investment in education and capacity building – particularly in maternal health – to support a better informed and skilled workforce. Aboriginal Mothers and Babies programs provide useful exemplars to guide respectful effective models of care for women with RHD, with relevance for non-Indigenous women in high-risk RHD communities.For key goals to be met in the context of RHD, maternal health must be better integrated into RHD strategies and RHD better addressed in maternal health.

Rheumatic Heart Disease in Pregnancy: New Strategies for an Old Disease?

RHD in pregnancy (RHD-P) is associated with an increased burden of maternal and perinatal morbidity and mortality. A sequellae of rheumatic fever resulting in heart valve damage if untreated, RHD is twice as common in women. In providing an historical overview, this commentary provides context for prevention and treatment in the 21 st century.Four underlying themes inform much of the literature on RHD-P: its association with inequities; often-complex care requirements; demands for integrated care models, and a life-course approach. While there have been some gains particularly in awareness, strengthened policies and funding strategies are required to sustain improvements in the RHD landscape and consequently improve outcomes.As the principal heart disease seen in pregnant women in endemic regions, it is unlikely that the Sustainable Development Goal 3 target of reduced global maternal mortality ratio can be met by 2030 if RHD is not better addressed for women and girls.

The Spectrum, Severity and Outcomes of Rheumatic Mitral Valve Disease in Pregnant Women in Australia and New Zealand

Rheumatic heart disease (RHD) poses significant perinatal risks. We aimed to describe the spectrum, severity and outcomes of rheumatic mitral valve disease in pregnancy in Australia and New Zealand. A prospective, population-based cohort study of pregnant women with RHD recruited 2013-14 through the hospital-based Australasian Maternity Outcomes Surveillance System. Outcome measures included maternal and perinatal morbidity and mortality. Univariable and multivariable logistic regression analyses were undertaken to test for predictors of adverse maternal and perinatal outcomes. Of 274 pregnant women identified with RHD, 124 (45.3%) had mitral stenosis (MS) and 150 (54.7%) had isolated mitral regurgitation (MR). One woman with mild MS/moderate MR died. There were six (2.2%) stillbirths and two (0.7%) neonatal deaths. Babies born to women with MS were twice as likely to be small-for-gestational-age (22.7% vs 11.4%, p=0.013). In women with MS, use of cardiac medication (AOR 7.42) and having severe stenosis (AOR 16.35) were independently associated with adverse cardiac outcomes, while New York Heart Association (NYHA) class >1 (AOR 3.94) was an independent predictor of adverse perinatal events. In women with isolated MR, use of cardiac medications (AOR 7.03) and use of anticoagulants (AOR 6.05) were independently associated with adverse cardiac outcomes. Careful monitoring and specialist care for women with RHD in pregnancy is required, particularly for women with severe MS, those on cardiac medication, and those on anticoagulation, as these are associated with increased risk of adverse maternal cardiac outcomes. In the context of pregnancy, contraception and preconception planning are important for young women diagnosed with RHD.

A RETROSPECTIVE STUDY ON CARDIAC DISEASE IN PREGNANCY

Cardiac disease in pregnancy is one of the common ,indirect obstetric causes of maternal mortality reported incidence varying between 0.5 and 5.9% worldwide. The rise in maternal mortality has been attributed to increasing numbers of women at advanced maternal age undertaking pregnancy, comorbid pre-existing conditions such as diabetes mellitus and hypertension and the growing number of women with congenital heart disease surviving to childbearing. Valvular heart disease is present in 80% of patients with heart disease during pregnancy in developing countries with rheumatic fever as the most common etiology and the mitral valve being the most commonly affected valve, but is uncommon in developed countries. Heart failure complicating rheumatic heart disease in pregnancy has been described in 22% women presenting to clinics in India and few African countries.

Rheumatic heart disease in pregnancy and neonatal outcomes: A systematic review and meta-analysis.

