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

Rheumatic Heart Disease in PregnancyPMMRC

June 2015

Dr Claire McLintockFaith Mahony

• 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

AMOSS Conditions

• Completed– 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

Rheumatic Fever

Pacific Island 96Maori 65

European <1

150-320

65375

per 100 000 population aged 10-15y

Rheumatic Fever Incidence

Aboriginal & Torres Strait Islanders

North-South Gradient

New Zealand Child and Youth Epidemiology Service www.otago.ac.nz/nzcyes

0-1

>25

16-25

6-15

2-5

2006-2010RF admissions age 0-24 y

(per 100 000)

0

5

10

15

20

25

30

35

40

45

0 1 2 3 4 5 6 7 8 9 10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

Ad

mis

sio

ns

pe

r 1

00

,00

0

Hospital Admissions due to Acute Rheumatic Fever in Children and Young People 0-24 Years, New Zealand

1990-2007

NZCYES 2012 www.otago.ac.nz/nzcyes

RF Admissions by AgeNZ 2006-2010

RF Admissions by Ethnicity0-24 Year Olds, NZ 2006-2010

0

10

20

30

40

50

60

70

80

90

2000-01 2002-03 2004-05 2006-07 2008-09 2010

Ad

mis

sio

ns

per

100

,000

Hospital Admissions due to ARF in Children and Young People 0-24 Years by Ethnicity, New Zealand

2000-2010

Pacific Maori European Asian / Indian

NZCYES 2012 www.otago.ac.nz/nzcyes

Duration of Secondary Prophylaxis

RHD category RecommendationNone or Mild Minimum 10 yrs Mod Until age 30 yrs then reassessSevere Until age 40 yrs (reassess age 30 yrs)

Benzyl penicillin im injection every 28 days

heart rate cardiac output

plasma volume

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

Data Collection

• Prospective identification of pregnant women with RHD Oct 1st 2012 -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

Recruitment

Pregnancies N=186*

Fulfill AMOSS criterian=146

History RF only or trivial RHD

n=34

No echo resultsn=5

Lost to follow-upn=1

*14 women 2 pregnancies, 2 women 3 pregnancies, 1 twin pregnancy

Location Oct 12- Dec 14

Northland 5%

Auckland 27%

Waitemata 4%

Manukau 32% Lakes 3%

Hawkes Bay 5%

Gisborne 5%Waikato 7%

Wellington 5%

Hutt 1%

Christchurch 3%

Tauranga 1%

New Plymouth 1%

Wanganui 1%

63% of cases in Auckland Region

Ethnicity

SE Asian 3NZ European 4

Age

> 40 y35-40 y30-34 y25-29 y20-24 y

Range 15-43 yMedian 27 y

Age of last episode RF (or 1st episode)

49

34

63

Child (<13 y) Adolescent (13-18 y) Adult (>18 y)

43% initial RF or recurrence ≥18 years

Severity of RHD Valve Lesion

43; 29%

41; 28%

38; 26%

4; 3%

10; 7%

10; 7%Mild

Moderate

Severe

Previous BMV - for severe stenosis

Previous valve replacement for severe RHD (mechanical or bioprosthetic)

Previous valve repair

Maternal OutcomeMaternal outcome N (%)Maternal death 0Surgical 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

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 0

Moderate 41 6 (14.6%) Moderate AR x2Moderate MRModerate MS+ARModerate AR+MRModerate MS+MR

Severe 38 21 (55.3%) Severe MR (n=13)Severe AR (n=1)Severe MS (n=6)Severe MS+MR (n=1)

All 7 women with severe MS decompensated. 5 required surgery during pregnancy or postpartum

AR – aortic regurgitationMR – mitral regurgitationMS – mitral stenosis

Outcomes in women with severe RHD

Valve lesion Pregnancies (N) ComplicationsN, %

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%) Diuretics, b-blockers

Severe AR + trivial or mild MR

3 0 Diuretics, b-blockers

Severe AR + moderate MR 3 1 Diuretics, b-blockers

AR – aortic regurgitationMR – mitral regurgitationMS – mitral stenosis

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%)

Infant OutcomesOutcome N (%)

Miscarriage or termination 14 (9.6)

Stillbirth 2 (1.5)

Preterm birth 15 (11.4)

Birthweight (mean, range) 3295 g (410-5300)

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)

Risk stratification and optimal care for women with RHD in pregnancy

Education about prevalence of RHD in NZImprove health literacy to reduce incidence RF