What if I am pregnant?
This information is designed to be used by health professionals working with women who are pregnant or planning to have a baby and are at risk of rheumatic heart disease (RHD). The information was developed by the Australian Maternity Outcomes Surveillance System RHD in Pregnancy Study. Clinical information is consistent with the Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd edition)2012.
The accredited RHDAustralia clinician module ‘Pregnancy and RHD’ contains further information about risks and management of RHD in pregnancy.
Why does RHD matter in pregnancy?
Rheumatic heart disease is up to twice as common in women, and tends to affect women during their child bearing years. There is a 30-50% increased cardiac workload in normal pregnancy. When a woman has rheumatic heart disease this can impact in a couple of ways.
- Diagnosis may not occur until the time of pregnancy. The added stress on the heart can result in symptomatic RHD where previously there were no symptoms. The earlier the diagnosis and treatment, the less likelihood she will have complications. If there are symptoms of early cardiac failure, or shortness of breath, or needing to sleep with two pillows, the possibility of RHD should be considered and investigated.
- She may already have been diagnosed with RHD, but pregnancy can worsen the disease. If she’s receiving anticoagulation therapy during pregnancy, careful assessment is required.
Does a history of rheumatic fever mean a pregnancy with RHD?
No. Rheumatic fever, especially if it’s treated with long-term secondary prophylaxis, doesn’t always lead to RHD. The critical thing is to follow-up any history of rheumatic fever (which may be described as an infection and/or sick heart as a kid with sore throat/joints and/or skin infections, or remembering the regular penicillin injection).
How is RHD diagnosed?
Definitive diagnosis is by echocardiogram, a non-invasive ultrasound. The echo test may be done one or more times during pregnancy, to monitor how well the heart is performing. Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd edition) 2012 recommends a cardiac review and echocardiogram for all women with a history of acute rheumatic fever/RHD.
Who gets RHD?
Risk factors include poverty, overcrowded housing and reduced access to medical care. Aboriginal and Torres Strait Islander women are at a much higher risk of having RHD in Australia. Maori and Pacifica women and migrant women from resource-poor countries are also at a greater risk.
Rheumatic heart disease is up to twice as common in women. This can vary according to age and region, but RHD is much more commonly diagnosed in women. The Northern Territory has about a third of all cases of women with RHD in Australia: yet its population is only one percent of the country. For the other two thirds of women with RHD, they are more likely to live in regional/remote Australia, particularly Western Australia and Queensland – but …
“We don’t have RHD here?!”
… one of the barriers to optimal care can be a lack of recognition of the disease, particularly in regions of lower prevalence such as New South Wales. Each year there are women diagnosed with RHD because they developed difficulties during pregnancy or early postpartum, when an earlier diagnosis would have prevented complications. The antenatal booking visit provides a critical opportunity to flag if there has been a history of acute rheumatic fever/RHD, and follow-up with assessment and review.
Secondary prophylaxis treatment during pregnancy – is it safe?
Yes! An important message is that any prescribed antibiotic should be continued during pregnancy, and in fact it’s really important women don't miss any injections to avoid a recurrence of acute rheumatic fever and worsening of RHD.
What about anticoagulation?
Anticoagulants include Warfarin or low-molecular weight heparin (LMWH) and are mostly taken where a heart valve has been replaced or for atrial fibrillation. Both groups of anticoagulants can cause problems; either by increased risk of thromboembolism or risk to the foetus. Careful monitoring, collaborative care and cardiac review pre conception and during pregnancy is critical.
What is important in planning pregnancy for women with RHD?
Preconception counselling is important for any woman with ARF/RHD. It gives an opportunity to have a talk about risks, how to minimise complications, contraception and being able to make informed choices. Similarly, inter-pregnancy interval is important for women with RHD. Pregnancy can put added strain onto a heart with RHD, depending on the woman it may be advised to have a longer time gap between babies.
Is it important to know if the woman is an Aboriginal or Torres Strait Islander?
