Rheumatic Heart Disease (RHD) in Pregnancy

Clinical features

• Exertional dyspnoea, fatigue, palpitations, reduced exercise tolerance
• Orthopnoea, paroxysmal nocturnal dyspnoea, cough or haemoptysis
• Features of pulmonary congestion: basal crepitations, wheeze, cyanosis
• Features of right heart failure: raised JVP, hepatomegaly, pedal oedema, ascites
• Atrial fibrillation: irregular pulse, tachycardia, palpitations
• In MS: loud S1, opening snap and mid-diastolic murmur at apex; pulmonary hypertension may cause loud P2.

Diagnosis

1. History
   • Previous rheumatic fever, recurrent sore throat, known valvular disease, previous cardiac failure or intervention.
   • Assess functional status using NYHA class.
2. Examination
   • Pulse, BP, JVP, cyanosis, oedema, cardiac murmurs, lung crepitations and hepatomegaly.
3. Investigations
   • ECG: atrial fibrillation, chamber enlargement or other arrhythmias.
   • Echocardiography with Doppler is the key investigation: identifies valve morphology, mitral valve area, gradients, regurgitation, pulmonary artery pressure, chamber size and ventricular function.
   • Chest X-ray with abdominal shielding if pulmonary oedema is suspected.
   • CBC for anaemia, renal function and electrolytes. BNP may support the diagnosis of cardiac failure.
   • Fetal growth surveillance, because significant stenotic lesions increase the risk of fetal growth restriction and preterm birth.

Complications

• Pulmonary oedema and congestive cardiac failure
• Atrial fibrillation and other arrhythmias
• Left atrial thrombus and systemic embolism, including stroke
• Pulmonary hypertension and right heart failure
• Infective endocarditis, pulmonary embolism and rarely massive haemoptysis
• Maternal death in severe decompensated disease

• Miscarriage, fetal growth restriction, low birth weight
• Preterm labour and prematurity
• Fetal distress or death due to maternal hypoxaemia and reduced uteroplacental perfusion.

Management

A. Antenatal management

• Assess severity clinically and by echocardiography; classify NYHA functional status.
• Mild, asymptomatic disease: regular antenatal and cardiology follow-up, avoidance of anaemia, infection, excessive exertion and excess salt intake.
• Advise rest, especially in symptomatic women; monitor weight, pulse, BP, JVP and signs of failure.
• Continue secondary prophylaxis for rheumatic fever, usually long-acting penicillin, where indicated.
• In MS, prevent tachycardia with a cardioselective beta-blocker such as metoprolol when required.
• Use diuretics, usually furosemide, for pulmonary congestion or oedema, with careful monitoring of maternal volume status and fetal growth.
• Atrial fibrillation: control ventricular rate with beta-blocker and/or digoxin; anticoagulate if AF, left atrial thrombus, or prior embolism. Heparin is preferred during pregnancy when anticoagulation is needed.
• Severe symptomatic MS despite medical treatment, or pulmonary hypertension: consider percutaneous balloon mitral valvotomy during pregnancy in an expert centre.
• ACE inhibitors, ARBs, and mineralocorticoid antagonists are contraindicated during pregnancy.
• Severe MS with pulmonary hypertension or refractory heart failure is very high risk. Discuss pregnancy continuation and referral to a tertiary centre.

B. Intrapartum management

• Plan delivery in a tertiary hospital. Vaginal delivery is preferred in most stable women because it causes less blood loss and haemodynamic disturbance than caesarean section.
• Admit early in labour; nurse propped up or in left lateral position.
• Monitor pulse, BP, oxygen saturation, urine output, fluid balance and ECG in moderate or severe disease.
• Provide oxygen if hypoxaemic.
• Use good analgesia, preferably carefully titrated epidural analgesia, to prevent pain-induced tachycardia.
• Avoid fluid overload. Give IV fluids cautiously.
• Shorten the second stage with forceps or vacuum extraction to avoid prolonged bearing down and tachycardia.
• Caesarean delivery only for obstetric indications or severe cardiac instability where rapid delivery is required.
• Routine infective endocarditis prophylaxis solely for vaginal delivery is not generally indicated; give antibiotics only for standard obstetric or specific cardiac indications.

C. Postpartum management

• Observe closely for at least 24-72 hours in high-dependency care if disease is moderate or severe.
• This period is dangerous because autotransfusion from uterine involution and mobilisation of extravascular fluid increase preload, potentially causing acute pulmonary oedema.
• Maintain strict input-output charting, avoid excess IV fluid, and continue diuretics if congested.
• Continue rate control and anticoagulation as indicated.
• Restart or introduce appropriate long-term heart failure therapy after delivery, including ACE inhibitor therapy where clinically indicated and compatible with breastfeeding.
• Provide contraception counselling. Avoid another pregnancy until cardiac assessment and definitive intervention, such as valvotomy or valve surgery, if required.

Management of Cardiac Failure in Pregnancy

1. Admit urgently, preferably to HDU/ICU; involve cardiology, obstetrics and anaesthesia teams.
2. Position: sit upright or prop up; give oxygen and consider non-invasive ventilatory support if pulmonary oedema is severe.
3. Monitoring: continuous ECG and oxygen saturation, frequent BP, strict fluid balance, urine output, daily weight, electrolytes and fetal monitoring if viable.
4. Treat pulmonary congestion: IV furosemide, then oral diuretic once stable.
5. Control precipitating factors: tachyarrhythmia, anaemia, infection, hypertension, pulmonary embolism, excess fluids and poor treatment adherence.
6. Control heart rate: beta-1 selective blocker in MS; digoxin can be used in selected patients, especially with AF or ventricular dysfunction.
7. Anticoagulate when AF, intracardiac thrombus, previous embolism, or another clear indication exists.
8. Avoid teratogenic drugs: ACE inhibitors, ARBs, direct renin inhibitors and mineralocorticoid receptor antagonists during pregnancy. Hydralazine with nitrates may be used for afterload reduction in selected systolic failure.
9. If failure remains refractory, consider balloon mitral valvotomy for severe MS, or delivery after maternal stabilisation when gestation is viable or maternal life is threatened.