Article published online: 2020-02-12

THIEME
28 Case Report

A Case Presentation on Rheumatic Heart Disease with

Mitral Regurgitation
Jayasudha A.1 Sreerenjini B.1 Kaveri P.1 Anitha P.1

1 Obstetrics and Gynaecological Nursing Department, Address for correspondence Anitha P, Obstetrics and Gynaecological
PSG College of Nursing, Coimbatore, Tamil Nadu, India Nursing Department , PSG College of Nursing, Coimbatore 641004,
Tamil Nadu, India (e-mail: [email protected]).

J Health Allied Sci NU 2019;9:28–30

Abstract During any pregnancy there is an increase in blood volume of 30 to 50% resulting
in increased pressure on the heart valves. For women with rheumatic heart disease
this increased pressure presents increased maternal and/or fetal risks. Counseling of
women with rheumatic heart disease gives appropriate surveillance of maternal and
fetal well-being, as well as planning and documentation of the management of elective
and emergency delivery. The care of pregnant women with rheumatic heart disease
thus requires a multidisciplinary approach, involving obstetricians, cardiologists,
and anesthetists. However, many women with rheumatic heart disease have healthy
pregnancies and healthy babies with the right medical care.

Introduction only when medical management fails. Emergency cardiac

surgery during pregnancy increases fetal mortality. However,
Rheumatic heart disease (RHD) is a disease of poverty. early diagnosis, appropriate management prior to pregnancy,
RHD describes a group of short-term (acute) and long-term and good functional status at the time of entering pregnancy
(chronic) heart disorders that occurs as a result of acute allowed for a good maternal and neonatal outcome.
rheumatic fever. It is usually seen in children who are 5 to
15 years old.
Case Description
RHD is a disease of the young and its impact is seen in
women of reproductive age. It is a preventable yet serious public This study describes a 26-year-old primigravida woman
health problem in low- and middle-income countries. Currently with 385/7 weeks of gestation with known history of
30 million people are thought to be affected by RHD globally. RHD disease with severe mitral regurgitation in the age
The disease results from damage to the heart valves caused of 14 years. She had rheumatic fever with sore throat
by one or several episodes of rheumatic fever, an autoimmune in childhood; later she developed RHD. She received
inflammatory reaction to throat infection caused by group A medications like tablet penicillin G potassium from the
streptococci. It is an active or inactive disease of the heart and onset of disease and she was on injection penicillin in
the most affected is generally the mitral valve which is char- 2012 for up to 18 months. She was admitted in antena-
acterized by reduced functional capacity of the heart caused tal ward with the complaints of breathlessness, palpi-
by inflammatory changes in the myometrium or scarring of tation, fatigue, weakness, and bilateral pitting pedal
the valves. Risk factors of RHD include poverty, poor housing, edema for 2 months’ duration. On assessment, her BP
overcrowding, and malnutrition. The signs and symptoms are was 110/80 mm Hg and pulse 96 beats/min and she was
joint pain, fatigue, joint stiffness, tachycardia, dyspnea and conscious and oriented. She has undergone investigations
weakness, a “butterfly’’ rash across the cheeks, sun sensitivi- like complete blood count and thyroid hormone test. Her
ty, and hair loss. For some of these women an initial diagnosis Hb was 12.1 gm/dL, WBC 9,400 cells, platelet 2.19 lakhs,
is made antenatal or postpartum, as they fail to tolerate the and TSH level was 4.760 micro IU/mL. Then she had
impact of the physiological changes of pregnancy on their echo. In that the findings were severe MR with dilated
damaged heart valves resulting in clinical decompensation. left atrium and pulmonary hypertension (42 mm Hg). EF
Cardiac surgery carries significant maternal and fetal com- level was 63%. She was on medical treatment with tab-
plications. Cardiac operation during pregnancy is indicated lets Lasix—40 mg, Pentids—400,000 units, Eltroxin—50 µg,

DOI https://doi.org/ Copyright ©2019 Nitte (Deemed

10.1055/s-0039-1692033 to be University)
 Rheumatic Heart Disease with Mitral Regurgitation Jayasudha et al. 29

