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American Journal of  Medical 
Science and Innovation (AJMSI) 

Effect of  Maternal Heart Disease on Fetal and Maternal Outcome in Omdurman 
Maternity Hospital

Roaa Mohamed Ahmed Elhaj1*, Zeinab Balla Ali Keer2, Kameel Kamal Kamil3, Sumia Mohammed ElShafie4

Volume 4 Issue 1, Year 2025
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v4i1.3857
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: September 27, 2024
Accepted: November 01, 2024
Published: February 14, 2025

Pregnancy significantly impacts cardiovascular system, leading to 1% to 4% complications in 
women without preexisting cardiac abnormalities globally. This study aims to determine the 
effect of  maternal heart disease on fetal and maternal outcomes. The cross-sectional study 
was conducted at Omdurman Maternity Hospital from February 2017 to January 2018, in-
volving 146 patients with cardiac disease who had antenatal care in the hospital. Data was 
collected through a questionnaire after informed written consent, and analyzed using SPSS 
version 20 on a computer. The study revealed results of  146 patients, with 42.5% aged 23-
35, primarily from rural areas. The majority delivered vaginally, with 32.6% undergoing a 
Cesarean section. The most common heart disease was rheumatic heart disease (67%), with 
mitral stenosis being the major lesion (41.8%). Congenital heart disease was 26%, with VSD 
affecting 81.6%. Acquired heart disease was seen in 7%, with 60% diagnosed as cardiomy-
opathies. Heart failure was the most common complications, with maternal deaths occurring 
in 3.4%. Perinatal complications included miscarriages (5%), terminations due to severe 
cardiac diseases (2%), preterm births (34.9%), IUGR (1.4%), congenital heart disease (2%), 
stillbirths (2%), and early neonatal deaths (2.7%). The study revealed that rheumatic heart 
disease and cardiomyopathies are common during pregnancy, posing significant maternal 
and fetal risks, including heart failure, prematurity, miscarriages, IUGR, still births, and early 
neonatal deaths. Future studies can focus on implementing systematic cardiac screening, 
enhance preconception counseling, and develop multidisciplinary protocols.

Keywords
Cardiac Diseases, Fetal, Heart 
Disease, Maternal, Neonatal, 
Pregnancy, Rheumatic Heart 
Disease, Sudan

1 M.B.B.S., MRCPI, Shaqra General Hospital, Saudi Arabia
2 M.B.B.S., MD (SMSB), MRCOG, Omdurman Maternity Hospital, Sudan
3 M.G.O, Khartoum MRCOG, Omdurman Maternity Hospital, Sudan
4 MD Internal Medicine, SMSB Omdurman Maternity Hospital, Sudan
* Corresponding author’s e-mail: roaahaddad2021@gmail.com

INTRODUCTION
Maternal heart disease is a significant issue in obstetrics, 
impacting both the mother and fetus’ health (Beaton 
et al., 2019). It can lead to serious consequences such 
as preeclampsia and maternal death, while less severe 
issues like pulmonary edema and cardiac arrhythmias 
may emerge (Keepanasseril et al., 2021). Neonatal 
consequences include low birth weight, premature birth, 
and a higher chance of  congenital heart disease in infants 
(Norman et al., 2020). Despite advancements in medical 
understanding and technology, maternal heart problems 
still burden a significant percentage of  pregnancies, 
affecting maternal death rates worldwide (Ramlakhan 
et al., 2020). Cardiac diseases complicate 1% to 4% of  
pregnancies in women without preexisting abnormalities, 
increasing the risk of  morbidity and mortality during 
pregnancy (Iftikhar & Biswas, 2019). Maternal cardiac 
diseases increase significantly the risk of  morbidity and 
mortality during pregnancy resulting in around 10% 
to 25% of  the maternal deaths every year. In the UK, 
maternal diseases of  heart are the most frequent causes 
of  maternal death, with 2.27 per 100,000 cases (Tubb, 
2024). In Saudi Arabia, a lack of  information on maternal 
heart disease has led to the need for newer research 
(Fayed et al., 2022; Zakaria et al., 2020).
The existence of  maternal heart disease that leads to 
complications like postpartum hemorrhage, sepsis, 

infective endocarditis, and congestive cardiac failure, 
vector-borne diseases is presented in some studies in 
Sudan (Isogai & Kamiya, 2019; Suliman, 2011). The 
heart problems also cause fetal deaths through stillbirths 
and neonatal ones. These findings, therefore, emphasize 
the importance of  research regarding the effect of  
maternal heart disease on pregnancy outcomes, especially 
in countries such as Sudan where this issue is still 
unclear. The maternal and neonatal morbidities remain 
high in such regions. Cardiovascular changes during 
pregnancy can have profound health implications both 
for the mother and for the fetus (Ramlakhan et al., 2020). 
Pregnancy leads to a significant increase in blood volume, 
cardiac output, and vascular resistance, often impacting 
existing heart disabilities or causing new complications 
like arrhythmia or in some cases heart failure (Ngene & 
Moodley, 2019; Troiano, 2018). Maternal heart disease 
also increases the risk of  miscarriage, premature birth, 
intrauterine growth restriction, and congenital heart 
defects in the fetus (Hardee et al., 2021).
The incidence of  maternal heart disease is very high in 
developing countries where women may be deprived of  the 
prenatal care, specialized cardiac services that are possibly 
accessible in the developed world. The research in Sudan 
revealed that maternal heart disease accounted for more 
than half  of  maternal deaths, and lethal complications 
such as postpartum hemorrhage, sepsis, and congestive 



