Approach to heart failure during pregnancy

“He was our first child and after a spell of miscarriages, my husband and I looked forward to holding our bundle of joy.”
Like any mother, Regina Akol looked forward to having a baby.

However, two days after delivery, she woke up feeling extremely tired and out of breath. Assuming that this was due to the long labour she had gone through, she decided to rest.

However, being short of breath, she could not lie down comfortably. Thankfully, she says, the medical team came in for their morning rounds and she told them how she was feeling.

“I am glad we came when we did,” the doctor said, looking alarmed. “You might be experiencing heart failure,” he added. It was a huge shock for Akol and she would, in the following minutes, be taken for an echocardiogram, the results of which confirmed the doctor’s fears.

“I was told that the condition was referred to as peripartum cardiomyopathy and I was immediately transferred to the cardiology ward. I was confused and overwhelmed that I cried wondering whether I was going to die and leave my son without a mother,” Akol says.

She was also advised to stop breastfeeding. “My husband had to take our son home and if there was a day I fought for anything, it was then because I wanted to go home with my family,” she shares.

Although she was later discharged, she still takes medication five years later and has had to cut back on her working hours.
“I am a nurse and while I used to work for 12 hours, I now work for only eight.

“Peripartum cardiomyopathy is a type of heart failure, which affects women who are about to give birth – one month before delivery or who have had a baby in the past six months. It weakens the heart muscle and causes it to become enlarged,” says Prof Karen Sliwa-Hahnle, the director of Hatter Institute for cardiovascular research in South Africa.

Complications
“While the heart is meant to pump blood, with this condition, it stores blood hence enlarging,” adds Dr Barbara Kakande, a cardiologist at UMC Victoria Hospital.
Dr Sliwa-Hahnle says over the last decade, there has been an increase in maternal mortality for cardiac disease in Africa and experts have discovered that after non-pregnancy related infections, cardiac disease is the second most common cause of indirect maternal death. They add that peripartum cardiomyopathy and complications due to rheumatic heart disease contribute to more than 50 per cent of cases.

Maureen Mugume had delivered three children and was due with her fourth. With no prior incidence, she did not think any would ever arise. So when she experienced extreme swelling of legs and feet, she brushed it off as usual blaming it on her advanced age. She was 37.
In the days after being discharged from hospital, Mugume started experiencing shortness of breath, severe back pain and found it almost impossible to lay flat.

Watch out for signs
“I panicked and I am forever thankful for a visiting friend who noticed my discomfort and encouraged me to call my doctor,” she says adding that after explaining what she felt, Mugume was asked to go to hospital immediately.
“Beyond admission into the emergency room and being given a drip, I cannot remember much of what happened that day but later the doctor told me that I had suffered heart failure,” she says.

An echo-cardiogram was done that night where it was discovered that her ejection fraction (EF) was at 13 per cent despite the normal being at 55 per cent and above.
With that, she spent the next five days in the intensive care unit before being discharged with medication. Five years later, her EF is at 50 per cent.
“I am also living a fairly normal life without medication,” she says.

Signs and symptoms
Signs of a failing heart include shortness of breath or difficulty in breathing, needing two to three pillows at night to sleep comfortably, oedema (swollen legs) and palpitations, among others.
Dr Sliwa-Hahnle says: “If this condition is not recognised early and treated, it may result in death.” That said, Dr Kakande says all these symptoms are akin to pregnancy and the tiredness associated to the period after delivery which aids delayed diagnosis. He, therefore, encourages mothers to go to hospital when they notice the symptoms mentioned above.

Risk factors
Dr Kakande points out that diabetes, obesity, alcohol, multiple pregnancies, premature delivery, being African are some of the factors that make a woman susceptible to this heart condition. She adds that anything that stresses the body causes Peripartum Cardiomyopathy.

Way forward
Although findings from laboratory and clinical research in South Africa, centres in Europe, the US and other regions have helped to understand what is leading to this disease, Dr Sliwa-Hahnle says:
“Further ongoing research is extremely important. Not only will this provide further understanding of this disease, it will also help us to manage it better.

Diagnosis

Your doctor will review your symptoms and perform a physical exam. A device called a stethoscope may be used to help the doctor listen for crackling noises in the lungs and abnormal sounds in the heart.
Your doctor will also test your blood pressure. It may be lower than normal and could drop significantly when you stand up.
A variety of imaging tests can measure your heart. These tests also determine the rate of blood flow. Some of these imaging tests can also view potential lung damage.

Prevention
Certain lifestyle habits can decrease your risk. This is especially important for first time mothers. Focus on getting regular exercise, eating a low-fat diet, avoiding cigarettes and alcohol.
Women who receive a diagnosis of peripartum cardiomyopathy are at risk for developing the condition with future pregnancies. In this case, women may consider taking birth control to prevent pregnancies.

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