RHD and Pregnancy video
Video transcript
Speaker 1 Rheumatic heart disease, or RHD, remains a significant issue in Queensland and is twice as common in women as it is in men. At risk groups include Aboriginal and Torres Strait Islander, Māori and Pacific Islander people, as well as migrants and refugees from developing countries. Despite rheumatic valve damage often first occurring during adolescence and young adulthood, many patients remain asymptomatic until significant disease progression or when increased workload of the heart exacerbates pre-existing valve damage.
Speaker 1 The increase in blood volume, heart rate, and cardiac output associated with pregnancy can unmask previously undiagnosed RHD, particularly during the second and third trimesters. Pregnant women with RHD are at an increased risk of maternal and fetal complications, including pulmonary oedema, arrhythmias, preterm birth, and low birth weights.
Speaker 1 Preconception care is vital for women with RHD to optimise cardiac status and develop a shared multidisciplinary care plan for safe pregnancy and birth. All females of childbearing age with RHD should be supported with early effective contraceptive counselling integrated into routine care, considering ease of use and patient preferences. Long acting reversible contraceptives are an important consideration based on a woman's reproductive goals.
Speaker 1 Maternal and fetal risks associated with RHD may be further increased in women who do not access early and regular antenatal care. The frequency of when antenatal or specialist care is accessed may be negatively influenced by cost of medical care, geographical isolation, language barriers and lack of culturally safe care. For mothers living in rural or remote areas the social challenges of leaving their families and communities for antenatal care or birthing may create feelings of isolation and distress.
Speaker 1 Models of care that place a woman and baby at the centre of care, recognising importance of culture, language, family and community are essential for positive maternal outcomes. Effective multidisciplinary care is essential to safely manage RHD in pregnancy. A multidisciplinary team should involve the patient and their family, primary provider, midwife, obstetrician, cardiologist and, if appropriate, cultural health worker.
Speaker 1 When needed multicultural or Aboriginal Torres Strait Islander health workers and midwives should be utilised to bridge clinical care with cultural knowledge, spiritual beliefs and community trust. Women and baby focussed antenatal care that is flexible and includes their partners and support people enhances engagement through shared decision making and individualised support. Where possible, community-based models and a designated care coordinator helps women navigate multiple appointments and services, improving continuity of care and trust.
Speaker 2 Perinatal outcomes in patients with rheumatic heart disease are influenced by functional cardiac status, presenting symptoms, echocardiogram results, and maternal health history. Mothers with rheumatic heart disease should be referred to antenatal services early to provide opportunity for early intervention and ensure regular monitoring to avoid subsequent complications. At a minimum, it is recommended that at least one echocardiogram and cardiology review occurs during each pregnancy with increasing frequency, with increasing pathology.
Speaker 2 Perinatal clinical pathways vary according to the severity of valve damage and the presence of symptoms. These provide recommendations on the frequency of specialist and echocardiogram follow up, surgical interventions and the recommended birthing facility. Examples of resources include the Australian Pregnancy Care Guidelines, Australian Acute Rheumatic fever and Rheumatic Heart Disease Guidelines, and Queensland RHD and Pregnancy Clinical Guidelines.
Speaker 2 It is essential to identify cardiac risk early, consider undiagnosed rheumatic heart disease, and complete an echocardiogram in pregnant women from high risk backgrounds presenting with symptoms of breathlessness when lying flat, wheeze, worsening fatigue, peripheral oedema, or an undiagnosed murmur. Many women with rheumatic heart disease can have a safe pregnancy when monitored appropriately. Women with moderate to severe disease, including mixed valvular involvement, low ejection fraction, or pulmonary hypertension, are at an increased risk of complications and require close monitoring and regular clinical reviews.
Speaker 2 For some women with severe cardiac compromise, the risks of pregnancy resulting in severe complications or death are so high the pregnancy may not be recommended. Early involvement of psychosocial and emotional support systems are crucial. Mitral stenosis is the most concerning cardiac lesion in pregnancy and severe mitral stenosis is associated with high rates of heart failure, risk of death and adverse fetal outcomes.
Speaker 2 Circulatory changes during pregnancy may cause cardiovascular decompensation and should be medically managed. Cardiac surgery during pregnancy carries high fetal risk and should only be considered when medical therapy fails. When females of childbearing age require valve surgery, preserving the ability to safely carry children should be considered, and is an important part of pre-conception planning. Options for surgical valve interventions before and during pregnancy need to consider impacts on current and future pregnancies with planned interventions requiring a patient centred, multidisciplinary approach.
Speaker 2 Where possible mechanical valves should be avoided pre-pregnancy as they require lifelong anticoagulation medication, with high doses contraindicated in pregnancy due to the risks of birth defects, stillbirth, and postpartum haemorrhage. Benzathine benzylpenicillin G, known as BPG or Bicillin for secondary prophylaxis is considered safe and should continue during pregnancy, breastfeeding, and after valve surgery if previously indicated.
Speaker 2 Labour and delivery may place further stress on damaged heart valves and amplify the risk of decompensation. Individual case assessment involving the patient, their family and a multidisciplinary team are recommended to plan for a safe birth, including an appropriate delivery location and method. For many women with rheumatic heart disease, vaginal delivery is recommended when possible. Women with high risk cardiac features should birth at specialist tertiary centres with cardio obstetric expertise. Women with minimal to no cardiac risk can often deliver an appropriate local or regional hospital. Epidurals may be beneficial in reducing tachycardia and hypertension that can precipitate acute heart failure during labour. A caesarean birth may be recommended for medically unstable women and those complicated by the need for anticoagulation. Where birth occurs early or unplanned in a rural or remote facility, specialist obstetric support should be sought to ensure hemodynamic stability in the context of cardiac valve damage.
Speaker 2 Clear communication when discharged, post delivery is essential to share treatment plans and follow up requirements with the patient, their family, the specialist and the primary care provider. Early postpartum follow up should include contraception counselling, cardiac reassessment and psychosocial support. For up to six months post birth, treating clinicians should maintain a high index of suspicion of rheumatic heart disease in mothers, particularly from high risk backgrounds who are presenting with symptoms concerning for heart failure.
Speaker 1 When it comes to RHD in pregnancy, key points to remember are; pregnancy can unmask previously undiagnosed and asymptomatic RHD. Preconception care is vital for all females of childbearing age, with ARF and RHD. Pregnant women with RHD, at increased risk of complications, should be referred to antenatal services early, have at least one echocardiogram and a cardiology review whilst pregnant.
Speaker 1 Effective patient centred multidisciplinary care incorporating cultural considerations is essential to safely manage RHD in pregnancy. Consider undiagnosed RHD in postpartum mothers from high risk backgrounds presenting with symptoms concerning for heart failure. And remember, BPG is safe for use in pregnancy and breastfeeding and should continue if previously indicated. The Queensland RHD Register is a statewide disease register that supports health care providers with long term management of patients living with ARF and RHD.
Speaker 1 The Register relies on timely updates from healthcare providers regarding patient treatment, management and movements to maintain accurate and current patient information. The Register sends recall lists to health services for patients who are due or overdue treatment or review. It also sends information to The Viewer allowing healthcare providers timely access to patient information. Information on The Viewer for patients of The Register includes the patient's diagnosis details, care plans, disease severity and secondary prophylaxis, and echocardiogram details.
Speaker 1 All Queensland Health employees and eligible health practitioners external to Queensland Health can access The Viewer. Useful information and resources can be found on the Queensland Health ARF and RHD web page.