CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 5, November/December 2023 AFRICA 289 in KZN. The Heart of Soweto study, conducted in Gauteng, South Africa, showed an incidence of new-onset rheumatic heart disease of 23.5/100 000 per annum among patients aged more than 14 years.11 Echocardiographic surveillance of South African school-aged children showed a prevalence of rheumatic heart disease of 20.2/1 000.12 In our cohort, the majority of women (86.3%) had diagnoses of PH secondary to left heart disease, classified as group 2 in the most recently updated classification of PH,6 largely caused by acquired mitral valve disease. This finding is in keeping with the large burden of rheumatic heart disease found in South Africa, as group 2 encompasses acquired vulvar lesions, including rheumatic heart disease. For this and other reasons, including socio-economic and cultural, the findings of many internationally published studies may not be applicable to the South African population. The ROPAC study (2016),7 originating from a multinational registry with South Africa as a contributor, and the only other local study,9 conducted in the Western Cape, South Africa, are the only two cohorts comparable to ours, where most women had diagnoses of PH belonging to group 2 and suffered from PH secondary to valvular heart disease. Additionally, the minority of women in these studies suffered from a severe form of PH, as was the case in our cohort. This is in stark contrast to the systematic review published by Jha et al. in 2020, which sought to summarise the outcomes of pregnant women with PH over the last three decades. In their review, most women had diagnoses of PH secondary to congenital heart disease. This consisted mostly of women with isolated atrial septal defects (19.4%) and ventricular septal defects (18.9%).13 With regard to maternal outcomes, PH in pregnancy can lead to cardiac failure, which accounts for much of the morbidity and mortality associated with this diagnosis. The overall incidence of cardiac failure in our cohort was just under 16%. The incidence of cardiac failure increased proportionally to the severity of PH, with 8.6, 20 and 50% of women with mild, moderate and severe PH, respectively, experiencing one or more episodes of cardiac failure (p < 0.001). The ROPAC cohort showed a similar relationship with rising PAP and increasing incidence of cardiac failure. Additionally, the indication for admission to hospital in the majority of women in their cohort was a diagnosis of cardiac failure. The overall incidence of cardiac failure in the ROPAC cohort was 20.5%.7 The Western Cape study, on the contrary, demonstrated a very high incidence of cardiac failure of 88%, with no relationship between the severity of PH and the incidence of cardiac failure, which may need to be investigated further.9 In our cohort, the need for admission to an ICU mirrored that of the incidence of cardiac failure, with most admissions to ICU occurring in women with severe PH and the fewest admissions occurring in women with mild PH (p < 0.001). Other studies did not report on the need for ICU admission in their cohorts, although one would expect it to follow the pattern of cardiac failure. Maternal mortality in women with PH is a grave concern, faced throughout pregnancy and the puerperium by women and their healthcare providers alike. In our cohort, there were no deaths in the group of women with mild PH, two deaths in the group with moderate PH and three deaths in the group with severe PH (p < 0.001). All deaths occurred in the postpartum period with four out of five deaths occurring in the first week postpartum. In the ROPAC cohort, there were five deaths up to 42 days postpartum; one of a woman with mild PH, three with moderate PH and one with severe PH and all deaths occurred in the first week postpartum.7 There was one death up to 42 days postpartum, reported in the Western Cape study, which occurred at two weeks postpartum.9 Our case fatality rate up to 42 days postpartum was 2.7%. This rate is comparable to that of the ROPAC and Western Cape studies, which reported 3.3 and 1.9%, respectively.7,9 The systematic review published by Jha et al. in 2020 reported a slightly higher maternal mortality rate of 11.5 per 100 pregnancies.13 Overall, these rates are much lower than that reported in the older literature, which ranged between 25 and 56%.8,14 The improvement in mortality rate may be attributable to many factors, including but not limited to, adoption of multidisciplinary teammanagement strategies and improvements in therapeutics. Although mortality in women with PH in pregnancy remains a serious concern, there is some reassurance from our study and that of the studies cited above that the overall mortality rate has decreased significantly over time. Mortality is more likely to occur in women with more severe forms of PH and more emphasis needs to be placed on improving outcomes in the postpartum period, where the dramatic physiological changes associated with pregnancy appear to have a significant negative impact on the pathology associated with PH. In our cohort of 185 women, four underwent elective medical terminations of their pregnancies and three experienced spontaneous miscarriages before 24 weeks, leaving reportable delivery outcomes for 178 women. C/S was the predominant mode of delivery in our cohort, accounting for close to 80% (n = 140) of all deliveries, with 46.4% (65/140) being elective and 53.6% (75/140) being emergency procedures. Within each category of PH severity, C/S remained the predominant mode of delivery. The proportion of C/S deliveries in our cohort appears to be high in comparison to the ROPAC cohort (C/S deliveries in 63% of the cohort) and the Western Cape cohort (C/S deliveries in 54% of the cohort).7,9 In our cohort, further data would need to be collected pertaining to the indications for C/S deliveries to elucidate the seemingly high proportion of C/S deliveries. With regard to foetal and neonatal outcomes, analysis of gestational age at delivery in our study showed it to be inversely proportional to the severity of PH in the mothers. Women with more severe disease delivered more remotely from term as opposed to those with milder disease, who mostly delivered at term gestational age. The overall proportion of women who delivered preterm (< 37 weeks) was 54.5% (n = 97), which was made up of 38.1% (37/97) of women with an early preterm (< 34 weeks) delivery and 61.9% (60/97) with a late preterm (34–37 weeks) delivery. The ROPAC and Western Cape studies7,9 did not report on preterm deliveries. The systematic review by Jha et al. reported a preterm delivery rate of 51.7 per 100 deliveries in their review.13 More data are needed to support our findings but it is useful to know that women with milder forms of PH are likely to carry pregnancies closer to term and that their offspring are less likely to suffer from the complication of prematurity. There were six stillbirths in our cohort, leaving 172 live births
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