Figure 1
PRISMA flow diagram.
Table 1
Demographic and obstetric data.
| STUDY ID | COUNTRY | DESIGN | SETTING | SAMPLE SIZE | AGE (YEARS) (MEAN ± SD) | HIGHEST LEVEL OF EDUCATION | HYPERTENSION, n (%) | DIABETES, n (%) | HIV n (%) | KNOWN CARDIAC DISEASE n (%) | GESTATIONAL AGE AT FIRST VISIT, WEEKS (MEAN SD) | PRIMIGRAVIDA, n (%) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Studies using Handheld or Portable Echocardiography | ||||||||||||
| Otto 2011 | Eritrea | Prospective cross sectional | 4 clinics in single city | 348 | 26.9 (±6) | NA | 0 | NA | NA | 0 | 30.9 ± 6.7 | NA |
| Beaton 2019 | Uganda | 24-month prospective longitudinal investigation | 2 health centres, 1 regional referral hospital | 3506 | 24.09 (N/A) | University Degree: 87 (2.5%) | 6 (1.7%) | NA | 141 (4.0%) | 2 (0.06%) | 24 (median) | 359 (10.2%) |
| Nascimento 2021 | Brazil | 13-month prospective longitudinal investigation | 22 primary care centres | 1112 | 27 ± 8 years | NA | 50 (4.5%) | 27 (2.4%) | NA | 9 (0.8%) | 22 ± 9 | NA |
| Snelgrove 2021 | Kenya | Cross sectional study | Antenatal clinic at tertiary maternity centre | 601 | 26.6 years (SD 5.7) | University degree: 82 (13.6%) | 1 (0.2%) | 1 (0.2%) | 45 (7.5%) | 27 (4.5%) | 25.3 ± 9.5 | NA |
| AlSharqi 2022 | India | cross sectional study | 10 hospitals across three states-India | 301 | 25.4 (18–42) | University degree: 31 (10.6%) | NA | NA | NA | 17 (5.6%) | NA | 183 (60.8%) |
| Screening using Standard Echocardiography or unspecified echocardiographer | ||||||||||||
| Selvarani 2014 | India | 6 months Cross sectional study | Antenatal clinic at a tertiary maternity centre | 1125 | 23.41 | NA | NA | NA | NA | NA | NA. | 55.73% |
| Bacha 2019 | Ethopia | Cross Sectional Study | Antenatal clinic at tertiary maternity centre | 398 | 27.0 (±4.6) | College/University 49 (12.31%) | 8 (2%) | 7 (1.8%) | NA | NA | NA | NA |
| Gomathi 2019 | India | 4-month cross-sectional study | Cardiology department at tertiary center | 300 | NA | NA | NA | NA | NA | 0 | NA | 186 (62%) |
| Bozkaya 2020 | Turkey | 12-month cross-sectional study | Tertiary delivery center | 900 | 27.4 (±5.8) | NA | 0 | 0 | 0 | 0 | NA/first trimester | NA |
| Patel 2021 | India | 36 month long cross sectional study | Antenatal care at two large hospitals | 14275 | NA | NA | NA | NA | NA | NA | NA | NA |
Table 2
Echo protocols and findings.