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heart failure were more common (Mohammed et al., 2011; 
Mohammed et al., 2022; Organization, 2018). However, 
the lack of  comprehensive information on maternal 
heart disease and its influence on pregnancy outcomes 
in places like Sudan highlights a crucial research gap. 
These findings prove the urgency to improve maternal 
heart disease impact on pregnancy outcome knowledge 
in regions like Sudan where data is not available enough, 
and maternal and neonatal complications are a big issue 
to the public health officials.
The maternal mortality rate in Sudan and South Sudan 
is higher than the global average, primarily due to 
infection, hemorrhage, obstructed labor, abortion, and 
hypertension. The armed conflict in Sudan has impacted 
maternal health services, causing challenges in accessing 
essential care, increased risk of  complications during 
pregnancy and childbirth, and mental health issues 
among pregnant women (Alemu et al., 2019; Olaleye et 
al., 2023). The maternal mortality rate in Sudan and 
South Sudan is significantly higher than the global 
average, largely due to factors like infection, hemorrhage, 
obstructed labor, abortion, and hypertension (Alemu et 
al., 2019; Makuei et al., 2020). The ongoing armed conflict 
in Sudan further complicates these issues, increasing the 
risks of  complications during pregnancy and childbirth. 
Heart disease is a significant contributor to pregnancy 
complications, especially in regions with prevalent 
maternal and perinatal morbidities (Ramage et al., 2019). 
Understanding the impact of  maternal heart disease 
on maternal health outcomes is crucial for improving 
healthcare delivery and reducing mortality rates among 
expectant mothers. This study aims to evaluate the 
outcomes of  mothers diagnosed with heart disease 
admitted for delivery and the babies delivered by these 
mothers at Omdurman Maternity Hospital. The findings 
will inform the development of  healthcare practices 
and prenatal care strategies, ultimately aiming to reduce 
maternal mortality and morbidity caused by heart disease 
in Sudan and similar low or low-middle-income countries.

LITERATURE REVIEW
Cardiovascular Impact of  Pregnancy
One of  the most significant cardiac complications 
during pregnancy is the worsening of  pre-existing heart 
diseases that are the top cause of  maternal mortality. 
Women who are pregnant with heart disease are more 
vulnerable to complexities during pregnancy and 
postpartum. Conditions such as valvular heart diseases, 
chronic hypertension, and congenital heart defects are 
risk factors for the mothers and the baby. Factors such as 
older maternal age, higher rate of  in vitro fertilization and 
multiple cardiovascular risk factors have been playing the 
main role in this rising concern (Sahu et al., 2022). Moreover, 
the cardiovascular system of  a healthy pregnancy itself  
undergoes dramatic alterations to bear with the larger size 
of  a fetus, thus imposing a greater burden on the heart. 
Complications during pregnancy must be identified and 
managed early, and a multidisciplinary team including 