Livogen, and calcium. She was on salt restriction diet with 1L Medical Management
fluid restriction. The mother was kept under observation. Steps for medical management are as follows:
Then she underwent the elective LSCS. She delivered an
•• Digoxin is indicated in atria fibrillation to slow the
alive male neonate with the birth weight of 2.01 kg. APGAR
ventricular response and in acute heart failure to increase
score was 7/10 at 1 minute and 8/10 at 5 minute. Mother
myocardial contractility.
and baby were healthy and kept under close observation
•• Diuretics are used in acute and chronic heart failure.
till the fourth postoperative day. Then the mother and her
•• Beta-adrenergic blockers as propranolol may be indicated
baby were discharged from the hospital on the seventh
for arrhythmia.
postoperative day with diuretics and antibiotics.
•• Anticoagulants including warfarin or low molecular
weight heparin should be taken to promote circulation
Diagnosis and to prevent clotting.
•• Secondary prophylaxis (antibiotics) should be adminis-
History of rheumatic fever, especially if it is treated with
tered to prevent infection.
long-term secondary prophylaxis, doesn’t always lead to RHD.
•• Oxygen supplementation is needed to improve circula-
Physical examination is used to assess the signs of rheumatic
tion and to maintain balance between oxygen need and
fever, including joint pain and inflammation. Stethoscope is
demand.
used to listen to the abnormal heart rhythms. Blood tests like
complete blood count, culture, and ESR is done to find out
Surgical Management
any infection and detect antibodies. Chest X-ray is done to
The options for surgical management are as follows:
check the size of the heart and to see if there is excess fluid in
the heart or lungs. Electrocardiogram is used to find out the •• Therapeutic abortion should be considered in early
changes seen on heart. pregnancy.
Echocardiography is a noninvasive ultrasound that uses •• Cardiac surgery may be an alternative to therapeutic
sound waves to create a moving image of the heart and to abortion.
measure its size and shape. The echo test may be done one or
more times during pregnancy, to monitor how well the heart
Effects of Pregnancy on Rheumatic Heart
is performing.
Disease
During any pregnancy there is an increase in blood volume
Management
of 30 to 50% resulting in increased pressure on the heart
Preventive aspects include the following: valves. For women with RHD this increased blood pressure
presents increased maternal and/or fetal risks.
•• Primordial prevention reduces the risk factors for rheu-
This is because the added stress on the heart can result
matic fever by covering the mouth while sneezing or
in symptomatic RHD where previously there were no
coughing, proper hand washing, and maintaining distance
symptoms.
from sick people.
•• Primary prevention of rheumatic fever can be achieved
Maternal
through the effective treatment of streptococcal pharyn-
Pregnancy can lead to the worsening of symptoms
gitis with penicillin.
including the following:
•• Secondary prophylaxis through the administration of
injections of benzathine benzylpenicillin every 3 to •• Shortness of breath with simple activity.
4 weeks to patients with a previous history of rheumatic •• Waking at night out of breath.
fever and/or RHD. •• Pulmonary edema.
•• Atria fibrillation or clotting.
General Management These changes begin in the first trimester but peak at 28
Steps for general management are as follows: to 30 weeks and are sustained until term, meaning most
women with valvular heart disease become more symptom-
•• Women with moderate or severe RHD require close
atic in the third trimester.
supervision, normally at a tertiary referral center with
cardiology and intensive care facilities.
Fetal
•• More frequent antenatal visits are required.
•• More rest is required. •• Abortion
•• Diet is directed to restrict weight gain and prevent anemia •• Intrauterine growth retardation
as it increases cardiac strain. •• Still birth
•• Infection should be avoided and properly treated. •• Premature labor
•• Hospitalization is needed if tachycardia (exceeding 100 beats/ •• Asphyxia
minute) occurs. •• Respiratory distress syndrome

Journal of Health and Allied Sciences NU Vol. 9 No. 1/2019

30 Rheumatic Heart Disease with Mitral Regurgitation Jayasudha et al.

Nursing care •• Clarify any misinformation and answer questions regard-

ing disease process.
•• RHD can be very unpredictable manifesting in many •• Provide psychological support to the mother.
atypical ways and leading to severe complications. •• Assist in identifying and using techniques to cope with
•• Attention should be drawn to the pulse, respiration, and and solve problems and gain control over the situation.
blood pressure during birth. Continuous monitoring of •• Refer family for additional support and counseling, if
pulse and repeated blood pressure measurements should indicated.
be taken.
4. Risk for infection related to chronic illness.
•• Fast initiation of proper treatment may be crucial for the
outcome. Goal: To prevent infection.

