Times of India
24 February 2011
By Malathy Iyer
Chembur resident Reena Vishvakarma had no inclination about her leaky heart valve when she started feeling severely breathless in the sixth month of her pregnancy. The 26–year–old was diagnosed with rheumatic heart disease and rushed to the civic–run Sion Hospital for immediate medical help. But Vishvakarma wasn’t the only pregnant woman treated at Sion Hospital for a valve problem in 2011. Four others underwent balloon mitral valvuloplasty—a minimally invasive procedure to fix a narrowed or leaky mitral valve—in less than a fortnight.

It is largely believed that the incidence of rheumatic heart disease has fallen, but Sion Hospital’s experience serves as a public health reminder. "It is a matter of chance but significant that we fixed the valves of three pregnant women on January 28 and two others on February 10. Each one of them had rheumatic heart disease that had either not been discovered or flared up due to pregnancy,’’ said Dr Ajay Mahajan, associate professor of cardiology at Sion Hospital.

Rheumatic fever has for decades been the biggest contributor of heart diseases in India. Caused by the streptococci bacteria, the fever has a way of affecting the heart’s valves that control unidirectional flow of blood. The mitral valve, which is between the left atrium and the left ventricle, is the most commonly affected.

The challenge in treating pregnant women lies in the fact that it is completed in the shortest possible time. Sion Hospital dean Dr Sandhya Kamat said, "While treating a pregnant woman, we have to remember that there are two patients, including the foetus." The radiation exposure in a cath–lab is minimized by placing a protective lead shield on the woman’s abdomen.

Mahajan added, "We were particularly worried about 35–year–old Yogita Bambarde who had undergone a valvuloplasty 19 years ago. The disease flared up during pregnancy as the heart has to handle extra blood during the period. Moreover, she had had a previous miscarriage and this child was precious.’’

Both Vishvakarma and Bambarde were discharged on February 14. The three previous patients who were operated on January 28—20–year–old Hasina Khan from Thane, Geeta Singh (25) from Malad and 32–year–old Akhtarunissa Khan from Kurla—are doing well, the doctor added.

Dr N O Bansal, who heads the cardiology department of J J Hospital in Byculla, said doctors would prefer not to offer major surgery or procedure during pregnancy because of fear of complications, both to the mother and foetus. "But on rare occasions doctors are forced to treat pregnant women because of a threat to their lives,’’ he said.

J J Hospital’s cardiology department performs procedures on over 250 patients with valve problems or rheumatic heart disease. "The incidence of rheumatic heart disease is dropping across the country perhaps due to growing affluence and better nutrition. We are not seeing so many patients of rheumatic heart disease as before. Hence the fact that five pregnant women underwent the procedure in one month is uncommon,’’ said Bansal.

The Disease

• Rheumatic heart disease begins as the body’s immune response to the streptococci bacteria
• Valves control the unidirectional flow of blood in the heart, but they become rigid or leaky after the infection. The heart’s muscles and lungs, too, are affected, causing severe breathlessness and excessive heartbeats
• Children infected with the bacteria develop a fever along with a sore throat and joint pains. If not treated with antibiotics, the bacterial infection affects the heart’s valves as well
• If rheumatic heart disease is left untreated, it can lead to heart failure in the long run
• It is mainly prevalent among people from the economically poorer section because of lack of access to healthcare facilities, and poor diagnosis and nutrition

Beating the Odds
A couple of decades ago, the incidence was 4 per 1,000 children. But an article published in the ‘Journal of the American College of Cardiology’ last year showed that in central India, the prevalence was down to 0.46 per 1,000 children

Treatment

• Leaky valves can be repaired by operation or replaced by artificial valves
• Narrowed valves could be stretched open by balloon tubes using minimally invasive techniques such as balloon mitral valvuloplasty
• The Indian Council for Medical Research (ICMR) started a programme two decades ago in which children who were identified with strep infection would be provided with a preventive treatment of penicillin for a 20–year period. It is believed that the incidence in India, like in the West, is falling

Pregnancy Complications

• The total volume of blood is five litres, but in pregnant women this volume increases by two litres. Due to the increased blood flow, women who have leaky or narrowed heart valves begin showing signs of discomfort such as breathlessness, palpitation, etc
• These women may need medical or surgical intervention during the pregnancy itself
• A protective shield is placed on the mother’s abdomen to protect the foetus from radiation during the cath–lab procedure to fix the narrowed valve