Severe morbidity and mortality associated with cardiac disease during pregnancy in the Free State public health service

English: Cardiac disease in pregnancy is an important component of maternal mortality. No good population based study on the extent of cardiac disease in pregnancy has, as yet, been published. A previous study conducted at this institution aimed to describe the morbidity and mortality of cardiac disease in pregnancy, but no guidelines to define morbidity in these cases were available. In 1999 a model was published by Mantel and eo-workers to define acute morbidity as organ dysfunction or failure that will lead to death without treatment. The aim of this study was to describe cardiac disease in a specific population by utilising this model and to try to determine the impact of the disease on the health system. From 1 January 1997 to 31 December 1998 all the available information of patients who presented with cardiac disease was documented. A research assistant was responsible to ensure that the completed hospital records of all the patients who were managed in Health Regions A and B of the Free State Province was available for evaluation. Ward registers and cardiac sonar reports in the regional and tertiary care hospitals (Pelonomi and Universitas) were also scrutinised to ensure that al possible cases were included. All cases with severe acute morbidity according to the Mantel criteria were classified as complicated. The information of the patients was also stratified as either part of the index population if they resided in Regions A or B (the population that was specifically targeted) or as the referred population if they lived in one of the other Regions and were referred to one of the two hospitals. During the 2-year study period 67 patients with cardiac disease were treated. In the study population there were 42 cases (prevalence of 0.12% of all deliveries in Regions A and B) and 31 (74%) were complicated and 11 (26%) uncomplicated. Rheumatic heart disease occurred in 14 (33%) of the cases whilst the majority (23, 54%) of the cases had cardiomyopathy. Four maternal deaths (9%) occurred which comprised 11.7 /100 000 deliveries in Regions A and B. Patients with valvular disease had predominantly mitral valve disease. Mitral regurgitation was the most common lesion, single or in combination with other lesions. Patients with mitral stenosis who were managed with beta-blockers developed less lung oedema. There were only five patients who had prosthetic valves of whom one (20%) died. This dramatic decrease in numbers compared to our previous report is probably due to an aggressive attempt to prevent pregnancies in this group of patients. As reported in the rest of Africa, cardiomyopathy was the most common lesion. It occurred in 1:4000 deliveries that took place in Regions A and B. Hypertension was present in 48% of these women. Only one case with a congenital abnormality and two cases with pericarditis were reported. The most expensive group to treat were those cases who were categorised according to the applied model as complicated cardiac disease. They also had significantly less specialist visits compared to the uncomplicated cases. The proposed model of acute morbidity is useful to evaluate cardiac disease in pregnancy and to monitor progress in the management of these patients. Specialist visits decrease the number of complications and should be encouraged. Management of patients with cardiac disease who did not receive antenatal care is expensive and communities should be informed of the advantages of antenatal care. Women with cardiac disease in pregnancy need specialist expertise and should preferably be evaluated and counselled prior to the onset of pregnancy.