1. Rheumatic Heart Disease in Pregnancy Dr Jane Thorn Obstetrician and Gynaecologist Royal Darwin Hospital October 2016

2.  Increases by 30 – 40% by around 27 weeks gestation then drops dramatically toward term (37 – 41 weeks)  Blood volume increases 1000 – 2000 mls  ~625 mls in the maternal circulation of the placenta

3. Cardiovascular changes in pregnancy

4.  First Stage  Labour  Uterine contractions  Pain  Second Stage  Birth of the baby  Active descent of the baby (pushing)  Third Stage  Delivery of the placenta  Associated maternal blood loss (up to 500 mls considered normal)

5.  Cardiac output rises progressively from the first stage of labour to an additional 50% in late second stage  An increase of >7 litres per minute  Birth causes a dramatic shift of fluid with a sharp rise in left atrial pressure. This can be exacerbated by post-partum haemorrhage  Epidural and general anaesthetics cause acute changes in cardiac output

6.  Cardiac disease is one of the major causes of maternal mortality in Australia  Pregnant women with mitral stenosis have a mortality risk of up to 1%  Pregnant women with mitral stenosis and atrial fibrillation have a mortality risk of up to 15%  Pregnant women with pulmonary hypertension have a mortality risk of up to 50%

7. Atrial fibrillation + risk of thromboembolism Heart failure Blood flow back to lungs > pulmonary oedema Increased pulmonary artery pressure (PAP) Left atria pressure builds >> chamber swells Mitral valve becomes thickened & immobile Moderate-severe stenosis: May be triggered by physiological stress (pregnancy!) Regurgitation & mild stenosis: Regular monitoring (echos & clinical checks) RHD in pregnant women

8. www.amoss.com.au 180 women giving birth with RHD 10 women had two or more pregnancies during the study 190 pregnancies 79% Aboriginal &/or Torres Strait Islander 187 liveborn babies 60 women resident in the Northern Territory 3 of 30 inpatients at RDH on 16/10/16 RHD Preliminary data

9. 36% women 1st antenatal visit >20 weeks 56% women transferred care during pregnancy 2/3 due to high-risk status &/or to access facilities due to their RHD 9 women transferred interstate; & significant number travelled distances >1800km to a referral hospital All women residing in remote communities in the NT must give birth in one of 4 hospitals RDH, ASH, Gove, Katherine Women from North East Arnhem and the Barkley region considered high risk must give birth at Royal Darwin Hospital health.uts.edu.au Antenatal Care

11.  27 year old woman  Living between Katherine and Minyerri  G6P3  NVB x3  1 in WA  2 at Katherine Hospital  PPH 700mls last baby  This pregnancy dated on 8/40 scan  RHD diagnosed May 2015 P2/3  Mild mitral stenosis and regurgitation  Mild aortic regurgitation  Commenced on LA Bicillin at diagnosis  No echocardiogram performed this pregnancy

12.  Syphilis +ve  1:18 in early pregnancy  Treated appropriately  Baby to receive treatment at birth  Anaemic  Hb 97  Did not have OGTT  Heavy tobacco smoker  Non-drinker  Domestic violence

13.  At least 7 antenatal visits  Antenatal care between Minyerri (Sunrise Health Service) and Katherine (Wurli-Wurlinjang Health Service and Katherine Hospital)  Obstetric ultrasound at 36/40  Oligohydramnios and raised umbilical artery dopplers  Induction of labour started but abandoned  Repeat ultrasound considered normal  No documented follow-up plan

14.  Presented to KH at 38/40 with SROM  Duration of ROM > 24 hours  Started on IV benzyl penicillin  Induction of labour  Normal vaginal birth  Retained placenta with 2000ml PPH necessitating manual removal in OT (general anaesthetic)  Retrieved to RDH for ongoing care

15.  Pre-pregnancy planning  Effective contraception to allow for:  Review of cardiac status and education around risks associated with pregnancy and birth  Change of medication if on ACE inhibitors, warfarin etc  Review of diabetic and renal status and BGL stabilisation and optimisation  Treatment of STIs  Correction of anaemia  Education around engaging in antenatal care and need for early pregnancy diagnosis

16.  Regular antenatal visits  From pregnancy diagnosis (preferably in first trimester)  Opportunity to offer aneuploidy screening  Allows time for appropriate referral and multidisciplinary management and planning for delivery  Collaborative care with both community clinics and obstetricians

17.  Echo and cardiac review in third trimester with recommendation regarding ability to tolerate normal labour  Anaesthetic review (after Echo)  Delivery in a hospital with appropriate level of obstetric, anaesthetic and cardiac expertise

18.  Access to services and expertise in regional and remote areas  Disconnected health information services  Awareness: Untold stories – under-reporting. (Generally) good awareness in high-prevalence regions… but diagnosis is still ‘missed’. Low awareness where RHD is overall rare  Conflicting priorities for women – how important is sub-clinical RHD when there’s no food in the home?

19. A taxi to get to the ferry to get to the plane to get to the cardiac centre … for an echocardiogram … when you don’t know if your kids are going to be all right …