CARDIOVASCULAR JOURNAL OF AFRICA: VOLUME 27, ISSUE
2, MAR/APR 2016
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- Cardiovascular disease in pregnancy:
the South African perspective
Authors: Anthony, J; Sarkin, A; Sliwa, K
From: Cardiovascular Journal of Africa, Vol 27, Issue 2, March/April
Published: 2016
Pages: 59
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Abstract: 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.
- Title: The importance of
cardiovascular pathology contributing to
maternal death: Confidential Enquiry into
Maternal Deaths in South Africa, 2011–2013
Authors: Soma-Pillay, P; Seabe, J; Sliwam, K
From: Cardiovascular Journal of Africa, Vol 27, Issue 2, March/April
Published: 2016
Pages: 60-65
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DOI Number:10.5830/CVJA-2016-008
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-008
Aim: Cardiac disease is emerging as an important contributor to maternal deaths in both lower-to-middle and higher-income countries. There has been a steady increase in the overall institutional maternal mortality rate in South Africa over the last decade. The objectives of this study were to determine the cardiovascular causes and contributing factors of maternal death in South Africa, and identify avoidable factors, and thus improve the quality of care provided.
Methods: Data collected via the South African National Confidential Enquiry into Maternal Deaths (NCCEMD) for the period 2011–2013 for cardiovascular disease (CVD) reported as the primary pathology was analysed. Only data for maternal deaths within 42 days post-delivery were recorded, as per statutory requirement. One hundred and sixty-nine cases were reported for this period, with 118 complete hospital case files available for assessment and data analysis.
Results: Peripartum cardiomyopathy (PPCM) (34%) and complications of rheumatic heart disease (RHD) (25.3%) were the most important causes of maternal death. Hypertensive disorders of pregnancy, HIV disease infection and anaemia were important contributing factors identified in women who died of peripartum cardiomyopathy. Mitral stenosis was the most important contributor to death in RHD cases. Of children born alive, 71.8% were born preterm and 64.5% had low birth weight. Seventy-eight per cent of patients received antenatal care, however only 33.7% had a specialist as an antenatal care provider. Avoidable factors contributing to death included delay in patients seeking help (41.5%), lack of expertise of medical staff managing the case (29.7%), delay in referral to the appropriate level of care (26.3%), and delay in appropriate action (36.4%).
Conclusion: The pattern of CVD contributing to maternal death in South Africa was dominated by PPCM and complications of RHD, which could, to a large extent, have been avoided. It is likely that there were many CVD deaths that were not reported, such as late maternal mortality (up to one year postpartum). Infrastructural changes, use of appropriate referral algorithm and training of primary, secondary and tertiary staff in CVD complicating pregnancy is likely to improve the outcome. The use of simple screening equipment and point-of-care testing for early-onset heart failure should be explored via research projects.
- Title: Electrocardiographic predictors of peripartum cardiomyopathy
Authors: Karaye, KM; Lindmark, K; Henein, MY
From: Cardiovascular Journal of Africa, Vol 27, Issue 2, March/April
Published: 2016
Pages: 66-70
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DOI Number:10.5830/CVJA-2015-092
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-092
Objective: To identify potential electrocardiographic predictors of peripartum cardiomyopathy (PPCM).
Methods: This was a case–control study carried out in three hospitals in Kano, Nigeria. Logistic regression models and a risk score were developed to determine electrocardiographic predictors of PPCM.
Results:A total of 54 PPCM and 77 controls were consecutively recruited after satisfying the inclusion criteria. After controlling for confounding variables, a rise in heart rate of one beat/minute increased the risk of PPCM by 6.4% (p = 0.001), while the presence of ST–T-wave changes increased the odds of PPCM 12.06-fold (p < 0.001). In the patients, QRS duration modestly correlated (r = 0.4; p < 0.003) with left ventricular dimensions and end-systolic volume index, and was responsible for 19.9% of the variability of the latter (R2 = 0.199; p = 0.003). A risk score of ≥ 2, developed by scoring 1 for each of the three ECG disturbances (tachycardia, ST–T-wave abnormalities and QRS duration), had a sensitivity of 85.2%, specificity of 64.9%, negative predictive value of 86.2% and area under the curve of 83.8% (p < 0.0001) for potentially predicting PPCM.
Conclusion: In postpartum women, using the risk score could help to streamline the diagnosis of PPCM with significant accuracy, prior to confirmatory investigations.
