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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 27, No 2, March/April 2016
AFRICA
63
low-molecular weight heparin without any monitoring of anti-
Xa levels and no anti-coagulant was prescribed in the other
patient post-delivery.
The average age of the mothers who died was 28.1
±
6.49
years. Twenty-four (68.5%) mothers presented for antenatal
care with a known history of cardiac disease, while 11 (31.5%)
mothers had undiagnosed cardiac lesions prior to pregnancy.
Twenty-six (74.1%) mothers booked for antenatal care but only
12 (34. 3%) were managed at a tertiary institution during the
antenatal period. Death occurred in the following institutions:
level one facility, two patients (5.7%); level two hospitals, 11
(3.4%), and level three hospitals, 22 (62.9%).
Table 3 summarises the factors contributing to death for
the entire study population, as well as women with PPCM and
RHD. This information was obtained from the MDNF and is
the opinion of the clinician reporting the death. Some patients
had more than one avoidable factor.
In 24.3% of cases, the assessors believed that different
management could reasonably have been expected to affect
outcome. The problems of failure to make a diagnosis, incorrect
management and delay in referring patients to the appropriate
level of care were important factors that contributed to cardiac
mortality (Table 4).
Discussion
This study has shown a disease pattern markedly different to
that seen in high-income countries, with cardiomyopathies and
RHD most commonly leading to death, often complicated
by HIV/AIDS, hypertension and anaemia as co-morbidities.
Confidential inquiries on maternal death reports from European
high-income countries and the European EURObservational
Research Programme registry on cardiac disease in pregnancy
typically report operated congenital heart disease as the most
common mode of death.
5
Access to care, avoidable factors and late maternal
death
The majority of patients attended antenatal care but booked
late. Only one-third had access to a specialist as an antenatal
care provider. The most important avoidable factors contributing
to death included: delay in patients seeking help (
>
50% of
patients), lack of expertise of medical staff managing the case
(30%), delay in referral to the appropriate level of care, and
inappropriate action.
A recent single-centre prospective cohort study from Groote
Schuur Hospital
6
has reported that most deaths were due to
different forms of cardiomyopathies, with only two related to
complications attributable to sepsis and thrombosis affecting
prosthetic heart valves. However, eight out of the nine deaths
reported in this 152-patient cohort with a six-month post-delivery
outcome period would not have been reported if the definition
of death within 42 days had been applied. This highlights the
underestimation of the number of cardiac deaths related to
pregnancy as a result of the late presentation, and these deaths
are especially important among women with familial or PPCM.
The European Society of Cardiology working group on
PPCM has defined PPCM as an ‘idiopathic’ cardiomyopathy
presenting with heart failure secondary to left ventricular
systolic dysfunction towards the end of pregnancy, or in the
months following delivery, where no other cause of heart
failure is found.
7
Patients most commonly present two to three
months postpartum and therefore outside the 42 days reporting
period.
8
This condition may be difficult to distinguish from
other forms of cardiomyopathy, such as familial or pre-existing
idiopathic dilated cardiomyopathy, which usually presents prior
to pregnancy or in the second or third trimester.
Reported incidence for PPCM varies among different
geographic regions, with potential hotspots in Africa (1:100 to
1:1 000).
9
There has been an increase in the reporting of PPCM
in high-income countries in the past decade and this is probably
due to increasing awareness created by a large prospective
international registry on PPCM, the ESC EURObservational
Research Programme
(http://www.eorp.org).
10
At present the
overall mortality rate is between 10 and 25%.
The fact that more than two-thirds of all deaths occurred
post-partum and that PPCM was the most common condition
leading to death in this tri-annual report is an important finding.
It also implies that the maternal death rate in South Africa,
which is already estimated to be 176/100 000,
2
is underestimated,
as death could only be reported until 42 days postpartum.
Cardiomyopathies or other causes of left ventricular dysfunction
that often present with heart failure or severe arrhythmia leading
to death beyond that period is of major concern. These deaths
are pregnancy related, even at late presentation.
Interventions to prevent these deaths include adequate
counselling about the risks of future pregnancy, access to
adequate contraceptive services, termination of breastfeeding,
and use of the medication bromocriptine
8
in patients with
PPCM. This is crucial as available data strongly suggest that
subsequent pregnancy in patients with PPCM is associated with
a high risk of relapse and death.
11
Improving care for women with undiagnosed,
diagnosed and operated RHD
Valvular heart disease in pregnant women, whether due to
congenital or acquired aetiologies, such as RHD, poses a
challenge to clinicians and their patients. Significant valve
Table 4. Foetal outcome for all pregnant women (
n
=
118),
women with peripartum cardiomyopathy (
n
=
41)
and rheumatic heart disease (
n
=
35)
Whole
group
Peripartum
cardiomyopathy
Rheumatic
heart disease
n
(%)
n
(%)
n
(%)
In utero
death
11 (9.3)
4 (9.8)
3 (8.6)
Gestation, mean (
±
SD)
32 (7.7)
35.6 (6.9)
27.2 (8.9)
Born preterm (
<
37 weeks gestation) 51 (71.8)
14 (34.1)
15 (42.9)
Low birth weight (
<
2 500 g)
37 (64.5)
10 (24.3)
11 (31.4)
Table 3. Factors contributing to death for the two major disease groups
Whole
group
Peripartum
cardiomyopathy
Rheumatic
heart disease
Avoidable factor
n
(%)
n
(%)
n
(%)
Patient delay in seeking help
49 (41.5)
16 (39.0)
16 (45.7)
Lack of expertise by medical staff
managing case
35 (29.7)
16 (39.0)
12 (34.3)
Delay in referral to appropriate level
of care
31 (26.3)
13 (31.7)
8 (22.9)
Delay in appropriate action
43 (36.4)
15 (36.6)
15 (42.9)