CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 5, November/December 2023 286 AFRICA Retrieved records were subsequently reviewed for eligibility to enter the study as per inclusion and exclusion criteria. The inclusion criterion was records of all pregnant women admitted with PH. Exclusion criteria were records of women without an echocardiogram documenting pulmonary artery pressure (PAP) and those with multiple pregnancies. Each patient was allocated a unique study number for the purposes of data collection and to maintain patient confidentiality. Data were initially collected on a pre-designed data-collection form, verified, electronically captured on Excel 2019 (Microsoft, USA) and analysed using SPSS version 25.0 (IBM Corporated, USA). The echocardiograms reported a mean PAP (mPAP). This was determined as follows: Doppler echo was used to determine the systolic PAP by measuring the flow velocity over the tricuspid valve and converting it to mPAP using Bernoulli’s equation. PH was defined as mPAP of ≥ 25 mmHg. Mild PH was defined as a resting mPAP ≥ 25 mmHg and < 50 mmHg. Moderate PH was a resting mPAP from 50 to 89 mmHg. Severe PH was a resting mPAP ≥ 90 mmHg. Maternal death was defined as death from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy. Intrauterine growth restriction was defined as foetal abdominal circumference and/or expected foetal weight below the 10th percentile for gestational age, associated with an abnormal umbilical artery resistance index. Low birthweight was defined as a birth weight of less than 2 500 g. Preterm delivery was defined as any birth before 37 weeks and zero days of pregnancy. Late preterm delivery was any birth at a gestational age between 34 weeks and zero days, and 36 weeks and six days. Early preterm delivery was any birth at a gestational age between 24 weeks and zero days, and 33 weeks and six days. Statistical analysis Continuous variables, such as patient ages, were summarised as mean ± standard deviation or median and interquartile range (IQR) as appropriate, and compared using the Student’s t-test or Wilcoxon–Mann–Whitney test as appropriate. Categorical variables, such as co-morbidities, were summarised as percentages and proportions and compared using the chi-squared test or Fisher’s exact test, as appropriate. A one-way ANOVA was used to compare patient outcomes among groups of different PAP. The level of statistical significance was set at a p-value of < 0.05. Results There was a total of 185 women with PH admitted to the HROU for the study period. The median (IQR) age of the cohort was 28 (23–33) years, with approximately 38% of the cohort being human immunodeficiency virus (HIV) infected at the first visit. Further analysis of baseline characteristics of the cohort, categorised according to PAP, showed no statistical differences among the categories, or in the prevalence of HIV infection (Table 1). The majority of women [109 (59%)] in the cohort had mild PH (Fig. 1). Classification of the cohort according to the cause of PH showed that most women [151 (85%)] had PH secondary to acquired heart disease, and within this group, the leading cause (21.7%) was mixed mitral valve disease. Group 1 (PAH) accounted for 13.7% of the cohort (Table 2). PH of other causes (PH due to lung disease, PH due to pulmonary artery obstruction and PH with multifactorial/unclear mechanisms) was not present in the cohort. Maternal outcomes were significantly different among the PAP groups (Fig. 2), with approximately eight, 20 and 50% of women in the mild, moderate and severe categories of PH, respectively, experiencing one or more episodes of cardiac failure during the pregnancy or puerperium (p < 0.001). The number of women admitted to an intensive care unit (ICU) also increased significantly with increasing PAP (p < 0.001), with more than 40% of women in the severe PH category needing admission to an ICU. There were five maternal deaths in the entire cohort, of whom three women had severe PH and two had moderate PH (p < 0.001). A detailed description of the maternal deaths is presented in Table 3. Of the 185 women in the cohort, there were four who underwent elective medical terminations of their pregnancies and three who experienced spontaneous miscarriages (< 24 weeks). There were 109 women in the group with mild PH, Table 1. Characteristics of cohort at admission Characteristics Entire cohort (n = 185) PAP < 50 mmHg (n = 109) PAP 50–89 mmHg (n = 60) PAP ≥ 90 mmHg (n = 16) p-value Age (years), median (IQR) 28 (23–33) 26 (22–33) 30 (23–33) 27 (26–33) Parity, median (IQR) 1 (0–2) 1 (0–1) 1 (0–2) 1 (0–2) HIV status, n (%) 0.08 Non-infected 115 (62.2) 75 (65.2) 32 (27.8) 8 (7.0) Infected 70 (37.8) 34 (48.6) 28 (40.0) 8 (11.4) < 50 mmHg 59% 50–89 mmHg 32% > 90 mmHg 9% Fig. 1. Chart showing the proportions of the cohort in different PAP groups (n = 185).
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