obstetricians, cardiologists, and other specialists, may be 
required to optimize management. Studies in this regard 
highlight the necessity of  making better evidence-based 
guidelines and specialized care centers (Hauspurg et al., 
2018). 
The effect of  pregnancy on the cardiovascular area 
goes beyond the pregnancy period itself. Women who 
previously experienced APOs (Adverse Pregnancy 
Outcomes) such as preeclampsia or gestational diabetes 
are more likely to develop cardiovascular disease in their 
future years (Lane-Cordova et al., 2019). Hypertension 
disorders during pregnancy (HDP) are a specific concern 
because studies have shown that HDP is associated with 
a higher risk of  cardiovascular diseases later in life, such 
as coronary artery disease, heart failure, and valvular heart 
diseases (Honigberg et al., 2019). Early intervention after 
delivery and modification of  life style can help reduce 
these risks. Obesity is a major factor which plays an 
important role in pregnancy combined with heart disease 
as it has been proven that obese women are at greater 
risk of  developing different maternal cardiovascular 
complications. Preconception counseling including 
weight management and other cardiovascular risk factors 
must be provided to these pregnant women (Pfaller et al., 
2021). 
Pregnancy has a considerable effect caused by the 
conditions such as valvular heart disease, chronic 
hypertension, congenital heart defect, and non-ischemic 
cardiomyopathies which are comorbid conditions 
and the ones that increased mortality rates as well as 
morbidities among the fetus and the mother (Sahu et 
al., 2022). The occurrence of  congenital heart disease 
because of  acquired maternal age, obesity, diabetes 
mellitus, and hypertension are among the reasons of  high 
prevalence (Hedermann et al., 2021; Owens et al., 2018). 
Adaptations of  the cardiovascular system go beyond 
simple hemodynamic modification during pregnancy, and 
these multiple hemodynamic, metabolic, and hormonal 
changes burden the cardiovascular system to such a 
degree that women may be more prone to cardiovascular 
disease precipitation or aggravation.
Hypertensive disorders of  pregnancy (HDP) are linked 
with early cardiovascular aging and a broader spectrum 
of  diseases not previously considered, such as valvular 
heart disease. Assessment and preventing HDP becomes 
an immediate need, since it leads to increased chances 
of  well-known classic cardiovascular risk factors such 
as essential hypertension, renal disease, abnormal lipid 
profile and diabetes (Melchiorre et al., 2020). Due to a 
lack of  guidelines to guide cardiovascular follow-up and 
preventive strategies after HDP, however, we propose that 
screening should be done as early as possible, particularly 
within one year of  delivery. The maternal obesity also 
may provoke the cardiac complications in maternal 
women with the heart disease. Addressing obesity during 
preconception counseling is a key factor for such cases, as 
for the high-risk pregnancy.



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Maternal Mortality and Heart Disease
Maternal mortality has been the major health problem in 
the low- and middle-income countries (LMICs). Although 
obstetric direct causes (hemorrhage, hypertension, sepsis) 
account for most of  obstetric deaths, cardiac disease is 
another indirect cause that is often neglected (Makuei, 
2021). A review covering 47 maternal mortality reports 
from 29 LMICs stated the percentage of  cardiac-related 
maternal mortality ratios as below 34% of  the total 
maternal deaths recorded. The authors state that the 
number of  cardiac disorders is certainly underestimated 
as some people, due to the lack of  medical facilities, are 
undiagnosed in resource-poor areas (Heemelaar et al., 
2020). A study conducted in Eritrea showed 2.3% of  
rheumatic heart disease among pregnant women who 
otherwise were asymptomatic and this shows that the 
burden of  cardiac disease in pregnant population might 
be huge (Otto et al., 2011).
Relevant factors to increase maternal mortality from 
cardiac disease in LMICs are late presentation, low 
availability of  specialized care, and poor monitoring 
and treatment during pregnancy. A study conducted on 
pregnant women in India concluded that the occurrence 
of  maternal mortality was higher (5.45%) in women with 
heart disease than those without any cardiac condition 
and that the functional class of  the heart (class with 
NYHA III-IV) is of  high risk category and closely tied 
with the adverse outcomes (Khan et al., 2018; Meh et al., 
2022; Sharma et al., 2022). To deal with this challenge 
the authors call on improving emergency obstetric care, 
educating midwives, and raising accessibility of  cardiology 
diagnostics and management especially in the countryside 
regions. Implementing cardiac screening at antenatal care 
routinely and the system of  referrals also might be helpful 
with detecting and monitoring high-risk cases.
Research on heart disease maternal mortality in low-
middle income countries (LMICs) is crucial. Collaboration 
between medical institutions, policymakers, and 
researchers will develop effective initiatives to improve 
outcomes for pregnant women with cardiac complications 
(Ponikowski et al., 2014). Reinforcing health systems, 
educating healthcare workers, and implementing early 
screening and intervention strategies are key approaches 
to cardiac disease reduction among LMIC women. By 
addressing these issues, significant progress can be made 
on heart disease maternal mortality and global maternal 
health outcomes.

Maternal Heart Disease in Sudan
Sudan has traditionally faced a very high maternal 
mortality rate, with a range of  750 to over 1400 maternal 
deaths per every 100,000 live births (Makuei, 2021; 
Sharma et al., 2022). However, the direct obstetric causes 
such as postpartum hemorrhage, obstructed labor, and 
sepsis account for the majority of  maternal deaths and, 
additionally, the indirect causes like cardiac diseases are 
also significant factors. A community-based reproductive 
age mortality survey (RAMOS) conducted in Kassala 