PurposeAssociations between rheumatic heart disease (RHD) in pregnancy and fetal outcomes are relatively unknown. This study aimed to review rates and predictors of major adverse fetal outcomes of RHD in pregnancy.MethodsMedline (Ovid), Pubmed, EMcare, Scopus, CINAHL, Informit, and WHOICTRP databases were searched for studies that reported rates of adverse perinatal events in women with RHD during pregnancy. Outcomes included preterm birth, intra-uterine growth restriction (IUGR), low-birth weight (LBW), perinatal death and percutaneous balloon mitral valvuloplasty intervention. Meta-analysis of fetal events by the New-York Heart Association (NYHA) heart failure classification, and the Mitral-valve Area (MVA) severity score was performed with unadjusted random effects models and heterogeneity of risk ratios (RR) was assessed with the I2 statistic. Quality of evidence was evaluated using the GRADE approach. The study was registered in PROSPERO (CRD42020161529).FindingsThe search identified 5949 non-duplicate records of which 136 full-text articles were assessed for eligibility and 22 studies included, 11 studies were eligible for meta-analyses. In 3928 pregnancies, high rates of preterm birth (9.35%-42.97%), LBW (12.98%-39.70%), IUGR (6.76%-22.40%) and perinatal death (0.00%-9.41%) were reported. NYHA III/IV pre-pregnancy was associated with higher rates of preterm birth (5 studies, RR 2.86, 95%CI 1.54–5.33), and perinatal death (6 studies, RR 3.23, 1.92–5.44). Moderate /severe mitral stenosis (MS) was associated with higher rates of preterm birth (3 studies, RR 2.05, 95%CI 1.02–4.11) and IUGR (3 studies, RR 2.46, 95%CI 1.02–5.95).InterpretationRHD during pregnancy is associated with adverse fetal outcomes. Maternal NYHA III/IV and moderate/severe MS in particular may predict poor prognosis.

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.

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.

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.

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.

Better Care for Pregnant Women With RHD: What Works?

Background: Rheumatic heart disease (RHD) persists globally as a chronic disease of inequity with added impact in pregnancy. This research aims to identify and examine gaps and facilitators in models of care for women with RHD with a focus on health services. Methods: A qualitative study explored models of care pathways, using thematic analysis of semi-structured interviews with 19 Australian health professionals. Results: Provision of cohesive women-centred care was challenged by a series of factors. Themes arising included conduits of care - helping to break down system blocks to improve access to care; ‘layers on layers’ – reflecting complexity of care issues and underlying ‘causes of the causes’; and shared understandings – identifying factors that built improved understandings of disease, agency in informed decision-making for women, and the importance of family and community in that decision-making. Collaborative, cross-disciplinary partnerships were embedded in models of care such as Aboriginal maternal infant health services and elements of RHD programs that described facilitators of optimal care. Discussion: This is the first known study to explore gaps and facilitators of models of care for women with RHD in pregnancy with a focus on health services. Despite often complex care requirements in challenging environments, pregnancy for women with RHD provides an opportunity at a critical juncture to strengthen health system responses, improve care pathways, address whole-of-life health and ultimately reduce the burden of RHD. To respond effectively, structural and cultural change is required to improve care pathways for women with RHD.

Using Research: Educational Resources for Rheumatic Heart Disease in Women

Background: A study of Aboriginal women's journeys with Rheumatic Heart Disease (RHD) in Australia found that women and their families rarely had a deep understanding of the cause or implications of their disease. Despite contact with health staff, often since childhood, participants lacked understanding of the severity of their illness and its implications for childbearing. Several information/educational initiatives were developed to improve health literacy and have informed other strategies. Methods: Content review related to an evidence-base of selected educational resources developed for and by women with RHD, health services and researchers since 2015. Results: Three resources were selected for review. The first, an information flier on RHD in pregnancy for health professionals, was co-designed by Australasian Maternity Outcomes Surveillance System (AMOSS) researchers, midwives and Aboriginal health practitioners. The second, ‘Sharing a heartbeat’ is a two-part video in multiple Aboriginal languages, which explores fertility, pregnancy and family for Indigenous women with RHD. It was written and directed by Aboriginal women in partnership with researchers. The third is a flipchart with brief text and corresponding illustrations, that guides interaction between health providers and women with RHD in primary health low/middle-income settings. It was developed by Reach, a global RHD technical assistance organisation, building on the AMOSS resource. Discussion: A shared understanding of RHD is essential to improve knowledge and decision-making about the disease and its impact for women's health. The resources described show how research can learn from and inform a collaborative approach to health literacy at both local and global levels.

Rheumatic heart disease in pregnancy: strategies and lessons learnt implementing a population-based study in Australia.

The global burden of rheumatic heart disease (RHD) is two-to-four times higher in women, with a heightened risk in pregnancy. In Australia, RHD is found predominantly among Aboriginal and Torres Strait Islander peoples. This paper reviews processes developed to identify pregnant Australian women with RHD during a 2-year population-based study using the Australasian Maternity Outcomes Surveillance System (AMOSS). It evaluates strategies developed to enhance reporting and discusses implications for patient care and public health. AMOSS maternity coordinators across 262 Australian sites reported cases. An extended network across cardiac, Aboriginal and primary healthcare strengthened surveillance and awareness. The network notified 495 potential cases, of which 192 were confirmed. Seventy-eight per cent were Aboriginal and/or Torres Strait Islander women, with a prevalence of 22 per 1000 in the Northern Territory. Effective surveillance was challenged by a lack of diagnostic certainty, incompatible health information systems and varying clinical awareness among health professionals. Optimal outcomes for pregnant women with RHD demand timely diagnosis and access to collaborative care. The strategies employed by this study highlight gaps in reporting processes and the opportunity pregnancy provides for diagnosis and re/engagement with health services to support better continuity of care and promote improved outcomes.

