Spectrum of cardiac disease in maternity in a low-resource cohort in South Africa

Anticoagulant therapy in pregnant women with mechanical and bioprosthetic heart valves

OBJECTIVE

The aim of the present study was to review maternal and fetal outcomes in pregnant women with prosthetic heart valves.

METHODS

A retrospective record review of pregnant women with prosthetic heart valves on anticoagulation was performed at the Specialist Cardiac Antenatal Clinic, Johannesburg South Africa from 2015 to 2023.

RESULTS

Fifty pregnancies with mechanical heart valves and three with tissue valves, on anticoagulation for comorbid atrial fibrillation were identified. The majority were of African ethnicity at a mean age of 33 ± 6 years. Anti-Xa adjusted enoxaparin was commenced at 10.5 ± 5.6 weeks' gestation until delivery in 48 (90.6%) pregnancies and warfarin was continued in five (9.4%) pregnancies. The live birth rates on enoxaparin and warfarin were 56.3% (95% confidence interval [CI]: 42.3-69.3) and 20.0% (95% CI: 2.0-64.0), respectively. There were 12 (22.6%) miscarriages at a mean of 11.3 ± 3.7 weeks' gestation, four (7.5%) intrauterine fetal deaths on warfarin and two (3.8%) warfarin embryopathy/fetopathy. The rates of antepartum/secondary postpartum bleeding and primary postpartum bleeding were 29.4% (95% CI: 18.6-43.1) and 5.9% (95% CI: 1.4-16.9), respectively. Maternal complications included anemia (n = 11, 20.8%), arrhythmia (n = 2, 3.8%), heart failure (n = 2, 3.8%) and paravalvular leak (n = 2, 3.8%). There was one (1.9%) mitral valve thrombosis and one (1.9%) stuck valve in pregnancies who defaulted warfarin prior to pregnancy. There were no maternal deaths.

CONCLUSION

Multidisciplinary management of pregnant women with prosthetic heart valves with anti-Xa adjusted low molecular weight heparin throughout pregnancy represents an effective anticoagulation option for low-middle-income countries.

Peripartum cardiomyopathy in low- and middle-income countries

Peripartum cardiomyopathy (PPCM) causes pregnancy-associated heart failure, typically during the last month of pregnancy, and up to 6 months post-partum, in women without known cardiovascular disease. PPCM is a global disease, but with a significant geographical variability within and between countries. Its true incidence in Africa is still unknown because of the lack of a PPCM population-based study. The variability in the epidemiology of PPCM between and within countries could be due to differences in the prevalence of both genetic and non-genetic risk factors. Several risk factors have been implicated in the aetiopathogenesis of PPCM over the years. Majority of patients with PPCM present with symptoms and signs of congestive cardiac failure. Diagnostic work up in PPCM is prompted by strong clinical suspicion, but Echocardiography is the main imaging technique for diagnosis. The management of PPCM involves multiple disciplines - cardiologists, anaesthetists, intensivists, obstetricians, neonatologists, and the prognosis varies widely.

Hypertension Related Co-Morbidities and Complications in Women of Sub-Saharan Africa: A Brief Review

Hypertension is the leading cause of cardiovascular disease in women, and sub-Saharan African (SSA) countries have some of the highest rates of hypertension in the world. Expanding knowledge of causes, management, and awareness of hypertension and its co-morbidities worldwide is an effective strategy to mitigate its harms, decrease morbidities and mortality, and improve individual quality of life. Hypertensive disorders of pregnancy (HDPs) are a particularly important subset of hypertension, as pregnancy is a major stress test of the cardiovascular system and can be the first instance in which cardiovascular disease is clinically apparent. In SSA, women experience a higher incidence of HDP compared with other African regions. However, the region has yet to adopt treatment and preventative strategies for HDP. This delay stems from insufficient awareness, lack of clinical screening for hypertension, and lack of prevention programs. In this brief literature review, we will address the long-term consequences of hypertension and HDP in women. We evaluate the effects of uncontrolled hypertension in SSA by including research on heart disease, stroke, kidney disease, peripheral arterial disease, and HDP. Limitations exist in the number of studies from SSA; therefore, we will use data from countries across the globe, comparing and contrasting approaches in similar and dissimilar populations. Our review highlights an urgent need to prioritize public health, clinical, and bench research to discover cost-effective preventative and treatment strategies that will improve the lives of women living with hypertension in SSA.

Pregnancy risk and contraception among reproductive-age women with rheumatic heart disease attending care at a tertiary cardiac center in Tanzania: a hospital-based cross-sectional study

BACKGROUND

Rheumatic heart disease (RHD) remains prevalent in the developing world and reproductive-age women are disproportionately affected. It is among the common est cardiac diseases during pregnancy and is associated with poor pregnancy outcomes. Despite its importance among reproductive-age women, there are no local studies that characterize the clinical characteristics, risk of poor pregnancy outcomes and contraception which represents one effective way to prevent unplanned pregnancies in this population.

METHODS

This was a hospital-based descriptive cross-sectional study. Non-pregnant reproductive-age women with echocardiographically diagnosed RHD were consecutively recruited from in- and out-patients units of the Jakaya Kikwete Cardiac Institute (JKCI). A clinical research form was used to gather socio-demographic, clinical characteristics, contraception status and echocardiographic information. The maternal/pregnancy risk class was determined using the modified World Health Organization (WHO) classification of maternal risk.

RESULTS

Two hundred thirty-eight women of reproductive age with RHD were recruited. The median age (range) was 36 years (15-49). Two-thirds were dyspneic on moderate exertion and 17.2% had New York Heart Association class IV heart failure. A quarter had atrial fibrillation/flutter. On echocardiography, mitral regurgitation was the most common valvular lesion (68.1%), followed by mitral stenosis (66.8%), and 12.2% of participants had reduced left ventricular ejection fraction. Two-thirds (66%) had a high pregnancy risk (class IV) based on the modified WHO classification system. The proportion of participants using contraception was 7.1% and common methods were: bilateral tubal ligation 5 of 17 (29.4%) and hormonal implant (4 of 17). The most common reason for the choice of a method was safety, 10 out of 17 (58.8%).

CONCLUSION

The majority of women of reproductive age with RHD in our hospital cohort are at the highest pregnancy risk based on the modified WHO classification and a very small proportion of them are on contraception. These results call for action among clinicians to offer counselling to these patients, educating them on their risk and offering appropriate contraception advice while waiting for definitive interventions.

