Background. The incidence of rheumatic fever (RF) and its complications has waned over the past three to four decades throughout the Western world, but RF remains a problem in developing countries and in the indigenous populations of some well-resourced countries. A marked decline in children presenting with acute rheumatic fever (ARF) and chronic rheumatic heart disease (RHD) has been observed over the past two decades at Chris Hani Baragwanath Academic Hospital (CHBAH) in southern Gauteng Province, South Africa, which mainly serves the peri-urban population of Soweto.
Objectives. To analyse the observed decline in ARF and RHD, and consider the reasons for the decrease.
Methods. Review of children with ARF and RHD captured on a computerised database of all children seen in the Paediatric Cardiology Unit at CHBAH during 1993 - 2010.
Results. The records of 467 children with ARF and RHD were retrieved from the database. The majority provided addresses in Gauteng, Soweto and North West Province. The number of children documented to have ARF or RHD declined from 64 in 1993 to 3 in 2010. One-third of the patients underwent surgery, the majority mitral valve repair. Most of the patients requiring surgery had addresses in parts of Gauteng other than Soweto and other provinces, with relatively few originating from Soweto.
Conclusion. The decline in the number of children with ARF and RHD presenting to CHBAH may be attributed to an improvement in socioeconomic conditions and better access to medical care for the referral population over the past two decades.
'The health of mothers and their children is the key to achieving development and equity' - Deputy President Cyril Ramaphosa at the World Health Organization (WHO)'s Partnership for Maternal, Newborn and Child Health Forum held in Johannesburg during July 2014. Indeed, the health and economic status of women and children usually provide an accurate overview of national viability.
Medical problems account for almost 50% of all maternal deaths in South Africa. The most recent report of the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) (2008 - 2010) stated that 40.5% of deaths were due to non-pregnancy-related infections, which are mostly HIV-related, and 8.8% were due to medical or surgical disorders.
Obstetric physicians have a specific role in managing pregnant and postpartum women with medical problems and, in partnership with obstetricians, can contribute to reducing maternal morbidity and mortality. There are physiological changes in almost all systems in pregnancy. For example, changes in the cardiovascular, respiratory and haematological systems are particularly important when assessing the cause and management of medical problems in pregnant women. Such problems may be unique to pregnancy, exacerbated by pregnancy, or unrelated to pregnancy. They may be present prior to pregnancy, or present for the first time in pregnancy. Some medical problems are worsened by pregnancy. Pregnant women may improve or remain stable, or their disease may predictably or unpredictably deteriorate.
This article discusses the role of obstetric physicians in managing medical problems in pregnant women. A case is described of a pregnant woman with common medical problems, resulting in a serious complication when treatment is interrupted.
As Head of Undergraduate Education in the Department of Obstetrics and Gynaecology at the University of Cape Town, South Africa, I have a particular interest in the competencies needed to perform primary care gynaecological procedures, one of which is the Pap smear. I was approached by a group of keen volunteer students to assist with Pap smear training to roll out a pilot screening programme at student-run after-hours clinics in Cape Town and at volunteer rural health promotion clinics. This article describes a novel approach to teaching the Pap smear technique, using fruit and toilet rolls, which can easily be replicated in resource-constrained areas. Students branded the workshops as 'Papshops', and the name has stuck. Increasing numbers of students are now taught by peers already trained in prior Papshops, thereby expanding the teaching workforce. To date, during 2013 - 2014, Papshop students have performed almost 300 Pap smears for eligible women in under-resourced areas.
Medical disorders in pregnancy are one of the top five causes of maternal mortality in South Africa (SA), cardiac disease (CD) being the main contributor to this group. In developed countries, surgically corrected congenital heart disease (CHD) comprises the greater proportion of maternal deaths from CD. In SA and other developing countries, acquired heart disease such as rheumatic heart disease and cardiomyopathies are the major causes, although CHD remains significantly represented.
