The high prevalence and impact of rheumatic heart disease in pregnancy in First Nations populations in a high‐income setting: a prospective cohort study

Abstract

Objective To describe the epidemiology of rheumatic heart disease (RHD) in pregnancy in Australia and New Zealand (A&NZ). Design Prospective population‐based study. Setting Hospital‐based maternity units throughout A&NZ. Population Pregnant women with RHD with a birth outcome of ≥20 weeks of gestation between January 2013 and December 2014. Methods We identified eligible women using the Australasian Maternity Outcomes Surveillance System (AMOSS). De‐identified antenatal, perinatal and postnatal data were collected and analysed. Main outcome measures Prevalence of RHD in pregnancy. Perinatal morbidity and mortality. Results There were 311 pregnancies associated with women with RHD (4.3/10 000 women giving birth, 95% CI 3.9–4.8). In Australia, 78% were Aboriginal or Torres Strait Islander (60.4/10 000, 95% CI 50.7–70.0), while in New Zealand 90% were Māori or Pasifika (27.2/10 000, 95% CI 22.0–32.3). One woman (0.3%) died and one in ten was admitted to coronary or intensive care units postpartum. There were 314 births with seven stillbirths (22.3/1000 births) and two neonatal deaths (6.5/1000 births). Sixty‐six (21%) live‐born babies were preterm and one in three was admitted to neonatal intensive care or special care units. Conclusion Rheumatic heart disease in pregnancy persists in disadvantaged First Nations populations in A&NZ. It is associated with significant cardiac and perinatal morbidity. Preconception planning and counselling and RHD screening in at‐risk pregnant women are essential for good maternal and baby outcomes. Tweetable abstract Rheumatic heart disease in pregnancy persists in First Nations people in Australia and New Zealand and is associated with major cardiac and perinatal morbidity.

Rheumatic heart disease in pregnancy: Profile of women admitted to a Western Australian tertiary obstetric hospital

“…Among the women who gave birth, 10.0% suffered decompensated heart failure peripartum, all with stenosis. Valvular surgery prior to pregnancy, a favourable prognostic factor for maternal outcome, was observed in 18.5% of women, similar to that found in the AMOSS study (16%) . An audit of Aboriginal RHD patients in primary care found that 84% of priority one patients 15–24 years had surgery, reflecting that young Australian patients mostly have access to surgery once diagnosed .…”

“…In Australasia, RHD in pregnancy is rare (4.3/10 000 women giving birth) compared with that seen in low‐ and middle‐income countries . Given the tertiary setting and high‐risk condition, caesarean births in our RHD cohort (44%) were higher than those for WA and KEMH in 2014 (39% and 36% respectively) as well as higher than found in the AMOSS study (30%) which included non‐tertiary settings . Mitral stenosis was reported in approximately half the women in our study compared with 37% in the AMOSS cohort, with similar prevalence of mitral regurgitation in the two studies .…”

“…Given the tertiary setting and high‐risk condition, caesarean births in our RHD cohort (44%) were higher than those for WA and KEMH in 2014 (39% and 36% respectively) as well as higher than found in the AMOSS study (30%) which included non‐tertiary settings . Mitral stenosis was reported in approximately half the women in our study compared with 37% in the AMOSS cohort, with similar prevalence of mitral regurgitation in the two studies . Among the women who gave birth, 10.0% suffered decompensated heart failure peripartum, all with stenosis.…”

“…Given KEMH’s unique position as the only stand‐alone and largest obstetric referral hospital in WA, our findings represent the majority of the tertiary‐referred RHD cases in WA. Congruent with the AMOSS study, Indigenous women comprised 75.9% of our study cohort, which is notably higher compared with the proportion of Indigenous women who gave birth in WA (5.1%) . This reflects the known high RHD burden among Indigenous Australians whose age, comorbidity and rurality profile are consistently different from that of non‐Indigenous women birthing in WA .…”

“…The prevalence of RHD in Australian Aboriginal and Torres Straits Islander (hereafter Indigenous) communities globally remains among the highest recorded . The recently published Australasian Maternity Outcomes Surveillance System (AMOSS) study investigating RHD in pregnancy across ~300 Australia and New Zealand maternity units between 2013 and 2014 reported that 78% of the Australian cohort were Indigenous . Our study aims to review the demographic, clinical characteristics, obstetric management and major outcomes of Indigenous and non‐Indigenous pregnant women with RHD presenting to the largest tertiary obstetric care facility in Western Australia (WA) since 2009.…”