Rheumatic heart disease in pregnancy

Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are common and under-diagnosed in remote Australia

Do

  • Ask about ARF/RDH
    • Check file notes and contact Rheumatic Heart Disease Register for more information
  • Medical consult as soon as possible for pregnant woman with RHD or suspected RHD
    • Arrange early obstetric ultrasound, ECG, ECHO and dental check
    • Urgent referral to obstetrician and physician/cardiologist as soon as possible
Talk with woman about
  • Looking after herself and continuing her medicine
  • More frequent antenatal checks and hospital visits to watch for problems
  • Seeing midwife or doctor any time she is concerned
  • Support services that can help her and assist with moving closer to hospital for birth
Antenatal care
  • At each visit ask about — physical activity, sleeping, any need to sleep sitting up, tiredness, light-headedness, dyspnoea (shortness of breath)
  • If signs or symptoms of heart failure or problem that could cause heart failure (eg anaemia, infection, high BP) — urgent medical consult straight away
  • Follow joint management plan from physician/cardiologist and obstetrician
  • Continue routine antibiotic prophylaxis during pregnancy
  • Any woman on warfarin needs urgent medical consult
    • Anticoagulation therapy usually needs to be changed — usually to heparin (eg enoxaparin) given by daily injections
  • Always plan for birth in hospital — delivery in hospital ICU may be required

Prevention of endocarditis

  • See Acute rheumatic fever and rheumatic heart disease
  • Highest risk of endocarditis (infection inside heart) in women with
    • Rheumatic heart disease
    • Artificial heart valve
    • Heart transplant
    • History of bacterial endocarditis
    • Certain congenital heart problems
  • May need preventive antibiotics before invasive, surgical or dental procedures
    • Always do medical/dental consult

Unplanned labour or birth in community

  • Put in IV cannula — largest possible, insert 2 if time
    • Medical consult before giving IV fluids — too much can cause heart failure
    • Record frequent observations and fluid balance during labour and after birth
  • Monitor closely. If woman becomes short of breath
    • Sit upright
    • Give oxygen to target O2 sats 94–98% OR if moderate/severe COPD 88–92%
    • Urgent medical consult
  • See Labour and birth
    • Do not give ergometrine alone or in combination after birth — after delivery only use plain oxytocin IM — 10 international units single dose — placenta should separate within a few minutes

Supporting resources

  • RHD Australia ARF/RHD guidelines