State, Eastern Sudan determined that 10.9% of  the 
maternal deaths were solely based on puerperal septicemia 
which would be a remnant effect of  an unverified cardiac 
disease (Gebreweld & Tsegaye, 2018). 
Another study from a referral hospital in Khartoum show 
that 2.7% of  maternal deaths were attributed to cardiac 
factors (Ounsa & Mohamed, 2011). The multifactorial 
influences leading to high maternal mortality due to heart 
disease in Sudan include delays in care-seeking, transport 
challenges and limited availability of  specialized cardiac 
services, particularly at the rural areas. The RAMOS study 
showed the rates of  illiteracy to be very high among the 
deceased women and their partners, which had a serious 
implication on seeking health care services. The authors 
advise to improve the quality of  emergency obstetric 
care, to extend the training and coverage of  midwifery 
services and to expand access to cardiological diagnostics 
especially in underserved regions. Integrating cardiac 
screening into the regular antenatal care check-up and 
improving referral systems can also be very useful for 
locating and treating high-risk cases (van Smoorenburg 
et al., 2023).
Maternal mortality in Sudan due to heart disease is a 
significant issue that requires improvement in emergency 
obstetric care, midwifery training, and cardiac diagnostics. 
Integrating cardiac screening into routine antenatal care 
and improving referral systems can help identify cases 
early. Addressing social determinants of  health, such 
as literacy levels and healthcare-seeking behaviors, and 
strengthening healthcare systems, increasing awareness, 
and using evidence-based approaches can significantly 
reduce maternal death and improve maternal health.

MATERIALS AND METHODS
Study Design
The study used a cross-sectional analytic hospital-based 
design, that is, particularly appropriate for establishing 
correlation between pregnancy complications and 
cardiovascular disease. This design helps researchers to 
gather data from a great number of  participants during 
an allotted period of  time and this allows them to identify 
patterns and recurring trends in the data (Mohajan, 2020). 
The study was carried out at Omdurman Maternity 
Hospital in Sudan, which is the first maternity hospital 
and the largest referral hospital in the country for obstetric 
cases. This setting brings a chance to collect evidence 
on the prevalence and consequences of  cardiovascular 
diseases in pregnancy involving Sudanese population.
The inclusion criteria for the study concerned all 
pregnant women who either delivered or terminated their 
pregnancy in hospital with cardiac disease (either new 
or old), and had antenatal care at Omdurman Maternity 
Hospital. With this, it ensures that the sample depicts 
the expectation of  the population of  women who are 
pregnant with cardiac disease in Sudan. The exclusion 
criteria includes pregnant women who didn’t take prenatal 
care in Omdurman maternity hospital, meanwhile, the 
same is done in order to mitigate the biases in the data.



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Data Collection
Data collection conducted using a questionnaire that 
covered major areas which the registrars filled during 
the delivery. The questionnaire consisted of  five parts: 
demographic information, obstetric history, medical 
and surgical history, modes of  delivery, maternal and 
fetal outcomes. This systematic method encompasses 
collection of  data with regards to the medical history of  
the participants, their pregnancy outcomes, and other 
critical factors.
At the initial visit, all pregnant women with cardiac 
disease were clinically examined by both an obstetrician 
and a physician, and an ECG and echocardiogram were 
conducted as standard procedures. This guarantees that 
the data gathered is accurate and dependable because it 
relies on clinical assessments and objective measures.

Data Analysis
Data analysis was done on the computer with SPSS 
version 20 (Statistical Package for Social Sciences). 
Descriptive frequency table was performed to determine 
the physiological and clinical characteristics of  the 
participants. Chi-square tests were used in the research 
for the correlation between different variables and to test 
for statistical significance (the P value). This statistical 
approach allows for the formulation of  the sources 
of  significant associations between variables and the 
identification of  potential tendencies in the data.

Sample Size
The sample represented 146 patients, which is a small 
but significant proportion of  the pregnant women with 
cardiac disease in Sudan. This sample size was selected 
according to the availability of  resources as well as the 
practicability of  study implementation within the span of  
February 2017 and January 2017.

Ethical Considerations
The research was conducted ethically and responsibly, 
obtaining permission from reputable bodies like 

Omdurman Maternity Hospital and the Sudan Medical 
Specialization Board. Participants’ voluntary informed 
written consent was obtained, and confidentiality and 
privacy were guaranteed. The study’s ethical considerations 
were particularly important in a healthcare-accessible 
setting where participants could be easily exploited. A 
structured questionnaire and clinical evaluations were 
used to provide accurate data, ensuring participants did 
not experience harm or discomfort.

RESULTS AND DISCUSSION
Within this observational period, which covered both 146 
deliveries and last trimester visits, nearly two-thirds of  the 
patients, i.e. 62 individuals (42.5%), belonged to the age 
group of  26 to 35 years old. This population breakdown 
illustrated in the Figure 1 emphasizes the widespread 
representation of  this age group in the patient group. 
Level of  patient’s education varied not much, as 16 (11%) 
of  the patients were illiterate, 54 (37%) as high school 
graduates and 46 (31.5%) as primary school graduates 
and 30 (20.5%) as university graduates, as seen in Figure 
2. The residence data also showed separation in the 
patient distribution with 84 individual (57.5%) patients 
from a rural area and another 62 (42.5%) patients from 
urban areas, as it is shown on Figure 3.
From the obstetric history, 40 patients (27.4%) were 
primigravida while 68 (46.6%) had a parity between 1 
and 4 and the last 38 (26%) were multiparous with 5 or 
more pregnancies as depicted in Figure 4. Prenatal care 
initiation through the trimesters demonstrated varied 
distribution and 64 patients (43.8%) were booked during 
their second trimester, 36 patients (24.7%) were booked 
during their first trimester, and 46 patients (31.5%) were 
booked during their third trimester. Among the few 
patients who had different booking times, the majority 
of  them delivered after 37 weeks of  gestation, 79 patients 
(54.1%), and ten (6.4%) experience early delivering due 
to premature before 24 weeks, so it is essential to provide 
full antenatal care for a timely manner. Additionally, 
there were 108 (74%) patients among those that had not 