- Title: Pre-eclampsia: its
pathogenesis and pathophysiolgy
Authors: Gathiram, P; Moodley, J
From: Cardiovascular Journal of Africa, Vol 27, Issue 2, March/April
Published: 2016
Pages: 71-78
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DOI Number: 10.5830/CVJA-2016-009
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-009
Abstract: Pre-eclampsia is a pregnancy-specific disorder that has a worldwide prevalence of 5–8%. It is one of the main causes of maternal and perinatal morbidity and mortality globally and accounts for 50 000–60 00 deaths annually, with a predominance in the low- and middle-income countries. It is a multisystemic disorder however its aetiology, pathogenesis and pathophysiology are poorly understood. Recently it has been postulated that it is a two-stage disease with an imbalance between angiogenic and anti-antigenic factors. This review covers the latest thoughts on the pathogenesis and pathology of pre-eclampsia. The central hypothesis is that pre-eclampsia results from defective spiral artery remodelling, leading to cellular ischaemia in the placenta, which in turn results in an imbalance between anti-angiogenic and pro-angiogenic factors. This imbalance in favour of anti-angiogenic factors leads to widespread endothelial dysfunction, affecting all the maternal organ systems. In addition, there is foetal growth restriction (FGR). The exact aetiology remains elusive.
- Title: Pre-conception counselling for key cardiovascular conditions
in Africa: optimising pregnancy outcomes
Authors: Zühlke, L; Acquah, L
From: Cardiovascular Journal of Africa, Vol 27, Issue 2, March/April
Published: 2016
Pages: 79-83
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DOI Number: 10.5830/CVJA-2016-017
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-017
Abstract: The World Health Organisation (WHO) supports pre-conception care (PCC) towards improving health and pregnancy outcomes. PPC entails a continuum of promotive, preventative and curative health and social interventions. PPC identifies current and potential medical problems of women of childbearing age towards strategising optimal pregnancy outcomes, whereas antenatal care constitutes the care provided during pregnancy. Optimised PPC and antenatal care would improve civil society and maternal, child and public health. Multiple factors bar most African women from receiving antenatal care. Additionally, PPC is rarely available as a standard of care in many African settings, despite the high maternal mortality rate throughout Africa. African women and healthcare facilitators must cooperate to strategise cost-effective and cost-efficient PPC. This should streamline their limited resources within their socio-cultural preferences, towards short- and long-term improvement of pregnancy outcomes.
This review discusses the relevance of and need for PPC in resource-challenged African settings, and emphasises preventative and curative health interventions for congenital and acquired heart disease. We also consider two additional conditions, HIV/AIDS and hypertension, as these are two of the most important co-morbidities encountered in Africa, with significant burden of disease. Finally we advocate strongly for PPC to be considered as a key intervention for reducing maternal mortality rates on the African continent.
- Title: Medical disease as a cause of
maternal mortality: the pre-imminence of
cardiovascular pathology
Authors: Mocumbi, AO; Sliwa, K; Soma-Pillay, P
From: Cardiovascular Journal of Africa, Vol 27, Issue 2, March/April
Published: 2016
Pages: 84-88
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DOI Number: 10.5830/CVJA-2016-018
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-018
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 developed 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, undiagnosed pulmonary hypertension, uncontrolled heart failure and complications of sickle cell disease may also be important 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.
- Title: Physiological changes in pregnancy
Authors: Soma-Pillay, P; Nelson-Piercy, C; Tolppanen, H; Mebazaa, A
From: Cardiovascular Journal of Africa, Vol 27, Issue 2, March/April
Published: 2016
Pages: 89-94
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DOI Number: 10.5830/CVJA-2016-021
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-021
Abstract: Physiological changes occur in pregnancy to nurture the developing foetus and prepare the mother for labour and delivery. Some of these changes influence normal biochemical values while others may mimic symptoms of medical disease. It is important to differentiate between normal physiological changes and disease pathology. This review highlights the important changes that take place during normal pregnancy.
- Title: Diagnosing cardiac disease during pregnancy: imaging
modalities
Authors: Ntusi, NAB; Samuels, P; Moosa, S; Mocumbi, AO
From: Cardiovascular Journal of Africa, Vol 27, Issue 2, March/April
Published: 2016
Pages: 95-103
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DOI Number: 10.5830/CVJA-2016-022
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-022
Abstract: Pregnant women with known or suspected cardiovascular disease (CVD) often require cardiovascular imaging during pregnancy. The accepted maximum limit of ionising radiation exposure to the foetus during pregnancy is a cumulative dose of 5 rad. Concerns related to imaging modalities that involve ionising radiation include teratogenesis, mutagenesis and childhood malignancy. Importantly, no single imaging study approaches this cautionary dose of 5 rad (50 mSv or 50 mGy). Diagnostic imaging procedures that may be used in pregnancy include chest radiography, fluoroscopy, echocardiography, invasive angiography, cardiovascular computed tomography, computed tomographic pulmonary angiography, cardiovascular magnetic resonance (CMR) and nuclear techniques.
