An investigation into the clinical outcomes of women with peripartum cardiomyopathy at Klerksdorp/Tshepong Hospital Complex.

Abstract

Introduction: Peripartum Cardiomyopathy (PPCM) is defined on the basis of 4 criteria:  The development of cardiac failure in the last month of pregnancy and up to 5 months after delivery;  Absence of an identifiable cause of cardiac failure,  Absence of a recognizable structural heart disease prior to the last month of pregnancy;  And left ventricular dysfunction demonstrated by classic echocardiographic criteria, such as depressed fractional shortening <30% or ejection fraction <45% and left ventricular end diastolic dimension >2.7 cm/m2. The incidence of PPCM is not always known because population-based estimates are not available as data is primarily based on case series from single centres. In the USA it ranges from 1 per 3000 to 1 per 4000. Some studies conducted in South Africa showed an incidence of 100-300 per 100 000 live births. Aim of the study: The aim of the study was to investigate the factors which contribute to the clinical outcomes of peripartum cardiomyopathy (PPCM) at Klerksdorp/Tshepong Hospital Complex in Klerksdorp South Africa, by means of quantitative research. Methods: A single centre, non randomised, retrospective cohort, chart review together with prospective assessment of patient outcomes was done on 34 patients attending Specialist Medical Outpatient Department Clinic at Klerksdorp/Tshepong Hospital Complex from January 2011 to September 2014. The patients would have delivered between January 2011 and March 2014. Recruitment followed the inclusion and exclusion criteria based on the definition of peripartum cardiomyopathy. The patient files were reviewed at the time of diagnosis and at six months looking at the background history, therapy, clinical progression and outcome. The last assessment was done with the patient. Demographic data, obstetric and medical history, clinical progression measured by serial signs and symptoms were collected. Chest radiograph, electrocardiograph and echocardiograms were also registered and correlated to the clinical outcome. Findings: A total of 38 patients were recruited with a diagnosis of peripartum cardiomyopathy. Four patients were excluded from the study. Of the 34 patients who completed the study 47% recovered, whilst 26.5% remained stable and 26.5% progressively declined. Three patients, 8.8% died. Thromboembolic phenomena were noted in 20.6% of patients whilst 33.3% were on anticoagulants. The period prevalence was 0.33% (3 per thousand live births). The mean proportion in different clinical outcome groups was compared using Tukey’s Studentised Range (HSD) test for result. There was a significant difference in the mean proportions between the three groups (p=0.0001). In the pairwise comparisons, the mean proportion of the recovered group was significantly higher than that of the stable (p<0.05). There was no difference in the mean proportion of the recovered and deteriorated groups (p>0.05). All the patients received standard cardiac failure treatment. Discussion: The prevalence of PPCM at Klerksdorp/Tshepong Hospital Complex was higher than other parts of South Africa. The clinical outcome distribution from the study faired with the reported 50% recovery, 25% stable and 25% progressive deterioration. The patients received standard medical therapy. Low usage of anticoagulants could have attributed to the high rate of thromboembolic events. Device therapy is indicated in refractory heart failure if resources permit. It was recommended that a high-quality, large, multicenter prospective study be conducted to better understand the clinical outcomes of PPCM and its influencing factors. Conclusion: PPCM is a rare condition, multifactorial in origin with a good clinical outcome in the majority of cases if treated appropriately. It should be considered in any patient who presents with acute dyspnea in the perinatal period. Patients with PPCM are being optimally treated at Klerksdorp/Tshepong Hospital Complex. Anticoagulation is recommended in patients with low ejection fractions. Further, large progressive studies are required to fully understand the aetiology and the effect of novel therapies.