Maternal health in Namibia: Lessons learned from obstetric surveillance

Over the past decades increasing efforts have aimed to improve the health of pregnant women around the world. Namibia has made limited progress in reducing severe maternal outcomes. Aims of this thesis were to enhance implementation of a national obstetric surveillance system and assess requirements to improve maternal health in Namibia. The findings of chapters 2-7 provided insight into several important drivers of severe maternal outcome. The most important contributor of the high-incidence of severe maternal outcome in Namibia was poor quality of facility-based care and particularly vulnerable women appeared to be at higher risk of severe maternal outcome. Obstetric surveillance played a crucial role in obtaining these insights. Based on these, targeted recommendations could be formulated. The maternity care system needs to be strengthened, to enable health workers to provide universal coverage of good health care to all women in Namibia. It is therefore crucial the next step will follow, which is to act on the proposed recommendations. The insights obtained through obstetric surveillance will contribute to such action, as for any intervention, it is key it addresses a local need in a context-specific manner. Financial support for printing of this thesis was kindly provided by the Department of Obstetrics and Gynaecology of Leiden University Medical Center, Walaeus University Library, Haaglanden Medical Center, Bayer, Titus Health Care, ChipSoft.LUMC / Geneeskund

Cardiac and obstetric outcomes of pregnancies for women after cardiotoxic therapy in childhood: a single center observational study

Background: Childhood cancer survivors (CCS) are at increased risk of cardiomyopathy during pregnancy if they have prior cardiotoxic exposure. Currently, there is no consensus on the necessity, timing and modality of cardiac monitoring during and after pregnancy. Therefore, we examined cardiac function using contemporary echocardiographic parameters during pregnancy in CCS with cardiotoxic treatment exposure, and we observed obstetric outcomes in CCS, including in women without previous cardiotoxic treatment exposure. Method: A single-center retrospective cohort study was conducted among 39 women enrolled in our institution's cancer survivorship outpatient clinic. Information on potential cardiotoxic exposure in childhood, cancer diagnosis and outcomes of all pregnancies were collected through interviews and review of health records. Echocardiographic exams before and during pregnancy were retrospectively analyzed for left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) if available. The primary outcomes were (i) left ventricular dysfunction (LVD) during pregnancy, defined as LVEF = 10% in LVEF below normal (Metabolic health: pathophysiological trajectories and therap

Maternal and fetal outcomes of pregnancies complicated by acute hepatitis E and the impact of HIV status:a cross-sectional study in Namibia

Background & Aims: Namibia has been suffering from an outbreak of hepatitis E genotype 2 since 2017. As nearly half of hepatitis E-related deaths were among pregnant and postpartum women, we analysed maternal and fetal outcomes of pregnancies complicated by acute hepatitis E and assessed whether HIV-status impacted on outcome. Methods: A retrospective cross-sectional study was performed at Windhoek Hospital Complex. Pregnant and postpartum women, admitted between 13 October 2017 and 31 May 2019 with reactive IgM for Hepatitis E, were included. Outcomes were acute liver failure (ALF), maternal death, miscarriage, intra-uterine fetal death and neonatal death. Odds ratios (OR) and 95% confidence interval (CI) were calculated. Results: Seventy women were included. ALF occurred in 28 (40.0%) of whom 13 died amounting to a case fatality rate of 18.6%. Sixteen women (22.9%) were HIV infected, compared to 16.8% among the general pregnant population (OR 1.47, 95% CI 0.84-2.57, P =.17). ALF occurred in 4/5 (80%) HIV infected women not adherent to antiretroviral therapy compared to 1/8 (12.5%) women adherent to antiretroviral therapy (OR 28.0, 95% CI 1.4-580.6). There were 10 miscarriages (14.3%), five intra-uterine fetal deaths (7.1%) and four neonatal deaths (5.7%). Conclusions: One in five pregnant women with Hepatitis E genotype 2 died, which is comparable to genotype 1 outbreaks. Despite small numbers, HIV infected women receiving antiretroviral therapy appear to be less likely to develop ALF in contrast with HIV infected women not on treatment. As there is currently no curative treatment, this phenomenon needs to be assessed in larger cohorts

Original research: long-term prognosis after ST-elevation myocardial infarction in patients with a prior cancer diagnosis

