Peripartum cardiomyopathy in Nigeria: A historical perspective

Okechukwu Samuel Ogah; Olanike Alison Orimolade; Omolola Boluwatife Awe; Fisayo Ogah; Ejiroghene Martha Umuerri

doi:10.4103/njc.njc_19_20

MINI REVIEW

Year : 2020 | Volume : 17 | Issue : 2 | Page : 156-161

Peripartum cardiomyopathy in Nigeria: A historical perspective

Okechukwu Samuel Ogah¹, Olanike Alison Orimolade², Omolola Boluwatife Awe², Fisayo Ogah³, Ejiroghene Martha Umuerri⁴
¹ Department of Medicine, Cardiology Unit, University of Ibadan; Department of Medicine, Cardiology Unit, University College Hospital; Institute of Advanced Medical Research and Training, College of Medicine, University of Ibadan, Nigeria
² Department of Medicine, Cardiology Unit, University College Hospital, Nigeria
³ Department of Chemical Pathology, University College Hospital, Ibadan, Oyo State, Nigeria
⁴ Cardiology Unit, Delta State University Abraka, Abraka; Cardiology Unit, Delta State University Teaching Hospital, Oghara, Delta State, Nigeria

Date of Submission	01-Jul-2020
Date of Decision	01-Aug-2020
Date of Acceptance	10-Aug-2020
Date of Web Publication	13-Nov-2021

Correspondence Address:
Dr. Okechukwu Samuel Ogah
Department of Medicine, Cardiology Unit, University of Ibadan, Ibadan, Oyo State
Nigeria

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/njc.njc_19_20

Abstract

Nigeria has the highest burden of PPCM in the world. The condition occurs in one out of every hundred deliveries in the western axis of Northern Nigeria. It is relative uncommon in the southern part of the country. The aim of the paper is to summarise the historical aspect of PPCM report and care in Nigeria.

Keywords: Cardiac failure, heart failure, peripartum cardiomyopathy, Women health

How to cite this article:
Ogah OS, Orimolade OA, Awe OB, Ogah F, Umuerri EM. Peripartum cardiomyopathy in Nigeria: A historical perspective. Nig J Cardiol 2020;17:156-61

How to cite this URL:
Ogah OS, Orimolade OA, Awe OB, Ogah F, Umuerri EM. Peripartum cardiomyopathy in Nigeria: A historical perspective. Nig J Cardiol [serial online] 2020 [cited 2023 May 31];17:156-61. Available from: https://www.nigjcardiol.org/text.asp?2020/17/2/156/330420

Preamble

Going through the period of pregnancy, labor, birth, and the postpartum period brings happiness and joy for the woman and the family. In a few, however, this period may be marred by illness. Peripartum cardiomyopathy (PPCM) is one of such conditions. It is associated with cardiac dysfunction that can be life-threatening.

The current definition according to the heart failure (HF) association of the European Society of Cardiology (ESC) working group on PPCM is “an idiopathic cardiomyopathy presenting with HF secondary to left ventricular (LV) systolic dysfunction toward the end of pregnancy or in the months following delivery, where no other cause of HF is found.”

It is a diagnosis of exclusion. The LV may not be dilated, but the LV ejection fraction is nearly always reduced below 45%.^[1],[2]

Historical Vignette

HF in the puerperium was first described in the 19^th century by Virchow, Porak,^[3] and Ritchie.^[4] In 1937, Gouley^[5] published the clinical and pathological findings of the condition in seven patients. They observed enlarged heart with areas of severe necrosis and fibrosis in four of these patients who died. Hull and Hafkesbring^[5] in 1937 described 80 patients with the condition seen in New Orleans (USA), and they noted that the condition was more common in African Americans.

In 1971, Demakis et al.^[6] described the natural history of 27 patients with the condition at the Cook County hospital in Chicago. The group suggested the name PPCM and proposed diagnostic criteria.

In 2000, the United States National Heart, Lung, and Blood Institute and the office of rare diseases convened a national workshop and came up with the following criteria for the diagnosis of PPCM: (i) development of HF secondary to decreased LV systolic function in the last month of pregnancy or within 5 months after delivery; (ii) absence of preexisting cardiac dysfunction; (iii) absence of determinable cause of cardiomyopathy; and (iv) LV systolic dysfunction demonstrated by echocardiography (ejection fraction <45%, fractional shortening, 30% or both, or indexed LV internal diameter in diastole >2.7 cm/m²).

