Pregnancy Risk and Contraception Among Reproductive Age Women With Rheumatic Heart Disease Attending Care at Jakaya Kikwete Cardiac Institute

Abstract

Background: Rheumatic heart disease (RHD) remains prevalent in the developing part of the world and females including those of reproductive age are disproportionately affected. It is one of the commonest cardiac diseases during pregnancy and is associated with poor pregnancy outcomes. Despite its importance among reproductive age women, there are no local studies that focus in this patient population with respect to clinical characteristics, their risk of poor pregnancy outcomes as well as contraception which represents one effective way to prevent unwanted pregnancies in this patient population. Aim: This study was aimed at describing the clinical characteristics, echocardiographic findings, pregnancy risk classification and contraception status among reproductive age women with RHD attending at the Jakaya Kikwete Cardiac Institute (JKCI). Materials and Methods: This was a hospital based descriptive cross sectional study in which reproductive age women with echocardiographically diagnosed RHD were consecutively recruited from in- and out-patients’ units of JKCI. A clinical research form was used to gather information on socio-demographic as well as clinical characteristics of patients and their contraception status. Information about echocardiographic findings (valvular lesions, ejection fraction, etc.) were recorded. The maternal/pregnancy risk class was determined using the modified World Health Organization (WHO) classification of maternal risk. Data handling and Analysis: Data entry and analysis was done using SPSS for Windows version 23 (IBM SPSS, Chicago, IL). Data was presented as mean ± standard deviation/ median with range for continuous variables and percentages for categorical variables. Results: A total of 238 females of reproductive age with an echocardiographic diagnosis of RHD were recruited from August, 2021 through January, 2022. The median age (range) of the participants was 36 years (15-49). Majority of the participants were of advanced maternal age (35-49) constituting more than half of the study population while those younger than 20 years comprised 14 (5.9%) of all participants. Almost two-thirds of participants resided outside Dartes Salaam. Sixty-five percent were married and 102 (42.9%) had a secondary level of education. Thirty-five percent were unemployed and 159 (66.8%) were insured. More than three quarters of the study participants were seen at the outpatient clinic and 18.1% were admitted. Seven (2.9%) participants had a history of stroke, one had diabetes mellitus and 6.7% had hypertension. The most commonly used medications were furosemide, spironolactone, ACEI/ARBs and warfarin. Almost two-thirds reported to be dyspneic on moderate exertion and on physical exam, 18.9% had lower limb edema. More than two-thirds were in NYHA class II and 17.2% were in NYHA class IV heart failure. Overweight and obese participants comprised 18.5% and 20.6% of all participants respectively. Almost a half of participants had a normal ECG while a quarter had atrial fibrillation/flutter. The most common valvular lesion was MR followed by MS. Left atrial dilatation was present in more than a quarter, 17.2% had severely elevated pulmonary arterial pressures and 12.2% had reduced left ventricular ejection fraction. Based on the modified WHO maternal risk classification system for women of reproductive age with heart disease, 66% of the participants were in class IV. The proportion of contraception among reproductive age women with RHD was 7.1%. The commonest contraceptive method used was bilateral tubal ligation 5 out of 17 (29.4%), followed by implant (4 of 17). The most common reason for choice of a particular method was safety 10 out of 17 (58.8%). Conclusion: Majority of reproductive age women with RHD are at the highest pregnancy risk based on the modified WHO classification and a very small proportion of them are on contraception. These results call for action among clinicians to offer counselling to these patients, educating them on their risk and offering appropriate contraception advice whilewaiting for definitive interventions.