Outcomes in pregnant women with valvular heart disease from sub Saharan Africa transferred to a developed nation. A distinct care model

Background

Pregnant women with valvular heart disease (VHD) in African countries still bear a disproportionate burden of maternal morbidity and mortality, due to the reduced accessibility to health care and the scarcity of skilled professionals. It is unclear if outcomes would be improved by care-delivery model changes.

Purpose

We performed a clinical audit of African pregnant women with VHD who were transferred for their care from five countries to our cardio-obstetrics unit, during a twenty-year period, through a memorandum of agreement of international cooperation.

Methods

A retrospective analysis of 81 pregnancies (P) in 45 African women with VHD (median age 24, IQR 22–29 years) from 2001 to 2020. The main outcome measures were major maternal complications and perinatal outcome.

Results

History of rheumatic heart disease was determined in 74.1% of the P. Most women were in NHYA I or II before P (79.0%), 43.2% had previous cardiac medication and 60.5% were anticoagulated (33.3% with acenocoumarol and 27.2% with warfarin). 59.3% of P had at least one valvular prosthesis, including 38 mechanical prosthetic valve (MPV) and 10 biological valves. 22.2% had prior surgical or percutaneous VHD correction, excluding prosthesis implantation. At baseline, impaired left ventricular ejection fraction was found in 12.3%. Previous arrhythmic event, stroke or infectious endocarditis were found in 12.3%, 8.6% and 6.2% of P, respectively.

During P, deterioration in NYHA functional class occurred in 42.0% and 9.9% required initiation or intensified cardiac medication. For MPV, 51% maintained a vitamin K antagonist, 15.7% used LMWH from 6 to 12th weeks and 9.8% used LMWH throughout P. Valve thrombosis occurred in 4 women (4.9% of P), with one maternal death in a patient with double MPV.

Hemorrhagic complications happened in 8.6% of P, all anticoagulated, in immediate postpartum or puerperal period. The 81 P resulted in 56 live births (69.1%), with a medium birth weight of 3026±471g. Delivery by caesarean section was performed in 28.3% of newborns. The incidence of miscarriage was 23.5% and fetal malformations occurred in 14.8%, with warfarin embryopathy in 4 cases. In univariate analysis, the presence of valvular protheses (p=0.001), and anticoagulation (p=0.001) were related to unsuccessful P. In multivariate analysis, VKA therapy was the unique independent predictor of unsuccessful P (p=0.048).

Conclusion

With the multidisciplinary care provided, pregnancy was relatively well tolerated and successful for women transferred from sub–Saharan Africa. However, the presence of a valvular prothesis is associated with unsuccessful pregnancy even in a developed nation. Efforts other than the implantation of a MPV should be pursued vigorously in sub Saharan Africa.

Funding Acknowledgement

Type of funding sources: None.

Mid-term post-fire losses of nitrogen and phosphorus by overland flow in two contrasting eucalypt stands in north-central Portugal

Wildfires affect vast areas of Mediterranean forests, thereby triggering changes in hydrological and geomorphological processes that can negatively affect both terrestrial and aquatic ecosystems. Although several studies have evaluated the post-fire hydrological and erosive response in burnt forest areas, an important knowledge gap remains with respect to nutrient mobilization by overland flow. To address this gap, a recently burnt area was selected near the Ermida village (north-central Portugal). The study area was instrumented shortly after a wildfire that occurred in July 2010, to evaluate the export of dissolved (nitrate - NO₃-N and orthophosphate - PO₄-P) and total nitrogen (TN) and phosphorus (TP) forms by overland flow. This was done in two burnt eucalyptus plantations due to their contrasting slope aspects (south-east vs. north-west). Bounded micro-plots were installed in August 2010 and monitored over two years. During this period, overland flow samples were collected on a 1- to 2-weekly basis, depending on the occurrence of rain. Results showed that the north west-facing slope (BE-N) presented higher nutrient losses than the south east-facing slope (BE-S), contradicting the findings of previous studies in the Mediterranean region. A logging operation that had taken place at the BE-N site shortly before the fire might account for these findings, by causing soil compaction and/or reducing the protective vegetation and litter cover. TN and TP exports were particularly pronounced during the first four months following the wildfire. After this initial period, further peaks in TN and TP exports occurred sporadically, mainly associated to intense rainfall events. The observed mid-term post-fire nutrient losses not only suggested a threat to the soil nutrient balance of Mediterranean eucalypt forests but also a potential risk of eutrophication of downstream water bodies.