Interventions
Nursing Diagnosis
•• Assess temperature, pulse, respiration, IV site, and WBC
1. Decreased cardiac output related to inadequate blood
count.
pumped by the heart to meet metabolic demands of the
•• Instruct the mothers to maintain personal hygiene
body as evidenced by tachycardia.
practices.
Goal: Maintaining normal cardiac output. •• Provide adequate rest and nutritional needs.
•• Wash hands before giving care.
Interventions •• Use sterile technique for IV maintenance.
•• Assess heart rate, heart sounds for gallops, and blood •• Administer antibiotics as ordered.
pressure. •• Inform to avoid contact with infected persons.
•• Note skin color, temperature, and moisture.
•• Check for peripheral pulses including capillary refill. Prognosis
•• Assess for reports of fatigue and reduced activity tolerance.
•• Inspect fluid balance and weight gain (weigh the mother Cardiovascular diseases are the leading cause of death
prior to breakfast). worldwide and in all regions except Africa. In 2015, RHD
•• Monitor ECG for rate, rhythm, and ectopy. was estimated to have been responsible for 3,05,000 deaths.
•• Provide adequate rest with semi fowler’s position. It is also estimated that by 2030, over 23 million people will
•• Administer oxygen therapy as prescribed. die from cardiovascular diseases each year.
RHD may be secondary to a combination of genetic
2. Activity intolerance related to imbalance between oxygen
predisposition and environmental factors. Organizations
supply and demand as evidenced by fatigue/ weakness.
such as the Indian Heart Association are working with the
Goal: Maintain normal activity. World Heart Federation to raise awareness about this issue.

Interventions
Conclusion
•• Assess level of fatigue, and ability to perform ADL and
other activities in relation to severity of the condition. RHD continues to be a major cause of cardiac disease com-
•• Assess dyspnea on exertion, and skin color changes during plicating pregnancy. Women with RHD of reproductive age
rest and when active. must receive early preconception evaluation and advice
•• Allow for rest periods between care. regarding the potential impact of pregnancy on their
•• Inform of activity or exercise restrictions and to set own cardiovascular function. Those who chose to conceive or
limits for exercise and activity. present after conception need management by a MDT with
•• Inform to request assistance when needed for daily activities. emphasis on identifying and avoiding triggers of decompo-
sition and fetal anomaly/loss throughout pregnancy and the
3. Ineffective family coping related to situational and devel-
puerperium. Even though multidisciplinary management
opmental crises of family and child as evidenced by family
reduces the adverse events resulting in satisfactory mater-
expresses concern and fear about delivery process.
nal and fetal outcomes.
Goal: Mother and her relatives will be free of fear to pro-
mote coping strategies. Conflict of Interest
None declared.
Interventions

•• Observe for erratic behaviors (anger, tension) and percep- References

tion of crisis situation. 1 Elizabeth M. Midwifery for Nurses. 1st ed. New Delhi: CBS
•• Assess usual family coping methods and effectiveness. Publishers; 2010
•• Assess need for information and support. 2 Weiner W. High Risk Pregnancy. 4th ed. New Delhi: Elsevier
•• Maintain good rapport with mother and her relatives. Publications; 2011
3 Queenan JT, Catherine YS, Lockwood CJ. Management of High
•• Encourage mother to expression of feelings and provide
Risk Pregnancy. 1st ed. Singapore: Markono Pvt Ltd; 2012
factual information about delivery process.

Journal of Health and Allied Sciences NU Vol. 9 No. 1/2019