Exploring the Hidden Dangers: Unrevealing the lack of awareness and its causes regarding conception and pregnancy in patients with established Rheumatic Heart Disease (RHD).

doi:10.21203/rs.3.rs-4098519/v1

Background:

Rheumatic heart disease (RHD), a significant public health concern, is a major contributor to maternal mortality globally, particularly in low- and middle-income countries. Among its numerous complications, RHD poses unique challenges for women of childbearing age.

Objective:

The aim of the study was to assess the level of awareness regarding conception counseling and the impact of RHD on maternal cardiovascular health in pregnancy in female patients of reproductive age with diagnosed Rheumatic Heart Disease (RHD) coming to the outpatient department of National Institute of Cardiovascular Diseases (NICVD).

Methods:

This is a cross-sectional descriptive study carried in the outpatient department of NICVD. The study population was women with RHD in the fertile age group. The sampling technique was non-probability, consecutive sampling. Analysis of data were performed with the help of IBM SPSS version 21.Statistical techniques used for the comparison were Chi-square test, Fisher’s Exact Test, or independent sample t-test, appropriately, with <0.05 level of significance.

Results:

320 female patients with RHD (diagnosed on the basis of echocardiography) were a part of the survey conducted in the outpatient department. Out of these 320 patients, only 217 women of childbearing age with mean age of 33.5 ± 7.5 were interviewed. A staggeringly high percentage (80.6%) of women of childbearing age between 19 to 49 years had no awareness regarding the impact of RHD on maternofetal health in pregnancy and had received no conception counseling whereas only 19.4% of the women showed some level of awareness regarding it.

Conclusion:

Level of knowledge and awareness of the impact of RHD on maternofetal health in pregnancy and counseling regarding conception in females of childbearing age with established RHD is alarmingly low. It is ideal for these women to be counseled before conception and risk-stratified according to their clinical state and pathology.

rheumatic heart disease

pregnancy

conception counseling

The highest prevalence of Rheumatic Heart Disease (RHD) has been reported in India, China, Pakistan, Indonesia, and the Democratic Republic of Congo—accounting for 73% of global cases. In the 20 countries where RHD persists as a prevalent issue, the age-standardized prevalence is projected to exceed 1%, with the highest rates observed among women of childbearing age.^[1] 88–90% of antenatal heart disease in low- and middle-income countries is attributable to RHD.^[2] Rheumatic Heart Disease in pregnancy (RHD-P) is also associated with increased burden of perinatal morbidity and mortality in these regions.^[3] Furthermore, 8–28% of the cases had their cardiac disease unmasked by the hemodynamic stresses of pregnancy. ^[2]

The substantial physiological alterations during pregnancy, such as increased stroke volume, heart rate, and cardiac output, pose challenges for individuals with severe valve stenosis, leading to an increased likelihood of clinical deterioration and adverse events. Maternal risks, including prematurity, low birth weight, and mortality, align with the rates of adverse outcomes in neonates. Additionally, these neonatal complications contribute to increased infant morbidity and mortality.^[4]

Warfarin is prescribed for anticoagulation in patients with valvular heart disease, however, warfarin has been well-known for its teratogenicity. Teratogenic effects are most likely between the 6th and 12th weeks of pregnancy, so it is advisable to stop warfarin during this period and switch to low molecular weight heparin (LMWH).^[5] However, most women with a pre-existing valvular condition seek medical assessment only after becoming pregnant, which is concerning.^[6]

The initial approach to management of women with valvular heart disease involves assessing maternal and fetal risk by considering factors such as functional status, severity and type of valvular disease, left ventricular function, and pulmonary pressures. If patients are at low risk, they can be assured that pregnancy is not contraindicated, and management by primary physician is suitable. However, a multidisciplinary team is required for the management of women at high risk of fetomaternal complications.^[6]

Therefore, it is critical to evaluate all women of childbearing age with RHD, in order to provide counseling on family planning and RHD complications during pregnancy. In cases where pregnancy is desired, pre-pregnancy interventions like percutaneous transvenous mitral commissurotomy (PTMC) should be considered.^[7] Although mitral regurgitation is better tolerated during pregnancy, patients with severe symptomatic mitral regurgitation and impaired left ventricular function should be considered for timely surgery.^[8]

The primary objective of this cross-sectional study is to assess the level of awareness of counseling regarding RHD implications on pregnancy and family planning in women of childbearing age with diagnosed RHD. The secondary objective of the study is to identify the reasons that prevented access to counseling among patients at risk.