Introduction It is unknown how long-term prognosis after ST-elevation myocardial infarction (STEMI) in patients with a prior cancer diagnosis is impacted by cancer-related factors as diagnosis, stage, and treatment. We aimed to assess long-term survival trends after STEMI in this population to evaluate both cardiovascular and cancer-related drivers of prognosis over a follow-up period of 5 years. Methods In this retrospective single-center cohort study, patients with a prior cancer diagnosis admitted with STEMI between 2004 and 2014 and treated with primary percutaneous coronary intervention (PCI) were recruited from the STEMI clinical registry of our institution. Results In the 211 included patients, the cumulative incidence of all-cause death after 5 years of follow-up was 38.1% (N = 60). The cause of death was predominantly malignancy-related (N = 29, 48.3% of deaths) and nine patients (15.0%) died of a cardiovascular cause. After correcting for age and sex, a recent cancer diagnosis ( 10 years, HRadj 2.98 [95% CI: 1.39-6.41], p = 0.005) and distant metastasis at presentation (HRadj 4.02 [1.70-9.53], p = 0.002) were significant predictors of long-term mortality. While maximum levels of cardiac troponin-T and creatinine kinase showed significant association with mortality (resp. HRadj 1.34 [1.08-1.66], p = 0.008; HRadj 1.36 [1.05-1.76], p = 0.019), other known determinants of prognosis after STEMI, e.g., hypertension and renal insufficiency, were not significantly associated with survival. Conclusions Patients with a prior cancer diagnosis admitted with STEMI have a poor survival rate. However, when the STEMI is optimally treated with primary PCI and medication, cardiac mortality is low, and prognosis is mainly determined by factors related to cancer stage.Cardiolog

Elevated resting heart rate is a marker of subclinical left ventricular dysfunction in hodgkin lymphoma survivors

Background: Thoracic irradiation is one of the cornerstones of Hodgkin lymphoma (HL) treatment, which contributes to high rates of long-term survivorship, but begets a life-long increased risk of heart disease including heart failure. At the cardio-oncology (CO) clinic, persistent sinus tachycardia or elevated resting heart rate (RHR) is frequently observed in these patients. The aim of this study was to evaluate the relation between RHR and left ventricular (LV) dysfunction.Methods: In 75 HL survivors visiting our CO-clinic echocardiographic evaluation of LV systolic and diastolic function including global longitudinal strain (GLS) was performed to assess subclinical LV dysfunction.Results: Median age of HL diagnosis was 24 [25th-75th percentile: 19,29] years with a 17 [12,25] year interval to CO-clinic visit and 31 patients (41%) were male. Average RHR was 78 +/- 14 bpm and 40% of patients (N = 30) had an elevated RHR defined as >= 80 bpm. While there was no difference in LV ejection fraction (55.6 +/- 4.3 vs. 54.8 +/- 6.6; p = 0.543), patients with elevated RHR had abnormal GLS (-15.9% vs. -18.3%, p = 0.045) and higher prevalence of diastolic dysfunction (73.3% vs. 46.7%; p = 0.022). GLS, E/e' ratio and presence of diastolic dysfunction were independently associated with RHR when correcting for age, sex and mantle field irradiation. A significant improvement was observed of the RHR association model with solely extracardiac confounders when LV-function parameters were added to the model (F-statistic = 6.36, p = 0.003).Conclusions: This study indicates RHR as a possible marker for subclinical LV-dysfunction in HL survivors. (C) 2021 The Authors. Published by Elsevier B.V.Biological, physical and clinical aspects of cancer treatment with ionising radiatio

Maternal health in Namibia: Lessons learned from obstetric surveillance

Over the past decades increasing efforts have aimed to improve the health of pregnant women around the world. Namibia has made limited progress in reducing severe maternal outcomes. Aims of this thesis were to enhance implementation of a national obstetric surveillance system and assess requirements to improve maternal health in Namibia. The findings of chapters 2-7 provided insight into several important drivers of severe maternal outcome. The most important contributor of the high-incidence of severe maternal outcome in Namibia was poor quality of facility-based care and particularly vulnerable women appeared to be at higher risk of severe maternal outcome. Obstetric surveillance played a crucial role in obtaining these insights. Based on these, targeted recommendations could be formulated. The maternity care system needs to be strengthened, to enable health workers to provide universal coverage of good health care to all women in Namibia. It is therefore crucial the next step will follow, which is to act on the proposed recommendations. The insights obtained through obstetric surveillance will contribute to such action, as for any intervention, it is key it addresses a local need in a context-specific manner. </p