Burden of disease and barriers to comprehensive care for rheumatic heart disease in South Africa: an updated systematic review protocol

INTRODUCTION

Rheumatic heart disease (RHD) is responsible for a significant burden of cardiovascular morbidity and mortality, and remains the most common cause of acquired heart disease among children and young adults in low-income and middle-income countries. Additionally, the global COVID-19 pandemic has forced the emergency restructuring of many health systems, which has had a broad impact on health in general, including cardiovascular disease. Despite significant cost to the health system and estimates from 2015 indicating both high incidence and prevalence of RHD in South Africa, no cohesive national strategy exists. An updated review of national burden of disease estimates, as well as literature on barriers to care for patients with RHD, will provide crucial information to assist in the development of a national RHD programme.

METHODS AND ANALYSIS

Using predefined search terms that capture relevant disease processes from Group A Streptococcal (GAS) infection through to the sequelae of RHD, a search of PubMed, Scopus, ISI Web of Science, Sabinet African Journals, SA Heart and Current and Completed Research databases will be performed. All eligible studies on RHD, acute rheumatic fever and GAS infection published from April 2014 to December 2022 will be included. Vital registration data for the same period from Statistics South Africa will also be collected. A standardised data extraction form will be used to capture results for both quantitative and qualitative analyses. All studies included in burden of disease estimates will undergo quality assessment using standardised tools. Updated estimates on mortality and morbidity as well as a synthesis of work on primary, secondary and tertiary prevention of RHD will be reported.

ETHICS AND DISSEMINATION

No ethics clearance is required for this study. Findings will be disseminated in a peer-reviewed journal and submitted to national stakeholders in RHD.

PROSPERO REGISTRATION NUMBER

CRD42023392782.

Cardiovascular diseases in Africa in the twenty-first century: Gaps and priorities going forward

In 2015, the United Nations set important targets to reduce premature cardiovascular disease (CVD) deaths by 33% by 2030. Africa disproportionately bears the brunt of CVD burden and has one of the highest risks of dying from non-communicable diseases (NCDs) worldwide. There is currently an epidemiological transition on the continent, where NCDs is projected to outpace communicable diseases within the current decade. Unchecked increases in CVD risk factors have contributed to the growing burden of three major CVDs-hypertension, cardiomyopathies, and atherosclerotic diseases- leading to devastating rates of stroke and heart failure. The highest age standardized disability-adjusted life years (DALYs) due to hypertensive heart disease (HHD) were recorded in Africa. The contributory causes of heart failure are changing-whilst HHD and cardiomyopathies still dominate, ischemic heart disease is rapidly becoming a significant contributor, whilst rheumatic heart disease (RHD) has shown a gradual decline. In a continent where health systems are traditionally geared toward addressing communicable diseases, several gaps exist to adequately meet the growing demand imposed by CVDs. Among these, high-quality research to inform interventions, underfunded health systems with high out-of-pocket costs, limited accessibility and affordability of essential medicines, CVD preventive services, and skill shortages. Overall, the African continent progress toward a third reduction in premature mortality come 2030 is lagging behind. More can be done in the arena of effective policy implementation for risk factor reduction and CVD prevention, increasing health financing and focusing on strengthening primary health care services for prevention and treatment of CVDs, whilst ensuring availability and affordability of quality medicines. Further, investing in systematic country data collection and research outputs will improve the accuracy of the burden of disease data and inform policy adoption on interventions. This review summarizes the current CVD burden, important gaps in cardiovascular medicine in Africa, and further highlights priority areas where efforts could be intensified in the next decade with potential to improve the current rate of progress toward achieving a 33% reduction in CVD mortality.

A clinical conundrum: review of anticoagulation in pregnant women with mechanical prosthetic heart valves

In South Africa, maternal mortality from cardiovascular disease remains high. The recent Saving Mothers report 2017-2019 from the Confidential Enquiries into Maternal Deaths revealed that indirect maternal death from medical and surgical disorders is the fourth commonest cause of maternal death, accounting for 16.9% of deaths, with cardiac disease accounting for one-third of this. The burden of rheumatic heart disease (RHD) is a significant contributor to maternal morbidity and mortality. The true burden is unknown due to limited data. The natural history of RHD confers additional risk as many cases may remain undiagnosed, with first presentation occurring during pregnancy. This undiagnosed subset of women may be the result of poor accessibility to healthcare facilities and primary healthcare interventions for acute rheumatic fever. RHD causes progressive damage to the heart valves, especially the left-sided valves, which eventually require surgical correction with mechanical prosthetic valves.

Experiences of a dedicated Heart and Maternal Health Service providing multidisciplinary care to pregnant women with cardiac disease in a tertiary centre in Namibia

OBJECTIVES

First, to describe the implementation process, benefits and challenges of a multidisciplinary service for pregnant women with cardiac disease in Namibia. Second, to assess pregnancy outcomes in this population.

METHODS

In a tertiary hospital in Namibia, a multidisciplinary service was implemented by staff of obstetric and cardiology departments and included preconception counselling, provision of antenatal care and reliable contraception. Management guidelines developed for high-income settings were used, since no locally adapted guidelines were available. A cohort study was performed to assess cardiac, obstetric and fetal outcomes. Included were pregnant women with cardiac disease, referred to this service between 1 August 2016 and 31 July 2018.

RESULTS

Important benefits of this service were the integrated approach, improved access to reliable contraception and insight into drivers of poor outcome. Several challenges with use of available guidelines were encountered, as contextual factors specific to lower-income settings were not taken into consideration, such as higher rates of infection or barriers to access care. The cohort consisted of 65 women. Cardiac disease was diagnosed for the first time in 16 (24.6%) women, of whom 11 had pre-existing cardiac disease. These women presented more often with heart failure than women with known heart disease (75.0% vs. 6.1%, RR 12.5, 95% CI 3.9-38.0). Five women died. Cardiac events occurred in twenty-two women of whom eight developed thromboembolic events and two endocarditis. The majority had no indication for prophylaxis, based on available guidelines. Fetal events occurred in 36 pregnancies. After pregnancy more than half of women (35/65, 53.8%) were using long-acting reversible contraception.

CONCLUSIONS

Despite several barriers, it was possible to implement a multidisciplinary service in a high-burden setting. Cardiac and fetal event rates in this cohort were high. To improve outcomes the focus should be on availability of context-specific guidelines and better detection of cardiac disease.

Unmet need for contraception and associated factors among women with cardiovascular disease having follow-up at Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia: a cross-sectional study

Background

Unmet need for contraception refers to the proportion of women who want to postpone or stop childbearing but are not using a contraceptive method. Addressing unmet need is especially important for women with medical conditions such as cardiovascular disease (CVD). Preventing unintended pregnancy is crucial to improve pregnancy outcomes and minimize complications of CVD during pregnancy. However, unmet need for contraceptives continues to undermine the potential benefits of contraceptive use. This research aimed to determine the rate of unmet need for contraceptives and associated factors among women with cardiovascular disease having follow-up at Saint Paul’s Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia.

