Cardiac and Obstetric Complications of Pregnant Women with Rheumatic Heart Disease in Sub-Saharan Africa: A Systematic Review

Evangelia Alexopoulos; Doreen Nakagaayi; Elizabeth R. Blackwood; Felix Barasa; Joan Kiyeng; Wycliffe Kosgei; G. Titus Ng’eno; Shanti Nulu; Rebecca Lumsden; Andrea Beaton; Gerald S. Bloomfield

doi:10.5334/gh.1522

Figures & Tables

Table 1

Study characteristics.

AUTHOR (YEAR)	COUNTRY	STUDY DESIGN	SAMPLE SIZE	SAMPLE WITH RHD, n (%)	AGE DIST. (YEARS)	FINDINGS/COMMENTS
*Beaton et al. (2019) (34)	Uganda	Prospective cohort	3506 (58 with cardiac disease)	51 (87.9%)	Participants with cardiac disease:Median 29.5 (IQR: 24, 35)	Two health centers and one referral hospital Echo was used to classify patients with heart disease (N = 58) and without heart disease (N = 3,448) Cardiovascular complications occurred in over half of women with heart disease, most commonly heart failure
Desai et al. (2000) (33)	South Africa	Case series	128	128 (100%)	Mean: 27 (Range: 16–44)	Mitral valve stenosis only Doppler-echo used for measurement of MVA Half (49%) had at least moderately severe disease Balloon valvulotomy performed in 20 individuals
*Diao et al. (2011) (38)	Senegal	Case series	50	46 (92%)	Mean: 28.4 (Range: 18–43)	32 participants with MS 36 with pulmonary edema at admission All participants required cardiovascular medication and three required cardioversions High mortality rate (17 deaths), 11 postpartum
Gebremedhin et al. (2022) (47)	Ethiopia	Case series	58	58 (100%)	Mean: 27 (SD: 4.5)	MS only Echo used for measurement of mitral valve area 67% of participants had severe pulmonary hypertension Most participants (69%) had heart failure and pulmonary edema
*Hailu et al. (2019) (39)	Ethiopia	Case series	21	20 (95.2%)	Mean: 26.7 (SD: 5.7)	Study of pregnant patients admitted with pulmonary hypertension (measured by echo); mean pulmonary arterial pressure was 102.9 (SD 16.9) Heart failure occurred in all patients Preeclampsia occurred in five patients
*Lumsden et al. (2020) (37)	Kenya	Case-control study	339 (97 cardiac cases and 242 controls)	73 (75.3%)	Participants with cardiac disease: Median: 26 (Range: 16–50)	Mitral regurgitation present in 45 patients; MS present in 40 participants (over half of those were severe) 61.4% NYHA Class III or IV on admission Higher rates of adverse events occurred than were predicted by risk scores Mortality in pregnant women with cardiac conditions was nearly 10 times higher than all-cause mortality among pregnant women
*Nqayana et al. (2008) (32)	South Africa	Case series	95	77 (81.1%)	72 (75.8%) < 30 years 54% ≤25 years	20 individuals had valve replacement prior to pregnancy Eight required balloon valvuloplasty during pregnancy No maternal deaths in study period Heart failure was most common cardiac complication, occurring in 13 individuals
*Poli et al. (2020) (40)	Kenya	Case series	91	80 (87.9%)	Median: 27 (IQR: 23, 33)	Heart failure, pulmonary edema, and arrhythmias were the most common cardiac adverse outcomes Investigated sociodemographic factors and risk of adverse outcomes After adjustment, maternal age, marital status, occupation, and residence were not associated with adverse outcomes; low education level increased odds of adverse outcomes 3.3-fold (p = 0.049)
*Soma-Pillay et al. (2008) (41)	South Africa	Case series	189	120 (63.5%)	Mean: 27.34 (SD: 6.7)	Investigated ‘near miss’ data, acute organ system dysfunction that could result in death Found 25 near misses Pulmonary edema was the cause of four maternal deaths

[i] *Study consisted of participants with RHD and other cardiac disease, including congenital disease and peripartum cardiomyopathy.

MS: mitral stenosis; MVA: mitral valve area; NYHA: New York Heart Association.

Table 2

Qualitative summary of cardiac complications in pregnant women with cardiac disease, largely RHD.