Performance of Iris pseudacorus and Typha domingensis for furosemide removal in a hydroponic system

The potential of Iris pseudacorus and Typha domingensis to remove the pharmaceutical active compound (PhAC) Furosemide from a nutrient solution was assessed. Both plants were exposed to 2 mg L^-1 of furosemide during 21 days and the removal of furosemide was monitored. Vessels without furosemide were also implemented as control systems for plants development. Likewise, unplanted vessels with furosemide were employed to assess abiotic removal mechanisms. All vessels were covered with aluminum foil to avoid photodegradation of the compound. Both plants showed potential to remove Furosemide, attaining, at the end of the experiment, a removal of 42.0-66.9% and 40.5-57.8%, for Typha and Iris, respectively. The plants do not presented a visible negative stress response to the exposure to furosemide, having a positive growth rate at the end of the experiment. Biodegradation seems to play an important role in furosemide removal, being enhanced by the presence of the plants. The two macrophytes presented different removal behaviors, particularly in the first 48 h of contact time. FUR removal by Iris follows a pseudo-first order while by Typha is divide in different phases. These results indicate that different plants species seem to have different mechanisms to remove pollutants from water.HighlightsPhACs removal potential of Iris pseudacorus and Typha domingensis was assessed.Plants were exposed to 2 mg L^-1 of furosemide during 21 days.Both macrophytes showed good removal efficiencies.Biodegradation of furosemide seems to be the main removal mechanism.Plants demonstrated different removal behavior along the experiment.Removal mechanisms of plants seem to differ between species.

Furosemide removal in constructed wetlands: Comparative efficiency of LECA and Cork granulates as support matrix

The removal efficiency of LECA and cork granulates as support matrix for pharmaceuticals active compounds in a constructed wetland system was investigated using the diuretic drug Furosemide. Kinetics studies were performed testing three different concentrations of Furosemide in an ultrapure water matrix, along seven days. LECA achieved higher removal values compared to cork granulates. However, cork granulates presented a higher removal in the first 24 h of contact time compared to the other adsorbent. The kinetic studies showed that LECA and cork granulates have different adsorption behaviours for Furosemide which is controlled by different adsorption mechanisms. Both materials showed good removal efficiencies and a combination of the two should be further explored in order to applied both materials as support matrix to cope with different furosemide concentrations.

Overview of the state of the art of constructed wetlands for decentralized wastewater management in Brazil

Conventional wastewater treatment plants (WWTPs) commonly require large capital investments as well as operation and maintenance costs. Constructed wetlands (CWs) appear as a cost-effective treatment, since they can remove a broad range of contaminants by a combination of physical, chemical and biological processes with a low cost. Therefore, CWs can be successfully applied for decentralized wastewater treatment in regions with low population density and/or with large land availability as Brazil. The present work provides a review of thirty nine studies developed on CWs implemented in Brazil to remove wastewater contaminants. Brazil current sanitation data is also considered to evaluate the potential role of CWs as decentralized wastewater treatment. Performance of CWs was evaluated according to (i) type of wetland system, (ii) different support matrix (iii) vegetation species and (iv) removal efficiency of chemical oxygen demand (COD), biological oxygen demand (BOD₅), nitrogen (N), and phosphorus (P). The reviewed CWs in overall presented good efficiencies, whereas H-CWs achieved the highest removals for P, while the higher results for N were attained on VF-CW and for COD and BOD₅ on HF-CW. Therefore, was concluded that CWs are an interesting solution for decentralized wastewater treatment in Brazil since it has warm temperatures, extensive radiation hours and available land. Additionally, the low percentage of population with access to the sewage network in the North and Northeast regions makes these systems especially suitable. Hence, the further implementation of CW is encouraged by the authors in regions with similar characteristics as Brazil.

