What if I'm pregnant?

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Pregnancy planning information

For women with rheumatic heart disease, careful preconception planning, as well as care, monitoring and support during pregnancy, can improve outcomes for both mother and baby.

Establishing the level of disease pre-conception is key. The earlier the diagnosis and treatment, the less likelihood a woman will have complications. An unexpected pregnancy, without the recommended preconception planning, puts the woman at increased risk.

Patients with known rheumatic heart disease should be properly assessed before pregnancy, and discussion regarding fertility planning should be undertaken with all women with more than mild valvular disease, even if immediate pregnancy is not planned.

Effects of pregnancy on rheumatic heart disease

During any pregnancy there is an increase in blood volume of 30% - 50% resulting in increased pressure on the heart valves. For women with rheumatic heart disease this increased pressure presents increased maternal and/or foetal risks.

It is not uncommon for women to be unaware that they have rheumatic heart disease until pregnancy.  This is because the added stress on the heart can result in symptomatic rheumatic heart disease where previously there were no symptoms.

Pregnancy can lead to the appearance or worsening of symptoms including shortness of breath with simple activity, and waking at night out of breath.  For women with more severe rheumatic heart disease, it could lead to the development of much more serious symptoms such as pulmonary oedema, atrial fibrillation or clotting. These changes begin in the first trimester but peak at 28-30 weeks and are sustained until term, meaning most women with valvular heart disease become more symptomatic in the third trimester.

Management of rheumatic heart disease in pregnancy

Women with moderate or severe rheumatic heart disease require close supervision, normally at a tertiary referral centre with cardiology and intensive care facilities.

Women requiring anticoagulation during pregnancy are at additional risk of complications. Where a heart valve has been replaced, or for atrial fibrillation, anticoagulants including Warfarin or low-molecular weight heparin (LMWH) are mostly taken. Both groups of anticoagulants can cause problems, either by increased risk of thromboembolism or risk to the foetus. Specialist review and close monitoring is critical and is not routinely available outside large urban centres.

Women on secondary prophylaxis should continue treatment. Any prescribed antibiotic secondary prophylaxis (usually LA bicillin injections every 21-28 days) is safe during pregnancy. It is vital the woman does not miss any injections to avoid a recurrence of rheumatic fever and worsening of the rheumatic heart disease.

Many women with a history of acute rheumatic fever or mild rheumatic heart disease require no special management during pregnancy but should have careful assessment preconception, or early in pregnancy, by a cardiologist and obstetrician to establish the safest birth pathway.

Additional considerations for management of rheumatic heart disease in pregnancy for women in remote and rural locations

Pregnant women with rheumatic heart disease in rural and remote locations may be required to be away from home to stay in urban centres while they wait for delivery.

• It is important that secondary prophylaxis is still administered if prescribed, and women are supported to access the most appropriate service to provide secondary prophylaxis.
• Reducing stress from isolation should be a consideration and appropriate supports and family escorts available whenever possible.
• Pregnancy is an opportunity to support the woman to establish links with social and support services. This requires careful coordination and communication between aboriginal health workers, remote area midwives, district medical officers, obstetricians and cardiologists.
• While every woman’s situation is different, it should be considered that pregnant women with rheumatic heart disease may also be managing multiple social, practical and emotional issues. Risk factors of rheumatic heart disease include poverty, overcrowded housing, reduced access to medical care, food security, domestic violence and substance abuse issues.

The AMOSS (Australasian Maternity Outcomes Surveillance System) RHD in Pregnancy Project is a research project which includes a quantitative study with nearly 300 maternity units across ANZ and a qualitative study exploring women’s journey with RHD. It aims to provide an evidence base with a view to improving clinical care and outcomes for women with RHD in pregnancy, and their babies. For more information on the project go to http://www.amoss.com.au/rhdinpregnancy

For more information on the clinical management of rheumatic heart disease in pregnancy, refer to the 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition) and the RHD in Pregnancy page of this website.