CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 1, January/February 2011
AFRICA
35
diligence must be given to use of rapid-acting antihypertensive
agents and frequent blood pressure measurements in the acute
phase of the condition. Attention should also be given to the use
of anticonvulsant therapy to arrest seizure activity. It is likely that
the blood pressure rises further during seizure activity and that
most cerebrovascular accidents occur at this time, particularly in
patients with low platelet counts.
Infrequent antenatal attendance continues to be a challenge.
In the public hospitals of South Africa, most women ‘book’ for
antenatal care but often this is in mid-gestation, and follow-up
visits are infrequent. Community education on the benefits of
antenatal care was emphasised in the last Saving Mothers report,
but it appears that implementation of this recommendation may
not have been done. Public health education and involvement of
partners and families should, once again, be a priority.
In the previous report, the issue of ‘hidden pregnancies’ was
highlighted.
3
In this report a large proportion of young women
died from eclampsia.
2
In particular, three teenagers aged 13, 14
and 15 years stand out. All had hidden pregnancies, therefore
there was considerable delay in seeking help. Education, provi-
sion of contraception and family support are key factors in
preventing teenage pregnancies
Maternity care is free of financial cost in South Africa and
access to antenatal clinics widely available, therefore other
issues, social and cultural factors may be involved. Improvement
in education in general, the dissemination of health information
on radio, television and the print media may be ways of over-
coming this challenge. More specifically, education of antenatal
attendees at time of booking and at every visit should be empha-
sised. Women with chronic hypertension or those pre-eclamptics
being treated as outpatients should be informed about the likely
complications and steps to take if these symptoms occur.
The previous report also highlighted the problems related
to emergency management and recommendations were made
regarding under-, post-graduate and continuing professional
education, short of instituting that all doctors should undergo a
course on emergency resuscitation prior to registering as general
practitioners. Hands-on courses on mannequins done at frequent
intervals are also recommended. The National Committee on
Confidential Enquiries into Maternal Deaths is promoting a
training programme on obstetric emergencies called Essential
Steps in the Management of Obstetric Emergencies (ESMOE).
This involves trainers visiting all health districts and carrying out
face-to-face training for doctors on mannequins and other visual
aids on the emergency management of common conditions caus-
ing maternal deaths.
Conclusion
Deaths from hypertensive disorders of pregnancy remain the
commonest direct cause of maternal death and most of the deaths
had avoidable factors and substandard care. There is a continuing
need for better education of women, families, communities and
professionals concerning the danger signs of the complications
of hypertension. The need for early and regular attendance of
antenatal care should also be emphasised. In addition, health
professionals need to be educated about women at risk and be
aware of factors associated with complications associated with
pregnancy hypertension (Table 8).
References
1. Neilson J. Pre-eclampsia and eclampsia in why women die 2003–2005.
Nice, UK: 72.
2. National Committee on Confidential Enquiries into Maternal Deaths.
Saving Mothers fourth report 2005–2007. Pretoria: Department of
Health, 2009.
3. National Committee on Confidential Enquiries into Maternal Deaths.
Saving Mothers: third report on confidential enquiries into maternal
deaths in South Africa 2002–2004. Pretoria: Department of Health,
2005.
4. National Committee on Confidential Enquiries into Maternal Deaths.
Saving Mothers: third report on confidential enquiries into maternal
deaths in South Africa 1999–2001. Pretoria: Department of Health,
2006.
5. Langer A, Villar J, Tell K,
et al
. Reducing eclampsia related deaths – a
call to action.
Lancet
2008;
371
: 705–706.
6. Martin NL (jun), Thigpen MF, Moore RC,
et al
. Stroke and pre-eclamp-
sia and eclampsia: a paradigm shift focusing on systolic blood pressure.
Obstet Gynecol
2005;
105
: 246–254.
7. Department of Health.
Guidelines for Maternity Care in South
Africa.
3rd edn. Pretoria: Department of Health, South Africa, 2007.
8. Paruk F, Moodley J. Untoward effects of rapid-acting antihypertensive
agents. In: S Arukumaran, J Moodley (eds).
Best Practice and Research
Clinical Obstetrics and Gynaecology.
London: Harcourt Ltd, 2001;
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(4): 491–506.
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Br J Obstet Gynaecol
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TABLE 8. BEAWARE / BEALERT
Preventing cerebrovascular accidents:
• Treat sustained systolic hypertension (
≥
160 mmHg)
• Treat fluctuating (very high levels) blood pressure (
≥
160 mmHg).
Lower high blood pressure smoothly with IV antihypertensive
agents
• Need for continuing close blood pressure monitoring; continuing
antihypertensive drugs in the immediate postpartum period
• The use of MgS0
4
in severe fulminant hypertension and its contin-
ued use for up to 24 hours following delivery
Preventing pulmonary oedema:
• Fluid overload: watch out for early signs
Continuing education:
• Face-to-face training on obstetric emergencies and the use of
obstetric drills
