CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 6, November/December 2022 AFRICA 327 A basic unit protocol for anticoagulation in pregnant women with MHV provides a good basis to direct management and provide women with the best available options. These recommendations can be adjusted to suit patient preferences if safe to do so, and to guide treatment in cases where patient risk may be complicated by other co-morbid conditions. The unit protocol is an effective tool but is not limited; instead, individual patient preferences after full counselling, past medical history, the background history of the valvular pathology and complications associated with valve replacement (such as history of stuck valves or TEC in the past) are all considered before a regimen is chosen. Conclusion It is evident that there are significant gaps in the literature. The current body of evidence is lacking and requires closer scrutiny to provide these women with the best evidence-based approach. However, there is a wealth of knowledge in the form of expert opinion dealing with these cases. This highlights the need to incorporate scientific research into our clinical practice through formal studies or audits, retrospective reviews and/or prospective ongoing collection of new data. Pregnant women with prosthetic valves represent a vulnerable group at risk for significant morbidity and mortality. When deciding on anticoagulation regimens, the balance between maternal and foetal benefit needs to be questioned throughout the management of these women. Furthermore, all risks and benefits must be carefully explained to ensure shared decision making. The above guideline recommendations are based on consensus statements from expert opinion or based on small retrospective studies or registries. Overall data in pregnancy are limited and there is an urgent need for more prospective studies to guide current practice. Key message • The current evidence is lacking • The primary valvular pathology, valve type and position are not adequately documented • This is of importance in SSA where the incidence of RHD is much higher in comparison to congenital heart disease • More data are needed on the use of dose-adjusted LMWH in terms of maternal risks • For LMWH, the importance of measuring peak levels versus trough versus both needs closer review • There are sparse data on the recommendation for use of lowdose aspirin • The use of low-dose warfarin < 5 mg needs to be explored further • Post-partum complications are not well documented as a result of a lack of conformity on definitions • A prospective study is urgently needed to bridge this current gap • The authors plan to do a retrospective chart review and a threeyear prospective study focusing on the above References 1. Steinberg ZL, Dominguez-Islas CP, Otto CM, Stout KK. 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Anticoagulation management for pregnant women withmechanical heart valves. University of Washington Obstetric Consensus Conference, September 2018. Maternal complications 1. TEC 2. Anthythmia 3. Congestive cardiac failure 4. Bleeding 5. Post-partum haemorrhage 6. Haematoma 7. Infective endocarditis 8. Ischaemic events 9. Valve dysfunction 10. Death Foetal/neonatal complications 1. Miscarriage 2. Termination of pregnancy 3. Stillbirth 4. Warfarin embryopathy/ foetopathy 5. Foetal growth restriction 6. Small for gestational age 7. Prematurity 8. Low birth weight Obstetric adverse events 1. Pre-eclampsia 2. Gestational diabetes mellitus 3. Antepartum haemorrhage 4. Preterm labour 5. Premature rupture of membranes Fig. 6. Complications that can occur in the antenatal and peripartum periods.
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