Methods

A facility-based cross-sectional study was conducted from February 1 to May 31/2020. A total of 284 reproductive age women with cardiovascular disease having follow-up at the cardiac clinic of SPHMMC were enrolled consecutively until the desired sample size was reached. Data was collected through an exit interview using a structured and pretested questionnaire. Descriptive, bivariate, and multivariable methods were used to analyze the level of unmet need and its associated factors.

Results

The overall unmet need for contraception was 36.0% (95% CI: 30.4–41.5). The majority of the respondents lack counseling on contraception use. The most common reasons for non-use of a contraceptive method were fear of drug side effects and drug interaction. Unmet need for contraception was found to be more likely among those who have not been counseled on contraceptive utilization (AOR 6.7, CI 1.8–24.7) and those who lack partner support on contraception use (AOR = 6.2, CI: 1.91–19.8). Unmet need was also found to be more likely among women who have never used contraception before (AOR = 3.2, CI 1.12–8.92).

Conclusion

Unmet need for contraception was high in this high-risk population group. The cardiac follow-up clinic should implement client-centered counseling by a multidisciplinary team to address the needs of women and prevent consequences of unintended pregnancy. Furthermore, there is a need to initiate interventions that encourage communication between couples and increase male partner involvement through a renewed focus on couples counseling.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40834-022-00173-0.

Rationale, design and protocol of a cross-sectional study on pregnancy-related cardiovascular diseases in Tanzania (PRECARDT): burden, characterisation and prognostic significance at delivery

INTRODUCTION

The paucity of data describing cardiovascular disease (CVD) in pregnancy in many parts of Africa including Tanzania has given rise to challenges in proper management by the healthcare providers. This study is set out to (1) determine the prevalence of a range of CVDs during pregnancy in women attending antenatal clinics in Tanzania and (2) determine the impact of these CVDs on maternal and fetal outcomes at delivery.

METHODS AND ANALYSIS

This is a cross-sectional study with a prospective component to be conducted in two referral hospitals in Tanzania. Pregnant women aged ≥18 years diagnosed with a CVD during the antenatal period are being identified and extensively characterised by performing clinical assessment, modified WHO staging, electrocardiography, echocardiography and laboratory tests. Patients identified with CVDs (exposed) and a subset without (unexposed) will be followed up to determine maternal and fetal outcomes at delivery. A minimum sample of 1560 will be sufficient to estimate the prevalence of CVDs with a 95% CI of 2.75% to 5.25%.

ETHICS AND DISSEMINATION

The study is being conducted in accordance with the Helsinki declaration on studies involving human subjects. Ethical approvals have been obtained from Muhimbili University (reference number DA.282/298/01.C/) and Bugando Medical Centre (reference number CREC/330/2019) Ethics Committees. Informed consent is sought from all potential participants before any interview or investigations are performed. Study findings will be disseminated to the scientific community through different methods. Results will also be communicated to policymakers and to the public, as appropriate.

Managing Rheumatic Heart Disease in Pregnancy: A Practical Evidence-Based Multidisciplinary Approach

Rheumatic heart disease (RHD) remains a leading cause of mortality and morbidity in pregnant patients in low- to middle-income countries. Apart from the clinical challenges, these areas face poor infrastructure and resources to allow for early detection, with many women presenting to medical services for the first time when they deteriorate clinically during the pregnancy. The opportunity for preconception counselling and planning may thus be lost. It is ideal for all women to be seen before conception and risk-stratified according to their clinical state and pathology. The role of the cardio-obstetrics team has emerged over the past decade with the aim of a seamless transition to and from the appropriate levels of care during pregnancy. Severe symptomatic mitral and aortic valve stenoses portend the greatest risk to both mother and fetus. In mitral stenosis, beta-blockers are the cornerstone of therapy and only a small number of patients require balloon valvuloplasty. Regurgitant lesions mostly require diuretics alone for the treatment of heart failure. The mode of delivery is usually vaginal; caesarean section is performed in those with obstetrical indications or in cases with severe stenosis and a poor clinical state. The postpartum period presents a second high-risk period for maternal adverse events, with heart failure and arrhythmias being the most frequent. This review aims to provide a practical evidence-based multi-disciplinary approach to the management of women with RHD in pregnancy.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

Cardiovascular adverse events in pregnancy: A global perspective

Pregnant women with heart disease are vulnerable to many adverse cardiovascular events (AE). AEs during and after pregnancy continue to be important causes of maternal mortality and morbidity worldwide, with huge variations in burden in different countries and regions. These AEs are classified as having direct or indirect causes, depending on whether they are directly caused by pregnancy or due to some pre-existing disease and/or non-obstetric cause, respectively. The risks continue throughout pregnancy and even after childbirth. Apart from immediate complications during pregnancy, there is increasing evidence of a significant link between several events and the risk of cardiovascular disease (CVD) later in life. A significant number of pregnancy-related deaths caused by cardiovascular disease are preventable. This prevention can be realized through increasing awareness of cardiovascular AE in pregnancy, coupled with the application of strategies for prevention and treatment. Knowledge of the risks associated with CVD and pregnancy is of extreme importance in that regard. We discuss the global distribution of cardiovascular maternal mortality, adverse events during and after pregnancy, their predictors and risk stratification. In addition, we enumerate possible solutions, particularly the role of cardio-obstetric clinics.

Prevalence of Rheumatic Heart Disease and Other Cardiac Conditions in Low-Risk Pregnancies in Kenya: A Prospective Echocardiography Screening Study

Background:

Rheumatic heart disease (RHD) in sub-Saharan Africa contributes to significant cardiac morbidity and mortality, yet prevalence estimates of RHD lesions in pregnancy are lacking.

Objectives:

Our first aim was to evaluate women using echocardiography to estimate the prevalence of RHD and other cardiac lesions in low-risk pregnancies. Our second aim was to assess the feasibility of screening echocardiography and its acceptability to patients.

Methods:

We prospectively recruited 601 pregnant women from a low-risk antenatal clinic at a tertiary care maternity centre in Western Kenya. Women completed a questionnaire about past medical history and cardiac symptoms. They underwent standardized screening echocardiography to evaluate RHD and non-RHD associated cardiac lesions. Our primary outcome was RHD-associated cardiac lesions and our secondary outcome was a composite of any clinically-relevant cardiac lesion or echocardiography finding. We also recorded duration of screening echocardiography and its acceptability among pregnant women in this sample.

Results:

The point prevalence of RHD-associated cardiac lesions was 5.0/1,000 (95% confidence interval: 1.0–14.5), and the point prevalence of all clinically significant lesions/findings was 21.6/1,000 (11.6–36.7). Mean screening time was seven minutes (SD 1.7, range: 4–17) for women without cardiac abnormalities and 13 minutes (SD 4.6, range: 6–23) for women with abnormal findings. Echocardiography was acceptable to women with 74.2% agreeing to participate.