Study design and Setting:

This is a cross-sectional study conducted in the outpatient department of Adult Cardiology at National Institute of Cardiovascular Diseases (NICVD), Karachi Pakistan - the tertiary cardiac care facility with a bed capacity of 2000, and a catchment population of 4700000 inhabitants. Besides the care of patients, it serves as a teaching hospital of the Jinnah Sindh Medical University.

Participants and Data collection:

320 female patients with RHD (diagnosed on the basis of echocardiography) were a part of the survey conducted in the outpatient department. Out of these 320 patients, only 217 women of childbearing age of 19 to 49 years were included. The sampling technique was non-probability, consecutive sampling. Patients with congenital heart disease, ischemic heart disease and cardiogenic shock were excluded from the study. Verbal informed consent was taken from all the patients. The participants were informed about the objective and benefits of participating in the study as they gathered in the waiting room of the outpatient department of the hospital.

Data Analysis:

Analysis of data were performed with the help of IBM SPSS version 21. Patients were stratified by awareness of rheumatic valvular heart disease and demographic, patients and physician related factors. Statistical techniques used for the comparison were Chi-square test, Fisher’s Exact Test, or independent sample t-test, appropriately, with < 0.05 level of significance.

Ethics:

This study was approved by the ethical review committee of the Institutional Review Board (IRB). The collected information was recorded using a predesigned questionnaire by a cardiologist investigator. Confidentiality and privacy of information was assured.

Table 1. Socio - demographic characteristics

	Total
	N=217
Education
Illiterate	74 (34.1%)
Up to secondary	120 (55.3%)
High school or higher	23 (10.6%)
Age	33.5 ± 7.5
Gender
Female	217 (100.0%)
Family Income
<20,000	82 (37.8%)
20,000 - 40,000	126 (58.1%)
40,000 - 60,000	8 (3.7%)
>60,000	1 (0.5%)

Table 2. Association of socioeconomic factors with level of awareness regarding conception and pregnancy in patients with established RHD

Awareness regarding the implications of RHD in pregnancy	Yes	No	p-value
	N=42	N=175
Education			0.23
Illiterate	19 (45.2%)	55 (31.4%)
Up to secondary	19 (45.2%)	101 (57.7%)
High School or higher	4 (9.5%)	19 (10.9%)
Age	30.8 ± 6.1	34.1 ± 7.7	0.008
Family Income			0.22
<20,000	16 (38.1%)	66 (37.7%)
20,000 - 40,000	23 (54.8%)	103 (58.9%)
40,000 - 60,000	2 (4.8%)	6 (3.4%)
>60,000	1 (2.4%)	0 (0.0%)

Table 3. Factors associated with level of awareness on conception and pregnancy in women of childbearing age

	Total (N=217)
Consulted physician
Cardiologist	78 (35.9%)
General physician	139 (64.1%)
Doctor counseled about the disease
No	104 (47.9%)
Yes	113 (52.1%)
Physician shared info about conception counseling
No	175 (80.6%)
Yes	42 (19.4%)
Physician shared individualized plan according to their state of RHD pathology (N=42)
No	40 (95.23%)
Yes	2 (4.76%)

Table 4. Association of related factors with the level of awareness among women of childbearing age

Awareness regarding the implications of RHD in pregnancy	Yes	No	p-value
Consulted Physician			0.013
Cardiologist	22 (28.20%)	56 (71.80%)
General Physician	20 (14.39%)	119 (85.61%)
Doctor counseled about the disease			0.52
No	22 (21.15%)	82 (78.85%)
Yes	20 (17.70%)	93 (82.30%)

Socio-demographic characteristics:

The characteristics of the study population are shown in Table 1. Out of the 320 participants, 217 women of childbearing age were interviewed with mean age of 33.5 ± 7.5. Most of the participants belonged to lower middle class with family income of (20,000 - 40,000 PKR) (58.1%). 34.1% of the patients were illiterate, the majority of the participants had up to secondary level of education (55.3%) whereas only 10.6% of the patients had more than secondary level of education.

