Evaluation of adequacy of management of cardiac disease in pregnancy at Kenyatta National Hospital : a retrospective cohort study

Abstract

Background-Heart disease is a significant cause of maternal morbidity and mortality. It complicates 1 – 4% of pregnancies, in which tolerance of the heart to the essential cardiovascular changes is hampered, resulting in an increased risk to decompensate. This increases the risk of severe morbidity and mortality. Management of cardiac disease in pregnancy ought to be from a multidisciplinary approach. Adequate and effective management of these patients from preconception care to post-partum period reduces both maternal and early neonatal morbidity and mortality. This study is an evaluation of the care given to patients with cardiac disease in pregnancy at Kenyatta National Hospital. Justification The burden of heart disease in pregnancy is high especially in low and middle-income countries. It accounts for about 80% of the indirect causes of maternal mortality. The incidence of heart disease in pregnancy is likely to increase as predisposing factors such as NCDs are on the rise and more children with congenital or rheumatic heart disease are reaching child bearing age. Multidisciplinary approach in care would enhance better management and decision making hence improve both the maternal and neonatal outcomes. Despite cardiac disease in pregnancy being relatively common, research interest in this area has been low. There is a definite need for well-defined standards of care, a hiatus that needs careful research and recommendation. This study will help to describe the current practice in the management of cardiac disease in pregnancy at Kenyatta National Hospital and generate baseline data from which future research can be done. Objectives: To evaluate the adequacy of management of patients with cardiac disease in pregnancy at Kenyatta National Hospital over the last 10 years. Specifically, evaluate the provision of preconception care, objective prenatal care, determine the adequacy of intrapartum and post-deliverymanagement of patients with heart disease in pregnancy. Methods –A descriptive retrospective cohort study in which 72 records of patients with heart disease in pregnancy who received care at Kenyatta National Hospital from 31st December 2017 were reviewed, retrospectively until a sample size was reached. Results: The mean age of the participants was 29.6 years (SD 7.1). A majority of the patients (76.4%) were multigravida. The preponderant NYHA classifications were NYHA IV in 19 (26.4%) participants and NYHA III in 12 (16.7%). Most 71 (98.6%) participants attended at least one ANC session with 29 (41.4%) participants attending 4 or more ANC sessions (Table 4). Seventy (97.2%) patients were referrals. Only 22.2% of patients received antenatal cardiologist review antenatally, while 51% of the patients had a cardiologist review in the postnatal period. None of the patients had a joint multidisciplinary conference. Most patients 48(66.7%) delivered vaginally. In the postnatal period, almost all the patients 71.0(98.8%) had monitoring of vital signs post-delivery, but only 16.0(22.2%) had a documented education on danger signs. Conclusion: The antenatal review of patients with cardiac disease in pregnancy and the joint interdisciplinary conference with patients is grossly lacking at Kenyatta National Hospital. There is good monitoring of patients' vital signs post-delivery with well documented post-delivery follow up plans but education on danger signs post admission was inadequate. Keywords- Cardiac disease, pregnancy, adequacy, multidisciplinary approach.