Conclusions:

The prevalence of clinically-relevant cardiac lesions was moderately high in a low-risk population of pregnant women in Western Kenya.

Burden, predictors and short-term outcomes of peripartum cardiomyopathy in a black African cohort

Background

Peripartum cardiomyopathy (PPCM) is an idiopathic cardiomyopathy presenting with acute heart failure during the peripartum period. It is common in patients of African ancestry. Currently, there is paucity of data on the burden, predictors and outcomes of PPCM in Uganda. This study aimed to investigate the prevalence, predictors and six-month outcomes of PPCM in an adult cohort attending a tertiary specialised cardiology centre in Kampala, Uganda.

Methods

This study consecutively enrolled 236 women presenting with features of acute heart failure in the peripartum period. Clinical evaluation and echocardiography were performed on all the enrolled women. PCCM was defined according to recommendations of the Heart Failure Association of the European Society of Cardiology Working Group on PPCM. Poor outcome at six months of follow-up was defined as presence of any of the following: death of a mother or her baby, New York Heart Association (NYHA) functional class III-IV or failure to achieve complete recovery of left ventricular function (left ventricular ejection fraction ≤55%).

Results

The median age, BMI and parity of the study participants was 31.5 (25.5–38.0) years, 28.3 (26.4–29.7) and 3 (2–4) respectively. The prevalence of PPCM was 17.4% (n = 41/236). Multiple pregnancy was the only predictor of PPCM in this study population (OR 4.3 95% CI 1.16–16.05, p = 0.029). Poor outcome at six-months was observed in about 54% of the patients with PPCM (n = 4, 9.8% in NYHA functional class III-IV and n = 22, 53.7% with LVEF <55%). No maternal or foetal mortality was documented.

Conclusion

PPCM is relatively common in Uganda and is associated with multiple pregnancy. Poor outcomes especially absence of complete recovery of left ventricular function are also common. Large studies to further investigate long-term maternal and foetal outcomes in Uganda are justified.

Reproductive health professional's reported knowledge on diagnosis and management of rheumatic heart disease in pregnant women in Maputo, Mozambique

BACKGROUND

Rheumatic heart disease (RHD) poses a threat to African women in their reproductive years, being an important cause of maternal mortality and poor foetal outcomes. Timely diagnosis and adequate management reduce significantly obstetric complications. Our study aimed to describe the knowledge of diagnosis and management of RHD in pregnant women among reproductive health professionals (RHP) working in a highly endemic area.

METHODS

The study that took place in May/2017 in two conveniently selected health facilities. Doctors (residents and specialists) and mid-level (maternal and child health nurses/technicians, MLRHP) were invited to respond to an anonymous, self-administered and standardized survey (electronic and paper-based questionnaires), which contained closed and open-ended questions on pregnancy-related RHD diagnosis, treatment and complications. The responses were coded and analysed using SPSS version 20.

RESULTS

Seventy-three RHP participated (27 doctors, 46 MLRHP). While RHP understand the fetal 49 (67%) and maternal 57 (53%) outcomes in presence of RHD, they are unprepared to diagnose, manage and refer them adequately.

CONCLUSION

RHP constitute a group that can be targeted for decentralization of diagnosis and management of RHD, a strategy that may be crucial to reduce maternal mortality by indirect causes in low-middle income countries.

Multimorbidity and cardiovascular disease: a perspective on low- and middle-income countries

New and changing patterns of multimorbidity (MM), i.e., multiple concurrent acute or chronic diseases in a person, are emerging in low- and middle-income countries (LMICs). The interplay of underlying population-specific factors and lifestyle habits combined with the colliding epidemics of communicable and non-communicable diseases presents new disease combinations, complexities and risks that are not common in high-income countries (HICs). The complexities and risks include those arising from potentially harmful drug-drug and drug-disease interactions (DDIs), the management of which may be considered as MM in the true sense. A major concern in LMICs is the increasing burden of leading cardiovascular diseases, prevalence of associated risk factors and co-occurrence with other morbidities. New models of MM management and integrated care can respond to the needs of specific multimorbid populations, with some LMICs making substantial progress (e.g., integration of tuberculosis and HIV services in South Africa). But there is a dearth of relevant data on the changing patterns and underlying factors and determinants of MM, the associated complexities and risks of DDIs in MM management, and the barriers to integrated care in LMICs. This requires careful attention.

Effectiveness of Implanted Cardiac Rhythm Recorders With Electrocardiographic Monitoring for Detecting Arrhythmias in Pregnant Women With Symptomatic Arrhythmia and/or Structural Heart Disease: A Randomized Clinical Trial

Importance

Arrhythmias are an important cause of maternal morbidity and mortality but remain difficult to diagnose.

Objective

To compare implantable loop recorder (ILR) plus 24-hour Holter electrocardiographic (ECG) monitoring with standard 24-hour Holter ECG monitoring alone in terms of acceptability, ability to identify significant arrythmias, and effect on management and pregnancy outcome in women who were symptomatic or at high risk of arrythmia because of underlying structural heart disease.

Design, Setting, and Participants

This single-center, prospective randomized clinical trial recruited 40 consecutive patients from the Cardiac Disease and Maternity Clinic at Groote Schuur Hospital in Cape Town, South Africa. Pregnant patients with symptoms of arrhythmia and/or structural heart disease at risk of arrhythmia were included.

Intervention

Patients were randomized to standard care (SC; 24-hour Holter ECG monitoring [n = 20]) or standard care plus ILR (SC-ILR; 24-hour Holter ECG monitoring plus ILR [n = 20]). Only 17 consented to ILR insertion, and the 3 who declined ILR were allocated to the SC group.

Main Outcomes and Measures

Arrhythmias considered included atrial fibrillation, atrial flutter, premature ventricular complexes, supraventricular tachycardia, ventricular tachycardia, or ventricular fibrillation.

Results

Among the 40 women in this trial, the mean (SD) age was 28.4 (5.5) years. Holter monitoring detected arrhythmias in 3 of 23 patients (13%) in the SC group and 4 of 17 patients (24%) in the SC-ILR group compared with 9 of 17 patients (53%) patients who had arrhythmias detected by ILR. Seven patients (4 with supraventricular tachycardia, 1 with premature ventricular complexes, and 2 with paroxysmal atrial fibrillation recorded by ILR) did not have arrhythmias detected by 24-hour Holter monitoring. Three of these 7 patients (43%) had a change in management as a result of their ILR recordings. There were no maternal deaths. However, the SC group had a significantly lower mean (SD) gestational stage at delivery (35 [5] weeks vs 38 [2], P = .04).

