Cardiovascular Journal of Africa: Vol 32 No 6 (NOVEMBER/DECEMBER 2021)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 6, November/December 2021 306 AFRICA Maternal outcomes The combined endpoint was seen in 21 (28.4%) women and any cardiac complication in 30 (40.5%) of the patients. The high rates of complications could partly be explained by the setting of the review, a tertiary centre attending to high-risk pregnancies. Other studies from different regions have shown rates of cardiac complications in 3.7 to 22.7% of pregnancies. 8,20,21 The large differences between these numbers could have been caused by differences in the definition of ‘cardiac complication’, and by women in this review first presenting late in their pregnancies with newly diagnosed disease and subsequently less time for optimal management throughout the pregnancy. There was one maternal death (1.4%), which could possibly have been avoided had she presented to antenatal care earlier in her pregnancy. Women with RHD had a significantly higher rate of cardiac complications. As women with RHD often have complex cardiac disease and many are on anticoagulation, this group would benefit greatly from pre-conceptual counselling and close follow up from the beginning of the pregnancy. 8 We found that a high heart rate on presentation, and peripheral oedema showed an increased risk for the patient later developing HF. Even a borderline tachycardia should be further investigated in order to detect any abnormalities at an early stage. Pre-eclampsia and pulmonary oedema were common in women with HHD. Pre-eclampsia is shown to be associated with HF in women with cardiac disease. 22 Due to lifestyle and poverty, a large proportion of this young patient group was obese and had co-morbidities such as chronic hypertension. Special attention should be given to cardiac patients with signs and symptoms of pre-eclampsia, as it is a major cause of maternal and neonatal morbidity and mortality. 3 Neonatal outcomes A high rate of prematurity and small-for-gestational-age babies was seen. This is in accord with a review on pregnancy in 2 491 women with congenital heart disease, 11 and could partly be due to worse adaptation of the heart to respond to the demands of pregnancy (such as poor placental perfusion due to poor cardiac output). 23 The rate of prematurity in our study (32.3%) was considerably higher than the overall number for South Africa, which was 8% for 2010. 24 Due to late presentation, many babies were exposed to harmful drugs in the first trimester. Furthermore, the presence of teratogenic medication, and the need to continue it despite foetal risk, indicates more severe disease in the mother, which is an independent, poor predictive factor for foetal outcome. 21 The high prevalence of pre-eclampsia in this review could partly explain the rate of prematurity. As prematurity can considerably affect long-term outcomes of children, great efforts should be made to ensure delivery at term, if feasible. We registered two perinatal mortalities (2.7% of all pregnancies, 3.2% of pregnancies carried past gestational week 26) compared to the institutional number of 4.4%. The review is however too small to reliably compare mortality rates with institutional numbers. The number of elective abortions ( n = 6, 8.1%), especially in women on anticoagulation or in mWHO class III or IV, emphasises the high burden of disease and intensive management needed in women with complicated heart disease, which needs to be discussed during pre-conceptual counselling. Strengths and limitations Astrength of this study is the detailed and comprehensive overview of the presentation and management, and maternal and neonatal outcomes in women with a wide variety of cardiac disease in pregnancy. The number of pregnant women with cardiac disease during the observed period shows that this is a very relevant issue in this population group. As the epidemiology of cardiac disease differs in different ethnic groups and in people with different socio-economic backgrounds, research on any subgroup is of value in order to contribute to future recommendations. CMJAH is one of several large, public academic hospitals in urban South Africa, and similar challenges can be expected to be present in other tertiary hospitals in the country. A limitation of this study is that the patient group was heterogenic, making comparison between subgroups less robust for statistical analysis. The large differences in the number of complications in our study compared to others could mean that standardised definitions of complications should be used in future research to better enable comparisons of outcomes between studies. The retrospective nature of this study based on handwritten documentation (and therefore sometimes incomplete journals) is sub-optimal for robust analysis of outcomes. Prospective studies with more comprehensive data collection, especially regarding clinical signs and symptoms on presentation, would be of value in contributing to the development of future guidelines. Conclusion There was a high rate of complications in this review of pregnant women with cardiac disease, with one maternal death, only 62 Table 6. Neonatal outcomes and mode of delivery Outcomes and delivery Number (%) Live births 62 (83.7) Cesarean section 42 (66.7) Emergency cesarean section 17 (40.5) Indication for cesarean section Maternal cardiac disease 11 (26.2) Combination of cardiac and obstetric and/or foetal 6 (14.3) Obstetric and/or foetal 25 (59.5) Elective abortion 6 (8.1) Mother’s choice 1 (16.7) Maternal cardiac disease 2 (33.3) Maternal obstetric indication 3 (50.0) Spontaneous abortion 5 (6.8) Stillbirth 1 (1.4) Early neonatal death 1 (1.4) Gestational age at birth, live births, median (IQR) 37.5 (35.8–38.0) Pre-term born (< 37 weeks) 20 (32.3) Very pre-term born (< 32 weeks) 6 (9.7) Low Apgar score at 5 min* 5 (8.1) Low Apgar score at 10 min* 2 (3.2) Birth weight (g), mean ± SD 2705 ± 687 Small for gestational age (< 10th percentile weight) 10 (16.1) Admissions to neonatal intensive care unit 5 (8.1) Congenital abnormalities 0 (0) *Score below 7 was deemed low