Figure 1: Distribution of  patients according to age

Demographics



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Figure 2: Distribution of  patients according to Educational level

Figure 3: Distribution of  patients according to location

Figure 4: Distribution of  patients according to parity



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Obstetric History

Figure 5: Distribution of  patients according to gestational age at booking

Medical and Surgical History

Figure 6: Distribution of  patients according to gestational age at delivery

Maternal and Fetal Outcomes

Figure 7: Distribution of  patients according to counseling



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Figure 8: Distribution of  patients according to Etiology of  disease

Figure 9: Distribution of  patients according to past history of  complications

Figure 10: Distribution of  patients according to NYHA classification



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Figure 11: Distribution of  patients according to mode of  delivery

Modes of  Delivery

Figure 12: Distribution of  patients according to type of  vaginal delivery

Figure 13: Distribution of  patients according to type of  cesarean section



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received information about the risk that can be imposed 
by the underlying medical condition during pregnancy 
which may mean that preconception care services had 
some gaps. On the other hand, 38 cases (26%) out of  146 
total patients were counseled before conception, based on 
the information provided in Figure 7. The results of  the 
analysis revealed a complex and varied demographic and 
clinical profile of  the patient base, thereby emphasizing 
the need for a personalized healthcare system with focus 
on better results during the perinatal period.
Rheumatic heart disease accounted for 67% of  the 
patients in the study, making it the most common kind 
of  cardiac disease (Figure 8). 10.3% of  the patients had 
previously had heart surgery, with balloon valvotomy, 
cardiac catheterization, valve replacement, and VSD 
closure being the most frequently performed operations. 
In addition, 19.2% of  the participants had previously 
been hospitalized for different cardiac problems, whereas 
70.5% had no prior issues (Figure 9). 28.8% of  patients 

were classified as belonging to class I, 24% as class II, 
37.6% as class III, and 9.6% as class IV according to the 
NYHA criteria (Figure 10). The vast majority of  patients 
(67.4%) gave birth vaginally; 72.5% did so spontaneously, 
9.9% had an induction for medical reasons, and 17.6% 
used an instrument (Figures 11 and 12). Nonetheless, 
32.6% of  patients underwent cesarean section; 34% of  
these cases were emergency cases, and 66% were elective 
cases (Figure 13).
The tables below include a thorough examination of  
maternal heart disease and its effects on pregnancy 
outcomes. They classify and examine data on cardiac 
conditions, medical variables, obstetric difficulties, 
perinatal outcomes, and the link between preconception 
counseling and complications. The methodical structuring 
of  this data aids comprehension of  the complicated 
relationship between mother cardiovascular health and 
pregnancy outcomes.

Table 1: Types of  Rheumatic Heart Diseases
Type n=98 Percent
MS 41 41.8
MR 22 22.4
MS+AS 9 9.2
MS+AR 6 6.1
MS+TR 6 6.1
MR+TR 7 7.1
AS 2 2
AR 1 1
TR 1 1
Total 98 100

Table 2: Congenital Heart Disease
Type n=38 Percent
ASD 3 7.9
VSD 31 81.6
TOF 1 2.6
PDA 2 5.3
Pulmonary stenosis 1 2.6
Total 38 100

Cardiac Conditions and Complications
Table 1 demonstrates the proportion of  various types 
of  Rheumatic Heart Diseases (RHD) among the 98 
patients. The most prevalent type is Mitral Stenosis (MS), 
accounting for 41.8%, then comes Mitral Regurgitation 
(MR) which is 22.4%. Other kinds, like the MS with 

AS (Aortic Stenosis) and the MS with AR (Aortic 
Regurgitation) each account for around 6.1% cases. 
The rarest types include Aortic Stenosis (AS), Aortic 
Regurgitation (AR), and Tricuspid Regurgitation (TR), 
each representing 1-2% of  cases.

Table 2 shows congenital heart diseases in the 38 patients. 
Ventricular Septal Defect (VSD) is the most common 
accounting for 81.6 percent of  the cases and Atrial Septal 
Defect (ASD) is the second following with 7.9 percent. 

