Call for increased access to echos in Indigenous women

Echocardiography should be more available to pregnant Indigenous women in areas with a high prevalence of rheumatic heart disease (RHD).

Cardiologist Dr James Marangou told the CSANZ 3rd Indigenous Cardiovascular Health Conference that data from a retrospective review of current referral practices suggests Indigenous pregnant women are probably being under serviced.

The Northern Territory study reviewed 322 echocardiograms performed between 2014–2018 for an indication relating to pregnancy.

It found Indigenous women were younger (25 years v 30 years), had significantly higher rates of abnormal echocardiograms (35.9% v 10%) and a higher burden of rheumatic fever/RHD (39.4% v 0.8%) compared to non-Indigenous women.

Moderate or severe valve lesions were detected in 13.3% of Indigenous women and 5.6% had previous cardiac surgery.

Transfer to a tertiary centre with valve intervention services available was required for 6.2% of the Indigenous women.

Speaking to the limbic, Dr Marangou said women in the Top End are currently referred for echocardiogram if there were signs or symptoms of cardiac pathology or a history of RHD.

But it could be hard to tease out normal pregnancy symptoms from a cardiac symptom.

“What we are seeing is that the majority of indications are either an incidental murmur, symptoms that may be cardiac or a history of RHD or acute rheumatic fever (ARF).”

“The extrapolation is that there is a proportion of women out there who aren’t referred because either they have no history of ARF, they have no history of RHD, they don’t see a doctor during their early weeks of pregnancy, they don’t report symptoms or signs but they may still have undiagnosed significant RHD.”

Dr Marangou, from the Fiona Stanley Hospital in Perth, said echo was relatively cheap as far as cardiovascular investigations go, very portable and safe.

“Really all women who have a risk of RHD should have access to it.”

“If you exclude it and they have no valve disease then they can proceed with pregnancy as they would wish. But at the same time, if you identify something it gives you time to then make appropriate plans to manage that women through her pregnancy.”

He said there was some recent data from Uganda that showed occult RHD was responsible for a substantial proportion of adverse pregnancy outcomes.

Sadly, Australia likely had similar results despite more resources.

“RHD is still a significant problem in certain populations. It still carries a high morbidity and mortality; it has the highest prevalence in the 3rd and 4th decade of life and has a female predominance so it affects women during their years of childbearing.”

“We know a proportion of women will have very limited antenatal care and may only be seen around their anatomy scan at 20 weeks. And some may not be seen at all depending on their location and engagement.”

However he said this was small retrospective study, which was more thought provoking than anything else, but supported a prospective study.

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