Rheumatic heart disease (RHD) is a chronic sequela of acute rheumatic fever (ARF), predominantly affecting young adults in low- and middle-income countries, where it remains a significant cause of cardiovascular morbidity and mortality (1). Pregnancy imposes additional hemodynamic stress, which can exacerbate underlying cardiac conditions, leading to an increased risk of adverse maternal and fetal outcomes (2). Among the complications of RHD, atrial fibrillation (AF) is one of the most critical arrhythmias, contributing to an elevated risk of heart failure, thromboembolism, and peripartum complications (3,4).

The presence of AF in pregnant women with RHD can further compromise cardiac output, leading to hemodynamic instability, increased left atrial pressure, and subsequent pulmonary hypertension (5). These factors not only complicate maternal management but also increase the likelihood of adverse perinatal outcomes such as preterm birth, intrauterine growth restriction, and neonatal complications (6). Despite advances in medical and surgical interventions, RHD remains a significant challenge in maternal-fetal medicine due to limited access to timely diagnosis and specialized care in resource-constrained settings (7).

Several studies have highlighted the increased risk of heart failure and thromboembolic events in pregnant women with RHD and AF, emphasizing the need for early risk stratification and multidisciplinary management (8,9). However, comparative studies evaluating the clinical outcomes of RHD in pregnancy with and without AF remain limited. Understanding the impact of AF on maternal and fetal prognosis is crucial for optimizing antenatal care and improving perinatal outcomes.

This study aims to compare the clinical outcomes, maternal complications, and fetal prognosis in pregnant women diagnosed with RHD with and without AF. By identifying the differences in risk profiles, this research will contribute to improving the management strategies for high-risk pregnancies associated with RHD and AF

Study Design and Setting

This study was designed as a prospective observational study conducted at a tertiary care hospital. The study aimed to compare maternal and fetal outcomes in pregnant women diagnosed with rheumatic heart disease (RHD) with and without atrial fibrillation (AF). Ethical approval was obtained from the institutional ethics committee, and written informed consent was secured from all participants prior to enrollment.

Study Population

A total of 120 pregnant women diagnosed with RHD were recruited between [Study Duration]. Participants were categorized into two groups:

• Group A (n=60): Pregnant women with RHD complicated by AF.
• Group B (n=60): Pregnant women with RHD but without AF.
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Inclusion criteria included pregnant women aged 18–40 years with echocardiographically confirmed RHD. Patients with congenital heart disease, pre-existing hypertension, diabetes mellitus, or other systemic illnesses were excluded to minimize confounding factors.

Data Collection and Clinical Assessment

Baseline demographic data, obstetric history, and cardiovascular status were recorded at the time of enrollment. Each participant underwent a comprehensive cardiovascular assessment, including:

• Echocardiography to evaluate valvular lesions, left atrial size, and pulmonary artery pressure.
• Electrocardiography (ECG) to confirm the presence or absence of AF.
• Blood Investigations including coagulation profile, complete blood count, and cardiac biomarkers.

Maternal outcomes, including heart failure (New York Heart Association classification), thromboembolic events, and need for intensive cardiac care, were documented. Fetal outcomes, such as gestational age at delivery, birth weight, Apgar scores, and neonatal complications, were recorded.

Management Protocol

All participants received standard antenatal care with multidisciplinary management involving obstetricians, cardiologists, and anesthetists. Women in Group A were managed with rate or rhythm control strategies, anticoagulation therapy, and close fetal surveillance. Vaginal delivery was preferred unless obstetric indications warranted a cesarean section.

Statistical Analysis

Data analysis was performed using SPSS software (version [26]). Descriptive statistics were used to summarize demographic and clinical characteristics. Continuous variables were expressed as mean ± standard deviation and compared using the Student’s t-test or Mann-Whitney U test. Categorical variables were analyzed using the chi-square test or Fisher’s exact test. A p-value of <0.05 was considered statistically significant.

Baseline Characteristics

A total of 120 pregnant women diagnosed with rheumatic heart disease (RHD) were included in the study. Group A (RHD with atrial fibrillation) comprised 60 participants, while Group B (RHD without atrial fibrillation) included 60 participants. The mean age of participants in Group A was 29.5 ± 4.2 years, whereas in Group B, it was 28.7 ± 3.9 years (p=0.32). The majority of patients in both groups were in their second trimester at the time of enrollment (Table 1).

Maternal Outcomes

The incidence of heart failure was significantly higher in Group A (35%) compared to Group B (12%) (p=0.01). Thromboembolic events occurred in 18% of women in Group A, whereas only 5% of women in Group B experienced such complications (p=0.03). The requirement for intensive cardiac care was also higher in Group A (42% vs. 20%, p=0.004) (Table 2).

