Rheumatic heart disease is a complication of rheumatic fever in which the heart valves have been permanently damaged. Recent clinical researches indicate that the mortality rate from this disease remains up to 1.5 % of all causes of death among Thai population. Typically, rheumatic heart disease does not produce any noticeable signs and symptoms in its early stage. In fact, the heart valve damage may start shortly after untreated or under-treated streptococcal infection during childhood. More importantly, rheumatic heart disease remains one of the leading causes of maternal cardiac complications in pregnancy worldwide. If left untreated or treated inappropriately, pregnant patients are at high risks of heart failure and abortion is compulsorily recommended.

Example of rheumatic heart disease in pregnant patient

A 21-year old Nauruan patient was referred to Bangkok Heart Hospital. She was diagnosed with rheumatic heart disease during her first pregnancy. Since she had developed rheumatic heart disease while being pregnant, she entirely lost her hope for keeping her first baby. Nevertheless, new hope had arisen when multidisciplinary team including highly experienced cardiologist, obstetrician-gynecologist and pediatrician collectively agreed that she could be treated safely without the need of abortion. The treatment plans arranged by multidisciplinary team involved: 

• The prescribing of certain medications to stimulate lung functions in order to prevent serious complications in case that preterm delivery might be urgently required.
• Baby’s heart system and general development were closely monitored every 2 weeks.
• Possible complications were closely observed under the supervision of multidisciplinary care provided by cardiac specialist, obstetrician-gynecologist and pediatrician.
• Cesarean delivery could be performed successfully and patient further underwent heart valve surgery with satisfactory outcomes and quick recovery.

The contributing factors to successful treatment of this complicated case include the great compliance obtained from the patient and the highly experienced multidisciplinary team specialized in cardiology, obstetrics-gynecology and neonatology. To get pregnant safely, heath check-ups and heart screening remain vital in order to assess related risks and identify any abnormalities before starting pregnancy for healthy lives of mothers and babies.

Get to know rheumatic heart disease

Rheumatic heart disease is described as a complication of rheumatic fever in which the heart valves have been permanently damaged. Rheumatic fever is an inflammatory disease caused by an autoimmune response to a bacterial (streptococcus) infection during childhood. Primary episodes of acute rheumatic fever occur mainly in children particularly in developing regions. From repeated effects of rheumatic fever, it can affect connective tissue throughout the body, especially in the heart valves, eventually leads to rheumatic heart disease with chronic valve damages. Since rheumatic heart disease may not exhibit noticeable symptoms, it is often undiagnosed until reaching certain period of time that aggravates the manifestations such as pregnancy.

Signs and symptoms of rheumatic heart disease

Most common signs and symptoms of rheumatic heart disease include: 

• Swollen, tender, red and extremely painful joints, particularly the knees and ankles
• Fever
• Nodules (lumps under the skin)
• Red, raised rash
• Uncontrolled movements of arms, legs or facial muscles
• Weakness and fatigue
• Being easily tired, shortness of breath and chest discomfort
• If left untreated for long time, sudden cardiac death is possible.

Complications of rheumatic heart disease during pregnancy 

During pregnancy, there is an increase in blood volume which results in increased pressure on the heart valves. For pregnant women with rheumatic heart disease, an increased pressure on the damaged heart valve leads to increased maternal and fetal risks. These complications might include: 

• Death of mother and baby.
• Increased risk of preterm delivery which may affect baby and mother’s health.
• In some cases, serious complication is associated with a greater risk of heart failure shortly before, during or after delivery.
• Increased risks of other complications during pregnancy.

Taking good care of pregnant women with rheumatic heart fever 

• If suspected signs and symptoms manifest, immediate medical attention must be provided as soon as possible in order to get the condition diagnosed accurately, leading to timely and appropriate treatment plan.
• If rheumatic heart disease is diagnosed during pregnancy, comprehensive treatments must be given by multidisciplinary team including cardiologist, obstetrician-gynecologist and pediatrician.
• Treatment primarily involves certain medicines that prevent possible complications. Valve surgery might be considered after giving birth.

Special neonatal care of the babies

Intensive care for preterm babies provided by well-trained neonatologists is extremely important since the baby’s organs are not fully developed and some functions might be impaired. During the first 4 hours after delivery, it is a critical period when the baby’s heart tries to function properly to get sufficient blood circulation. Close monitoring is essentially required in order to observe any abnormal signs and provide immediate treatments, if needed, in time.
 Although this Nauruan patient was treated successfully, preterm delivery could result in impaired growth and poor development of the baby. To prevent these complications, multidisciplinary team worked collectively to provide the treatment with the best possible outcomes supported by advanced technology in cardiac and neonatal practices. The satisfactory results could be eventually obtained when both mother and baby were safe.   

Pregnant women with rheumatic heart disease essentially require comprehensive treatments given by highly expert multidisciplinary team consisting of cardiologists, obstetrician-gynecologist and pediatrician. Expertise in a combination with cutting-edge technology and world-class standard care of Bangkok Hospital and Bangkok Heart Hospital could save the lives of patient and her beloved baby. They could eventually return home with smiles.