Oral Presentation Society of Obstetric Medicine of Australia and New Zealand ASM 2018

Despite the determined efforts of public health bodies, Acute Rheumatic Fever and consequent Rheumatic Heart Disease (RHD) remain major causes of morbidity and mortality for indigenous populations of both Australia and New Zealand.¹ The combination of RHD and the usual cardiovascular changes of pregnancy can pose a serious risk to both mother and fetus. However, unlike the poor outcomes evident in many developing countries,² the results in advanced health care systems can be excellent.³

Good peripartum outcomes require accurate assessment of the type and severity of RHD through patient history and echocardiography. Close liaison between obstetric carers and cardiologists or suitably experienced general physicians is essential. Most patients require either no specific treatment or simple medication such as frusemide or beta blockers. Procedural interventions (percutaneous valvotomy or surgery) are required for patients with severe disease, especially if unresponsive to medical therapy.

To balance medical with socio-cultural factors, the delivery hospital should be tailored to the severity of disease. Labour and delivery management should also be stratified. For moderate or severe disease, assisted vaginal delivery under epidural analgesia is generally recommended if obstetric considerations allow. Invasive monitoring is indicated rarely. Care should be taken to avoid excessive fluid therapy or injudicious use of uterotonic drugs which can precipitate pulmonary oedema or profound hypotension.

References:

1. Oliver J et al. Comparison of approaches to rheumatic fever surveillance across OECD and development countries. J Paediatr Child Health 2015; 51:1071-1077
2. Van Hagen I et al. Pregnancy outcomes in women with rheumatic mitral valve disease. Circulation 2018; 137:806-816.
3. Sartain J et al. Rheumatic heart disease in pregnancy: cardiac and obstetric outcomes. Int Med J 2012: 42:978-984.