The generally used and current definition of PPCM is that of the ESC working group on PPCM published in 2010.^[2]

Synonyms

Some of the names used interchangeably for PPCM include puerperal cardiomyopathy,^[7] myocardiopathy in postpartum,^[8] postpartum congestive HF,^[9] toxic postpartal heart disease,^[10] postpartum HF,^[11],[12] idiopathic myocardial failure in the last trimester of pregnancy and the puerperium,^[13] idiopathic myocardiopathy of the puerperium,^[14] postpartum cardiomyopathy,^[15] cardiomyopathy of pregnancy and the puerperium,^[16] postpartum myocardosis,^[17] Zaria syndrome,^[18] and idiopathic myocardial degeneration associated with pregnancy.^[5]

Peripartum Cardiomyopathy in Nigeria

When the University College Hospital Ibadan was officially opened to clinical services on November 20, 1957, the early clinicians (mainly expatriates) encountered an array of peculiar tropical diseases. Cardiac diseases were not an exception. The early cardiologists eminently documented some of these unique cardiac conditions. [Table 1] shows the list of early physicians at the department of medicine.

Table 1: The early physicians at the Department of Medicine, University of Ibadan

Click here to view

Some of the unique cardiac diseases include dilated cardiomyopathy, postpartum cardiomyopathy, endomyocardial fibrosis (EMF), and annular subvalvular aneurysm. The expatriate cardiac physicians were Derek Gordon Abrahams, Eldryd Hugh Owen Parry, and Ian Fraser Brockington.

Derek Gordon Abrahams

In his autobiography, “It was the best of times.,”, Professor Adetokunbo Lucas recorded that Prof Abrahams was “distinguished for doing substantial original research” at Ibadan and that “Prof Abrahams work helped to define the clinical manifestations of some of the peculiar diseases of the heart and blood vessels in the early days of the University College Hospital Ibadan, Nigeria. His studies included work on endomyocardial fibrosis, heart muscle disease as well as multiple nonluetic aneurysms.”^[19]

Derek was educated at Bedford School and Caius College, Cambridge, and completed his medical studies at St. George's Hospital in 1943. In 1956, he was appointed as a senior lecturer by the University of Ibadan, Nigeria, and was later promoted to a Professor of Medicine. In 1963, he returned to Australia as an Associate Professor in Medicine at the newly established University of New South Wales.

He died in 1981 from the complications of lung malignancy. The publications of Derek at Ibadan are listed in [Table 2].

Table 2: The publications of the early cardiac physicians at the University College Hospital, Ibadan, Nigeria

Click here to view

Eldryd Hugh Owen Parry

Eldryd Hugh Owen Parry was educated at Shrewsbury School in the United Kingdom [Figure 1]. He studied Medicine at Emmanuel College Cambridge and Cardiff. Thereafter, he worked at the Royal Postgraduate Medical School in London before he was seconded to the newly established University College Hospital, Ibadan, Nigeria, in 1960 as a Senior Registrar to Derek Gordon Abrahams.

Figure 1: Sir Eldryd Hugh Owen Parry Knight Commander of the order of St Michael and George Order of the British Empirein

Click here to view

At Ibadan, he conducted his doctoral research on EMF, which was submitted to the University of Cambridge.^{[29],[30],[31]} He returned to Britain in 1963.

Parry returned to Africa 3 years after and was at the Haile Selassie University, Addis Ababa, Ethiopia.

In 1969, Parry made a second missionary journey to Nigeria, now at the Ahmadu Bello University, Zaria, Northern Nigeria, as a Professor of Medicine. It was at Zaria that he conducted seminal work on PPCM with his colleagues: L Ford, A Abdullahi, FI Anjorin, CO Adesanya, IA Sada, GA MacGregorMacGregor, IO Adeoshun, JE Sanderson, NM Davidson, SF Fillmore, GOA Ladipo, JRL Froude, L Trevitt, and H Watkin.

In 1977, he took the post of Foundation Dean of Medicine, at the University of Ilorin, Nigeria. It was in Ilorin that he introduced a radical community-based program, COBES with Professor Ladipo Akinkugbe, the then Vice-Chancellor.

Between 1980 and 1985, Parry was appointed as Dean and Professor of Medicine at the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. He was also a Foundation Member of the Faculty of Medicine and Surgery of Amoud University, Somaliland.

He was given a lifetime achievement award by the Royal Society of Tropical Medicine and Hygiene in 2007. He received the Order of the British Empirein 1982 as well as the Knight Commander of the order of St Michael and George (KCMG) in 2011.

