Cardiac and Obstetric Complications of Pregnant Women with Rheumatic Heart Disease in Sub-Saharan Africa: A Systematic Review.

Background: Rheumatic heart disease (RHD) is a key contributor to maternal cardiovascular morbidity and mortality in sub-Saharan Africa (SSA). Though low- and middle-income countries (LMICs), particularly those in SSA, face a greater burden of RHD, existing systematic reviews have not specifically focused on cardiac and obstetric complications among affected women. We aimed to study cardiac and obstetric complications in pregnant and postpartum women with RHD in SSA and to evaluate the rate of valvular interventions in pregnant or postpartum women with severe disease. Methods: We performed a systematic search in MEDLINE and online sources for studies of women of childbearing age (15-49 years) with RHD published after 2000 in SSA. Included study types were randomized controlled trials, retrospective and prospective cohort studies, case-control studies, case reports, and case series. Two authors independently extracted data and critically appraised articles. PROSPERO registration number: CRD42024628121. Results: We identified 1,478 unique citations, and nine full-text studies met inclusion criteria. Included studies were case series (7), one cohort study, and one case-control study, including a total of 787 pregnant women with cardiac disease, of whom the majority had RHD. Mitral stenosis and regurgitation were the most common valve lesions. Heart failure and arrhythmia occurred in at least 12.9% and up to 36% of study participants, respectively. Eight studies reported deaths due to cardiac causes (median: six deaths due to cardiac disease; total number of deaths: 56). Preterm labor/delivery was the most reported obstetric event, with incidence ranging from 5.2-35.2%. Few pregnant patients received any valve intervention. Conclusions: Pregnant women with RHD in SSA are at risk for both adverse cardiac and obstetric outcomes in pregnancy, particularly heart failure and preterm labor. Future efforts may include registries focused on pregnant women with RHD and scaling cardiac interventional capacity to benefit pregnant women with RHD in SSA. Unstructured Abstract: We performed a systematic search in MEDLINE and online sources to study cardiac and obstetric complications and rates of valvular interventions in pregnant and postpartum women with rheumatic heart disease (RHD) in sub-Saharan Africa (SSA). Two authors independently extracted data and critically appraised articles. Nine full-text studies met inclusion criteria, capturing 787 pregnant women with cardiac disease, mostly RHD. Heart failure and arrhythmia occurred in at least 12.9% and up to 36% of study participants, respectively. Fifty-six deaths were reported from cardiac causes. Preterm labor/delivery was the most reported obstetric event, and few pregnant patients received any valve intervention. We found that women with RHD in SSA are at risk for adverse cardiac and obstetric outcomes in pregnancy, particularly heart failure and preterm labor. Future efforts may include registries focused on pregnant women with RHD and scaling cardiac interventional capacity to benefit pregnant women with RHD in SSA.