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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 2, March/April 2016
116
AFRICA
Antenatal and obstetric care
Antenatal care plans should be dependent on the risk
stratification.
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Women in WHO class I have a very low risk
and cardiology follow up during pregnancy can be limited to
one or two visits. Women in WHO class II are deemed to be
low or moderate risk and follow up once during each trimester
of pregnancy is recommended. Women in WHO class III are
high risk with an increased risk of complications. These women
should be followed up at least monthly, then increasing to
twice a month during the latter stages of pregnancy. Women
in WHO class IV are extremely high risk. In these women,
pregnancy is considered contra-indicated but if they do fall
pregnant and decline termination of pregnancy, these women
should have close cardiology follow up monthly if not twice
monthly. In addition, factors that may contribute to cardiac
decompensation, such as anaemia, infections, arrhythmias,
hypertension and hyperthyroidism should be actively sought so
they may be avoided or corrected.
34,51
The foetal baseline scan, 13-week nuchal translucency scan
and 20-week foetal anomaly scan should all be done routinely,
with an extra emphasis given to excluding cardiac disease in
the foetus. Growth scans should be performed as obstetrically
indicated but in addition, those women with severe cardiac
disease, cyanotic congenital heart disease or on medications
known to cause growth restriction should have serial growth
scans to detect foetal growth restriction.
The combined cardiac and antenatal clinic visits are the
time when decisions regarding timing and mode of delivery,
and the analgesic and anaesthesia options available are
discussed and preferences are documented. Cardiac monitoring,
antibiotic prophylaxis and thromboprophylaxis will need to be
individualised. The entire team, including the patient, should be
involved in the decision-making process.
In general, vaginal delivery with a short second stage and
good analgesia is the preferred option. Caesarean section
increases the risk of haemorrhage, postpartum sepsis and
thrombo-embolic disease. Blood loss should be minimised at all
costs and blood should be replaced promptly. Operative delivery
should be limited to those patients with obstetric indications and
very specific cardiac conditions.
34,51
Specific management for specific lesions
Stenotic valve diseases carry a higher risk of maternal and foetal
complications than regurgitant lesions. Patients with MS, even
when asymptomatic, should be advised against pregnancy and
interventions should be performed prior to pregnancy. In those
patients who continue the pregnancy, there should be monthly
follow up. When symptoms or pulmonary hypertension develop,
activity should be restricted and beta-1 selective blockers should
be commenced. Low-dose diuretics can be added if symptoms
persist. Therapeutic anticoagulation is recommended in patients
with atrial AF or those with documented left atrial thrombosis
and should also be considered in those with a large left atrium
on echocardiography.
Vaginal delivery is the preferred method of delivery in
mild, moderate or severe MS with NYHA class I/II with no
pulmonary hypertension. Caesarean section can be considered
in those patients with moderate or severe MS, with NYHA
class III/IV or who have pulmonary hypertension refractory to
medical therapy.
Aortic stenosis, if asymptomatic, or mild or moderate disease
in pregnancy is well tolerated. Of note though is that patients
with severe AS may be asymptomatic, and echocardiography
is important for this diagnosis. All symptomatic patients with
severe AS or even asymptomatic patients with reduced left
ventricular function should be counselled against pregnancy
and in these patients, surgery should be performed first. In those
patients who continue the pregnancy, regular monthly follow up
with echocardiography is recommended. In those patients with
worsening symptoms, diuretic therapy can be administered. A
beta-blocker or calcium channel antagonist can be initiated for
rate control in AF, and where both of these are contra-indicated,
digoxin may be considered.
In non-severe AS, vaginal delivery is preferred so as to
avoid the decrease in peripheral vascular resistance during
regional anaesthesia and analgesia. In patients with severe AS,
particularly those who are symptomatic, caesarean section is
advocated with endotracheal intubation and general anaesthesia.
Regurgitant valve disease carries a lower risk for poor
maternal and foetal outcomes than stenotic lesions. Maternal
risk is dependent on the severity of the regurgitation symptoms
and left ventricular function.
Those patients with severe disease and symptoms, or impaired
left ventricular function should be advised to have surgery prior
to pregnancy. In those who continue with the pregnancy, close
follow up on a monthly basis is recommended. Medical therapy
Table 5.WHO class IV
• Pulmonary arterial hypertension of any cause
• Severe systemic ventricular dysfunction (LVEF < 30%, NYHA III–IV)
• Previous peripartum cardiomyopathy with any residual impairment of
left ventricular function
• Severe mitral stenosis, severe symptomatic aortic stenosis
• Marfan syndrome with aorta dilated > 45 mm
• Aortic dilation > 50 mm in aortic disease associated with bicuspid aortic
valve
• Native severe coarctation
Table 4.WHO class II and III
WHO II (if otherwise well and uncomplicated)
• Unoperated atrial or ventricular septal defect
• Repaired tetralogy of Fallot
• Most arrhthmias
WHO II–III (depending on individual)
• Mild left ventricular impairment
• Hypertrophic cardiomyopathy
• Native or tissue valvular heart disease not considered WHO I or IV
• Marfan syndrom without aortic dilatation
• Aorta < 45 mm in aortic disease associated with bicuspid aortic valve
• Repaired coarctation
WHO III
• Mechanical valve
• Systemic right ventricle
• Fontan circulation
• Cyanotic heart disease (unrepaired)
• Other complex congenital heart disease
• Aortic dilatation 40–45 mm in Marfan syndrome
• Aortic dilatation 45–50 mm in aortic disease associated with bicuspid
aortic valve