Abstract
Background:Cardiac disease is a leading cause of non-obstetric maternal death worldwide, but little is known about its burden in sub-Saharan Africa.Objectives and Methods:We conducted a retrospective case-control study of pregnant women admitted to a national referral hospital in western Kenya between 2011–2016. Its purpose was to define the burden and spectrum of cardiac disease in pregnancy and assess the utility of the CARPREG I and modified WHO (mWHO) clinical risk prediction tools in this population.Results:Of the 97 cases of cardiac disease in pregnancy, rheumatic heart disease (RHD) was the most common cause (75%), with over half complicated by severe mitral stenosis or pulmonary hypertension. Despite high rates of severe disease and nearly universal antenatal care, late diagnosis of cardiac disease was common, with one third (38%) of all cases newly diagnosed after 28 weeks gestational age and 17% diagnosed after delivery. Maternal mortality was 10-fold higher among cases than controls. Cases had significantly more cardiac (56% vs. 0.4%) and neonatal adverse events (61% vs. 27%) compared to controls (p < 0.001). Observed rates of adverse cardiac events were higher than predicted by both CARPREG I and mWHO risk scores, with high cardiac event rates despite low or intermediate risk scores.Conclusions:Cardiac disease is associated with significant maternal and neonatal morbidity and mortality among pregnant women in western Kenya. Existing clinical tools used to predict risk underestimate adverse cardiac events in pregnancy and may be of limited utility given the unique spectrum and severity of disease in this population.
Highlights
Cardiac disease is a leading cause of maternal mortality worldwide, contributing to over 10% of all maternal mortality cases globally [4, 7, 10]
Data from the Registry of Pregnancy and Cardiac Disease (ROPAC), the largest registry of pregnant women with cardiac disease globally, illustrates that 55% of women enrolled from low- and middle-income countries (LMICs) had valvular heart disease, predominantly rheumatic mitral stenosis, and studies from South Africa
With up to one-third of maternal deaths in western Kenya attributable to non-obstetric causes, our findings indicate that cardiac disease may be a significant, under-recognized threat to persistent maternal mortality in this region [25, 26, 27, 28]
Summary
Cardiac disease is a leading cause of maternal mortality worldwide, contributing to over 10% of all maternal mortality cases globally [4, 7, 10]. Sub-Saharan Africa (SSA) bears a disproportionately high burden of RHD among women of reproductive age, yet the prevalence of cardiac disease in pregnancy in this region is largely unknown [22, 30]. Lumsden et al: High Burden of Cardiac Disease in Pregnancy at a National Referral Hospital in Western Kenya patients with RHD from 12 African countries, found that nearly two-thirds of all cases were women of reproductive age. Results: Of the 97 cases of cardiac disease in pregnancy, rheumatic heart disease (RHD) was the most common cause (75%), with over half complicated by severe mitral stenosis or pulmonary hypertension. Existing clinical tools used to predict risk underestimate adverse cardiac events in pregnancy and may be of limited utility given the unique spectrum and severity of disease in this population
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