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

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 6, November/December 2021 302 AFRICA Methods A retrospective, observational review of patient records at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) was performed. CMJAH is a public tertiary hospital in Johannesburg, South Africa, with a combined cardiac obstetrics clinic. The files of all women of any age with any cardiac disease diagnosed before or during pregnancy or during the postpartum period (up to six months postpartum) who delivered in the period 1 January to 31 December 2017 were reviewed. Exclusion criteria were: insufficient information in the patient file on maternal cardiac disease or pregnancy, files wrongly marked as cardiac patients, and hypertension without proven left ventricular dysfunction. There were 89 patient files from this period that were marked as cardiac patients and 74 patient files were included in this review. Fig. 1 shows the flow chart for inclusion. There were no controls. A waiver of consent was granted by the Institutional Review Board as this was a retrospective review. The study was approved by the Human Research Ethics Committee (HREC) (Medical) at the University of the Witwatersrand, Johannesburg, with clearance certificate number M180901. Maternal data included demographic characteristics, risk factors for cardiac and obstetric complications, obstetric history, blood tests, medication, cardiological diagnosis, echocardiographic measurements, electrocardiogram (ECG), New York Heart Association functional class (NYHA FC) and mWHO score on first visit, clinical signs and symptoms, management during pregnancy or information on termination of pregnancy, mode of delivery, cardiac and non-cardiac complications during pregnancy and delivery, and maternal outcome. Foetal data included an anomaly scan. Neonatal data included gestational age at birth, birth weight, length, Apgar scores, complications, structural abnormalities and neonatal outcome. CMJAH is a centre using enoxaparin as standard in all pregnant women requiring anticoagulation. Cardiac complications were classified as any of the following complications that were not present on the first visit: arrhythmias needing therapy, any cardiomyopathy, infective or sterile endocarditis, heart failure (HF), sudden cardiac death, pulmonary oedema requiring ventilator support not caused by pre-eclampsia, deep-vein thrombosis or pulmonary embolism, HHD, pulmonary hypertension (PHT) (diagnosed by transthoracic echocardiography), ischaemic heart disease, and transfusion as a consequence of anticoagulation. A combined endpoint was used for severe cardiac complications: death, HF, myocardial infarction, surgical cardiac interventions, thromboembolic disease, and arrhythmia needing therapy. Perinatal mortality was defined as any death to the foetus after 26 weeks of gestation and early neonatal death until seven days postpartum. 18 Loss of the pregnancy prior to 26 weeks was defined as miscarriage (spontaneous or induced). Echocardiography was performed and interpreted by cardiologists at the cardiac obstetric clinic. A complete basic echocardiogram was performed on each patient, including two-dimensional, M-mode recording, and spectral and colour tissue Doppler measurements. 19 A standardised recording sheet is used for the patients at the cardiac obstetric clinic, including measurements of left atrial size, left ventricular dimensions and function, right ventricular function, evaluation of the aortic root and all valves, mean pulmonary arterial pressure, and assessment of the inferior vena cava, pericardium and any masses or shunts present. Statistical analysis IBM Statistical Package for the Social Sciences (SPSS) 25 was used for data analysis. Data are presented as numbers and percentages, as means with standard deviation (SD) or as median with range or interquartile range (IQR). For comparison between groups, the Student’s t -test, Mann–Whitney test, chi-squared test for independence and Fisher’s exact test were used as appropriate. Odds ratio (OR) is presented with the 95% confidence interval (CI). A p -value of 0.05 or less was used to deem results significant. Results The patient files of 74 women were included. Baseline characteristics are presented in Tables 1 and 2. Co-morbidities were common and 47 (63.5%) of the women had at least one co-morbidity. Themeanweek of first presentationwas gestational week (± SD) 17.0 (± 7.1), and five (6.8%) women presented only after delivery or miscarriage. All except one woman (98.6%) were seen by a cardiologist on at least one occasion, and 50 (67.6%) were seen by an anaesthesiologist. Women presenting on anticoagulation were switched to enoxaparin and seen weekly by a haematologist for optimal dose management. Type of cardiac disease, medication use and presentation RHD ( n = 21, 28.4%), PHT ( n = 13, 17.6%) and cardiomyopathies ( n = 11, 14.9%) were the most prevalent acquired cardiac diseases. CHD was seen in 12 (16.2%) patients, of whom six (50%) had been surgically treated in the past. Table 3 presents cardiac diagnoses and medication use. The same distribution of cardiac diseases was seen in women with and without co-morbidities. Table 4 shows a detailed echocardiographic assessment of the patients. Deliveries at CMJAH in 2017 ( n = 8 902) Patient files marked as cardiac ( n = 89) Files included for review ( n = 74) Patients excluded due to: • files incorrectly marked as cardiac ( n = 10) • hypertension without proven left ventricular dysfunction ( n = 4) • inadequate information on pregnancy and cardiac disease available ( n = 1) Fig. 1. Flow chart for inclusion of patients. CMJAH, Charlotte Maxeke Johannesburg Academic Hospital.