Global disparities in the detection and management of rheumatic heart disease in pregnancy across endemic settings.

Background: Rheumatic heart disease (RHD) remains a leading cause of cardiovascular morbidity and maternal mortality in pregnancy worldwide. Despite near-eradication in high-income countries, RHD continues to disproportionately affect young women in low- and middle-income regions, where delayed diagnosis, limited access to preventive care, and constrained availability of cardiac interventions contribute to adverse maternal and fetal outcomes. Objective: To present contemporary evidence on the global burden, pathophysiology, detection, surgical and interventional management, of maternal and fetal outcomes of rheumatic heart disease in pregnancy, with principal emphasis on low-resource and endemic settings. Methods: We conducted a structured narrative review of the existing literature using PubMed/MEDLINE, Embase, Scopus, and the Cochrane Library, identifying observational cohorts, multicenter registries, randomized trials, systematic reviews, international clinical guidelines, and expert reviews published between January 2005 and May 2026. Studies were included if they reported on RHD epidemiology, screening and prophylaxis strategies, cardiac or obstetric outcomes, surgical or transcatheter interventions, valve prosthesis selection, anticoagulation management, or intrapartum and postpartum care during pregnancy. Evidence was narratively synthesized and organized by thematic domains relevant to pregnancy-associated risk. Result: RHD accounts for the majority of acquired heart disease in pregnancy across endemic regions, with contemporary registries reporting that 30%-70% of cardiac disease complicating pregnancy is rheumatic in origin. Mitral stenosis predominates and is associated with high rates of maternal heart failure, arrhythmia, thromboembolism, and postpartum decompensation. Maternal adverse cardiac events occur in approximately 15%-40% of pregnancies, with mortality ranging from 1%-10% depending on lesion severity, rhythm status, and access to care. Fetal complications, including preterm birth, low birth weight, and pregnancy loss, are common and are exacerbated by severe stenotic disease and prosthetic valves. Screening studies demonstrate that many women with RHD are unaware of their diagnosis prior to pregnancy, while randomized evidence supports echocardiographic screening coupled with secondary antibiotic prophylaxis to reduce disease progression in early-stage RHD. Surgical and interventional management during pregnancy remains high-risk, particularly in women with mechanical heart valves, underscoring the importance of preconception optimization and multidisciplinary care. Conclusion: Rheumatic heart disease in pregnancy confers substantial and preventable risk to both mother and fetus, particularly in low-resource settings where disease is often advanced at presentation. Improved strategies for early detection, primary and secondary prophylaxis, preconception counseling, and timely referral for valve intervention are essential to reducing maternal and fetal morbidity and mortality. Strengthening health systems to deliver integrated cardio-obstetric care remains central to improving outcomes for women with RHD worldwide.