title: Spectrum of cardiac disease in maternity in a low-resource cohort in South Africa.
abstract: BACKGROUND
  Lack of evidence-based data on the spectrum of cardiovascular disease (CVD) in pregnancy or in the postpartum period, as well as on maternal and fetal outcome, provides challenges for treating physicians, particularly in areas of low resources. The objectives of this study were to investigate the spectrum of disease, mode of presentation and maternal and fetal outcome of patients referred to a dedicated Cardiac Disease and Maternity Clinic (CDM).
  
  
  METHODS
  The prospective cohort study was conducted at a single tertiary care centre in South Africa. Two hundred and twenty-five women presenting with CVD in pregnancy, or within 6 months postpartum, were studied over a period of 2 years. Clinical assessment, echocardiography and laboratory tests were performed at baseline and follow-up visits. Prepartum, peripartum and postpartum complications were grouped into cardiac, neonatal and obstetric events.
  
  
  RESULTS
  Ethnicity was black African (45%), mixed ethnicity (32%), white (15%), Indian/others (8%) and 12% were HIV positive. Of the 225 consecutive women (mean age 28.8±6.4), 196 (86.7%) presented prepartum and 73 in modified WHO class I. The 152 women presenting in a higher risk group (modified WHO class II-IV) were offered close follow-up at the CDM clinic and were diagnosed with congenital heart disease (32%, 15 operated previously), valvular heart disease (26%, 15 operated previously), cardiomyopathy (27%) and other (15%). Women presenting with symptoms of CVD or heart failure postpartum (n=30) presented in a higher New York Heart Association, had higher heart rates (p<0.001) and NTproBNP levels (p<0.0005). Of the 152 patients, 9 (6%) died within the 6-month follow-up period. Eight of the nine patients died >42 days postpartum. Perinatal death occurred in 1/152 (0.7%)-translating to a perinatal mortality rate of 7/1000 live births.
  
  
  CONCLUSIONS
  Disease patterns were markedly different to that seen in the developed world. However, joint obstetric-cardiac care in the low-resource cohort was associated with excellent survival outcome rates of pregnant mothers (even with complex diseases) and their offspring and was similar to that seen in the western world. Mortality typically occurred in the postpartum period, beyond the standard date of recording maternal death.
authors.affiliation: Department of Medicine, Faculty of Health Sciences, Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa Faculty of Health Sciences, Inter-Cape Heart MRC Unit and Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa Division of Cardiology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Karen
authors.initials: K
authors.lastname: Sliwa
authors.affiliation: Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Elena
authors.initials: E
authors.lastname: Libhaber
authors.affiliation: Division of Obstetrics and Gynaecology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors.forename: Catherine
authors.initials: C
authors.lastname: Elliott
authors.affiliation: Division of Obstetrics and Gynaecology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors.forename: Zoe
authors.initials: Z
authors.lastname: Momberg
authors.affiliation: Division of Obstetrics and Gynaecology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors.forename: Ayesha
authors.initials: A
authors.lastname: Osman
authors.affiliation: Division of Cardiology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa Department of Paediatrics, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa.
authors.forename: Liesl
authors.initials: L
authors.lastname: Zühlke
authors.affiliation: Division of Obstetrics and Gynaecology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors.forename: Tony
authors.initials: T
authors.lastname: Lachmann
authors.affiliation: Department of Medicine, Faculty of Health Sciences, Hatter Institute for Cardiovascular Research in Africa, University of Cape Town, Cape Town, South Africa.
authors.forename: Lauren
authors.initials: L
authors.lastname: Nicholson
authors.affiliation: Faculty of Health Sciences, Inter-Cape Heart MRC Unit and Institute of Infectious Diseases and Molecular Medicine, University of Cape Town, Cape Town, South Africa Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors.forename: Friedrich
authors.initials: F
authors.lastname: Thienemann
authors.affiliation: Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands.
authors.forename: Jolien
authors.initials: J
authors.lastname: Roos-Hesselink
authors.affiliation: Division of Obstetrics and Gynaecology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.
authors.forename: John
authors.initials: J
authors.lastname: Anthony
mesh_terms: D000328:Adult; D036861:Delivery, Obstetric / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008428:Maternal Mortality; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000453:epidemiology / Q000208:ethnology / Q000628:therapy*; D011256:Pregnancy Outcome; D011295:Prenatal Care / Q000706:statistics & numerical data; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012959:Socioeconomic Factors; D013019:South Africa / Q000453:epidemiology
keywords: QUALITY OF CARE AND OUTCOMES