Maternal health in Namibia: Lessons learned from obstetric surveillance

Over the past decades increasing efforts have aimed to improve the health of pregnant women around the world. Namibia has made limited progress in reducing severe maternal outcomes. Aims of this thesis were to enhance implementation of a national obstetric surveillance system and assess requirements to improve maternal health in Namibia. The findings of chapters 2-7 provided insight into several important drivers of severe maternal outcome. The most important contributor of the high-incidence of severe maternal outcome in Namibia was poor quality of facility-based care and particularly vulnerable women appeared to be at higher risk of severe maternal outcome. Obstetric surveillance played a crucial role in obtaining these insights. Based on these, targeted recommendations could be formulated. The maternity care system needs to be strengthened, to enable health workers to provide universal coverage of good health care to all women in Namibia. It is therefore crucial the next step will follow, which is to act on the proposed recommendations. The insights obtained through obstetric surveillance will contribute to such action, as for any intervention, it is key it addresses a local need in a context-specific manner. </p

Cardiac and obstetric outcomes of pregnancies for women after cardiotoxic therapy in childhood: a single center observational study

Abstract Background Childhood cancer survivors (CCS) are at increased risk of cardiomyopathy during pregnancy if they have prior cardiotoxic exposure. Currently, there is no consensus on the necessity, timing and modality of cardiac monitoring during and after pregnancy. Therefore, we examined cardiac function using contemporary echocardiographic parameters during pregnancy in CCS with cardiotoxic treatment exposure, and we observed obstetric outcomes in CCS, including in women without previous cardiotoxic treatment exposure. Method A single-center retrospective cohort study was conducted among 39 women enrolled in our institution’s cancer survivorship outpatient clinic. Information on potential cardiotoxic exposure in childhood, cancer diagnosis and outcomes of all pregnancies were collected through interviews and review of health records. Echocardiographic exams before and during pregnancy were retrospectively analyzed for left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) if available. The primary outcomes were (i) left ventricular dysfunction (LVD) during pregnancy, defined as LVEF < 50% or a decline of ≥ 10% in LVEF below normal (< 54%), and (ii) symptomatic heart failure (HF). Rate of obstetric and fetal complications was compared to the general population through the national perinatal registry (PERINED). Results All pregnancies (91) of 39 women were included in this study. The most common malignancy was leukemia (N = 17, 43.6%). In 22 patients, echocardiograms were retrospectively analyzed. LVEFbaseline was 55.4 ± 1.2% and pre-existing subnormal LVEF was common (7/22, 31.8/%). The minimum value of LVEF during pregnancy was 3.8% lower than baseline (p = 0.002). LVD occurred in 9/22 (40.9%) patients and HF was not observed. When GLS was normal at baseline (< -18.0%; N = 12), none of the women developed LVD. Nine of out ten women with abnormal GLS at baseline developed LVD later in pregnancy. In our cohort, the obstetric outcomes seemed comparable with the general population unless patients underwent abdominal irradiation (N = 5), where high rates of preterm birth (only 5/18 born at term) and miscarriage (6/18 pregnancies) were observed. Conclusion Our study suggests that women with prior cardiotoxic treatment have a low risk of LVD during pregnancy if GLS at baseline was normal. Pregnancy outcomes are similar to the healthy population except when patients underwent abdominal irradiation

Maternal mortality due to cardiac disease in low- and middle-income countries

Objectives To assess the frequency of maternal death (MD) due to cardiac disease in low- and middle-income countries (LMIC).Methods Systematic review searching Medline, EMBASE, Web of Science, Cochrane Library, Emcare, LILACS, African Index Medicus, IMEMR, IndMED, WPRIM, IMSEAR up to 01/Nov/2017. Maternal mortality reports from LMIC reviewing all MD in a given geographical area were included. Hospital-based reports or those solely based on verbal autopsies were excluded. Numbers of MD and cardiac-related deaths were extracted. We calculated cardiac disease MMR (cMMR, cardiac-related MD/100 000 live births) and proportion of cardiac-related MDs among all MDs. Frequency of cardiac MD was compared with the MMR of the country.Results Forty-seven reports were included, which reported on 38,486 maternal deaths in LMIC. Reported cMMR ranged from 0/100 000 live births (Moldova, Ghana) to 31.9/100 000 (Zimbabwe). The proportion of cardiac-related MD ranged from 0% (Moldova, Ghana) to 24.8% (Sri Lanka). In countries with a higher MMR, cMMR was also higher. However, the proportion of cardiac-related MD was higher in countries with a lower MMR.Conclusions The burden of cardiac-related mortality is difficult to assess due limited availability of mortality reports. The proportion of cardiac deaths among all MD appeared to be higher in countries with a lower MMR. This is in line with what has been called 'obstetric transition': pre-existing medical diseases including cardiac disease are becoming relatively more important where the MMR falls