Post-caesarean section outcomes of obstetric patients with valvular heart disease at Charlotte Maxeke Johannesburg Academic Hospital, South Africa

Abstract

Background: Valvular heart disease presents a unique set of conditions during pregnancy and delivery, with the potential for adverse
outcomes increased by prior interventions and anticoagulation.
Objectives: To describe the profile and outcomes of obstetric patients with valvular heart disease who delivered via caesarean section at
Charlotte Maxeke Johannesburg Academic Hospital, South Africa.
Methods: A 5-year retrospective descriptive cross-sectional study was performed. All patients with valvular heart disease who
underwent caesarean section, irrespective of age, were included. Exclusion criteria were absence of important clinical data relevant
to the study and outcomes data. All records of patients who delivered by caesarean section and were booked in the obstetric cardiac
unit were reviewed. Data for those who had valvular heart disease were separated from non-valvular heart disease data. A total of
69 patients were included in the analysis. Univariate logistic regression analysis was done to assess the predictors of maternal and
fetal outcomes.
Results: The mean (standard deviation) age of the patients in the study was 30.1 (5.6) years, 82.6% were gravida 1 - 3 and 89.8% para
0 - 2, and the majority (56.5%) had an elective caesarean section. General anaesthesia was the most common mode used, and most of
the patients had fixed-interval analgesia postoperatively. Approximately two-fifths of the patients (n=28; 40.6%) were on anticoagulants.
A significantly higher percentage of those who were on anticoagulants had complications (n=12/28; 42.9%) compared with those who were not on anticoagulants (n=3/41; 7.3%) (p<0.001). There was a total of 19 complications, mainly bleeding (n=7) and cardiac  arrhythmias (n=6). New York Heart Association class and use of anticoagulants were individually associated with adverse maternal  outcomes after univariable logistic regression analysis (p=0.006 and p=0.017, respectively). In univariable logistic regression analysis, a  low ejection fraction was associated with adverse fetal outcome (odds ratio 0.94; 95% confidence interval 0.90 - 0.99; p=0.032). One infant  (1.4%) died, in the early neonatal period.
Conclusion: Pregnancy in women with cardiac disease is possible, but it is not without risk, and a structured plan and multidisciplinary team approach to provide prehabilitation is therefore necessary. Our patients were young and with relatively good functional status (metabolic equivalent >4), and most pregnancies continued to term or early term (median (interquartile range) 37 (36 - 38) weeks). Some patients experienced adverse outcomes, mainly related to bleeding and arrhythmias, but none died. There was one early neonatal death. These patients need a structured multidisciplinary team care plan.