Echocardiographic Findings

Echocardiographic assessment revealed that the mean left atrial diameter was significantly larger in Group A (48.6 ± 5.2 mm) compared to Group B (42.3 ± 4.8 mm) (p=0.002). Pulmonary artery pressure was also elevated in Group A, with a mean value of 38.2 ± 7.5 mmHg, compared to 30.6 ± 6.2 mmHg in Group B (p=0.01) (Table 3).

Fetal Outcomes

Adverse fetal outcomes were more prevalent in Group A, with preterm birth occurring in 28% of cases compared to 15% in Group B (p=0.04). Intrauterine growth restriction (IUGR) was observed in 22% of fetuses in Group A, whereas only 10% of fetuses in Group B exhibited growth restriction (p=0.05). The mean birth weight was lower in Group A (2.4 ± 0.5 kg) than in Group B (2.8 ± 0.4 kg) (p=0.02) (Table 4).

Tables

Table 1. Baseline Characteristics of Study Participants

Table 2. Maternal Outcomes in Study Groups

Table 3. Echocardiographic Parameters in Study Groups

Table 4. Fetal Outcomes in Study Groups

These findings suggest that the presence of atrial fibrillation in pregnant women with RHD significantly increases the risk of maternal and fetal complications (Table 2, Table 3, Table 4).

Rheumatic heart disease (RHD) remains a significant public health concern, particularly in low- and middle-income countries where access to preventive measures and timely interventions is limited (1). Pregnancy places additional hemodynamic stress on the cardiovascular system, which can exacerbate underlying RHD and lead to severe complications, particularly in patients who develop atrial fibrillation (AF) (2,3). The present study evaluated the impact of AF on maternal and fetal outcomes in pregnant women with RHD, revealing a significantly higher risk of adverse events in those with AF.

The findings indicate that heart failure was significantly more prevalent in RHD patients with AF, affecting 35% of cases, compared to 12% in those without AF. This aligns with previous studies that have reported an increased incidence of heart failure due to hemodynamic overload and impaired left atrial function in pregnant women with valvular heart disease (4,5). The higher pulmonary artery pressure observed in the AF group further supports the hypothesis that left atrial dysfunction leads to increased pulmonary congestion and subsequent cardiovascular decompensation (6).

AF is a known risk factor for thromboembolic events due to blood stasis in the dilated left atrium and the prothrombotic state of pregnancy (7,8). In this study, 18% of women with AF experienced thromboembolic events compared to 5% of those without AF, emphasizing the need for careful anticoagulation management. This finding is consistent with previous research indicating that RHD patients with AF have a higher risk of ischemic stroke and systemic embolism during pregnancy (9,10). Anticoagulation therapy in pregnancy remains a clinical challenge due to the need to balance maternal safety with fetal risks, necessitating individualized management approaches (11).

Echocardiographic findings demonstrated significantly larger left atrial diameters in patients with AF, supporting the role of atrial remodeling in the development of arrhythmias (12). The presence of AF also correlated with higher pulmonary artery pressures, which could explain the increased incidence of maternal cardiovascular complications in this group. These results are in agreement with prior studies indicating that left atrial enlargement and pulmonary hypertension are predictive markers for adverse outcomes in pregnant women with RHD (13,14).

Fetal outcomes were also significantly affected by the presence of AF in RHD patients. The incidence of preterm birth (28% vs. 15%) and intrauterine growth restriction (22% vs. 10%) was notably higher in the AF group. The compromised maternal cardiovascular function in AF cases likely leads to reduced uteroplacental perfusion, contributing to fetal distress and restricted growth (15). These findings underscore the importance of multidisciplinary management in high-risk pregnancies, involving obstetricians, cardiologists, and neonatologists to optimize maternal and fetal outcomes (6).

Despite advancements in cardiac care, RHD continues to pose a substantial risk to pregnant women, particularly when complicated by AF. The study highlights the need for early risk stratification and close monitoring of hemodynamic parameters to reduce adverse outcomes. Prophylactic anticoagulation, rate or rhythm control strategies, and timely delivery planning are critical components of management in such cases (7,8).

Several limitations of this study should be acknowledged. The sample size, although adequate for statistical analysis, may limit the generalizability of the findings to larger populations. Additionally, variations in anticoagulation strategies and access to specialized care across different healthcare settings could influence outcomes. Future studies with larger cohorts and long-term follow-up are needed to refine management guidelines for pregnant women with RHD and AF (9).

In conclusion, this study confirms that AF significantly worsens maternal and fetal outcomes in pregnant women with RHD. The increased risk of heart failure, thromboembolic events, and adverse perinatal outcomes necessitates an individualized, multidisciplinary approach to management. Early detection, optimal anticoagulation, and hemodynamic stabilization are essential to improving prognosis in this high-risk population.

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