The determination of the prognosis of pregnancy in rheumatic heart disease

In determining the prognosis in pregnancy of 142 women with rheumatic heart disease, the following factors were considered: duration of rheumatic fever, age, functional capacity, history of previous failure, type of valvular damage, size of heart, nature of earlier rheumatic manifestations, and parity. It was found that the important signs were those which helped prognosticate congestive failure. That failure is the governing feature in prognosis is supported by the observations (1) that it is the most common cause of death in pregnancy complicated by rheumatic heart disease and (2) that the infant mortality rate for our group of patients with congestive heart failure was three times as high as for patients who had heart disease without failure and four times as high as for normal pregnant women delivered on the same obstetrical service.The factors found to be important in prognosticating failure and in estimating the risk involved in pregnancy form integral parts of a basic principle, which consists of establishing the patient's position in the natural course of her rheumatic heart disease. This principle gains validity when data collected under wellcontrolled conditions indicate that pregnancy per se does not alter the course of this disease. The application of this principle for determining prognosis led to interruption (per vagina) of only eleven of 142 pregnancies. No hysterotomies were performed after the patient was permitted to pass through the first trimester of pregnancy. There were no deaths from congestive heart failure among the 129 patients who remained under our care through pregnancy and parturition.