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

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 2, March/April 2016 84 AFRICA
Medical disease as a cause of maternal mortality:
the pre-imminence of cardiovascular pathology
AO Mocumbi, K Sliwa, P Soma-Pillay
Abstract
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 devel-
oped 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, undiag-
nosed pulmonary hypertension, uncontrolled heart failure
and complications of sickle cell disease may also be impor-
tant 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.
Submitted 6/9/15, accepted 2/3/16
Cardiovasc J Afr 2016; 27: 84–88
DOI: 10.5830/CVJA-2016-018
The 2010 Millennium Development Goals summit concluded
with an action plan to accelerate progress on maternal and child
health. The target of the millennium development goal 5 was
to reduce by three-quarters the maternal mortality ratio and
achieve universal access to reproductive health between 1990
and the end of 2015. A 2013 report by the United Nations states:
‘The maternal mortality ratio dropped by 45 per cent between
1990 and 2013, from 380 to 210 deaths per 100 000 live births.
All regions have made progress but accelerated interventions are
required in order to meet target.’1
The maternal mortality ratio in low- to middle-income
countries (LMIC) is 14 times higher than in high-income
countries (HIC). 1 Problems such as lack of antenatal care,
the need for family planning and education, and the low rates
of birth managed by skilled birth attendants contribute to
the high maternal deaths rates in LMICs. 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 however is an important
contributor to maternal mortality in both the developing and
developed world, justifying a better understanding of its profile
and relative burden in both regions.
Cardiac disease and maternity in high-income
countries
HIC such as the United States of America and the United
Kingdom have reported decreases in direct causes of maternal
mortality, but deaths due to cardiovascular disease have remained
unchanged or are increasing.2,3 Considering the surveillance
period in the United States (2006–2009), cardiovascular
conditions accounted for a third of all pregnancy-related deaths
(Fig. 1), while cardiac disease is currently the leading cause of
maternal mortality in the United Kingdom.3 The most common
causes of maternal death in the United Kingdom for the period
2006–2008 were sudden adult death syndrome, peripartum
cardiomyopathy, aortic dissection and myocardial infarction.4
There were no deaths due to rheumatic heart disease and a
decrease in deaths due to congenital heart disease. Lifestyle
factors such as advanced maternal age, obesity and smoking
were important contributors to maternal mortality.
Sudden adult death syndrome (SADS)
SADS is defined as sudden death in an adult where no cause
is identified. It is believed that obesity, cardiac hypertrophy
and severe atherosclerosis can cause arrhythmia and sudden
death.5 The condition is also associated with the presence of
high concentrations of circulating non-esterified fatty acids, and
women with central obesity are at greater risk than those with a
peripheral pattern of obesity. There were 10 maternal deaths due
to SADS in the United Kingdom during the period 2006–2008;
four mothers were obese (BMI 30–45 kg/m 2) and seven had an
enlarged heart (the median heart weight at autopsy was 390 g).
Instituto Nacional de Saúde and Department of Medicine,
Universidade Eduardo Mondlane, Maputo, Moçambique
AO Mocumbi, MD, PhD, FESC,
Hatter Institute for Cardiovascular Research in Africa, and
IDM, Department of Medicine, Faculty of Health Sciences,
University of Cape Town, South Africa; Soweto Cardiovascular
Research Unit, University of the Witwatersrand,
Johannesburg; Inter-Cape Heart Group, Medical Research
Council South Africa, Cape Town, South Africa
Karen Sliwa, MD, PhD, FESC,
Inter-Cape Heart Group, Medical Research Council South
Africa; University of Pretoria and Steve Biko Academic
Hospital, Pretoria, South Africa
P Soma-Pillay, MB ChB, MMed (O et G) FCOG, Cert (Maternal
and Foetal Med) SA