Rheumatic Heart Disease During Pregnancy: Understanding Its Different Types and Development Phases

Understanding Rheumatic Heart Disease in Pregnancy

Phase 1: Degenerative Exudative Stage

The first stage in the development of rheumatic heart disease is known as the degenerative exudative phase. During this period, collagen fibers within connective tissues undergo splitting and swelling, leading to hyaline and fibrinoid degeneration. This process is accompanied by an inflammatory response, with infiltration of lymphocytes, plasma cells, eosinophils, and neutrophils surrounding the affected areas. These immune cells contribute to the body's reaction to tissue damage and play a role in disease progression.

This initial phase typically lasts between one to two months. During this time, patients may experience symptoms related to inflammation, such as joint pain and swelling. Some individuals may recover without further progression, while others may advance to the next stages of the disease.

Phase 2: Proliferative Stage

The second stage is characterized by the formation of Aschoff bodies, which are granulomatous lesions unique to rheumatic fever. These structures serve as key diagnostic indicators of active rheumatic disease. At the center of these lesions, fibrinoid necrosis occurs, surrounded by a rim of inflammatory cells including lymphocytes and plasma cells.

A distinctive feature of this phase is the presence of Anitschkow cells, also known as rheumatic cells. These cells are round, oval, or polygonal in shape, with abundant basophilic cytoplasm and prominent nucleoli. In some cases, these cells may fuse to form multinucleated giant cells, signaling progression toward the final stage of tissue remodeling.

This proliferative phase generally lasts approximately three to four months. During this time, the immune response continues to shape the pathological landscape of affected tissues, particularly in the heart and joints.

Phase 3: Sclerotic Stage

The final stage of rheumatic heart disease is marked by fibrosis and scar formation. The degenerative and necrotic material in the center of Aschoff bodies is gradually absorbed, while inflammatory cell infiltration decreases. Simultaneously, fibrous tissue proliferates, ultimately replacing the granulomatous lesions with scar tissue.

This scarring process, which can take four to six months to complete, primarily affects the endocardium and myocardium, particularly heart valves. While earlier stages involve significant exudative changes that contribute to clinical symptoms, the fibrotic changes in this phase lead to permanent structural alterations in cardiac tissue.

Clinical Implications and Disease Patterns

Rheumatic heart disease often follows a relapsing-remitting pattern, with multiple phases occurring simultaneously in different parts of the body. Exudative lesions dominate in joints and the pericardium, explaining the common symptoms of arthritis and pericarditis. In contrast, fibrosis remains localized to cardiac structures, particularly the valves, leading to long-term complications such as valvular stenosis or regurgitation.

Understanding these three developmental phases is essential for clinicians managing pregnant women with rheumatic heart disease. Early diagnosis and appropriate intervention can significantly improve maternal and fetal outcomes, making this knowledge crucial in prenatal care settings.