Rheumatic heart disease (RHD) is twice as common in women as in men,1^,2^,3^,4 and up to 78% of women with RHD in Australia are Aboriginal and Torres Strait Islander women.5 Māori and other Pacific Islander women, and potentially women who have migrated from resource-poor countries are also at a high risk for RHD.

A woman’s journey with RHD often starts when she is a child or adolescent; therefore, discussions about the importance of good care, timing of pregnancies, and treatment interventions should start early for young women with acute rheumatic fever (ARF) and RHD and continue throughout their reproductive years. Women who wish to become pregnant need support to make decisions often against a complex and challenging clinical background.

Transitional care

First episodes of acute rheumatic fever (ARF) are most common among children aged 5 to 14 years.6 Planning for adulthood should include reproductive health and preconception care, as well as the transition to adult cardiovascular care. Preconception counselling provides an opportunity for young women and their families to talk with midwives and other health professionals about potential risks during pregnancy, how to minimise complications, contraception options, and birthing options. Obstetric and related planning and care for young Aboriginal and Torres Strait Islander women should be provided within a cultural safety framework and include members of the Aboriginal and Torres Strait Islander health workforce.7

Where pregnancy is not advised or delayed due to health reasons, contraceptive options should be discussed with the woman and her family with support from local Aboriginal and Torres Strait Islander health workers. Long-acting reversible contraceptives which are effective over long periods include the intra-uterine contraceptive device or etonogestrel implants. Oestrogen-containing contraceptives are associated with elevated risk of thrombosis and should be avoided.8^,9^,10

Impact of RHD during pregnancy

Aboriginal and Torres Strait Islander women with RHD should be referred to an Aboriginal Maternal/Child Health program.

During pregnancy, the work of the heart is increased by up to 50%.11 For women who have RHD there are several considerations:

1. Added stress on the heart from pregnancy can result in the development of RHD symptoms, where previously there were no symptoms, or the existence of RHD was unknown. In some cases this can lead to heart failure or abnormal heart rhythm that may result in unexpected complications for mother and baby.12

If a pregnant woman develops heart failure symptoms, experiences unexplained shortness of breath, or needs to sleep propped up by pillows or in a chair to assist breathing, the possibility of RHD should be investigated. The earlier RHD is diagnosed and managed, the less likelihood of complications later in the pregnancy.

2. Added stress on the heart from pregnancy can result in the worsening of existing RHD symptoms.

Women living with RHD need to be monitored carefully before and during pregnancy by a multi-disciplinary team which includes obstetric and cardiology specialists.

3. Added stress on the heart can place extra pressure on repaired or mechanical heart valves.

Timing of heart valve surgery and pregnancies should be part of a comprehensive early management plan for all girls and young women with RHD.

4. Anticoagulation therapy, where indicated, poses a risk to mother and baby and needs to be carefully monitored and regulated throughout pregnancy and delivery.

Anticoagulation is required for all girls and women with mechanical prosthetic valves and may be prescribed if there is atrial fibrillation. All anticoagulants pose risks in pregnancy, therefore, anticoagulation during pregnancy requires careful balancing of risk following individual assessment.13

Antibiotic prophylaxis during pregnancy

Secondary prophylaxis in the form of regular penicillin injections helps prevent recurrent ARF. 14^,15 Penicillins do cross the placenta in low concentrations, however, there is no evidence that penicillins have any teratogenic effects on the foetus.16 Developing ARF while pregnant poses a very high risk of additional cardiac complications; therefore, women who have had ARF, and women who have RHD should continue penicillin injections during pregnancy and while breastfeeding, as indicated.17

For more information, see Chapter 12 in the RHDAustralia 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edition).

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