Conclusions and Relevance

The ILR was better than 24-hour Holter monitoring in detecting arrhythmias, which led to a change in management for a significant proportion of patients. Our findings suggest that ILR may be beneficial for pregnant women at risk of arrhythmia.

Trial Registration

ClinicalTrials.gov Identifier: NCT02249195.

Maternal mortality due to cardiac disease in low- and middle-income countries

Objectives

To assess the frequency of maternal death (MD) due to cardiac disease in low‐ and middle‐income countries (LMIC).

Methods

Systematic review searching Medline, EMBASE, Web of Science, Cochrane Library, Emcare, LILACS, African Index Medicus, IMEMR, IndMED, WPRIM, IMSEAR up to 01/Nov/2017. Maternal mortality reports from LMIC reviewing all MD in a given geographical area were included. Hospital‐based reports or those solely based on verbal autopsies were excluded. Numbers of MD and cardiac‐related deaths were extracted. We calculated cardiac disease MMR (cMMR, cardiac‐related MD/100 000 live births) and proportion of cardiac‐related MDs among all MDs. Frequency of cardiac MD was compared with the MMR of the country.

Results

Forty‐seven reports were included, which reported on 38,486 maternal deaths in LMIC. Reported cMMR ranged from 0/100 000 live births (Moldova, Ghana) to 31.9/100 000 (Zimbabwe). The proportion of cardiac‐related MD ranged from 0% (Moldova, Ghana) to 24.8% (Sri Lanka). In countries with a higher MMR, cMMR was also higher. However, the proportion of cardiac‐related MD was higher in countries with a lower MMR.

Conclusions

The burden of cardiac‐related mortality is difficult to assess due limited availability of mortality reports. The proportion of cardiac deaths among all MD appeared to be higher in countries with a lower MMR. This is in line with what has been called ‘obstetric transition’: pre‐existing medical diseases including cardiac disease are becoming relatively more important where the MMR falls.

High Burden of Cardiac Disease in Pregnancy at a National Referral Hospital in Western Kenya

Background

Cardiac disease is a leading cause of non-obstetric maternal death worldwide, but little is known about its burden in sub-Saharan Africa.

Objectives and Methods

We conducted a retrospective case-control study of pregnant women admitted to a national referral hospital in western Kenya between 2011-2016. Its purpose was to define the burden and spectrum of cardiac disease in pregnancy and assess the utility of the CARPREG I and modified WHO (mWHO) clinical risk prediction tools in this population.

Results

Of the 97 cases of cardiac disease in pregnancy, rheumatic heart disease (RHD) was the most common cause (75%), with over half complicated by severe mitral stenosis or pulmonary hypertension. Despite high rates of severe disease and nearly universal antenatal care, late diagnosis of cardiac disease was common, with one third (38%) of all cases newly diagnosed after 28 weeks gestational age and 17% diagnosed after delivery. Maternal mortality was 10-fold higher among cases than controls. Cases had significantly more cardiac (56% vs. 0.4%) and neonatal adverse events (61% vs. 27%) compared to controls (p < 0.001). Observed rates of adverse cardiac events were higher than predicted by both CARPREG I and mWHO risk scores, with high cardiac event rates despite low or intermediate risk scores.

Conclusions

Cardiac disease is associated with significant maternal and neonatal morbidity and mortality among pregnant women in western Kenya. Existing clinical tools used to predict risk underestimate adverse cardiac events in pregnancy and may be of limited utility given the unique spectrum and severity of disease in this population.

Standardizing clinical care measures of rheumatic heart disease in pregnancy: A qualitative synthesis

BACKGROUND

Rheumatic heart disease (RHD) is a preventable cardiac condition that escalates risk in pregnancy. Models of care informed by evidence-based clinical guidelines are essential to optimal health outcomes. There are no published reviews that systematically explore approaches to care provision for pregnant women with RHD and examine reported measures. The review objective was to improve understanding of how attributes of care for these women are reported and how they align with guidelines.

METHODS

A search of 13 databases was supported by hand-searching. Papers that met inclusion criteria were appraised using CASP/JBI checklists. A content analysis of extracted data from the findings sections of included papers was undertaken, informed by attributes of quality care identified previously from existing guidelines.

RESULTS

The 43 included studies were predominantly conducted in tertiary care centers of low-income and middle-income countries. Cardiac guidelines were referred to in 25 of 43 studies. Poorer outcomes were associated with higher risk scores (detailed in 36 of 41 quantitative studies). Indicators associated with increased risk include anticoagulation during pregnancy (28 of 41 reported) and late booking (gestation documented in 15 of 41 studies). Limited access to cardiac interventions was discussed (19 of 43) in the context of poorer outcomes. Conversely, early assessment and access to regular multidisciplinary care were emphasized in promoting optimal outcomes for women and their babies.

CONCLUSIONS

Despite often complex care requirements in challenging environments, pregnancy provides an opportunity to strengthen health system responses and address whole-of-life health for women with RHD. A standard set of core indicators is proposed to more accurately benchmark care pathways, outcomes, and burden.

Congenital Heart Disease in Low- and Lower-Middle-Income Countries: Current Status and New Opportunities

PURPOSE OF REVIEW

The paper summarises the most recent data on congenital heart disease (CHD) in low- and lower-middle-income countries (LLMICs). In addition, we present an approach to diagnosis, management and interventions in these regions and present innovations, research priorities and opportunities to improve outcomes and develop new programs.

RECENT FINDINGS

The reported birth prevalence of CHD in LLMICs is increasing, with clear evidence of the impact of surgical intervention on the burden of disease. New methods of teaching and training are demonstrating improved outcomes. Local capacity building remains the key. There is a significant gap in epidemiological and outcomes data in CHD in LLMICs. Although the global agenda still does not address the needs of children with CHD adequately, regional initiatives are focusing on quality improvement and context-specific interventions. Future research should focus on epidemiology and the use of innovative thinking and partnerships to provide low-cost, high-impact solutions.

The effect of beta-blockers on foetal birth weight in pregnancies in women with structural heart disease: a prospective cohort study

OBJECTIVE

To examine whether treatment with beta-blockers (BBs) in pregnant women with structural heart disease (SHD) resulted in a decrease in foetal birth weight (FBW) in a South African cohort.

METHODS

This was a prospective cohort study conducted in a tertiary-level hospital in Cape Town from 2010 to 2016. Of the 178 pregnant women with SHD, 24.2% received BBs for a minimum of two weeks. Adverse foetal outcomes and mean FBW were compared between the BB groups and subgroups (congenital, valvular, cardiomyopathy and other). Adverse foetal outcome was defined as: low birth weight (LBW) < 2 500 g, Apgar score < 7, premature birth (< 37 weeks) and small for gestational age (SGA).