The incidence of  PDA and TOF is 5.3% and 2.60% each. 
Only one patient came along with pulmonary stenosis 
that is equivalent to the percentage of  cases of  2.6%.



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Table 3: Acquired Heart Diseases
Type n=10 Percent
Cardiomyopathies 6 60
Ischemic Heart Disease 3 30
Pulmonary Stenosis 1 10
Total 10 100

Table 4: Associated Medical conditions
Disease Frequency Percent
Hypertension 8 5.5
Diabetes Mellitus 1 0.7
Thyroid 1 0.7
None 136 93.2
Total 146 100

Table 3 depicts acquired heart disease in 10 individuals. 
60% of  cases are cardiomyopathies while 30% are 
ischemic heart disease which is the second highest. One 

Table 5: Type of  treatment
Treatment Frequency Percent
Antiarrhythmic 31 21.2
Anticoagulants 55 37.7
Antihypertensive 8 5.5
Diuretics 9 6.2
Beta Blockers 1 0.7
Oral Hypoglycemic 1 0.7
Thyroxine 1 0.7
None 40 27.4
Total 146 100

of  the patients suffer from Pulmonary Stenosis, which is 
10% of  total cases.

Medical Conditions and Treatments

Table 5 displays the treatment types given to the patients. 
Anticoagulants have the highest usage at 37.7%, while 
antiarrhythmic drugs follow at 21.2%. The use of  
diuretics, antihypertensive drugs, and oral hypoglycemic 

Table 6: C/S Indications
Indication Frequency Percent
2PS 13 29.5
3PS 15 34.1
4PS 7 15.9
Fetal Distress 2 4.5
FOP 4 9
BOH 1 2.3
Refusal of  VBAC 1 2.3
Tubal Ligation 1 2.3
Total 44 100

agents are reduced proportionally. One third (27.4%) of  
people get no treatment.

Pregnancy and Obstetric Factors

Table 4 shows coexisting medical conditions among 
the mentioned population. Arterial hypertension is a 
most frequently encountered condition (5.5%), followed 

by diabetes mellitus and thyroid conditions, each 
representing 0.7% of  cases. Majority of  patients (93.2%) 
have no coexisting diseases.



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Table 7: Obstetrics Complications
Complication Frequency Percent
PPH 5 3.4
PIH 3 2.1
Sepsis 2 1.4
Death 5 3.4
None 131 89.7
Total 146 100

Table 8: Cardiac Complications
Complications Frequency Percent
Heart Failure 20 13.6
Infective endocarditis 3 2.1
Cerebrovascular Accident 1 0.7
Respiratory Tract Infection 1 0.7
Pulmonary Hypertension 4 2.7
Pulmonary Edema 3 2.1
Arrhythmias 3 2.1
None 113 77.4
Total 146 100

Table 6 shows the indications for Cesarean section 
(C-section). The most frequent reason is the 3PS (pre 
C/S, classical C/S or uterine rupture), which account for 
34.1% of  all cases, followed by the 2PS (pre C/S) at the 

Table 9: Perinatal Complications
Complications Frequency Percent
Miscarriage 8 5.5
Termination of  Pregnancy 3 2.1
IUGR 2 1.4
Premature 51 34.9
Congenital Heart disease 3 2.1
Still births 4 2.7
Early Neonatal Deaths 4 2.7
None 71 48.6
Total 146 100

rate of  29.5%. Other situations, including 4P (previous 
C/S with other high-risk factors), fetal distress, and failed 
operative cesarean, are of  lesser occurrences.

Table 9 shows the perinatal complication among the 
patients. Premature birth is the leading most challenge 
(34.9%) followed by miscarriage at 5.5%. Other kinds 
of  complications like, abortion, IUGRs, stillbirths, early 
neonatal deaths and congenital heart disease are reported 

at small proportions. The great majority (48.6%) of  
patients did not get into any perinatal complications.

Association and Counseling
Table 10 shows the connection between NYHA 

Table 7 reveals obstetric complications of  women during 
childbirth in patients. In most instances (89.7% of  the 
treated patients did not suffer from any complications). 

PPH and maternal death take place in 3.4% of  cases each 
and PIH and sepsis happen to a smaller part of  patients.

Table 8 represents the cardiac complications that should 
be observed in patients. The primary complication is heart 
failure and it accounts for 13.6% of  all cases, coming 
after pulmonary hypertension and pulmonary edema, 
each representing 2.7% and 2.1% of  cases, accordingly. 

Infective endocarditis, cerebral stroke, respiratory tract 
infection and arrhythmias drop to a lesser extent. In 
the majority (77.4%) of  patients there were no cardiac 
complications.



