CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 5, November/December 2023 288 AFRICA There were five maternal deaths (up to 42 days postpartum) in the cohort. Two (3.3%) of the maternal deaths were in the moderate PH group and three (18.8%) were in the severe PH group (Table 3). An additional death of a woman with severe PH was recorded three months postpartum (admitted with cardiac failure and requiring urgent mitral valve replacement) but this was not analysed for statistical purposes. Of the entire cohort, 2.7% of women suffered a mortality (Table 4). Discussion This report of our cohort of 185 women, admitted with PH during pregnancy, is the largest of its kind published in South Africa and possibly globally. This large sample size contributes to the reliability and relevance of the study findings. The largest international study cohort, prior to ours, was that by Sliwa et al., consisting of 151 women with PH, and locally by Osman et al., consisting of 52 women with PH.7,9 HIV-infected womenmade up 37.8%of our cohort. According to the 2017 National Antenatal Sentinel HIV survey, the overall prevalence of HIV infection among antenatal clinic attendees in South Africa was 30.7%, with KZN having the highest prevalence of 41.1%.10 This provides some reassurance that our cohort was representative of the population of pregnant women Table 4. Description of maternal deaths Patient Age (years) Diagnosis Parity Gestational age at 1st visit (weeks) PAP (mmHg) Complications Gestational age at delivery (weeks) Delivery Foetal state Time of maternal death Cause of death Additional information 1 26 Mitral stenosis (MVA: 0.58 cm2) diagnosed in pregnancy G1P0 19 115 Cardiac failure 30 Emergency C/S for foetal compromise Alive Day 1 post C/S Cardiac failure Decompensated intra-op post delivery – died day 1 post delivery in ICU 2 39 Asthma/ obesity/ peripartum cardiomyopathy × 4 G5P4 31 51 Septicaemia/ cellulitis/ renal failure 34 NVD Alive Day 3 post NVD Cardiac failure Cardiac failure secondary to cardiomyopathy – died in ICU, was on ionotropic support 3 22 MMVD (MVA: 1.24 cm2) diagnosed in pregnancy G1P0 27 52 Developed cardiac failure/ severe anaemia post delivery 37 Elective C/S for cardiac disease Alive Day 30 post C/S Cardiac failure 4 28 TB pericarditis (treated 4 years prior to pregnancy) G3P1 20 110 Cardiac failure/sepsis 37 Emergency C/S for worsening cardiac failure Alive Day 2 post C/S Cardiac failure Developed cardiorespiratory failure and sepsis peridelivery 5 30 Severe tricuspid regurgitation (diagnosed in pregnancy) G2P1 37 91 Cardiac failure 37 Emergency C/S for worsening cardiac failure Alive Day 2 post C/S Cardiac failure Transferred to ICU from peripheral hospital with cardiac failure and newly diagnosed severe tricuspid regurgitation with pulmonary hypertension MVA, mitral valve AREA; MMVD, mixed mitral valve disease; C/S, caesarean section; G, gravidity; P, parity; ICU, intensive care unit. (n = 178) Gestational age at delivery < 50 mmHg 50–90 mmHg > 90 mmHg < 34 weeks 34–37 weeks > 37 weeks Percentage of cohort (%) 100 75 50 25 0 33.3% 37.5% 10.1% 30.3%33.3% 43.8% 56.9% 28.3% 12.5% Fig. 4. Gestational age at delivery, stratified according to severity of maternal PH. (n = 172) Pulmonary artery systolic pressure IUGR Low birth weight < 34 weeks 34–37 weeks > 37 weeks Percentage of live births (%) 70 53 35 18 0 17% 8% 18% 45% 29% 63% Fig. 5. Neonatal characteristic according to severity of maternal PH. IUGR, intra-uterine growth restriction.
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