AUTHOR (YEAR)	SAMPLE WITH CARDIAC DISEASE	SAMPLE WITH RHD	ANY CARDIAC COMPLICATION, n (%)	HEART FAILURE, n (%)	ARRHYTHMIA, n (%)	IE, n (%)	STROKE, n (%)	ARTERIAL OR VTE, n (%)	DEATH DUE TO CARDIAC CAUSE, n (%)
Beaton et al. (2019)	58	51	51.8%*	33%*	3.6%*	N/A	N/A	N/A	1 (1.7%)
Desai et al. (2000)	128	128	Not clearly stated	N/A	2 (1.6%)	1 (0.8%)	N/A	1 (0.8%)	0
Diao et al. (2011)	50	46	Not clearly stated	24 (48%)	18 (36%)	N/A	N/A	2 (4%)	13 (26%)
Gebremedhin et al. (2022)	58	58	Not clearly stated	40 (68.9%)	15 (25.9%)	N/A	N/A	2 (3.4%)	N/A
Hailu et al. (2019)	21	20	20 (95.2%)	20 (95.2%)	N/A	N/A	N/A	1 (4.8%)	3 (14.3%)
Lumsden et al. (2020)	97	73	54 (55.7%)	41 (42.2%)	7 (7.2%)	N/A	2 (2.1%)	10 (10.3%)	6 (6.2%)
Nqayana et al. (2008)	95	77	30 (31.5%)	10**(12.9%)	11**(14.3%)	2** (2.6%)	1**(1.3%)	N/A	13 (13.7%)
Poli et al. (2020)	91	80	54 (59.3%)	21 (23.1%)	14 (15.4%)	N/A	N/A	N/A	8 (8.8%)
Soma-Pillay et al. (2008)	189	120	Not clearly stated	N/A	2 (1.1%)	N/A	N/A	N/A	4 (2.1%)

[i] Percentages given out of the total sample with cardiac disease.

ACS: acute coronary syndrome; IE: infective endocarditis; N/A: not available; RHD: rheumatic heart disease; VTE: venous thromboembolism.

*Provided prevalence/100 **Specific to participants with RHD.

Table 3

Qualitative summary of obstetric complications in pregnant women with cardiac disease, largely RHD.

AUTHOR (YEAR)	SAMPLE WITH CARDIAC DISEASE	SAMPLE WITH RHD	ANY OBSTETRIC COMPLICATION, n (%)	ANY PREGNANCY LOSS, n (%)	EARLY PREGNANCY LOSS, n (%)	IUFD OR STILLBIRTH, n (%)	NEWBORN (NEONATAL) DEATH, n (%)	PRE-TERM DELIVERY, n (%)	IUGR OR LOW BIRTH WEIGHT, n (%)	PREECLAMPSIA, n (%)	PPH, n (%)	MATERNAL DEATH, n (%)
Beaton et al. (2019)	58	51	Not clearly stated	7.1%*	N/A	4 (6.9%)	3 (5.2%)	3 (5.2%)	N/A	N/A	N/A	1 (1.7%)
Desai et al. (2000)	128	128	Not clearly stated	14 (10.9%)	6 (4.7%)	8 (6.3%)	N/A	45 (35.2%)	20 (16.7% out of 120)	10 (7.8%)	N/A	0
Diao et al. (2011)	50	46	Not clearly stated	4 (8%)	N/A	4 (8%)	Not clearly stated	5 (10%)	N/A	N/A	N/A	17 (34%)
Gebremedhin et al. (2022)	58	58	Not clearly stated	13 (22.4%)	10 (17.2%)	3 (5.2%)	N/A	8 (13.8%)	13 (22.4%)	N/A	N/A	4 (6.9%)
Hailu et al. (2019)	21	20	Not clearly stated	2 (9.5%)	Not clearly stated	2 (9.5%)	1 (4.8%)	3 (14.3%)	N/A	5 (23.8%)	N/A	3 (14.3%)
Lumsden et al. (2020)	97	73	63 (64.9%)	10 (10.3%)	N/A	10 (10.3%)	4 (4.1%)	32 (33%)	24 (24.7%)	14 (14.4%)	5 (5.2%)	6 (6.2%)
Nqayana et al. (2008)	95	77	Not clearly stated	6(7.8%)**	1(1.3%)**	5(6.5%)**	1(1.3%)**	14(18.2%)**	10(13%)**	1(1.3%)**	4(5.2%)**	N/A
Poli et al. (2020)	91	80	68 (74.7%)	5 (5.5%)	3 (3.3%)	2 (2.2%)	N/A	20 (22%)	N/A	13 (14.2%)	10 (10.9%)	8 (8.8%)
Soma-Pillay et al. (2008)	189	120	Not clearly stated	22 (11.6%)	N/A	N/A	N/A	18 (9.5%) delivered before 34w	N/A	N/A	N/A	5 (2.6%)

[i] Percentages given out of the total sample with cardiac disease.

*Provided prevalence/1000 **Specific to participants with RHD.

IUFD: intrauterine fetal demise; IUGR: intra-uterine growth restriction; N/A: not available; PPH: post-partum hemorrhage; RHD: rheumatic heart disease.

Cardiac and Obstetric Complications of Pregnant Women with Rheumatic Heart Disease in Sub-Saharan Africa: A Systematic Review

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