Fire-induced pine woodland to shrubland transitions in Southern Europe may promote shifts in soil fertility

Since the mid of the last century, fire recurrence has increased in the Iberian Peninsula and in the overall Mediterranean basin due to changes in land use and climate. The warmer and drier climate projected for this region will further increase the risk of wildfire occurrence and recurrence. Although the impact of wildfires on soil nutrient content in this region has been extensively studied, still few works have assessed this impact on the basis of fire recurrence. This study assesses the changes in soil organic C and nutrient status of mineral soils in two Southern European areas, Várzea (Northern Portugal) and Valencia (Eastern Spain), affected by different levels of fire recurrence and where short fire intervals have promoted a transition from pine woodlands to shrublands. At the short-term (<1year), the amount of soil organic matter was higher in burned than in unburned soils while its quality (represented as labile to total organic matter) was actually lower. In any case, total and labile soil organic matter showed decreasing trends with increasing fire recurrence (one to four fires). At the long-term (>5years), a decline in overall soil fertility with fire recurrence was also observed, with a drop between pine woodlands (one fire) and shrublands (two and three fires), particularly in the soil microsites between shrubs. Our results suggest that the current trend of increasing fire recurrence in Southern Europe may result in losses or alterations of soil organic matter, particularly when fire promotes a transition from pine woodland to shrubland. The results also point to labile organic matter fractions in the intershrub spaces as potential early warning indicators for shifts in soil fertility in response to fire recurrence.

Short-term nitrogen losses by overland flow in a recently burnt forest area in north-central Portugal: A study at micro-plot scale

Over the past decades, wildfires have affected extensive areas of the Mediterranean region with negative impacts on the environment. Most of the studies on fire-affected areas have focused on sediment losses by overland flow, whereas few have addressed post-fire nutrient export. The present study aimed to address this research gap by assessing nitrogen (nitrate and total nitrogen) losses by overland flow in a recently burnt area in north-central Portugal. To this end, three burnt slopes were selected for their contrasting forest types (eucalypt vs. pine) and parent materials (granite vs. schist). The selected study sites were a eucalypt site on granite (BEG), a eucalypt site on schist (BES) and a maritime pine site on schist (BPS). Overland flow samples were collected during the first six months after the wildfire on a 1- to 2-weekly basis, after which this study had to be cancelled due to bench terracing of some of the sites. A peak in total nitrogen concentrations was observed in burnt areas immediately after the first post-fire rainfall event as a response to the erosion of the N-enriched ash layer. After this initial peak, smaller peaks were observed throughout the study period, mainly as a response to overland flow and/or erosion events. Nitrogen export differed strikingly between the two types of forests on schist, being higher at the eucalypt than at the pine site, due to the lack of a protective soil layer. Parent material did not play an important role on nitrogen export by overland flow since no significant differences were found between the eucalypt sites on granite and schist. The present study provides some insight into the differences in post-fire soil fertility losses between forest types and parent materials in the Mediterranean region, which is crucial information for defining post-fire land management measures to reduce soil degradation.

Cation export by overland flow in a recently burnt forest area in north-central Portugal

The current fire regime in the Mediterranean Basin constitutes a serious threat to natural ecosystems because it drastically enhances surface runoff and soil erosion in the affected areas. Besides soil particles themselves, soil cations can be lost by fire-enhanced overland flow, increasing the risk of fertility loss of the typically shallow and nutrient poor Mediterranean soils. Although the importance of cations for land-use sustainability is widely recognized, cation losses by post-fire runoff have received little research attention. The present study aimed to address this research gap by assessing total exports of Na(+), K(+), Ca(2+) and Mg(2+) in a recently burnt forest area in north-central Portugal. These exports were compared for two types of planted forest (eucalypt vs. maritime pine plantations), two types of parent materials (schist vs. granite) and for two spatial scales (micro-plot vs. hill slope). The study sites were a eucalypt plantation on granite (BEG), a eucalypt plantation on schist (BES) and a maritime pine plantation on schist (BPS). Overland flow samples were collected during the first six months after the wildfire. Cation losses differed strikingly between the two forest types on schist, being higher at the eucalypt than pine site. This difference was evident at both spatial scales, and probably due to the extensive cover of a needle cast from the scorched pine crowns. The role of parent material in cation export was less straightforward as it varied with spatial scale. Cation losses were higher for the eucalypt plantation on schist than for that on granite at the micro-plot scale, whereas the reverse was observed at the hill slope scale. Finally, cation yields were higher at the micro-plot than slope scale, in agreement with the general notion of scaling-effect in runoff generation.