RESULTS

BB exposure during pregnancy was found to be associated with a non-significant increased FBW (2 912 vs 2 807 g, p = 0.347). A significant decrease (p = 0.009) was noted in FBW for valvular SHD pregnancies using BBs, while a significant increase (p = 0.049) was observed for the same outcome in the cardiomyopathy subgroup using BBs. A significant increase was observed for SGA (p = 0.010) and LBW (p = 0.003) pregnancies within the valvular subgroup when exposed to BBs.

CONCLUSIONS

BB use in pregnant women with SHD in a South African cohort showed no association with a decrease in FBW or an increase in adverse foetal outcomes when compared to non-BB usage.

Maternal cardiovascular complications at the time of delivery and subsequent re-hospitalization in the USA, 2010-16

AIMS

Cardiovascular (CV) complications are the leading cause of maternal morbidity and mortality. The objective was to estimate trends in the incidence of peripartum CV complications in the USA between 2010 and 2016.

METHODS AND RESULTS

This was a retrospective analyses using data from the Healthcare Cost and Utilization Project. We included women with delivery codes consistent with delivery, weighted to a national estimate. The primary outcome was the age-adjusted incidence of CV complications among all deliveries, including complications that occurred during re-hospitalizations. Complications were identified using International Classification of Diseases (ICD) codes. Joinpoint regression was used to evaluate time trends and complications were stratified by type. The secondary outcome was in-hospital maternal death among women with a CV complication. We identified a weighted estimate of 27 408 652 women hospitalized for delivery from 2010 to 2016. Including all years, the complication incidence was 7.36/1000 births [95% confidence interval (CI) 7.18-7.54], with an estimated annual percentage change of 5.8% (95% CI 3.7-7.8%). Cardiac dysrhythmia was the most common complication [3.98/1000 births (95% CI 3.88-4.08)] and acute myocardial infarction was the least common complication [0.11/1000 births (95% CI 0.10-0.11)]. The incidence of hypertension, acute myocardial infarction, and cardiac arrest increased over time, the incidence of congestive heart failure and acute cerebrovascular disease remained stable, the incidence of pulmonary heart disease increased from 2015 onward, and the incidence of cardiac dysrhythmia decreased in 2016. Complications during re-hospitalization accounted for 13.6% (95% CI 13.2-14.1%) of all complications and was highest for acute myocardial infarction [28.1% (95% CI 23.2-33.1)]. Among women with any complication, the mortality rate was 1.20 (95% CI 1.11-1.29) per 100 complications.

CONCLUSION

Our analyses suggest the rate of peripartum CV complications are increasing in the USA, which highlights the need for active efforts in research and prevention.

State of the Art Management of Mechanical Heart Valves During Pregnancy

PURPOSE OF THE REVIEW

To review the management of women with mechanical heart valves during pregnancy, from preconception counseling through delivery with a summary of the latest guidelines.

RECENT FINDINGS

The hypercoagulability of pregnancy combined with the imperfect choices of anticoagulant agents contribute to a high risk of complications in pregnant women with mechanical heart valves. Valve thrombosis remains a major concern, much of which occurs during the first trimester transition to heparin-based products. The safest method of anticoagulation, with the best balance of maternal and fetal risk, is use of low-dose vitamin K antagonists, but only if therapeutic anticoagulation can be achieved with warfarin doses of ≤ 5 mg/day. Management of mechanical heart valves in pregnancy remains fraught with difficult decisions involving balancing of maternal and fetal risks as well as a high risk of maternal and fetal complications. Preconception counseling and planning is imperative. A risk-benefit discussion with the patient will help guide the choice of anticoagulation and outline the plan for safe delivery options. A multidisciplinary approach to management is advisable with close follow-up and care in a tertiary center.

The Pan-African Society of Cardiology position paper on reproductive healthcare for women with rheumatic heart disease

This position paper summarises the current knowledge on the epidemiology, diagnosis and management of women of childbearing age with rheumatic heart disease (RHD) in Africa, as well as the available data on their use of reproductive health services. The aim is to provide guidance to health professionals on aspects of sexual and reproductive health in women with RHD. It reviews the diagnosis, management and counselling of women with RHD throughout their reproductive life. Additionally, this publication discusses potential ways of integrating obstetric and cardiovascular care at peripheral levels of the health systems, as a way of improving outcomes and reducing maternal mortality rates related to cardiovascular disease in Africa. Finally, the article proposes responses to fulfil the actual needs for better reproductive health services and improvement in care for women with RHD.

Reducing late maternal death due to cardiovascular disease - A pragmatic pilot study

BACKGROUND

Late maternal mortality (up-to 1-year postpartum) is poorly reported globally and is commonly due to cardiovascular disease (CVD). We investigated targeted interventions aiming at reducing peripartum heart failure admission and late maternal death.

METHODS AND RESULTS

Prospective single-centre study of 269 peripartum women presenting with CVD in pregnancy, or within 6-months postpartum. Both cardiac disease maternity (CDM) Group-I and Group-II were treated by a dedicated cardiac-obstetric team. CDM Group-II received additional interventions: 1. Early (2-6 weeks) postpartum follow-up at the CDM clinic and immediate referral to dedicated CVD specialist clinics. 2. Beta-blocker therapy was continued in women with LVEF<45% while pregnant, or immediately started postpartum. Of 269 consecutive women (mean age 28.6 ± 5.9), 213 presented prepartum, 22% in NYHA groups III-IV and 79% in modified WHO groups III-IV. Patients were diagnosed with congenital heart disease (30%), valvular heart disease (25%) and cardiomyopathy (31%). The groups were similar in age, diagnosis, NYHA, modified WHO, BP and HIV, but Group-II had a higher rate of previously known CVD (p < 0.001) and a lower rate of being nulliparous (p < 0.0005). Of Group-I patients 9 died within the 12-month follow-up period versus one death in Group-II (p = 0.047). Heart failure leading to admission was 32% in Group-I versus 14% in Group-II (p = 0.0008), with Group-II having a higher beta-blocker use peripartum (p = 0.009). Perinatal mortality rate was 22/1000 live births with no differences between groups.

CONCLUSION

Early follow-up in a dedicated CDM clinic with targeted pharmacological interventions led to a significant reduction in peripartum heart failure admission and mortality.

Influence of socioeconomic factors on pregnancy outcome in women with structural heart disease

Objective

Cardiac disease is the leading cause of indirect maternal mortality. The aim of this study was to analyse to what extent socioeconomic factors influence the outcome of pregnancy in women with heart disease.