| PROTOCOL | OPERATORS | LVSD, n (%) | LV HYPERTROPHY, n (%) | PULMONARY HYPERTENSION, n (%) | RV DILATATION, n (%) | SYMPTOMS/NYHA FUNCTIONAL CLASS AT ENTRY | CONGENITAL HEART DISEASE (ANY) n | |
|---|---|---|---|---|---|---|---|---|
| Studies using Portable or Handheld Echocardiography | ||||||||
| Otto 2011 | Full TTE with Doppler; Vivid-I GE Healthcare | Trained Medical students | Moderate LVSD: 1 (0.29%) | 0 | 0 | 0 | Asymptomatic | Any: 1 (0.3%) ASD |
| Beaton 2019 | Focussed Echo; Vivid-Q GE Healthcare or Philips ClearVue 350 | Nurses | DCM, Mild LVSD: 1 (0.03%) | 0 | Any: 1 (0.03%) | 0 | Cases with echo findings: I–7 (13.4%) II–41 (78.8%) III–4 (7.7%) IV–0 (0%) | Any: 1 (0.03%) Large secundum ASD: 1 |
| Nascimento 2021 | Focussed 7-view protocol; Vscan GE Healthcare and Vivid-Q & IQ GE Healthcare, if positive scan | Healthcare workers | Mild/moderate LVSD: 1 (0.1%) | 2 (0.2%) | 0 | 3 (0.3%) | 37.7% (419) had dyspnoea | 0 |
| Snelgrove 2021 | Focussed Echo; Vivid-Q GE Healthcare | Cardiac sonographer | 0 | 0 | Any: 1 (0) | 0 | 10.3% (62) had unspecific symptoms | Any: 2 (0.3%) Unroofed CS: 1; PDA: 1 |
| AlSharqi 2022 | Focussed protocol; Lumify Philips Healthcare | Obstetricians | LVEF 45–54% 8.4% (25) LVEF 30–44% 8.8% (26) LVEF <30% 4.7% (14) | 0 | 0 | 19/285 (6.7%) | Cases with echo findings (n = 172): I–13 (7.8%) II–37 (22.2%) III–19 (11.4%) IV–98 (58.6%) | 0 |
| Screening using Standard Echocardiography or unspecified echocardiographer | ||||||||
| Selvarani 2014 | Full TTE with Doppler; Echocardiographer not specified | NA | Any: 1 (0.1%) DCM: 1 | 0 | 0 | 0 | All asymptomatic “except for a few in NYHA class II” | Any: 24 (2.1%) ASD: 7; VSD: 2; MVP: 3; Bicuspid Ao: 3; Corrected: 9 |
| Bacha 2019 | Full TTE with Doppler; Vivid-E9 GE Healthcare | NA | Any: 1 (0.3%) Peri-natal CM: 1 | 5 (1.3%) | Any: 15 (3.8%) Mild: 11 Moderate: 2 Severe: 2 | NA | NA | 0 |
| Gomathi 2019 | Full TTE with Doppler; Echocardiographer not specified | NA | NA | NA | NA | NA | Asymptomatic | Any: 7 (2.3%) ASD: 2; MVP: 3; Pulm Stenosis: 1; Aortic Coarct: 1 |
| Bozkaya 2020 | Full TTE with Doppler; – Vivid S5 System, GE Healthcare | Cardiologist | 0 | NA | NA | 0 | Asymptomatic | Any: 9 (1.0%) ASD: 8; PDA (1) |
| Patel 2021 | “Screening echocardiogram”; Echocardiographer not specified | NA | Cardiomyopathy: 66 (0.5%) DCM: 30 (0.2%) LVEF < 55% 36 (0.3) | 27(0.18%) | NA | NA | NA | Any: 63 (0.4%) ASD or PFO: 43; VSD: 4; PDA (7), Bicuspid Aortic valve (9) |
[i] Legend: LVSD – left ventricular systolic dysfunction; ASD – atrial septal defect; CS – coronary sinus; PDA – patent ductus arteriosus; CM – cardiomyopathy, MVP – mitral valve prolapse; Pulm – pulmonary; Coartct – coarctation. Other findings: Alsharqi et al. reported 4 thrombi; Bozkaya et al. also reported significant cases of non-rheumatic valve disease: moderate pulmonary stenosis (1), moderate AR (1), moderate MR (5), and severe MR (1).
Table 3
Rheumatic heart disease findings on screening echo.
| CRITERIA USED | RHD ANY n, % | MITRAL REGURGITATION, n (%) | MITRAL STENOSIS (ANY), n (%) | AORTIC REGURGITATION (ANY), n (%) | AORTIC STENOSIS (ANY), n (%) | |
|---|---|---|---|---|---|---|
| Studies using Portable or Handlehd Echocardiography | ||||||
| Otto 2011 | WHO consensus statement 2001 | Any: 16 (4.6%) Definite: 8 Nondefinite: 8 | Any: 12 (3.6%) Mild: 7 Mid/Moderate: 2 Moderate: 2 Moderate/Severe: 1 | 0 | Any: 6 (1.7%) Mild: 6 | 0 |
| Beaton 2019 | WHF | Any: 51 (1.5%) Mild: 31 Moderate: 14 Severe: 6 | Any: 45 (1.3%) Mild: 28 Moderate: 15 Severe: 2 | Any: 3 (0.1%) Mild: 2 Moderate: 1 | Any: 7 (0.2%) Mild: 5 Moderate: 1 Severe: 1 | 0 |
