Rheumatic heart disease in pregnancy and neonatal outcomes: A systematic review and meta-analysis

Abstract

Purpose: Associations between rheumatic heart disease (RHD) in pregnancy and fetal outcomes are relatively unknown. This study aimed to review rates and predictors of major adverse fetal outcomes of RHD in pregnancy.

Methods: Medline (Ovid), Pubmed, EMcare, Scopus, CINAHL, Informit, and WHOICTRP databases were searched for studies that reported rates of adverse perinatal events in women with RHD during pregnancy. Outcomes included preterm birth, intra-uterine growth restriction (IUGR), low-birth weight (LBW), perinatal death and percutaneous balloon mitral valvuloplasty intervention. Meta-analysis of fetal events by the New-York Heart Association (NYHA) heart failure classification, and the Mitral-valve Area (MVA) severity score was performed with unadjusted random effects models and heterogeneity of risk ratios (RR) was assessed with the I2 statistic. Quality of evidence was evaluated using the GRADE approach. The study was registered in PROSPERO (CRD42020161529).

Findings: The search identified 5949 non-duplicate records of which 136 full-text articles were assessed for eligibility and 22 studies included, 11 studies were eligible for meta-analyses. In 3928 pregnancies, high rates of preterm birth (9.35%-42.97%), LBW (12.98%-39.70%), IUGR (6.76%-22.40%) and perinatal death (0.00%-9.41%) were reported. NYHA III/IV pre-pregnancy was associated with higher rates of preterm birth (5 studies, RR 2.86, 95%CI 1.54-5.33), and perinatal death (6 studies, RR 3.23, 1.92-5.44). Moderate /severe mitral stenosis (MS) was associated with higher rates of preterm birth (3 studies, RR 2.05, 95%CI 1.02-4.11) and IUGR (3 studies, RR 2.46, 95%CI 1.02-5.95).

Interpretation: RHD during pregnancy is associated with adverse fetal outcomes. Maternal NYHA III/IV and moderate/severe MS in particular may predict poor prognosis.

Fig 1. Study flow diagram.

Fig 2. Risk of bias assessment for included studies and risk of bias summary.

Fig 3. Comparison of New York health assessment I/II and New York health assessment III/IV scores for preterm births in women with baseline New York health assessment scores.

Fig 4. Sensitivity analyses: Comparison of New York health assessment I/II and New York health assessment III/IV scores for preterm births in women with baseline New York health assessment scores.

Fig 5. Comparison of mild and moderate/severe mitral stenosis for preterm births.

Fig 6. Comparison of New York health assessment I/II and New York health assessment III/IV for Intra-uterine growth restriction/small for gestational age outcome.

Fig 7. Comparison of mild and moderate/severe mitral stenosis severity for intra-uterine growth restriction/small for gestational age outcome.

Fig 8. Comparison of New York health assessment I/II and New York health assessment III/IV for low birth weight outcome.

Fig 9. Sensitivity analyses—comparison of New York health assessment I/II and New York health assessment III/IV for low birth weight outcome.

Fig 10. Comparison of New York health assessment I/II and New York health assessment III/IV for perinatal death outcome.

Fig 11. Sensitivity analyses–comparison of New York health assessment I/II and New York health assessment III/IV for perinatal death outcome.