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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 6, November/December 2018
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AFRICA
converted to either low-molecular-weight heparin (LMWH) or
unfractionated heparin (UFH). Delivery is usually planned to
allow a UFH infusion to be started 36 hours prior to induction/
Caesarean section, and to be discontinued six hours before
planned delivery. If there are no bleeding complications during
the delivery, then, according to common practice, the UFH
infusion is usually restarted four to six hours after delivery.
However, this is not evidence-based practice and needs more
research. In the case of significant vaginal tears, haematoma or
postpartum haemorrhage (PPH), a later start of heparin could
be considered, depending on the clinical situation and the risk of
valve thrombosis (higher risk for mitral position).
Caesarean delivery could be considered in a number of case
scenarios, for example for patients with valvular lesions presenting
in pre-term labour on oral anticoagulants, in patients with
symptomatic severe stenotic lesions (aortic or mitral stenosis), or
in the presence of an ascending aorta
>
45 mm, severe pulmonary
hypertension or acute heart failure.
25
If an emergency delivery
must be carried out while the patient is taking warfarin, then a
Caesarean section should be performed under general anaesthetic,
with fresh frozen plasma cover and prothrombin complex
concentrate added if necessary, to reverse anticoagulation.
Peripartum and postpartum obstetric complications are
more common in patients with valvular heart disease and can
include PPH, defined as blood loss
>
500 ml (vaginal delivery) or
>
1 000 ml (Caesarian section), which require transfusion or are
accompanied by a drop in haemoglobin
>
2.0 g/l. Ergometrine
is relatively contra-indicated due to its effects on blood pressure
and the potential to cause coronary artery spasm. Oxytocin
can also have adverse effects, inducing vasodilatation in the
subcutaneous vessels, and vasoconstriction in the splanchnic
bed and coronary arteries. The direct effect on cardiac receptors
increases heart rate, with the overall effect of hypotension,
tachycardia and myocardial ischaemia.
60,61
If a PPH does occur,
oxytocin should be given and prostaglandins are generally well
tolerated, but early intervention is key to keeping control of the
situation. One should use mechanical approaches, including an
intra-uterine balloon and uterine compression sutures.
Infective endocarditis is rare in pregnancy in patients with
valvular lesions, and has been reported with an incidence of
0.5%.
47
Endocarditis prophylaxis is recommended for high-
risk patients (prosthetic valve) with high-risk procedures,
such as dental procedures. During delivery, the indication
is controversial and at present antibiotic prophylaxis is not
routinely recommended for vaginal or Caesarian delivery.
62
However, in our practice, we use prophylaxis with any mode of
delivery other than an uncomplicated vaginal delivery, especially
in patients with a mechanical valve.
The need for integrated and responsive health
systems
Understanding the clinical interventions and requirements is
crucial, but due consideration must be given as to how these
interventions can and should be supported in health system
contexts of resource-poor settings, as is the case in many of the
LMICs. A very important consideration is how cardiovascular
requirements for women with RHD are integrated with sexual
and reproductive health (SRH) and general cardiovascular and
other relevant services.
In general, the current high adolescent fertility rates mean
that almost one-fifth of women in Africa have an unmet need
for family planning.
63
This points to a general challenge with
access to SRH services, including young women at risk of or with
established RHD. In a recent study in school-going children in
South Africa and Ethiopia, the odds of having asymptomatic
RHD increased with worsening socio-economic circumstances
and the condition affected predominantly girls. Therefore
young women, particularly those living in poverty, may present
with undetected disease to reproductive health services for
contraception and obstetric care.
64
This confirms the need for
an integrated and responsive health system, so as to enable the
identification, treatment and follow-up support of women with
RHD, in particular young women of reproductive age.
Global efforts to develop health systems that are resilient,
responsive and able to meet the multiple needs of health
service users include the development of sound maternal
and reproductive health services, particularly considering the
unfinished millennium development goals agenda, which strongly
emphasised maternal health and the reduction of maternal
mortality rates. This unfinished agenda is now incorporated into
the sustainable development goals, in particular goals 3, 4 and 5,
which speak to equitable development to promote healthy lives
for women and girls.
28
Women with RHD require a continuum of care, from
prevention of the disease, which involves addressing the social
determinants of health; to interventions at primary care level
following a
Streptococcus
group A sore throat, including the
necessary long-term follow up; through to first diagnosis of
rheumatic fever in childhood and subsequent follow up and
support in their schooling, adolescence and young adulthood;
through their reproductive years and into later adulthood.
In their reproductive years, the school setting and primary
level health facilities (with reproductive and obstetric health
services) become crucial sites for care and support. Therefore
SRH services must be equipped to diagnose women who have
undetected RHD, provide secondary prophylaxis after rheumatic
fever, treat symptomatic RHD, and provide sexual healthcare,
contraceptive care, and antenatal, obstetric and postnatal care.
Since health systems across Africa are subject to significant
stressors, the development of a pro-active service response to this
demand poses an ongoing challenge. However, with appropriate
protocols and interventions to enable good antenatal, obstetric
and postnatal care, some settings have reduced bad outcomes
to a minimum.
65
The major gaps in access to SRH described for
women in SSA apply to those with RHD and call for innovative
approaches to improve the current situation in this high-risk
group of people.
School-based reproductive health services
The school setting is the place where children and adolescents
can be: alerted to the importance of seeking care for a strep
sore throat; sensitised to the symptoms and signs of rheumatic
heart disease; exposed to counselling and support if they are
on penicillin prophylaxis; and targeted for appropriate sexual
health education and contraceptive provisioning. School health
services must be linked to the appropriate primary level services,
including SRH services, to provide a comprehensive continuum
of care.