CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 1, January/February 2011
34
AFRICA
ing) high blood pressure values and continuing antihyperten-
sive therapy.
Discussion
It is of obvious concern that large numbers of deaths still occur
from pre-eclampsia and eclampsia in South Africa. These
pregnancy-specific hypertensive conditions are treatable and
most are preventable by early detection, adequate treatment and
timely delivery. The present report indicates that 304 cases were
clearly avoidable.
A recent article
5
indicates that in poorly resourced countries,
the availability of MgS0
4
and the lack of clinical protocols of
management are significant issues associated with maternal
deaths due to pre-eclampsia.
5
In South Africa, these factors
should not be issues, as MgS0
4
is widely available and is on the
essential drug list for use at all health facilities. Further, clinical
guidelines for the management of hypertension and, in particu-
lar, the management of obstetric emergencies have been widely
distributed to all hospitals and clinics (Guidelines for Maternity
Care in South Africa; Essential steps in the management of
common conditions associated with maternal mortality). It does
appear though that these guidelines might not be reaching all
health professionals. Face-to-face teaching and emergency drills
on the labour ward floor, on a regular basis, may improve the
situation.
Intracranial haemorrhage remains the commonest final cause
of death in hypertensive disorders of pregnancy. Although, the
exact mechanisms that are associated with hypertension and
intracranial haemorrhage are not clearly understood, it would
appear that both systolic and diastolic hypertension play a
role. It is generally accepted that diastolic blood pressures of
≥
110 mmHg are linked with intracranial pathology but recently
sustained systolic hypertension has also been found to play a
significant role. A systolic blood pressure value above which
urgent antihypertensive treatment should be given has been iden-
tified as 155–160 mmHg.
6
In addition, the latest Why Women
Die, 2003–2005 publication recommends ‘that women with a
systolic blood pressure of
≥
160 mmHg need antihypertensive
treatment. Consideration should also be given to initiating anti-
hypertensive treatment at lower blood pressure values if the over-
all clinical picture suggests rapid deterioration with anticipation
of severe hypertension’.
1
Clinical experience indicates that in young women with an
abrupt onset of severe hypertension, the blood pressure levels
are often labile, therefore not only should blood pressure meas-
urements be performed more frequently, but early treatment of
hypertension considered. Treatment of very high blood pressure
is an essential component of the immediate management of
severe hypertension, impending eclampsia and eclampsia, and
serious consideration must be given to the use of rapid-acting
antihypertensive agents. In South Africa, oral nifedipine, dihy-
drallazine in some institutions, and intravenous labetalol are
available for this purpose.
The commonly used antihypertensive medications for lower-
ing very high blood pressure in pregnancy in South Africa
are labetalol, dihydrallazine and nifedipine. These drugs are
recommended in the Guidelines for maternity care for clinics
and district hospitals.
7
Parenteral hydralazine and labetalol are
not easily available at district hospitals in South Africa. Oral
nifedipine is therefore recommended in emergencies to lower
very high blood pressure. About 11% of women with hyperten-
sive crises require rapid-acting agents and in order to reduce the
hypotensive episodes associated with these medications, it has
been recommended that acute high blood pressure be reduced
reasonably quickly but in a controlled manner, ideally by slow
bolus injections or titration of parenteral drugs. In pregnancy,
sodium nitroprusside is only used in an ICU setting or in the
operating theatre, therefore the agents most available for use are
labetalol, dihydrallazine and nifedipine.
7,8
The latest Saving Mothers report (2005–2007) indicates a
number of women developed eclampsia/severe hypertension
in the postpartum period. This suggests that antihypertensive
medications are stopped once delivery of the baby has occurred.
In general, high blood pressures may take up to six weeks to
normalise. Therefore, antihypertensive medications must be
continued postpartum and the dosage reduced in a stepwise
manner.
Cardiac and renal failure were assigned as the final and
contributory causes of maternal deaths in 42.9 and 8% of cases,
respectively. The number of cases of death due to renal failure
has declined but those from cardiac failure have increased since
the 2002–2004 report. In the previous report,
3
it was believed that
guidelines for the appropriate fluid balance might be working.
However, it is of concern that the number of deaths from cardiac
failure (probably pulmonary oedema) has increased, particularly
when guidelines on fluid balance are available. In the latest UK
report (Why Women Die), there were no deaths from pulmo-
nary causes alone, and this improvement is probably due to the
availability and informed use of clinical protocols on good fluid
management.
1
In a recent report on maternal deaths related to hypertension,
one of 27 deaths between 2000 and 2004 was due to cardiac
failure. The authors point out that postpartum mobilisation of
extracellular water and subsequent shift into the intravascular
compartment can aggravate hypertension, and that obstetricians
should be aware of this.
9
The categorisation of patients into deaths from renal failure,
cardiac failure and respiratory causes of death is to a large extent
arbitrary and should not necessarily be viewed as distinct entities.
The three entities should be regarded as the same thing, namely
fluid overload. Fluid overload should be recognised early and
be treated adequately. There is a predominance of deaths from
pulmonary oedema in this group of deaths. Therefore, detecting
patients at risk by history and examination, early referral and
appropriate critical care are essential for this group of patients.
In this audit, of the 207 women who had cerebral complica-
tions, the average blood pressure values were systolic 177 (103–
244 mmHg) and diastolic 115 mmHg (74–162 mmHg). These
are extremely high values and do imply that young women with
severe pre-eclampsia and eclampsia require lowering of high
blood pressure in a controlled and smooth manner to prevent
severe hypotension. This is of particular importance as most of
the patients are young and the onset of hypertension is usually
abrupt.
Eighty per cent of the 207 women who had convulsions were
primigravidae and their mean age was 27 years (range 13–45).
Furthermore, 16 had systolic blood pressure values above 160
mmHg with diastolic blood pressures of less than 110 mmHg.
High blood pressure control is of extreme importance and due