Echocardiography and CMR appear to be completely safe in pregnancy and are not associated with any adverse foetal effects, provided there are no general contra-indications to MR imaging. Concerns related to safety of imaging tests must be balanced against the importance of accurate diagnosis and thorough assessment of the pathological condition. Decisions about imaging in pregnancy are premised on understanding the physiology of pregnancy, understanding basic concepts of ionising radiation, the clinical manifestations of existent CVD in pregnancy and features of new CVD. The cardiologist/physician must understand the indications for and limitations of, and the potential harmful effects of each test during pregnancy. Current evidence suggests that a single cardiovascular radiological study during pregnancy is safe and should be undertaken at all times when clinically justified. In this article, the different imaging modalities are reviewed in terms of how they work, how safe they are and what their clinical utility in pregnancy is. Furthermore, the safety of contrast agents in pregnancy is also reviewed.
- Title: Hypertensive disorders of pregnancy: what the physician needs
to know
Authors: Anthony, J; Damasceno, A; Ojjii, D
From: Cardiovascular Journal of Africa, Vol 27, Issue 2, March/April
Published: 2016
Pages: 104-110
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DOI Number: 10.5830/CVJA-2016-051
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-051
Abstract: Hypertension developing during pregnancy may be caused by a variety of different pathophysiological mechanisms. The occurrence of proteinuric hypertension during the second half of pregnancy identifies a group of women whose hypertensive disorder is most likely to be caused by the pregnancy itself and for whom the risk of complications, including maternal mortality, is highest. Physicians identifying patients with hypertension in pregnancy need to discriminate between pre-eclampsia and other forms of hypertensive disease. Pre-eclamptic disease requires obstetric intervention before it will resolve and it must be managed in a multidisciplinary environment. The principles of diagnosis and management of these different entities are outlined in this review.
- Title: Valvular heart disease in
pregnancy
Authors: Anthony, J; Osman, A; Sani, MU
From: Cardiovascular Journal of Africa, Vol 27, Issue 2, March/April
Published: 2016
Pages: 111-118
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DOI Number: 10.5830/CVJA-2016-052
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2016-052
Abstract: Valvular heart disease may be a pre-existing complication of pregnancy or it may be diagnosed for the first time during pregnancy. Accurate diagnosis, tailored therapy and an understanding of the physiology and pathophysiology of pregnancy are necessary components of management, best achieved through the use of multidisciplinary clinics. This review outlines the management of specific lesions, with particular reference to post-rheumatic valvular heart disease.
- Title: Assessing perinatal depression as an indicator of risk for
pregnancy-associated cardiovascular disease
Authors: Nicholson, L; Lecour, S; Wedegärtner, S; Kindermann, I; Böhm, M; Sliwa, K
From: Cardiovascular Journal of Africa, Vol 27, Issue 2, March/April
Published: 2016
Pages: 119-122
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DOI Number: 10.5830/CVJA-2015-087
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-087
Abstract: Cardiovascular conditions associated with pregnancy are serious complications. In general, depression is a well-known risk indicator for cardiovascular disease (CVD). Mental distress and depression are associated with physiological responses such as inflammation and oxidative stress. Both inflammation and oxidative stress have been implicated in the pathophysiology of CVDs associated with pregnancy. This article discusses whether depression could represent a risk indicator for CVDs in pregnancy, in particular in pre-eclampsia and peripartum cardiomyopathy (PPCM).
- Title: Pregnancy and childbirth in a patient after multistep surgery
and endovascular treatment of cardiovascular disease
Authors: Buczkowski, P; Puślecki, M; Stefaniak, S; Kulesza, J; Trojnarska, O; Urbanowicz, T; Jemielity, M
From: Cardiovascular Journal of Africa, Vol 27, Issue 2, March/April
Published: 2016
Pages: 123-124
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DOI Number: 10.5830/CVJA-2015-084
DOI Citation Reference Link: dx.doi.org/10.5830/CVJA-2015-084
Abstract: Nowadays physicians see an increasing population of patients reaching reproductive age after surgery for complex congenital heart defects. Correction of congenital and acquired cardiovascular defects does not exclude experiencing a safe pregnancy. We present the case of a 27-year-old woman, who, after multistep surgery and endovascular treatment of her cardiovascular system, underwent successful pregnancy and uncomplicated childbirth. Recent developments in medicine and interdisciplinary involvement have allowed women with corrected cardiovascular disease the opportunity to become pregnant and experience safe childbirth.
