Cardiovascular Journal of Africa: Vol 27 No 2 (March/April 2016)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 2, March/April 2016

AFRICA

disease increases the risk of pregnancy to the mother and

foetus and requires a careful preconception risk assessment and,

subsequently during pregnancy, specialised care to minimise

maternal and foetal morbidity and mortality.

All women with valvular heart disease should ideally have

preconception evaluation, including advice on risk prediction

and contraception by a joint cardiac–obstetric team. Zühlke

and co-authors reported recently from the REMEDY study

that among 1 825 women of child-bearing age with RHD, only

3.6% were on contraception.

A recent publication by Sliwa

et al

summarises how counselling on maternal and offspring

risk should be carried out in women with valvular heart disease,

according to the modified World Health Organisation (WHO)

classification, and should include information on complications

such as heart failure and valve thrombosis, which can occur

during and beyond the immediate delivery period.

Management of the patients in our cohort was clearly

sub-optimal. Many patients presented late to healthcare

providers and this was possibly due to lack of knowledge of the

underlying cardiac problem. This could potentially be improved

by providing better information by a counsellor, cell phone/

web-based information or via short featured video clips, e.g.

www.heduafrica.org

and MomConnect website (www.rmch.

org/wp-content/uploads/2014/08/MomConnect-Booklet.pdf).

Appropriate guidance in referral to secondary and tertiary care

hospitals with dedicated cardiac disease in maternity clinics should

be implemented and is currently being explored in South Africa.

Cardiac disease contributing to institutional

maternal mortality rate in South Africa

There has been a steady increase in the institutional maternal

mortality rate (iMMR) for cardiac disease over the last decade

in South Africa.

The iMMR for cardiac disease in 2005–2007

was 3.73 and this increased to 5.64 during 2008–2010, and to

6.00 per 100 000 during 2011–2013. After non-pregnancy-related

infections, cardiac disease is the second most common cause of

indirect maternal death.

The Saving Mothers reports of 2002–2004 and 2005–

2007 have grouped all cases of cardiomyopathy (peripartum

cardiomyopathy and other cardiomyopathies) in one category

when analysing causes of cardiac death.

4,15

In these reports,

complications of RHD and cardiomyopathy were the most

important and equal contributors to cardiac deaths. In the

triennium 2011–2013, the number of deaths due to peripartum

cardiomyopathy was more than double that of complications

related to RHD, and formed 34% of the total number of cardiac

deaths.

Our data suggest that care in the postpartum period needs

to be improved, possibly including earlier referral to the general

cardiac clinic or cardiomyopathy clinic. However, joint obstetric–

medical–cardiac clinics would be the optimal approach for these

patients. Medical physicians and cardiologists need to be actively

involved in the postpartum care of women with cardiac disease.

A need to provide focused training to medical registrars has

already been identified. Most tertiary level hospitals in South

Africa, such as Steve Biko Academic Hospital, Pretoria and

Groote Schuur Hospital, Cape Town, now provide a bi-weekly

cardiac–obstetric clinics and regular obstetric medicine lectures

in their registrar training programmes.

The use of simple screening equipment, such as hand-held

echocardiography and point-of-care testing for early-onset heart

failure, should be explored via research projects. A recent

publication evaluated the ability of medical students who

had previously received training in echocardiography (eight

hours) to detect RHD. The students’ averaged sensitivity for

diagnosing RHD was 81%, while specificity was 95%.

Hand-

held echocardiography as a routine diagnostic facility should be

considered as a training module for students and could improve

detection of significant cardiac disease in primary and secondary

care.

Research on the use of simple point-of-care testing on

NT-proBNP, a marker of early heart failure, could lead to earlier

detection of heart failure related to various forms of CVD.

Limitations

The retrospective analysis of patients’ files, and the limited

number of investigations that can be performed in primary or

secondary care or due to the emergency condition itself clearly

impacts on the quality of data that can be collected via such a

retrospective audit. It is a major limitation that not all patients’

files were accessible. In many cases the diagnosis, often made by

a junior doctor, could not be verified or the patient died prior to

reaching a higher-level hospital.

Conclusion

The pattern of CVD contributing to maternal deaths in South

Africa was dominated by cardiomyopathies and complications

of RHD, which could have been avoided to a large extent. There

is most likely an underestimation of maternity-related death,

as late maternal mortality (up to one year postpartum) is not

recorded. Infrastructural changes, use of an appropriate referral

algorithm and training of primary, secondary and tertiary staff

in cardiovascular disease complicating pregnancy is likely to

improve the outcome.

The authors thank the National Department of Health of South Africa for

the use of the data. K Sliwa acknowledges the Medical Research Council of

South Africa, the University of Cape Town, the Maurice Hatter Foundation

and Servier South Africa for institutional support.

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