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 AFRICA 59
Editorial
Cardiovascular disease in pregnancy: the South African
perspective
John Anthony, Andrew Sarkin, Karen Sliwa
Maternal mortality in South Africa, as in many developing nations,
is avoidably high. The causes of death are well documented because
statutory notification of mortality, happening during pregnancy and
for 42 days after delivery, has been in place for 15 years now. The
mortality data have been compiled into a triennial report (Saving
Mothers) published by the National Department of Health.1 These
reports map the epidemiology of avoidable maternal mortality,
for which there are diverse causes, none more significant than the
dual failure on the part of attending clinicians to correctly identify
potentially life-threatening illness, together with recurrent failure to
provide an adequate standard of care to ill pregnant women.
The death of a pregnant woman may adversely affect the chance
that her surviving children will thrive. In South Africa approximately
1 600 women die every year because of pregnancy complications.
Many others suffer the burden of on-going morbidity related
to childbirth. Preventing premature death and disability among
women and children is a priority to which the National Department
of Health has committed itself. Given the pivotal role of women
in society, especially within poorer communities, this targeted
intervention is one with which few would take issue.
The epidemiology of maternal mortality informs a variety of
proposed recommendations aimed at reducing the risk of death
related to childbirth. The burden of disease is described by Soma-
Pillay and Sliwa in this issue (page 60). The contribution of cardiac
disease in pregnancy is recognised to be the single most prevalent
medical disorder giving rise to death during pregnancy among South
African women. Reducing deaths due to cardiac disease has not yet
been accomplished. The need for accurate diagnosis and appropriate
management depends on identifying women with some evidence
of cardiac disease, followed by referral to an appropriate level of
medical care where the greatest available level of expertise may be
employed in the further management of such patients.
However, such a simple principle is difficult to implement. Often
those providing care at the community level (where most South
African women deliver their babies) are ill-equipped to recognise
significant disease and even less able to provide the necessary
medical management. Innovative approaches have been necessary
and are also part of the recommendations made in the triennial
report.
Sliwa et al. have described the function of a combined obstetric
and cardiac clinic where multi-disciplinary care is provided to women
with suspected heart disease.2 The object of this clinic is to diagnose,
triage and implement care during pregnancy and to ensure that
those who present with undiagnosed disease during pregnancy have
ongoing access to care after childbirth. Preconception counselling
and contraceptive advice are all provided within the same clinical
environment. The triennial report has endorsed this type of
combined clinic that encompasses the skills of both obstetricians
and cardiologists as a means to eliminate any failure to recognise
problems correctly and to ensure that the incidence of substandard
care is kept to a minimum.
Such clinics are feasible in metropolitan areas of the country
where the greatest concentration of people live. Smaller towns
and rural communities have less access to the same level of care.
Nevertheless, co-responsibility for patient care between practitioners
with different skills sets is recognised to be beneficial, and combined
obstetric and medical clinics have been suggested as an attainable
goal throughout the country. Monthly joint clinics would enable
more considered evaluation of suspected medical disorders during
pregnancy and an enhanced level of care together with appropriate
referral to regional hospitals.
The difficulty of discerning between normal pregnancy
physiology and clinical disease, as well as understanding the impact
of pregnancy physiology on underlying medical disease has not been
taught or examined in the post-graduate training curriculum of
general physicians. The anticipated benefits of combined care would
only be realised once essential aspects of pregnancy physiology
and pathophysiology and their influence on the expression and
management of medical disease complicating pregnancy is
incorporated into the university curriculum. Such changes are under
consideration at present and to that end, this publication establishes
a template for understanding the epidemiology of cardiac problems
in pregnancy, understanding the (patho)physiology of pregnancy
and how interventions, both obstetric and medical, may influence
the outcome of these pregnancies. The broader object of this process
still remains the targets set 15 years ago and enunciated as the
millennium development goals.3
References
1. National Department of Health. Saving Mothers 2011–2013: Sixth
report on confidential enquiries into maternal deaths in South Africa.
Short report, 2015.
2. Sliwa K, et al. Spectrum of cardiac disease in maternity in a low-
resource cohort in South Africa. Heart 2014: p. heartjnl-2014-306199.
3. United Nations Declaration. Millennium Development Goals, 2000.
Division of Obstetrics and Gynaecology, Groote Schuur
Hospital, University of Cape Town, South Africa
John Anthony, MB BCh, FCOG, MPhil,
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,
Department of Cardiology, Faculty of Health Sciences,
University of Pretoria, South Africa
Andrew Sarkin, MB BCh, FCP (Med)