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Table 10: Association between NYHA classification and cardiac complications
Class Complicated Not complicated Total
I 4 38 42
II 6 29 35
III 14 41 55
IV 9 5 14
Total 33 113 146

Chi-Square 35.115 P.V. 0.009

Table 11: Association between NYHA classification and perinatal complications
Class Miscarriage Termination IUGR Premature Congenital 

H e a r t 
disease

Stillbirth E a r l y 
Neonatal l

None Total

C. I 5 0 1 21 1 0 0 14 42
C. II 2 0 1 2 0 0 2 27 35
C. III 0 3 0 21 1 2 1 28 55
C. IV 0 0 0 7 1 2 1 2 13
Total 7 3 2 51 3 4 4 71 146

Chi-Square 55.198 P.V. 0.000

Table 11 shows the relation of  NYHA group to perinatal 
complications. The number of  newborn injuries vary 
among different Classes of  NYHA. Class III includes 
most of  the complications such as danger of  miscarriage, 
termination, IUGR, premature birth, congenital heart 

Table 12: Association between preconception counseling and cardiac complications
Preconception 
counseling

Heart 
failure

P. edema Arrhythmias I.E. CVA R.T.I. P.HTN None Total

Yes 5 0 0 0 0 1 2 30 38
No 13 3 3 3 1 0 2 83 108
Total 17 3 3 3 1 1 4 113 146

Chi-Square 6.031 PV 0.420

disease, stillbirths and early neonatal deaths. The link 
between NYHA classification and perinatal risks is 
strong, given the p-value of  0.000, which is statistically 
significant.

Table 13: Association between preconception counseling and perinatal complications
Class Miscarriage Termination IUGR Premature Congenital 

Heart 
disease

Stillbirth Early 
Neonatal 
Deaths

None Total

Yes 5 3 1 9 1 1 1 18 38
No 3 1 1 42 2 3 3 53 108
Total 8 3 2 51 3 4 4 71 146

Chi square 10.663 P.V. .154

classification (heart failure severity) and cardiac 
complications. In patients of  NYHA class I, 4 of  them 
had cardiac complications and 38 were among the ones 
who did not face cardiovascular complications. The 

association between cardiac complications and NYHA 
class turned out to be statistically significant and it was 
reflected with the p-value of  0.009.

Table 12 shows the relation between preconception 
counseling and cardiac events as shown in the table. 

Preconception counseling resulted in 5 cases of  heart 
disease among women when compared to those who 



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Table 14: Association between previous complication and cardiac complication
Previous 
complications

Heart 
failure

P. 
Edema

Arrhythmias I.E. CVA R.T.I. P.HTN None Total

Heart surgery 4 0 0 1 1 1 3 5 15
Hospitalization 11 3 3 2 0 0 1 8 28
None 3 0 0 0 0 0 0 100 103
Total 17 3 3 3 1 1 4 113 146

Chi-Square 20.373 PV 0.040

Table 14 provides the association between previous 
complications and cardiac complications. Patients that 
have experienced heart surgery and hospitalization prior 
have demonstrated a greater risk of  cardiac comorbidities 
when compared with patients without previous 
complications. The results indicate that the number of  
previous complications is associated with the occurrence 
of  the cardiac complications at the significance level of  
0.040.

Discussion
Rheumatic heart disease (RHD) was the most common 
cardiac disease complicating pregnancy in this study, 
affecting 67% of  patients, which is comparable with 
results from comparable research in Sudan, Egypt, and 
South Africa. Mitral valve involvement, especially mitral 
stenosis (41.8%), was significant, but significantly lower 
than in Pakistan and India (Makate, 2021). Congenital 
cardiac problems impacted 26% of  patients, including 
ventricular septal defect (VSD) being the most common 
lesion, similar to a study conducted in Khartoum 
Teaching Hospital six years ago (Ottaviani & Buja, 2022; 
Yassin et al., 2015). VSD was the most prevalent lesion 
(81.6%), which is greater than in India. According to 
one study, rheumatic heart disease is the most prevalent 
cardiac lesion in pregnancy, followed by isolated mitral 
stenosis as the most common acquired lesion and mitral 
valve prolapse as the main congenital heart disease (Puri 
et al., 2013).
Early identification and treatment of  congenital cardiac 
disorders are critical for reducing unfavorable maternal 
and neonatal outcomes. These findings give useful 
information for healthcare policymakers and practitioners 
seeking to improve mother and child health outcomes in 
comparable settings.
This study analyzed maternal complications, focusing 
on cardiac and obstetrics. Postpartum hemorrhage was 
noted in 3.4% of  cases, which is lower than India (11.9%) 
and Pakistan (8.8%) (Joshi et al., 2015; Rafiq et al., 2023). 
Pregnancy-induced hypertension was seen in 2.1% of  