Methods

The Registry of Pregnancy and Cardiac disease is a global prospective registry. For this analysis, countries that enrolled ≥10 patients were included. A combined cardiac endpoint included maternal cardiac death, arrhythmia requiring treatment, heart failure, thromboembolic event, aortic dissection, endocarditis, acute coronary syndrome, hospitalisation for cardiac reason or intervention. Associations between patient characteristics, country characteristics (income inequality expressed as Gini coefficient, health expenditure, schooling, gross domestic product, birth rate and hospital beds) and cardiac endpoints were checked in a three-level model (patient–centre–country).

Results

A total of 30 countries enrolled 2924 patients from 89 centres. At least one endpoint occurred in 645 women (22.1%). Maternal age, New York Heart Association classification and modified WHO risk classification were associated with the combined endpoint and explained 37% of variance in outcome. Gini coefficient and country-specific birth rate explained an additional 4%. There were large differences between the individual countries, but the need for multilevel modelling to account for these differences disappeared after adjustment for patient characteristics, Gini and country-specific birth rate.

Conclusion

While there are definite interregional differences in pregnancy outcome in women with cardiac disease, these differences seem to be mainly driven by individual patient characteristics. Adjustment for country characteristics refined the results to a limited extent, but maternal condition seems to be the main determinant of outcome.

Status and Challenges of Care in Africa for Adults With Congenital Heart Defects

The 54 countries in Africa have an estimated total annual congenital heart defect (CHD) birth prevalence of 300,486 cases. More than half (51.4%) of the continental birth prevalence occurs in only seven countries. Congenital heart disease remains primarily a pediatric health issue in Africa because of the deficient health-care systems: the adults with CHD made up just 10% of patients with CHD in Ghana, and 13.7% of patients with CHD presenting for surgery in Mozambique. With Africa's population projected to double in the next 35 years, the already deficient health systems for CHD care will suffer unbearable strain unless determined and courageous action is undertaken by the African leaders.

Organisation of care for pregnancy in patients with congenital heart disease

Improvements in surgery have resulted in more women with repaired congenital heart disease (CHD) surviving to adulthood. Women with CHD, who wish to embark on pregnancy require prepregnancy counselling. This consultation should cover several issues such as the long-term prognosis of the mother, fertility and miscarriage rates, recurrence risk of CHD in the baby, drug therapy during pregnancy, estimated maternal risk and outcome, expected fetal outcomes and plans for pregnancy. Prenatal genetic testing is available for those patients with an identified genetic defect using pregestational diagnosis or prenatal diagnosis chorionic villus sampling or amniocentesis. Centralisation of care is needed for high-risk patients. Finally, currently there are no recommendations addressing the issue of the delivery. It is crucial that a dedicated plan for delivery should be available for all cardiac patients. The maternal mortality in low-income to middle-income countries is 14 times higher than in high-income countries and needs additional aspects and dedicated care.

Spectrum of cardiovascular diseases in six main referral hospitals of Ethiopia

Background

The spectrum of cardiovascular diseases varies between and within countries, depending on the stage of epidemiological transition and risk factor profiles. Understanding this spectrum requires regional and national data for each region or country. This study was designed to determine the spectrum of cardiovascular diseases in six university hospitals in Ethiopia.

Methods

This is a cross-sectional study of the spectrum of cardiovascular diseases in six main referral/teaching hospitals located in different parts of the country. Consecutive patients visiting the follow-up cardiac clinics of these hospitals from 1 January to 30 June 2015 were included in the study. Data were collected on a pretested questionnaire.

Results

A total of 6275 patients (58.5% females) were included in the study. Nearly 61% of the patients were from urban areas. The median age was 33 years (IQR 14-55 years). Valvular heart disease was the most common diagnosis, accounting for 40.5% of the cases. Of 2541 patents with valvular heart disease, 2184 (86%) were cases of chronic rheumatic heart disease.

Conclusion

Our study shows that chronic rheumatic valvular heart disease is the most common cardiovascular diagnosis among patients seen at cardiology clinics of six referral/teaching hospitals in the country, followed by congenital heart diseases. Hypertensive and ischaemic heart diseases also accounted for a significant proportion of the cases. Therefore, strategies directed towards primary and secondary prevention of acute rheumatic fever as well as prevention of risk factors for hypertension and ischaemic heart disease may need to be strengthened.

Cardiovascular disease in Africa: epidemiological profile and challenges

From a global perspective, the large and diverse African population is disproportionately affected by cardiovascular disease (CVD). The historical balance between communicable and noncommunicable pathways to CVD in different African regions is dependent on external factors over the life course and at a societal level. The future risk of noncommunicable forms of CVD (predominantly driven by increased rates of hypertension, smoking, and obesity) is a growing public health concern. The incidence of previously rare forms of CVD such as coronary artery disease will increase, in concert with historically prevalent forms of disease, such as rheumatic heart disease, that are yet to be optimally prevented or treated. The success of any strategies designed to reduce the evolving and increasing burden of CVD across the heterogeneous communities living on the African continent will be dependent upon accurate and up-to-date epidemiological data on the cardiovascular profile of every major populace and region. In this Review, we provide a contemporary picture of the epidemiology of CVD in Africa, highlight key regional discrepancies among populations, and emphasize what is currently known and, more importantly, what is still unknown about the CVD burden among the >1 billion people living on the continent.

Pre-conception counselling for key cardiovascular conditions in Africa: optimising pregnancy outcomes

The World Health Organisation (WHO) supports pre-conception care (PCC) towards improving health and pregnancy outcomes. PPC entails a continuum of promotive, preventative and curative health and social interventions. PPC identifies current and potential medical problems of women of childbearing age towards strategising optimal pregnancy outcomes, whereas antenatal care constitutes the care provided during pregnancy. Optimised PPC and antenatal care would improve civil society and maternal, child and public health. Multiple factors bar most African women from receiving antenatal care. Additionally, PPC is rarely available as a standard of care in many African settings, despite the high maternal mortality rate throughout Africa. African women and healthcare facilitators must cooperate to strategise cost-effective and cost-efficient PPC. This should streamline their limited resources within their socio-cultural preferences, towards short- and long-term improvement of pregnancy outcomes.

This review discusses the relevance of and need for PPC in resource-challenged African settings, and emphasises preventative and curative health interventions for congenital and acquired heart disease. We also consider two additional conditions, HIV/AIDS and hypertension, as these are two of the most important co-morbidities encountered in Africa, with significant burden of disease. Finally we advocate strongly for PPC to be considered as a key intervention for reducing maternal mortality rates on the African continent.

Cardiology-cardiothoracic subspeciality training in South Africa: a position paper of the South Africa Heart Association

Over the past decades, South Africa has undergone rapid demographic changes, which have led to marked increases in specific cardiac disease categories, such as rheumatic heart disease (now predominantly presenting in young adults with advanced and symptomatic disease) and coronary artery disease (with rapidly increasing prevalence in middle age). The lack of screening facilities, delayed diagnosis and inadequate care at primary, secondary and tertiary levels have led to a large burden of patients with heart failure. This leads to suffering of the patients and substantial costs to society and the healthcare system.