| Nascimento 2021 | Adapted ASE criteria for major heart disease | Any: 12 (1.1%)* | Any: 12 (1.1%) Mild to moderate: 11 Moderate: 1 | Any: 1 (0.1%) Mild: 1 | Any: 3 (0.3%) Mild: 3 | Any: 1 (0.1%) Mild: 1 |
| Snelgrove 2021 | WHF | Any: 3 (0.5%) | Any: 1 (0.2%) Moderate: 1 | Any: 2 (0.33%) Severe: 2 | Any: 1 (0.2%) Moderate: 1 | 0 |
| AlSharqi 2022 | ASE/EACVI recommendations | Any: 20 (6.6%) | ‘mitral valve involvement’: 20 (6.6%) | Significant: 17 (5.6%) | ‘aortic valve involvement’ 3 (1%) | Significant: 1 (0.3%) |
| Screening using standard echocardiography or nonspecified echocardiographer | ||||||
| Selvarani 2014 | NA | Any: 17 (1.5%) | Any: 1 (0.1%) | Any: 14 (1.2%) | Any: 3 (0.03%) | NA |
| Bacha 2019 | WHF | Significant: 9 (2.3%) | Any: 4 (1%) Moderate to Severe: 2 NS: 2 | Moderate to Severe: 3 (0.8%) | Moderate to Severe: 2 (0.5%) | Moderate to Severe: 2(0.5%) |
| Gomathi 2019 | NA | Any: 12 (4.0%) | Any: 4 (1.3%) | Any: 4 (1.3%) Moderate: 3 Not specified: 1 | Any: 1 (0.3%) Not specified: 1 | Any: 1 (0.3%) Not specified: 1 |
| Bozkaya 2020 | WHF | Any: 26 (2.9%) | Any 24 (2.7%) Mild: 20 Moderate: 4 | Mild: 2 (0.2%) | 0 | 0 |
| Patel 2021 | NA | 61 (0.4%) | Any: not specified; ‘mitral valve involvement’: 61 | Number not specified, but ‘90% were mild to moderate, and 67% had Wilkins score <8’ | NA | NA |
[i] *RHD on screening was suspected in 36 women (3.2%), but only 56 of the 100 women who screened positive had a confirmatory echocardiogram.
Figure 2
Prevalence of RHD in studies using portable or handheld echocardiography.
Figure 3
Prevalence of RHD in studies using stationary or non-specified echocardiography.
Table 4
Newcastle Ottawa scale for quality assessment of cross-sectional studies.
| STUDY ID | SELECTION | COMPARABILITY | OUTCOME | TOTAL | RESULT | |||
|---|---|---|---|---|---|---|---|---|
| REPRESENTATIVENESS OF THE SAMPLE | SAMPLE SIZE | NON- RESPONDENTS | Ψ | ASSESSMENT OF OUTCOME | STATISTICAL TEST | |||
| Studies using Portable or Handheld Echocardiography | ||||||||
| Otto 2011 | * | - | * | ** | ** | - | 6 | Medium Risk |
| Beaton 2019 | * | * | - | ** | ** | * | 7 | Low Risk |
| Nascimento 2021 | * | * | - | ** | ** | * | 7 | Low Risk |
| Snelgrove 2021 | * | * | - | ** | ** | * | 8 | Low Risk |
| AlSharqi 2022 | * | - | * | ** | ** | * | 7 | Low Risk |
| Screening using Standard Echocardiography or nonspecified echocardiographer | ||||||||
| Selvarani 2014 | - | * | - | * | ** | - | 4 | High Risk |
| Bacha 2019 | * | * | - | ** | ** | - | 6 | Medium Risk |
| Gomathi 2019 | - | - | - | - | ** | - | 2 | High Risk |
| Bozkaya 2020 | * | * | - | ** | ** | * | 7 | Low Risk |
| Patel 2021 | * | * | - | - | ** | - | 4 | High Risk |
[i] Ψ Comparability of subjects across studies with enough information provided on study design, analysis, and confounding factors (**); information provided on 2 of the 3 previously mentioned factors (*).
Table 5
Assessment of Certainty of Evidence using the GRADE approach.
| NO OF STUDIES | RISK OF BIAS | INCONSISTENCY | INDIRECTNESS | IMPRECISION | PUBLICATION BIAS | CERTAINTY |
|---|---|---|---|---|---|---|
| 10 | Serious | Serious | Low risk | Serious | Serious | ⨁◯◯◯Very low |
| 5 of 10 studies had medium to high risk of bias as per the Newcastle Ottawa scale | Inconsistency was very high: I2 = 95% | Study population of pregnant women in high prevalence countries in all studies | The detection rate of RHD was <1% in 2 studies | Asymmetric funnel plot, with Four studies are outside the 95%CI limits |
Figure 4
Funnel-plots for assessment of publication bias.