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

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 6, November/December 2021 AFRICA 303 Anticoagulation was used by 11 (14.9%) patients at baseline (in eight for metallic valve replacement, in two for cardiological complications associated with autoimmune systemic disease and in one for unoperated mixed mitral valve disease with atrial fibrillation). All of them had conceived on warfarin. Due to late presentation, 50% of switches from warfarin or other unsafe medication in pregnancy happened after the first trimester. Enoxaparin was started in 27 (36.5%) patients during their pregnancy (for valve disease, thromboembolic disease, PHT, cardiomyopathy, biventricular failure and intrinsic lung disease). One patient was thrombolysed with alteplase for bilateral pulmonary embolism and both mother and baby had good outcomes. There were no thromboembolic events in women using anticoagulation at conception. Maternal outcomes Cardiac complications were seen in 30 (40.5%) patients, and the combined endpoint was seen in 21 (28.4%) of the pregnancies (Table 5). The presence of any co-morbidity was not related to a higher prevalence of cardiac complications. There was one maternal death. She first presented to the clinic at gestational week 32 in respiratory distress. She was treated with therapeutic enoxaparin for PHT and congestive HF secondary to pulmonary embolism. She had defaulted on her treatment for severe right heart disease. She underwent an elective caesarean section at gestational week 34. One day postpartum, she developed decompensated HF and died after attempted cardiopulmonary resuscitation. The baby needed resuscitation but was discharged alive. One woman with newly diagnosed RHD presented with severe mitral valve stenosis and severe PHT. She underwent balloon valvuloplasty during the pregnancy and both she and the baby had good outcomes. See Fig. 2 for an overview of maternal outcomes. Of the 15 (20.3%) patients that later developed HF, 12 (80.0%) had attended antenatal care. The mean heart rate at first visit of the patients who later developed HF was significantly higher than in the patients who did not: 99 (± 19) vs 86 (± 14) beats per minute (bpm), p = 0.007. Patients with peripheral oedema at presentation had 17 times higher risk of developing Table 1. Demographics and baseline characteristics Characteristics Values Black African ethnicity, n (%) 69 (93.2) Body mass index (kg/m 2 ), mean ± SD ( n = 51) 30.0 ± 7.3 Maternal age (years), mean ± SD 30.2 ± 6.4 Smoking, n (%) 2 (2.7) Obstetric history and current pregnancy Gravida (median, range) 3 (1–9) Para (median, range) 1 (0–6) Primigravida, n (%) 10 (13.5) Current pregnancy in vitro fertilisation, n (%) 1 (1.4) Previous stillbirth or early neonatal death, n (%) 10 (13.5) Co-morbidities, n (%) Any co-morbidity 47 (63.5) Asthma 6 (8.1) Chronic hypertension 16 (21.6) Cerebrovascular event (previous) 3 (4.0) Diabetes mellitus type 2 1 (1.4) Epilepsy 1 (1.4) Human immunodeficiency virus 19 (25.7) On antiretroviral therapy 19 (100.0) Suppressed (adequately treated) 13 (68.4) Systemic autoimmune disease 6 (8.0) Thyroid disease 1 (1.4) Tuberculosis, current 1 (1.4) Other 5 (6.8) NYHA functional class on presentation, n (%) I 61 (82.4) II 6 (8.1) III 6 (8.1) IV 1 (1.4) mWHO class on presentation, n (%) I (mild disease) 32 (43.2) II 15 (20.3) III 15 (20.3) IV (pregnancy contraindicated) 8 (10.8) Diagnosis not fitting into the mWHO criteria* 4 (5.4) SD, standard deviation; NYHA, New York Heart Association; mWHO, modi- fied World Health Organisation classification. * congenital lung disease, previous dilated cardiomyopathy but no ejection frac- tion available and Takayasu arteritis. Table 2. Clinical signs and symptoms Signs and symptoms Values First visit ( n = 69) Blood pressure on presentation, median (IQR) Systolic blood pressure (mmHg) 117 (108–128) Diastolic blood pressure (mmHg) 74 (63–81) Heart rate, bpm, mean ± SD 88 ± 15 Cardiac signs and symptoms, n (%) Abnormal heart auscultation 21 (30.4) Heart murmurs 15 (71.4) Abnormal lung auscultation 2 (2.9) Orthopnoea 5 (7.2) Palpitations 2 (2.9) Paroxysmal nocturnal dyspnoea 0 (0) Peripheral oedema 6 (8.7) Raised jugular venous pressure 0 (0) Shortness of breath 6 (8.7) Electrocardiogram performed, n (%) 20 (30.0) Abnormal, n (%) 14 (70.0) Chest X-ray performed, n (%) 10 (14.5) Abnormal, n (%) 7 (70.0) Late follow up prior to delivery ( n = 69) Blood pressure, median (IQR) Systolic blood pressure (mmHg) 120 (108–134) Diastolic blood pressure (mmHg) 74 (63–87) Heart rate, bpm, mean ± SD 92 ± 16 Cardiac signs and symptoms, n (%) Abnormal heart auscultation 28 (40.6) Heart murmurs 28 (100.0) Abnormal lung auscultation 8 (11.6) Orthopnoea 13 (18.8) Palpitations 1 (1.4) Paroxysmal nocturnal dyspnoea 7 (10.1) Peripheral oedema 15 (21.7) Raised jugular venous pressure 9 (13.0) Shortness of breath 19 (27.5) Electrocardiogram performed, n (%) 39 (56.5) Abnormal 25 (64.1) Chest X-ray performed, n (%) 27 (39.1) Abnormal 15 (55.5) SD, standard deviation; IQR, interquartile range; bpm, beats per minute.