In this position paper, the South African Heart Association (SA Heart) National Council members have summarised the current state of cardiology, cardiothoracic surgery and paediatric cardiology reigning in South Africa. Our report demonstrates that there has been minimal change in the number of successfully qualified specialists over the last decade and, therefore, a de facto decline per capita. We summarise the major gaps in training and possible interventions to transform the healthcare system, dealing with the colliding epidemic of communicable disease and the rapidly expanding epidemic of non-communicable disease, including cardiac disease.

Peripartum Cardiomyopathy

Peripartum cardiomyopathy is a potentially life-threatening pregnancy-associated disease that typically arises in the peripartum period and is marked by left ventricular dysfunction and heart failure. The disease is relatively uncommon, but its incidence is rising. Women often recover cardiac function, but long-lasting morbidity and mortality are not infrequent. Management of peripartum cardiomyopathy is largely limited to the same neurohormonal antagonists used in other forms of cardiomyopathy, and no proven disease-specific therapies exist yet. Research in the past decade has suggested that peripartum cardiomyopathy is caused by vascular dysfunction, triggered by late-gestational maternal hormones. Most recently, information has also indicated that many cases of peripartum cardiomyopathy have genetic underpinnings. We review here the known epidemiology, clinical presentation, and management of peripartum cardiomyopathy, as well as the current knowledge of the pathophysiology of the disease.

Medical disease as a cause of maternal mortality: the pre-imminence of cardiovascular pathology

Maternal mortality ratio in low- to middle-income countries (LMIC) is 14 times higher than in high-income countries. This is partially due to lack of antenatal care, unmet needs for family planning and education, as well as low rates of birth managed by skilled attendants. While direct causes of maternal death such as complications of hypertension, obstetric haemorrhage and sepsis remain the largest cause of maternal death in LMICs, cardiovascular disease emerges as an important contributor to maternal mortality in both developing countries and the developed world, hampering the achievement of the millennium development goal 5, which aimed at reducing by three-quarters the maternal mortality ratio until the end of 2015. Systematic search for cardiac disease is usually not performed during pregnancy in LMICs despite hypertensive disease, rheumatic heart disease and cardiomyopathies being recognised as major health problems in these settings. New concern has been rising due to both the HIV/AIDS epidemic and the introduction of highly active antiretroviral therapy. Undetected or untreated congenital heart defects, undiagnosed pulmonary hypertension, uncontrolled heart failure and complications of sickle cell disease may also be important challenges. This article discusses issues related to the role of cardiovascular disease in determining a substantial portion of maternal morbidity and mortality. It also presents an algorhitm to be used for suspected and previously known cardiac disease in pregnancy in the context of LIMCs.

Valvular heart disease in pregnancy

Valvular heart disease may be a pre-existing complication of pregnancy or it may be diagnosed for the first time during pregnancy. Accurate diagnosis, tailored therapy and an understanding of the physiology and pathophysiology of pregnancy are necessary components of management, best achieved through the use of multidisciplinary clinics. This review outlines the management of specific lesions, with particular reference to post-rheumatic valvular heart disease.

Hypertensive disorders of pregnancy: what the physician needs to know

Hypertension developing during pregnancy may be caused by a variety of different pathophysiological mechanisms. The occurrence of proteinuric hypertension during the second half of pregnancy identifies a group of women whose hypertensive disorder is most likely to be caused by the pregnancy itself and for whom the risk of complications, including maternal mortality, is highest. Physicians identifying patients with hypertension in pregnancy need to discriminate between pre-eclampsia and other forms of hypertensive disease. Pre-eclamptic disease requires obstetric intervention before it will resolve and it must be managed in a multidisciplinary environment. The principles of diagnosis and management of these different entities are outlined in this review.

The importance of cardiovascular pathology contributing to maternal death: Confidential Enquiry into Maternal Deaths in South Africa, 2011-2013

Aims

Cardiac disease is emerging as an important contributor to maternal deaths in both lower-to-middle and higher-income countries. There has been a steady increase in the overall institutional maternal mortality rate in South Africa over the last decade. The objectives of this study were to determine the cardiovascular causes and contributing factors of maternal death in South Africa, and identify avoidable factors, and thus improve the quality of care provided.

Methods

Data collected via the South African National Confidential Enquiry into Maternal Deaths (NCCEMD) for the period 2011–2013 for cardiovascular disease (CVD) reported as the primary pathology was analysed. Only data for maternal deaths within 42 days post-delivery were recorded, as per statutory requirement. One hundred and sixty-nine cases were reported for this period, with 118 complete hospital case files available for assessment and data analysis.

Results

Peripartum cardiomyopathy (PPCM) (34%) and complications of rheumatic heart disease (RHD) (25.3%) were the most important causes of maternal death. Hypertensive disorders of pregnancy, HIV disease infection and anaemia were important contributing factors identified in women who died of peripartum cardiomyopathy. Mitral stenosis was the most important contributor to death in RHD cases. Of children born alive, 71.8% were born preterm and 64.5% had low birth weight. Seventy-eight per cent of patients received antenatal care, however only 33.7% had a specialist as an antenatal care provider. Avoidable factors contributing to death included delay in patients seeking help (41.5%), lack of expertise of medical staff managing the case (29.7%), delay in referral to the appropriate level of care (26.3%), and delay in appropriate action (36.4%).

Conclusion

The pattern of CVD contributing to maternal death in South Africa was dominated by PPCM and complications of RHD, which could, to a large extent, have been avoided. It is likely that there were many CVD deaths that were not reported, such as late maternal mortality (up to one year postpartum). Infrastructural changes, use of appropriate referral algorithm and training of primary, secondary and tertiary staff in CVD complicating pregnancy is likely to improve the outcome. The use of simple screening equipment and point-of-care testing for early-onset heart failure should be explored via research projects.

Decompensated Heart Failure in Pregnancy

Heart disease is a common cause of morbidity and mortality during pregnancy. Symptoms and signs of heart failure in a pregnant woman are an indication for urgent assessment to establish a diagnosis and appropriate management. This is best accomplished through a multidisciplinary approach in which both cardiologists and obstetricians need to participate in order to provide expert counselling and care in pursuit of safe motherhood. Congenital heart disease, although common, once corrected is an unusual source of complications, which are more likely to develop as a consequence of ventricular failure, pulmonary hypertension and aortic arch disease. Rheumatic valvular heart disease is a challenge because of the need for anticoagulation during pregnancy and the risk of sepsis associated with childbirth. This review outlines a contemporary approach to heart failure presenting during pregnancy.