Impact of heart disease on maternal, fetal and neonatal outcomes in a low-resource setting

Abstract

BackgroundThe burden of pre-existing cardiovascular disease and the contribution to adverse pregnancy outcomes are not robustly quantified, particularly in low-income countries. We aimed to determine both the prevalence of maternal heart disease through active case finding and its attributable risk to adverse pregnancy outcomes.MethodsWe conducted a 24-month prospective longitudinal investigation in three Ugandan health centres, using echocardiography for active case finding during antenatal care. Women with and without heart disease were followed to 6 weeks post partum to determine pregnancy outcomes. Prevalence of heart disease was calculated. Per cent attributable risk estimates were generated for maternal, fetal and neonatal mortality.ResultsScreening echocardiography was performed in 3506 women. The prevalence of heart disease was 17 per 1000 women (95% CI 13 to 21); 15 per 1000 was rheumatic heart disease. Only 3.4% of women (2/58) had prior diagnosis. Cardiovascular complications occurred in 51% of women with heart disease, most commonly heart failure. Per cent attributable risk of heart disease on maternal mortality was 88.6% in the exposed population and 10.8% in the overall population. Population attributable risk of heart disease on fetal death was 1.1% and 6.0% for neonatal mortalityConclusionsOccult maternal heart disease may be responsible for a substantial proportion of adverse pregnancy outcomes in low-resource settings. Rheumatic heart disease is, by far, the most common condition, urging global prioritisation of this neglected cardiovascular disease.

Standardizing clinical care measures of rheumatic heart disease in pregnancy: A qualitative synthesis

“…The most common types of study design were cohort (19) and case series (20), with two qualitative studies, one cross‐sectional and one longitudinal screening study . There was considerable heterogeneity in the methodologies, levels of evidence, and reporting measures of these predominantly retrospective studies.…”

“…All studies were conducted in tertiary care settings with access to cardiac (or dedicated obstetric‐cardiac) care, as well as primary health settings and regional centers . Maternal mortality ranged from 0% (16/42) to 37% .…”

“…Study designs affected the quality and were subject to high levels of bias, especially the case series. Referral and other selection biases as acknowledged in several papers were particularly related to the predominantly single‐site tertiary‐care‐level settings.…”

“…Others referred to late diagnosis in the context of poorer outcomes and health system shortcomings . Diagnosis during pregnancy/postpartum ranged from 1% to 97% in a longitudinal screening study, with eight studies above 20% and four above 40%. In one high‐income country, four women (of 95 pregnancies) were diagnosed with RHD after developing peripartum acute pulmonary edema .…”

“…Thirty‐six studies specified echocardiographic review during pregnancy, although only four referenced diagnostic criteria . Six studies did not specify RHD diagnosis confirmed by echocardiography, nor its use during pregnancy …”