Prevalence and Characteristics of Peripartum Cardiomyopathy among Women with Cadiac Failure Referred for Echocardiography in a Tertiary Hospital in Northern Nigeria

Introduction: Peripartum cardiomyopathy (PPCM) is a common clinical condition in northern Nigeria. This study aimed to determine the prevalence and characteristics of PPCM among women with heart failure referred for echocardiography. Materials and Methods: This is a retrospective study of 401 women managed for heart failure referred for echocardiography between October 2016 and September 2017. Their reports were analyzed for demographic and echocardiographic parameters. Results: The mean age of the 401 individuals studied was 41.28 ± 16.25 years. The commonest cause of heart failure was PPCM, accounting for 256 (69.5%), followed by hypertension 79 (19.7%) and rheumatic heart disease (RHD) 24 (5.9%). Conclusion: PPCM is a common and important cause of heart failure among women in Northern Nigeria.


Journal of Biosciences and Medicines
pump adequate blood to meet the demands of the body and/or doing so at increased filling pressures. It is a serious and major clinical problem worldwide. It has been recognized as a contributor to cardiovascular disease burden in Africa, and an important cause of hospital admission [1]- [6].
Available data suggest that the etiologies of heart failure in Africa differ from those in the Western world [7]. The most common underlying cause of heart failure in high-income countries is coronary artery disease [8]. In sub-Saharan Africa, the predominant causes are hypertensive heart disease, rheumatic heart disease and cardiomyopathies [9] [10] [11].
Peripartum cardiomyopathy is defined as dilated cardiomyopathy of uncertain origin that occurs in pregnant women from the last trimester to the postpartum period with no preexisting heart disease [12]. It is recognized as a separate entity because of its distinct epidemiologic characteristics, relatively rapid onset and association with unique auto antigens and autoantibodies [13].
Virchow recognized heart failure in association with pregnancy as early as 1880 [14]. However, it was not until the 1930s when Hull and Hafkes formally described the syndrome of heart failure following pregnancy as "postpartum cardiomyopathy" [14]. Demakis and Rahmitoola in 1971 formally defined PPCM and gave criteria for its diagnosis, the basis of which remains today [15].
Although several studies have assessed the clinical profile and natural history of the condition, there is still the need of data from parts of the world with high disease prevalence. With the availability of echocardiographic facility in our centre, we observed a change in trend in the aetiology and pattern of presentation of heart failure among women. The prevalence of PPCM was noted to be rising. The present study aims to determine the prevalence and characteristics of PPCM among women with heart failure referred for echocardiography.

Methods
This is a retrospective study of the echocardiographic data of women with heart failure referred for echocardiography collected over 1 year period between 1 st October 2016 to 30 th September 2017. The study was carried out at Murtala Muhammad Specialist Hospital (MMSH), Kano. Subjects were eligible if they were 18 years and older and with a confirmed diagnosis of heart failure. Heart failure was defined according to the recommendations of the European Society of Cardiology [16]. The New York Heart Association functional (NYHA) of the subjects was also assessed [17].
Baseline clinical and demographic characteristics were obtained from the patient's folders and echocardiography register. These included: age, place of residence, parity, BMI (body mass index), BP (blood pressure) at time of first presentation, echocardiographic parameters and diagnoses.
Ethical approval was obtained from the institution's ethical review committee. Journal of Biosciences and Medicines were performed on all the patients by three cardiologists, using Toshiba HDI Machine and a 2.5 to 5.0 Hz linear array transducer, according to the recommendation of the American Society of Echocardiography (ASE) [18]. Subjects were examined in the left lateral decubitus position using standard parasternal, short axis and apical views. The M-mode cursor on the 2D scan was moved to specific areas of the heart to obtain measurements according to the recommendations of the committee on M-mode standardization of the ASE [19]. 2) Absence of an identifiable cause of cardiac failure.
3) Absence of recognizable heart disease prior to the last month of pregnancy

Results
Four hundred and ninety-eight women were referred for echocardiography during the study period out of which 401 (80.5%) had diagnosis of heart failure.  Table 1 shows the socio-demographic characteristics of the study population. Figure 1 shows the causes of heart failure among females.
Sixty-eight percent 124 (68%) of the patients had severe left ventricular systolic dysfunction (EF < 35%). Thrombus in the Left ventricle was found in 10 (5.4%) and 3 (33.3%) had stroke. LV diastolic dysfunction was found in (157) 86.5%. Figure 2 shows the pattern of LV dysfunction among the PPCM patients. Table   2 shows the echocardiographic characteristics of patients with PPCM.

Discussion
Peripartum cardiomyopathy was the commonest aetiology of heart failure among females, accounting for more than half of cases (62.5%). This disorder has been recognized as an important cause of heart failure in Northern Nigeria al., in Sokoto [30].
In this study the incidence of traditional Puerperal practice is lower than in previous reports [30] [35] [36]. Hot water bath was practiced in 84 (46.2%) while 67 (37%) consumed dried lake salt pap (kunun kanwa). These practices have been previously described in over 90% of Hausa-Fulani tribes of Nigeria [35] [36]. These practices are believed to stimulate breast milk production and general health of the mother. The resultant volume overload is thought to aggravate heart failure in a heart already stressed by the haemodynamic changes of pregnancy [36]. The decline in these practices may be attributed to the greater awareness of their hazardous effects and also its economic consequences since a lot of money is spent on buying fire wood for boiling the water. Despite this, however, the incidence of peripartum cardiomyopathy remains high, due to multifactorial etiology.

Conclusions
Peripartum cardiomyopathy is the leading cause of heart failure among women presenting for echocardiography in Murtala Muhammad Specialist Hospital, Kano, and North-western Nigeria. The incidence of the disease is rising despite some decline in the harmful traditional birth practices in the environment, thus reinforcing the importance of other aetiological factors.
This study has some limitations. The data collection was time-consuming as record keeping is done manually. There were also missing and incomplete data.
As we aim to determine the prevalence of the disease, our patients were not followed up, thus outcome data in terms of mortality and recovery of left ventricular function were not available. However, this condition found to be the most common cause of heart failure among women in this tertiary health institution,

Recommendation
We recommend continuous health education programmes to women of child bearing age on the risk factors of the disease and the importance of antenatal and postnatal period care. We also recommend focused echocardiographic screening of high risk women in the peripartum period to identify and treat asymptomatic left ventricular dysfunction. There is also the need to promote family planning measures to assist women who wish to avoid the higher risk of the disease and or relapse.