patients. Sepsis was noticed in 1.4% of  cases, both ending 
with death. Overall maternal mortality due to cardiac 
disease was 5.4% cases, with all five deaths occurring in 
women with unsupervised pregnancy and one antenatal 
care in late pregnancy.
The most common cardiac complication was heart 
failure complicating (13%), which often leads to maternal 
death. Monitoring cardiac patients for early detection 
and management is crucial throughout pregnancy, labor, 
and puerperium. Infective endocarditis was reported 
2.1%, while arrhythmias complicated 2.1% lower than 
in a study conducted in brazil (6.82%) (Martins et al., 
2016). Pulmonary edema was reported in 2.1%, and 
cerebral vascular accident was seen in 0.7% of  cases. 
Fetal complications were seen in 51.4% of  deliveries, with 
prematurity affecting being the most common (34.9%). 
There were 4 still births and 4 early neonatal deaths 
reported (2.7%), less than India’s 12.1% and Netherlands’ 
12.1%. Out of  146 cases, eleven ended with miscarriages, 
3 of  which were therapeutic terminations due to severe 
cardiac disease.
The New York Heart Association classification showed 
that most patients in class I & II (52.8%) and class III 
& IV (47.3%) had adverse maternal and fetal outcomes 
(Webb et al., 2020). Cardiac disease itself  could be a risk 
factor for maternal and fetal complications. The majority 
of  patients did not receive preconception counseling 
regarding their illness (74%), suggesting that educating 
prospective parents and screening for heart diseases is 
essential to reduce the burden of  the disease.
Regarding previous history of  cardiac surgery, 19% had 
undergone cardiac surgery before pregnancy, more than 
Khartoum teaching hospital’s (13.3%) and India’s (9.09%) 
studies. The study found that a higher rate of  surgical 
interventions allowed patients with cardiac disease to 
survive to child-bearing age and cope with changes 
during pregnancy. However, surgical intervention before 
pregnancy does not guarantee free pregnancy course 
of  complications, as 10 out 15 patients who underwent 
surgery had complicated pregnancies.

did not receive any advice which constituted 13 cases 
of  heart disease. No important correlation was found 
between preconception consultation and cardiac issues 
worth of  0.420.
Table 13 shows the correlation between preconception 
counseling and perinatal problems. The case of  perinatal 

complications including miscarriage, termination, IUGR, 
low birth weight due to premature births, congenital heart 
diseases, stillbirths, and early neonatal deaths do not show 
a significant association with preconception counseling 
but only with zero to low odds ratio (p-value of  0.154).



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19.2% of  patients had a previous history of  hospitalization 
due to heart failure, arrhythmias, or other cardiac 
indications, which is less than what was reported in 
Canada (46%) (Wald et al., 2015). A significant predictor 
of  maternal cardiac complication was found in 20 out 
of  28 patients with a history of  previous complications. 
Most patients were aged between 23-35 years, with a 
mean of  30. In developing countries like ours, many cases 
tend to get missed due to lack of  awareness and poor 
healthcare facilities. The majority of  patients lived in rural 
areas, where health care facilities are either inappropriate 
or inadequate.
Educational level was lower in the study, with 31.5% 
or less having primary education and 75.5% or more 
having secondary education. Most patients delivered at 
more than 37 weeks’ gestation (54.1%), which is lower 
than data from India (86.3%) (Abbasi et al., 2017). 
Assisted vaginal delivery with instruments was preferred 
to prevent maternal strain and exhaustion, with 17.6% 
of  instrumental deliveries. Epidural analgesia was 
recommended for patients with short second stages 
of  labor and without assistance. Cesarean section was 
performed in 30% of  patients with good outcomes, 
but the JCS joint working group recommended it only 
for patients with cardiac dysfunction, hemodynamic 
instability, pulmonary hypertension, uncontrolled 
arrhythmia, mechanical valve prosthesis, and patients 
with cyanosis.

CONCLUSION
Rheumatic heart disease and cardiomyopathies stay 
among the main factors that cause cardiac complications 
during pregnancy as well. Heart failure is one of  the 
major issues, causing adverse maternal outcomes such as 
exacerbated morbidity and mortality. Prematurity is the 
primary cause of  the fetal complication. The course of  
pregnancy is determined by the maternal functional class 
which reflects heart failure (III or IV), maternal previous 
cardiac problems being a powerful predictor of  adverse 
maternal and fetal outcomes. Regardless, an immediate 
diagnosis, a pre-conception management, and a favorable 
maternal functionality at the time of  conception are 
among the factors that contribute to these positive 
maternal and neonatal outcomes. These findings highlight 
the priority of  customizing whole care approaches while 
women are within the peripartum period, with particular 
emphasis being given to early intervention and smooth 
maternal health prior to conception.

Future Recommendations
Adequate treatment of  streptococcal infections in 
women can reduce rheumatic heart disease incidence. 
Preconception counseling and regular antenatal follow-up 
with a multidisciplinary team can improve the outcome 
of  pregnant cardiac patients. Proper management during 
labor and early detection of  complications are also crucial 
for ensuring the best outcome for cardiac patients.

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