Both congenital and acquired cardiac lesions may present for the first time during pregnancy. CD may also occur for the first time during or after pregnancy, e.g. peripartum cardiomyopathy. The risk to both the mother and the fetus increases exponentially with the complexity of the underlying disease. Generally, the ability to tolerate a pregnancy is related to: (i) the haemodynamic significance of any lesion; (ii) the functional class - New York Heart Association classes III and IV have poorer outcomes; (iii) the presence of cyanosis; and (iv) the presence of pulmonary hypertension. While the ideal time to assess these factors is before conception, women frequently present when already pregnant. This review discusses risk assessment and management of CD in pregnant women and the role of a combined cardiology and obstetric clinic.
Renal disease in pregnancy may cause a feeling of trepidation, even in the most experienced physician. However, before disease can be established, it is important to understand the substantial physiological changes that may occur during a normal pregnancy. Renal disease may take several forms and pregnancy may be the first medical review for women with a previously undiagnosed renal problem. Patients may have pre-existing renal disease, e.g. diabetic nephropathy. Additionally, women with renal transplants and renal diseases, e.g. lupus nephritis, require immunosuppression. Hypertensive disorders of pregnancy, including pre-eclampsia, are the commonest medical complications in pregnancy, and remain the most prevailing direct cause of maternal mortality in South Africa (SA). Both pre-existing hypertension and renal disease increase the risk of pre-eclampsia, which predisposes to preterm delivery, and maternal morbidity and mortality.
Pregnancy outcomes in renal disease are determined by baseline creatinine levels, hypertension and degree of proteinuria. The risk of progression of chronic kidney disease increases as renal function worsens. In SA, this is complicated by restricted access to dialysis in the state sector. To ensure the best outcome for mother and child, pre-pregnancy counselling and review of medication are essential. Renal patients and those with hypertension are at high risk of complications, and regular antenatal assessments by a multidisciplinary team are required to monitor blood pressure, proteinuria, diabetes control and fetal wellbeing.
Rheumatic diseases predominantly affect young women of childbearing age; therefore pregnancy is a topic of major interest. Pregnancy-induced changes in immune function can have an effect on underlying disease activity. Systemic lupus erythematosus (SLE), the most common autoimmune disease affecting women during their reproductive years, has an increased incidence of disease flares during pregnancy. In rheumatoid arthritis, on the other hand, there is spontaneous improvement in disease symptoms. However, rheumatic diseases and their treatment can have a significant impact on pregnancy outcomes. Poor pregnancy outcomes are largely associated with high disease activity. Pregnant women with rheumatic diseases constitute a high-risk population, with potential adverse fetal and maternal outcomes. Treatment options can be limited in pregnant women owing to concerns about the adverse effects of commonly used medication on the fetus. The aim of this article is to discuss the optimal management of pregnant women with SLE and other rheumatic diseases, including antiphospholipid antibody syndrome, Sjögren's syndrome, systemic sclerosis, rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. The effects of pregnancy on underlying diseases and vice versa are discussed.
Contraception and fertility planning should form part of every consultation, as it is key to reducing maternal mortality and morbidity associated with unplanned pregnancy. It also prevents pregnancy in women who are medically unfit for pregnancy until their condition has been optimised. This is only the tip of the iceberg compared with the social and economic burden of unintended pregnancy. The South African (SA) National Department of Health has recognised the importance of contraception and fertility planning. A national policy and guideline have been formulated that promote this agenda. In the past, the commonest contraceptives used in SA were the combined oral contraceptive and the injectable contraceptive. Long-acting reversible contraceptives (LARCs) offer the most benefit, and have efficacy comparable to permanent contraception. Their failure rates are the same for typical and perfect use. In addition, continuation rates after one year of use remain high. The intrauterine contraceptive device, the levonorgestrel intrauterine system and the injectable progestogen contraceptives form part of this group of contraceptives. The most recently launched LARC is Implanon NXT. A comprehensive guideline to assess suitability of the various contraceptive methods in various medical conditions is the World Health Organization Medical Eligibility Criteria for contraceptive use. Counselling is key to choice and suitability of contraceptive methods. Compliance, in part, is dependent on adequate discussion of side-effects, availability and acceptance of the method.