MATERNAL AND
CHILD HEALTH:
RHEUMATIC
HEART DISEASE
BACKGROUND | RHEUMATIC FEVER RHD | EFFECTS ON MOTHERS
AND RHEUMATIC HEART DISEASE
CARDIAC COLLAPSE
Group A streptococcal infection can cause rheumatic fever (RF) In late pregnancy, blood volume increases and heart rate
progressing to rheumatic heart disease (RHD) in children and rises. Normal heart function is needed to adapt to these
young people. RHD causes damage to the heart valves which changes and prepare for birth. In women with RHD, this
leads to progressive heart failure, disability, and premature capacity is limited by established heart failure or blood flow
death. Women with heart valves damaged by RHD are at an restricted by scarred (sclerotic) rheumatic heart valves.
increased risk of complications during pregnancy and delivery.
Women with RHD are at risk of heart failure and
BACKGROUND | MATERNAL MORTALITY arrhythmias during pregnancy. Signs and symptoms of
heart failure are easily confused with late pregnancy:
The World Health Organization completed a systematic review
breathlessness, fatigue and swelling, and heart murmurs.
of 60,799 maternal deaths in 2014. In developing countries,
Undiagnosed, catastrophic cardiovascular collapse can lead
more than one in five maternal deaths were from indirect
to maternal death.
causes, most commonly exacerbation of pre-existing medical
conditions. RHD is a significant cause of these indirect deaths.
EFFECTS OF ANTICOAGULATION
Women who have received metallic valve replacement
14% 10% require a lifetime of powerful anticoagulation to prevent
Sepsis Other
direct
blood clots forming and blocking the metallic valve. When
14% causes
15% pregnant women adhere to anticoagulants following
Hypertension metallic valve replacement, this dramatically increases the
27%
Pre-existing
medical 7%
conditions Other chance of bleeding during pregnancy and hemorrhage at
Indirect causes indirect
causes the time of delivery.
27% 5%
Haemorrhage HIV-related
8%
Abortion
3% Embolism
CAUSES OF MATERNAL DEATH IN DEVELOPING COUNTRIES
Say et al. Global causes of maternal death: a WHO systematic analysis.
The Lancet Global Health. 2014.
National and local research confirms the tragic toll of RHD on pregnant women:
• In Senegal, 36% of pregnant women with RHD admitted to a tertiary cardiac
department died during pregnancy, at an average age of 29 years.
• In South Africa, 41% of indirect obstetric deaths are associated with heart disease,
overwhelmingly from RHD.
• In Brazil, 33% of women who died of heart disease during pregnancy had RHD. continued on next page >
RHD | EFFECTS ON NEWBORNS References
1. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of
BACKGROUND OF MATERNAL CARDIAC DISEASE maternal death: a WHO systematic analysis. The Lancet Global Health. 2014; 2(6):
Women with symptomatic RHD do not have normally e323-e33.
2. Diao M, Kane A, Ndiaye M, Mbaye A, Bodian M, Dia M, et al. Pregnancy
functioning hearts. This increases the risk of serious in women with heart disease in sub-Saharan Africa. Archives of Cardiovascular
effects on developing babies including inter-uterine Disease. 2011; 2011: 370-4.
growth restriction, prematurity, and low birth weight. 3. Watkins D, Sebitloane M, Engel M, Mayosi B. The burden of antenatal heart disease
in South Africa: a systematic review. BMC Cardiovascular Disorders. 2012; 12(33).
4. Avila W, Rossi E, Famires J, Grindberg M, Bortolotto M, Zugaib M, et al. Pregnancy
EFFECTS OF ANTICOAGULATION in patients with heart disease: experience with 1,000 cases. Clinical Cardiology.
Warfarin anticoagulation is associated with very poor 2003; 26: 135-42.
pregnancy outcomes including late pregnancy fetal loss in 5. Reimold S, Rutherford J. Valvular heart disease in pregnancy. The New England
Journal of Medicine. 2003; 349: 52-9.
an estimated 10% of cases. Warfarin also causes serious 6. Hameed A, Karalp I, Tummala P, Wani O, Canetti M, Akhter M, et al. The effect
developmental abnormalities in a large number of of valvular heart disease on maternal and fetal outcome of pregnancy. Journal of
surviving infants. American College of Cardiology. 2001; 37(3): 893-9.
7. McLintock C, McCowan L, North R. Maternal complications and pregnancy
outcomes in women with mechanical prosthetic heart valves threated with
MATERNAL DEATH enoxaparin. British Journal of Obstetrics and Gynaecology. 2009; 116: 1585-92.
Infants who survive the death of their mother during, or 8. Cotrufo M, de Fero M, de Sandos L, Romano G, Della Corte A, Renzulli A, et al.
shortly after, labor begin life with a social and biologic Risk of warfarin during pregnancy with mechanical valve prostheses. Obstetrics and
Gynaecology. 2002; 99(1): 35-40.
disadvantage. Maternal deaths from RHD therefore 9. Vitale N, De Feo M, De Santo L, Pollice A, Tedesco N, Cotrufo M. Dose-dependent
contribute to the intergenerational transfer of poverty fetal complications of warfarin in pregnant women with mechanical heart valves.
which, in turn, predisposes to further RHD. Journal of American College of Cardiology. 1999; 33(6): 1637-41.
10. Yamin A, Boulanger V, Falb K, Shuma J, Leaning J. Cost of inaction on maternal
mortality: qualitative evidence of the impacts of maternal deaths on living children in
Tanzania. PLoS One. 2013; 8(8): doi:10.1371/journal.pone.0071674.
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