Yes! Ask all women under your care if they are Aboriginal and/or Torres Strait Islander. This is important to provide women with the best possible, culturally safe care. Reliable information on the health of Aboriginal and Torres Strait Islander women is essential for measuring the effectiveness of health services in meeting their needs, and for planning and improvement in service delivery.
How are the babies and families of women affected?
Where women are the main care-givers in a family, any illness will affect the whole family and community. Women with RHD can have poorer outcomes for their babies either because of complications caused by damage to the heart valves, or the anticoagulation medication that may be required if the woman has had a valve replacement or atrial fibrillation. Pregnancy provides an opportunity to help break the cycle: to provide education about rheumatic fever and RHD to build awareness of prevention and importance of treatment for mother and children.
Pregnancy and childbirth should be a joyous time – how can I help support woman with RHD in pregnancy?
Women with rheumatic heart disease can often have an event free, normal pathway to birth. This is why it’s so important to have multidisciplinary care, monitoring and support during pregnancy. This can help minimise avoidable problems, optimise good outcomes for mother and baby and support the woman to feel safe in pregnancy.
- Secondary prophylaxis is safe for pregnant women
A 27 year old Maori woman who migrated to NSW from NZ a year ago received an echocardiogram and cardiac review at 13 weeks’ gestation, after her antenatal booking visit picked up a history of rheumatic fever. She had received regular bicillin injections (secondary prophylaxis) whilst in NZ, but only two of the prescribed 13 injections since she arrived in Australia. She re-commenced the 3-4 weekly bicillin schedule, and had further reviews and another echo at 37 weeks’ gestation which showed that her moderate mitral regurgitation had not worsened in pregnancy. She gave birth without complications to a healthy baby boy at 39 weeks.
- Regular monitoring and multidisciplinary care during pregnancy help avoid / minimise complications
A 21 year old Aboriginal woman from a regional centre presented to Emergency Department with severe breathlessness and palpitations at 33 weeks’ pregnant. She had a history of rheumatic fever as a child with regular injections, but had not received these recently. She was diagnosed with mitral stenosis due to rheumatic heart disease, transferred via Royal Flying Doctor Service to a tertiary hospital, admitted to intensive care and commenced on digoxin, metoprolol and frusemide. She had a vaginal birth whilst in ICU to a premature baby, and is being reviewed for a mitral valve replacement with subsequent lifelong anticoagulation requirements.
Take Home Messages
- High risk populations include Aboriginal and/or Torres Strait Islander women, Maori and Pacifica women, and migrant women from resource poor countries
- RHD can have added impact during pregnancy, when there is 30-50% increased cardiac workload
- Pregnancy provides an ideal point in time for diagnosis and monitoring
- Identify a woman’s cultural background, to best understand her risks – Is she ATSI? Refugee?
- During the antenatal booking visit, check history:
- Has the woman (or her family) had rheumatic fever (RF) as a child (sore throat/joints, skin infections)
- Has she ever had regular antibiotic injections over a period of time for her heart (she would remember - these hurt!)
- Has she ever had a scan/ultrasound (echocardiogram) or heart surgery
- “Yes” to any of the above questions? Clarify the woman’s history in collaboration with other services that provide care (maternity services, Aboriginal medical services, refugee health services)
- Is the woman prescribed antibiotic ‘secondary prophylaxis’ (usually 3-4 weekly penicillin injections)? This is safe and should continue during pregnancy.
- Women requiring anticoagulation during pregnancy are at additional risk of complications.
- If you’re in NT, WA, QLD, NSW or SA: is the woman registered with the RHDControl Register?
- Early diagnosis and multidisciplinary care are vital to optimise good outcomes for mother and baby.
- Has conception counselling been discussed as part of the woman’s care?
- Does the woman need an interpreter? At the antenatal booking visit to help with conversations about health history, and ongoing throughout pregnancy to discuss management and progress.