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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 2, March/April 2016
82
AFRICA
The evaluation of a woman with rheumatic heart disease
prior to pregnancy should include taking a careful history and
performing a detailed physical examination, 12-lead ECG and
comprehensive echocardiogram, which should focus on the
degree of left-sided valvular obstruction and systolic function.
Finally, careful counselling to address both the general points of
PCC and the specific risks of pregnancy (including the risk of
miscarriage, early delivery, foetal losses and small for-gestational-
age babies) should be paramount in this population.
Hypertension
Blood pressure (BP) control before pregnancy should improve
the effects of chronic hypertension on pregnancy outcomes. The
weight of evidence indicates that chronically hypertensive women
are at a higher risk of developing complications. Specific anti-
hypertensive agents used by the chronically hypertensive woman
should be titrated, discontinued or changed to other agents,
in order to optimise her BP prior to pregnancy. Angiotensin
converting enzyme inhibitors (ACEIs) and angiotensin receptor
blockers (ARBs) are contra-indicated during pregnancy and
must be discontinued when pregnancy is being planned.
29-32
Whenever possible, pre-pregnancy BP should be normalised
with lifestyle changes before pregnancy. These comprise: dietary
changes (low-salt intake, increased intake of fresh fruits and
vegetables), healthy weight modification to avoid obesity, and
adherence to anti-hypertensive medications, which should
improve health and pregnancy outcomes. When ACEIs or ARBs
are discontinued before initiating a pregnancy, they could be
replaced with other medications, e.g. hydralazine, alpha-methyl-
dopa, nifedipine, diltiazem, labetalol or clonidine, if the benefits
of the chosen drug outweigh its risks.
HIV/AIDS
HIV/AIDS is a major public health concern and cause of death
in many parts of Africa. The worst HIV/AIDS-affected people
live in sub-Saharan Africa (SSA); 69% of all people living with
HIV and 70% of all AIDS-related deaths in 2012 were from
SSA,
33
which had approximately 1.6 million new HIV infections
and approximately 1.2 million AIDS-related deaths.
Globally, AIDS-related illnesses are the leading cause of death
among childbearing women. SSA women are disproportionally
affected; the percentage of those aged 15–24 years living with
HIV is twice that of young men.
34
HIV-infected women have
many HIV-related medical and psychosocial issues, which may
increase the risks of adverse HIV-pregnancy outcomes, perinatal
and sexual transmission. While advances in HIV treatment
and perinatal transmission have resulted in prolonged survival,
improved quality of life and an increased number of pregnancies,
PPC is required to optimise management to improve perinatal
outcomes and minimise transmission risks (Table 2).
Key objectives for HIV/AIDS-related PPC are necessary.
Firstly, maximal viral suppression should be achieved before
conception. Detectable HIV plasma viral loads (PVL) and lack
of effective antiretroviral treatment (ART) are associated with
increased perinatal and sexual transmission.
35
Furthermore,
uncontrolled viral replication and non-adherence to ART cause
viral resistance and overt disease. Sustaining high levels of
adherence to ART with maximal viral suppression challenges
resource-limited SSA, yet several programmes have demonstrated
achievability.
36
Secondly, PPC should explore the fertility desires of
serodiscordant couples and offer options for safer conception.
Early patient–provider communication about fertility goals could
decrease peri-conception risks to HIV-uninfected partners.
37
Although PPC is usually directed at women, exploring fertility
goals with HIV-positive men in serodiscordant relationships
could decrease peri-conceptional seroconversion in women.
35
Exploring contraception needs informed, educated, reversible
and irreversible contraception choices.
38
An HIV-positive woman
with excellent disease control and fertility control (reversible
contraception) could have a healthy child at an optimal time, while
preventing HIV transmission to her sexual partner and child.
Thirdly, PPC facilitates the appropriate choice of ART
regimens. WHO guidelines recommend prescribing the same
group of drugs to HIV-infected pregnant and non-pregnant
women.
39
Efavirenz has been associated with an increased risk
of teratogenicity in recent studies conducted among infants
exposed to efavirenz-containing regimens,
40
however, WHO
guidelines recommend the use of efavirenz as first-line therapy.
41
Finally, PPC allows the assessment of common HIV-related
co-morbidities before pregnancy, e.g. cardiovascular, kidney
and liver diseases, cognitive dysfunction and mental health,
42
malignancies and metabolic bone disease, and infections (viral
hepatitis, HPV).
39
A comprehensive assessment of metabolic
and mental capacity before conception would improve general
health-related outcomes (Table 1).
Conclusion
Providing PPC in Africa is challenging at best. Due to the
complexities barring access to PPC, the task of providing
such care should be shared corporately among all healthcare
providers who may have any appreciable encounter with women
of childbearing age. There should be a concerted effort to
position PCC as a public health intervention for maternal and
child health, and it should aim at improving the general health
status of women beyond perinatal care.
Public health educational campaigns should target at-risk
groups to discuss the importance of reducing adverse pregnancy
outcomes in order to optimise PPC. Beneficiaries and indirect
stakeholders of the advantages of improved pregnancy outcomes
should endeavour to provide cost-efficient and cost-effective
PPC, within their resource-challenged settings, towards the
reduction of maternal morbidity and mortality rates.
There is a clear need for research into PPC in African
countries, particularly to explore novel and innovative ways
to deliver PPC within existing traditional maternal and health
programmes. We call on all cardiac professionals to integrate
PCC into their standard of practice in order to improve
pregnancy outcomes for their patients.
References
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