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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 6, November/December 2018
398
AFRICA
Surgery
There is a growing array of repair procedures aimed at preserving
the patient’s own heart valves.
25,38,39
They can be used during
pregnancy and as an emergency intervention.
25,40-44
The different
risk and benefit profiles of bioprostheses and mechanical valves
with regard to valve haemodynamics, durability, incidence of
thrombotic events, need for anticoagulation, and impact on
foetal outcome must be considered in women of childbearing
age.
45-47
The type of operation for the treatment of mitral valve
disease and the decision to preserve the native valve have been
determined mainly by the surgeon’s skill to perform mitral repair
or commissurotomy, which are the interventions of choice in
young women. PMD and repair need pliable valves that are
not heavily calcified. Limited data are available on pregnancy
outcomes in women with aortic homographs and aortic valve
repair (David’s operation), as well on those who have had the
Ross procedure.
The Ross procedure is a complex operation that involves
removal of the patient’s own pulmonary valve and pulmonary
artery, which is then used to replace the diseased aortic valve, with
re-implantation of the coronary arteries into the graft, as well as
the insertion of a human homograft into the pulmonary artery.
This procedure can provide an excellent haemodynamic result,
with the added benefit that the valves are not thrombogenic.
However, the procedure is difficult and seldom performed. The
reported pregnancies had an overall good maternal and foetal
outcome.
48,49
In general, there is very limited access for young females in
LMICs to procedures such as mitral and aortic valve repair,
aortic homograft insertion and the Ross procedure. This is due to
the complexity of the surgery, limited resources and considerably
fewer surgeons available in most endemic areas.
Contraception
Health professionals in Africa should adopt a pro-active attitude
to holistically address the reproductive and cardiovascular
health needs of women with RHD. Owing to the high risk
associated with pregnancy, these women should be prioritised
for appropriate contraceptive advice.
39,50
Patients with moderate
mitral stenosis and a dilated left atrium have an increased risk
of stroke during pregnancy, and this should be openly discussed
with them prior to conception.
50
Women of childbearing age with
severe mitral stenosis should be prioritised for family planning
advice, since they have an extremely high risk of morbidity and
mortality. When pregnancy is strongly desired, PMD and/or
surgery should be considered.
51
Contraceptive counselling should consider factors such as
the known risk of pregnancy for the women, the risks of a
given contraceptive method (failure rates and availability),
the individual’s preferences, protection against infections, and
costs. Since there are no studies performed in women with
RHD to investigate the relative risks and benefits of different
contraceptive methods,
25,52
and no studies on contraceptive
devices have been performed in these women, the relative risks
and benefits of different contraceptive methods are based on
consensus only. Input may be necessary from all specialists
involved in care to select the best method.
Fig. 2 summarises the most commonly recommended
contraceptives. As women with mitral stenosis, mechanical valve
prostheses and/or left ventricular dysfunction are at a substantial
risk of thrombo-embolic events, hormonal contraceptives with
a pro-thrombotic effect should be avoided. The risk of venous
thrombosis is significantly increased (up to seven-fold) by
the oestrogen component in oral contraceptives, irrespective
of the type of progestin used.
53
Oestrogen-containing oral
contraceptives also increase the risk of arterial thrombosis
and hypertension.
54
The most effective types of contraceptives
are the long-acting reversible forms, including intra-uterine
contraceptive devices or progesterone cutaneous implants. The
progestogen (etonogestrel) implant has no cardiac effects, is
effective and has fewer side effects compared to other implants.
25
The new progesterone-releasing intra-uterine systems for long-
acting contraception are now preferred to the older copper
intra-uterine device.
55
Pre-conception evaluation
Ideally, pre-conception evaluation and advice on risk prediction
should be given to all women with RHD when pregnancy is
planned.
52
Pre-conception evaluation usually includes a careful
history, detailed physical examination, electrocardiogram and
cardiac ultrasound,
50
but an exercise test may be considered for
objective assessment of functional classification (Table 1). The
type of lesion, presence of impaired left ventricular function,
and need for anticoagulation are among the issues that need to
be addressed when anticipating pregnancy.
56
Particular attention must be given to a woman with
prosthetic heart valves wanting to fall pregnant. The choices of
anticoagulation therapy (e.g. heparin, warfarin or enoxaparin)
during pregnancy must be discussed, with a clear plan to prevent
complications and mortality. Severe symptomatic valve disease
should be corrected prior to pregnancy, because cardiac surgery
during pregnancy carries high risks for the foetus.
52
Pre-natal care
For optimal cardiac and obstetric care, high-risk pregnant
patients with RHD should preferably be cared for in centres
with expertise and availability of diagnostic and therapeutic
options.
25
Pregnant women with known or suspected RHD often
DMPA: Depomedroxyprogesterone acetate.
Contraception (Male)
• Condom
• Vasectomy
Contraception (Female)
• Oral contraceptive (combined or progestin only pills)
• DMPA injections
• Tubal ligation
• Diaphragm
• Contraceptive implants*
• Contraceptive patch
• Hysteroscopic tubal occlusion (HTO)
• Intrauterine contraceptive device
(e.g. Mirena or copper IUCDs)*
• Vaginal ring
• Safe period
Fig. 2.
Type of contraceptives that can be used by females
and males, indicating the most recommended.