Medical Management of Rheumatic Heart Disease: A Systematic Review of the Evidence.

Rheumatic heart disease (RHD) is an important cause of heart disease globally. Its management can encompass medical and procedural (catheter and surgical) interventions. Literature pertaining to the medical management of RHD from PubMed 1990-2016 and via selected article reference lists was reviewed. Areas included symptom management, left ventricular dysfunction, rate control in mitral stenosis, atrial fibrillation, anticoagulation, infective endocarditis prophylaxis, and management in pregnancy. Diuretics, angiotensin blockade and beta-blockers for left ventricular dysfunction, and beta-blockers and If inhibitors for rate control in mitral stenosis reduced symptoms and improved left ventricular function, but did not alter disease progression. Rhythm control for atrial fibrillation was preferred, and where this was not possible, rate control with beta-blockers was recommended. Anticoagulation was indicated where there was a history of cardioembolism, atrial fibrillation, spontaneous left atrial contrast, and mechanical prosthetic valves. While warfarin remained the agent of choice for mechanical valve implantation, non-vitamin K antagonist oral anticoagulants may have a role in RHD-related AF, particularly with valvular regurgitation. Evidence for anticoagulation after bioprosthetic valve implantation or mitral valve repair was limited. RHD patients are at increased risk of endocarditis, but the evidence supporting antibiotic prophylaxis before procedures that may induce bacteremia is limited and recommendations vary. The management of RHD in pregnancy presents particular challenges, especially regarding decompensation of previously stable disease, the choice of anticoagulation, and the safety of medications in both pregnancy and breast feeding.

The New Zealand Rheumatic Heart Disease Registry

Background: Acute rheumatic fever (ARF) has been extensively chronicled in New Zealand. Huge ethnic disparities continue. In contrast, the burden of chronic rheumatic heart disease (RHD) in New Zealand is not well defined. Some surgical outcomes are known and there is data about RHD in pregnancy. Beyond that, morbidity, access to care, adherence to care, and the quality of medical and surgical care are poorly defined. Aims:•To create the first New Zealand wide contemporary cohort of significant RHD to be known as the NZ RHD registry. This will better define the morbidity and mortality of RHD.•To establish a governance group for the NZ RHD registry•To plan retrospective and prospective studies of RHD outcomes Methods: This NZ RHD registry will be populated utilising surgical, echocardiographic and outpatient databases, cross-referencing with ARF registries, ICD hospital discharge and National mortality data. Results: Major funding from the Heart Foundation. Data managers recruited. Collaborating investigators established in all NZ cardiac units. HDEC approval July 2017. Enrolment in the registry has commenced. 850 cases enrolled, pre-dominantly from ADHB data sources by March 2018. Conclusion: The first phase of the New Zealand Rheumatic Heart Disease Registry is now well established. This large study will involves all the cardiac units of New Zealand. The establishment of such a cohort/registry will be a platform to increase understanding of the true morbidity of significant RHD, allow comparisons to the NZ Heart Foundation Guidelines for RHD, and explore inequities by age, region and ethnicity.

Rheumatic heart disease in pregnancy: How can health services adapt to the needs of Indigenous women? A qualitative study.

To study rheumatic heart disease health literacy and its impact on pregnancy, and to identify how health services could more effectively meet the needs of pregnant women with rheumatic heart disease. Researchers observed and interviewed a small number of Aboriginal women and their families during pregnancy, childbirth and postpartum as they interacted with the health system. An Aboriginal Yarning method of relationship building over time, participant observations and interviews with Aboriginal women were used in the study. The settings were urban, island and remote communities across the Northern Territory. Women were followed interstate if they were transferred during pregnancy. The participants were pregnant women and their families. We relied on participants' abilities to tell their own experiences so that researchers could interpret their understanding and perspective of rheumatic heart disease. Aboriginal women and their families rarely had rheumatic heart disease explained appropriately by health staff and therefore lacked understanding of the severity of their illness and its implications for childbearing. Health directives in written and spoken English with assumed biomedical knowledge were confusing and of limited use when delivered without interpreters or culturally appropriate health supports. Despite previous studies documenting poor communication and culturally inadequate care, health systems did not meet the needs of pregnant Aboriginal women with rheumatic heart disease. Language-appropriate health education that promotes a shared understanding should be relevant to the gender, life-stage and social context of women with rheumatic heart disease.

Rheumatic Heart Disease in Pregnancy: A Health Services Challenge

Rheumatic Heart Disease in Pregnancy: A Health Services Challenge

Rheumatic Heart Disease in Pregnancy [22D

Rheumatic Heart Disease in Pregnancy [22D