Reproductive health among women of child-bearing age after surgery for rheumatic heart disease in Rwanda.

Objective: To determine maternal and fetal outcomes in postoperative women with rheumatic heart disease who become pregnant after valve surgery and evaluate current anticoagulation management during pregnancy.

Methods: Data from the Rwandan rheumatic heart disease cardiac surgical registry identified all female patients who underwent valve surgery before or during childbearing age since 2006. In total, 136 participants completed a mixed-methods questionnaire detailing each pregnancy after surgery, including anticoagulation regimen and outcomes.

Results: We found that 38.2% (n = 136) of patients reported at least 1 pregnancy after surgery, of which more than one half were unintentional (53.9%, n = 52). Among those patients with mechanical valves, most remained on warfarin alone during pregnancy (58.5%, n = 53) whereas one third were switched to low molecular weight heparin during the first, second, or third trimesters (5 vs 4 vs 7, n = 18). Women with bioprosthetic valve replacement or valve repair were more likely to experience live term births (84.6% vs 45.3%, P < .01) and less likely to report spontaneous abortion (3.9% vs 30.2%, P < .01) compared with women with mechanical valve replacement. Excessive bleeding was the most common complication during pregnancy (9.1%, n = 79), and 2 infants were diagnosed with congenital defects associated with warfarin embryopathy (4.8%, n = 42).

Conclusions: Despite preoperative counseling discouraging conception, many women with prosthetic valves still become pregnant after surgery. The results of this study will inform evidence-based and context-specific practices for anticoagulation during pregnancy in Rwanda and the region.