1. Rheumatic Heart Disease in Pregnancy PMMRC June 2015
Dr Claire McLintock
Faith Mahony

2. Aim
Improve the safety and quality of maternity care in Australia and New Zealand
Background
Uncommon conditions are difficult to study
little research available
Clinical practice not based on robust evidence base

3. AMOSS Conditions Completed Ongoing Peripartum hysterectomy Eclampsia
Antenatal pulmonary embolism
Placenta accreta/increta/percreta
Gestational breast cancer
Rheumatic heart disease
Ongoing
Blood transfusion >5 units in <4 h
Amniotic fluid embolism

4. Rheumatic Fever
Let’s concentrate on the who -the majority of patients with MS have developed it as a result of RF - an autoimmune disease caused by antibodies to an untreated streptococcal sore throat. I

5. Rheumatic Fever Incidence
Aboriginal & Torres Strait Islanders
375 65
Pacific Island 96
Maori 65
per population aged 10-15y
European <1

6. North-South Gradient 2006-2010 RF admissions age 0-24 y (per 100 000)
0-1
2-5
6-15
16-25
>25
New Zealand Child and Youth Epidemiology Service

7. RF Admissions by Age NZ 2006-2010
NZCYES

8. RF Admissions by Ethnicity 0-24 Year Olds, NZ 2006-2010
NZCYES

9. Duration of Secondary Prophylaxis
Benzyl penicillin im injection every 28 days
RHD category
Recommendation
None or Mild
Minimum 10 yrs
Mod
Until age 30 yrs then reassess
Severe
Until age 40 yrs (reassess age 30 yrs)

10. heart rate cardiac output plasma volume
In pregnancy there are increases in plasma volume, heart rate and cardiac output.
The increase in HR means that there is less time for diastolic filling of the ventricle, which in women with mitral stenosis prevents an increase in cardiac output and with the increase in plasma volume combine to increase the gradient across the valve, cause more pulmonary hypertension and thereby worsening of clinical symptoms.
Women who were previously asymptomatic can develop symptoms and this seems to occur at the time of the second increase in heart rate around week
The inability to increase cardiac output with MS leads to symptoms of fatigue, shortness of breath, orthopnoea and PND.

11. Research questions Which women are affected? How severe is the RHD?
previous RHD surgery, valvotomy
What are the outcomes for mother & baby?
Cardiac decompensation
Intensification of therapy
Surgical intervention
Adverse infant outcomes

12. Data Collection
Prospective identification of pregnant women with RHD Oct 1st Dec 31st 2014
Sources
PMMRC Local Coordinators
Cardiologists, MFM, Midwives, Obstetric Specialists
DHB decision
Data collection and data entry NZ RHD coordinator
Demographics
Cardiac status
Medical complication
Pregnancy outcomes

13. Recruitment Pregnancies N=186* Fulfill AMOSS criteria n=146
History RF only or trivial RHD
n=34
No echo results
n=5
Lost to follow-up
n=1
*14 women 2 pregnancies, 2 women 3 pregnancies, 1 twin pregnancy

14. 63% of cases in Auckland Region
Location Oct 12- Dec 14
Northland 5%
Waitemata 4%
Auckland 27%
Manukau 32%
Tauranga 1%
Lakes 3%
Waikato 7%
Gisborne 5%
New Plymouth 1%
Hawkes Bay 5%
Wanganui 1%
Hutt 1%
Wellington 5%
63% of cases in Auckland Region
Christchurch 3%
69% Upper North Island

15. Ethnicity
SE Asian 3
NZ European 4

16. Age
Range y
Median 27 y

17. Age of last episode RF (or 1st episode)
43% initial RF or recurrence ≥18 years

18. Severity of RHD Valve Lesion

19. Smoking

20. Maternal Outcome Maternal outcome N (%) Maternal death
Surgical intervention in pregnancy
6 (3.4%)
Initiation of cardiac medications in pregnancy
36 (25%)
1st diagnosis of RHD during index pregnancy or postpartum*
16 (11%)
antenatal, n=12
postpartum, n=4
*cardiac decompensation postpartum in 4 women with previously unrecognised RHD

21. Outcomes in Pregnancy in Women with No Previous Cardiac Surgery
RHD disease severity
Number of Pregnancies
Clinical decompensation in pregnancy or postpartum (n, %)
Description of RHD valve lesion in women with decompensation
Mild 43
Moderate 41
6 (14.6%)
Moderate AR x2
Moderate MR
Moderate MS+AR
Moderate AR+MR
Moderate MS+MR
Severe 38
21 (55.3%)
Severe MR (n=13)
Severe AR (n=1)
Severe MS (n=6)
Severe MS+MR (n=1)
AR – aortic regurgitation
MR – mitral regurgitation
MS – mitral stenosis
All 7 women with severe MS decompensated.
5 required surgery during pregnancy or postpartum

22. Outcomes in women with severe RHD
Valve lesion
Pregnancies (N)
Complications
N, %
Description
Severe MR 26
13 (50%)
Diuretics, b-blockers
Severe MS - isolated 6
6 (100%)
Balloon mitral valvotomy (n=3)
Valve replacement surgery (n=3)
Severe MS + severe MR 1
1 (100%)
Severe AR
+ trivial or mild MR 3
Severe AR + moderate MR
AR – aortic regurgitation
MR – mitral regurgitation
MS – mitral stenosis

23. Outcomes in Pregnancy in Women with Previous Cardiac Surgery
24 women previous cardiac surgery
RHD status at start of index pregnancy
Mild (n=15)
cardiac meds in pregnancy (n=2, 13.3%)
Moderate (n=6)
cardiac meds in pregnancy (n=3, 50%)
Severe (n=3)
cardiac meds in pregnancy (n=1, 33%)

24. Infant Outcomes Outcome N (%) Mode of birth Miscarriage or termination
14 (9.6)
Stillbirth
2 (1.5)
Preterm birth
15 (11.4)
Birthweight (mean, range)
3295 g ( )
Mode of birth
Spontaneous vaginal birth, unassisted
88 (60.3)
Assisted birth (forceps, ventouse)
12 (9.1)
Induction of labour
42 (32.8)
Caesarean section
31 (23.5)

25. Risk stratification and optimal care for women with RHD in pregnancy
Education about prevalence
of RHD in NZ
Improve health literacy to reduce incidence RF