In a study of more than 1,000 pregnant women, doctors of Madras Medical College (MMC) found that three of five women had come to know of their heart disease for the first time during pregnancy.
While rheumatic heart disease (RHD) was the most common, followed by congenital heart disease (CHD), the doctors observed high maternal mortality and morbidity in pregnant women with heart diseases.
Aiming to lay the basis for Indian guidelines to manage pregnant women with heart diseases, the doctors conducted a study — ‘Pregnancy Outcomes in Women with Heart Disease: the Madras Medical College Pregnancy and Cardiac Registry from India’. A total of 1,029 consecutive pregnancies in 1,005 women with heart diseases registered in the institution between July 2016 and December 2019 were prospectively followed up throughout pregnancy and post-partum.
The findings were published in the European Heart Journal this month. One of the key findings was the time of diagnosis of heart disease. It was diagnosed for the first time during pregnancy in 60.5% women. Most of the pregnancies involved asymptomatic or minimally symptomatic women, with some of them coming late in pregnancy — second or third trimester — with breathlessness, said one of the authors, G. Justin Paul, professor of cardiology, MMC, and State Heart Disease Nodal Officer, National Health Mission, Tamil Nadu. “In fact, we observed a lot of social issues as well. There were instances of broken marriages and domestic violence for women with heart diseases,” he said. The doctors found that 42.1% of the pregnancies involved RHD. Of the 433 pregnancies involving RHD, mitral valve involvement was the most common.
More than one-fifth of the RHD patients had undergone prior surgical/interventional procedure before conception, of which prosthetic valve replacement (65 women) was the most common. CHD was the next largest group (33.6%), with shunt lesions accounting for 76.3%.
One-third of the pregnancies — 359/1,029 — had pulmonary hypertension. Observing the outcomes, the study found 15.2% maternal cardiac events, 33.7% adverse foetal events and 8.8% foetal loss. “The maternal mortality was 1.9%. When we look at pregnant women without heart diseases during the corresponding period, we found that the mortality among pregnant women with heart diseases was 35 times more. Pulmonary hypertension, prosthetic heart valves and left ventricular dysfunction were among the top causes,” he said.
What are the learnings? Dr. Paul explained, “A cardio-obstetric team approach was a must for optimal management of heart diseases in pregnancy. A cardio-obstetric team should be developed, while a curriculum should also be developed to train manpower.”
At present, there are no Indian guidelines for managing pregnant women with heart disease, he said, adding, “We are using western guidelines that are based on western data to guide our population. In the west, pregnant women predominantly have CHD, while low and middle income countries such as India have more RHD. So, we need to develop our own guidelines for which Indian data need to be generated. Our study is a step towards this.”
In addition, the doctors are developing a risk scoring system to categorise high and low risk heart diseases in pregnancy based on their data. MMC Dean E. Theranirajan said an effective screening of adolescent girls for heart diseases is must. “This will help in early identification and treatment to prevent complications. This will put in place a proper tracking and follow-up system. In addition, pre-conception counselling for women with heart diseases is crucial,” he said.