Knowledge and awareness of conception and pregnancy in women with established RHD
A staggeringly high percentage (80.6%) (p<0.001) of women of childbearing age between 19 to 49 years had no awareness regarding the impact of RHD on maternofetal health in pregnancy and had received no conception counseling whereas only 19.4% of the women showed adequate level of awareness regarding it. In addition to that, level of education (p=0.23) and family income (p=0.22) were not significantly associated with the level of awareness regarding conception and pregnancy in patients with established rheumatic heart disease as shown in Table 2. Of the 42 (19.4%) patients who received conception counseling, we found out that only 2 (4.76%) patients received individualized plan according to their RHD state and pathology while 40 (95.23%) patients did not. Factors associated with an adequate knowledge of family planning among women of childbearing age with established RHD are shown in Table 3. First referral to a cardiologist rather than a general practitioner showed better awareness regarding RHD implications in pregnancy at 28.20% whereas when referred to a general physician, it was as low as 14.39% as shown in Table 4. In addition to that, 47.9% of the women were not counseled by the physician about their diagnosis.

Rheumatic heart disease (RHD) continues to be a significant contributor to morbidity and mortality among pregnant women in low- to middle-income countries (LMICs). In addition to the medical complexities, these regions struggle with inadequate infrastructure and limited resources for early detection, resulting in many women seeking medical care only when their health deteriorates clinically during pregnancy.^[9]

Stenotic valvular lesions pose a greater risk during pregnancy compared to regurgitant lesions. Among rheumatic lesions, moderate to severe mitral stenosis (MS) is particularly concerning and poorly handled during pregnancy. The increased heart rate reduces diastolic filling time, leading to increased pulmonary hypertension and venous congestion.^[10] Consequently, women with moderate to severe MS may have their symptoms unmasked during pregnancy. Severe MS independently increases the risk of adverse fetal outcomes, such as preterm birth and low birth weight.^[11]

During labor and delivery, there are changes in maternal hemodynamics that result in a 30% increase in cardiac output during the first stage of labor and an up to 80% increase in the immediate postpartum period due to higher stroke volume.^[12] With each uterine contraction, approximately 300–500 ml of blood is "auto-transfused" from the placental to systemic circulation.^[13] These alterations elevate the risk for symptomatic heart failure (HF) among women.

Chronic mitral regurgitation, on the other hand, is generally well tolerated during pregnancy if the patient has good left ventricular systolic function and is asymptomatic.^[14] However, these patients are usually treated with ACE inhibitors which is concerning due to their teratogenic effects and strong association with fetal malformations.^[15] Early planning for pregnancy and timely antenatal care is crucial for women taking lifelong warfarin. It is important to prioritize early optimization with heparin or low-molecular weight heparin in these patients since warfarin has been linked to poor fetal outcomes such as abortion and stillbirth.^[16]

Despite ample evidence about the impact of RHD on maternal cardiovascular health in pregnancy,^[11] which should essentially lead to widespread conception counseling among women of child bearing age, our study demonstrated alarming results. It showed staggeringly low levels of awareness regarding implications of RHD during pregnancy and conception counseling at 19.4% in women of reproductive age with diagnosed RHD. A pilot study was conducted among these 42 patients who were aware about the consequences of RHD in pregnancy, however, only 2 patients were properly counseled regarding their condition with an individualized plan according to their pathological state.

Hence, patients should be stratified based on their echocardiography findings and clinical symptoms, as well as the current medication regimen, to determine their level of risk and appropriate care. Counseling sessions should assess the safety of proceeding with a pregnancy, and if there are potential risks involved, continuous monitoring throughout each trimester is necessary. Therefore, an individualized plan and counseling tailored to the patient's pathological state will lead to improved fetomaternal outcomes.

In a previous study conducted by Snelgrove JW et al ^[17], evaluating the prevalence of RHD among women with low risk pregnancies in Kenya, it demonstrated that low socioeconomic background and the lower level of literacy was associated with lack of awareness regarding cardiac history. However, we found out contrasting results for these social determinants of health in our part of the population. Our study showed that level of education and socioeconomic status had no significant association with the lack of awareness among these women. Unfortunately, we were unable to find a cause to this anomalous finding and this has to be explored with further studies. Also, we could find no data available regarding the impact of socioeconomic status and level of education on the awareness regarding maternal health complications among women of childbearing age with established RHD in developed countries. This, again, stems from the fact that RHD is a disease of low and middle income countries with low prevalence in developed nations.^[18]

Our study also revealed a concerning trend: a high percentage of women of childbearing age diagnosed with RHD were not receiving counseling from physicians about their diagnosis and the maternal-fetal complications associated with it. This could possibly be due to the heavy patient load in overcrowded outpatient clinics, which leaves little time for counseling. Furthermore, the lack of privacy and space in these busy clinics hinders discussions on culturally sensitive issues related to conception, making it difficult for physicians to properly counsel at-risk populations such as women of reproductive age. In addition to that, in comparison to patients being counseled by the general practitioner, counseling by a cardiologist showed better awareness among these women. This is likely because cardiologists have more expertise in managing RHD during pregnancy, as they treat these patients more frequently than general physicians.

Interestingly, our findings also indicate that socioeconomic status and education level did not impact awareness of RHD, as patients across all levels were lacking physician counseling. Additionally, another factor could be insufficient knowledge among physicians regarding the impact of RHD on maternal health during pregnancy—a possibility supported by a study in Maputo, Mozambique ^[19] showing low levels of knowledge among reproductive health professionals on this topic.

Therefore, this article emphasizes the need for conception counseling and preconception intervention and optimization. It is advisable for all women with RHD to undergo preconception evaluation, including guidance on risk assessment and birth control, by a combined cardiac–obstetric team seeking input from other specialties. Detailed advice on maternal and fetal risk should be provided based on the CARPREG risk score2 or modified World Health Organization (WHO) classification,^[20,21] which should cover complications such as heart failure and valve thrombosis that can arise during or after delivery.

The maternal and perinatal costs associated with RHD are significantly higher, especially when considering the indirect economic impact. Counseling aimed at addressing RHD in women of childbearing age aims to enhance maternal and child health outcomes while also reducing the economic burden on healthcare systems that contribute to poor maternal and child health outcomes.^[9]

This is the first study to assess the knowledge and awareness of counseling regarding conception and the impact of RHD on maternal health during pregnancy among women of childbearing age with established RHD in Pakistan. We found a disturbingly low level of awareness among these women, despite RHD being endemic in our region. The lack of counseling by physicians about their diagnosis was part of the reason for this. Surprisingly, we observed that low socioeconomic status did not have an association with the low levels of awareness. Our findings emphasize the need for establishing a nationwide program for routine preconception counseling of women at reproductive age with RHD, as well as developing private counseling spaces within outpatient departments to address these culturally and gender-sensitive issues. It also underscores the importance of educating physicians about complications related to RHD in pregnancy and its impact on maternal health. This highlights the necessity for conducting a prospective study to assess gaps in knowledge concerning managing RHD during pregnancy among healthcare professionals working in highly endemic areas of Pakistan.

Rheumatic heart disease (RHD), rheumatic heart disease in pregnancy (RHD-P), low molecular weight heparin (LMWH), percutaneous transvenous mitral commisurotomy (PTMC)

Ethics approval and consent to participate:

This study was approved by the ethical review committee of a tertiary cardiac care facility in Karachi, Pakistan.

Availability of data and materials:
The data that support the findings of this study are not openly available due to reasons of sensitivity and are available from the corresponding author upon reasonable request.

Competing interests:

None to declare

Author contributions:

All authors have contributed significantly to the development and completion of this research, and they are in agreement with the content of the manuscript. The order of authorship reflects the level of contribution, following the authorship guidelines of the International Committee of Medical Journal Editors (ICMJE).

Funding:

None

Acknowledgments:

None

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No competing interests reported.

Exploring the Hidden Dangers: Unrevealing the lack of awareness and its causes regarding conception and pregnancy in patients with established Rheumatic Heart Disease (RHD).

Status:

Version 1

Abstract

INTRODUCTION

METHODS

Study design and Setting:

Participants and Data collection:

Data Analysis:

Ethics:

RESULTS

DISCUSSION

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1