In 1988, he founded THET, which he chaired until 2007. Parry was senior editor of Principles of Medicine in Africa until 2009, and an Honorary Fellow at Cardiff, Emmanuel College Cambridge, the London School of Hygiene and Tropical Medicine, the Royal College of Surgeons of England, the College of Physicians and Surgeons of Ghana.

Parry's significant and seminal research work was in the field of cardiomyopathies. He worked on EMF at Ibadan for his MD (University of Cambridge) thesis. He also carried out series of work on PPCM in Zaria [Table 2]. He and his team described the geographical distribution of PPCM in Northern Nigeria^[32],[38] [Figure 2].

Figure 2: Geographical distribution of peripartum cardiomyopathy in Northern Nigeria

Click here to view

Ian Fraser Brockington

Brockington was the first to publish on PPCM in Nigeria [Figure 3]. In 1971, he reported on the clinical profile of 50 cases of postpartum HF that presented at the University College Hospital Ibadan in 1962, 1965, and 1967–1969. He noted that many of these patients had transitory hypertension and argued that the condition could be “a special form of acute hypertensive HF based on postpartum hypertension described by Stout in 1934.”^[46]

Figure 3: “Being text of the President of the Nigerian Cardiac Society (Okechukwu S Ogah) Speech keynote address delivered on Friday, June 19, 2020, at the first of the biannual state-of-the-art Lecture (Web Conference) organized by the Nigerian Cardiac Society”

Click here to view

Prof Brockington was educated at the Winchester College and Gonville and Caius College Cambridge and graduated in 1957. He completed his training in Medicine at the University of Manchester in 1960. He spent 4 years in Ibadan, alternating with training posts at the Royal Postgraduate Medical School with Professor Goodwin; this resulted in a number of papers on African heart diseases and a doctoral thesis on 'Heart muscle disease. He received MPhil degree in 1972 from the University London and defended his MD in 1974 at Cambridge University based on his work on Cardiomyopathies at the University College Hospital Ibadan, Nigeria. Prof Brockington's publications are shown in [Table 2].

On his return to the United Kingdom, Ian switched to psychiatry, with training at the Maudsley Hospital. He is currently an Emeritus Professor of Psychiatry at the University of Birmingham. Professor Brockington had his long and distinguished career as a Psychiatrist. He was the Head of the Department of Psychiatry at the University of Birmingham for 14 years in the 1980s and 1990s. He played significant roles in the development of regional services for pregnancy-related mental illness in Birmingham area. Ian provided great and quality leadership in the field of perinatal psychiatry and he also found the Marcee Society in 1980. He became its first President in 1981. Professor Brockington also has deep interest in French, Italian, and German literature.

More recent or contemporary publications on PPCM in Nigeria have come from Talabi et al.^[52] in Lagos, Danbauchi^[18] in Zaria, Isezuo et al.^[53],[54] in Sokoto, and Karaye et al.^{[55],[56],[57],[58],[59],[60],[61],[62],[63]} and Saidu in Kano. In 1985, Falase^[64] wrote a comprehensive review of PPCM based on the existing knowledge at that time.

PPCM is a multifactorial disease involving both nature and nurture. Some of the environmental and social factors include low socioeconomic class, lack of education (especially maternal education), early girl child marriage and pregnancy, nutritional deficiencies, poor maternal nutrition, and traditional practices. Genetics may also play an important part in the etiology.

Prevention of this disease in Nigeria requires addressing these factors. This will involve the active participation of the government, the traditional institution, health-care providers, as well as involvement of clinical, basic, and social scientist.

For reasons unknown to us, EMF is almost wiped out in Southern Nigeria. It may not be unrelated to improvement in population nutrition, housing condition, and environmental sanitation in Southern without any formal control program targeted against the disease. It is^[65] traditionally less in Northern Nigeria. There have been some case reports.^{[66],[67],[68]}

The prevalence and incidence of acute rheumatic fever and rheumatic heart disease have also fallen drastically in the region.

It is my utmost belief that if we place emphasis on girl child education, improve population nutrition, improve maternal nutrition and obstetric care, and wipe out some traditional practices, especially in Northern Nigeria, we can also wipe out PPCM in Nigeria in our lifetime. Yes, we can!

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Bauersachs J, König T, van der Meer P, Petrie MC, Hilfiker-Kleiner D, Mbakwem A, et al. Pathophysiology, diagnosis and management of peripartum cardiomyopathy: A position statement from the Heart Failure Association of the European Society of Cardiology Study Group on peripartum cardiomyopathy. Eur J Heart Fail 2019;21:827-43.
2.	Sliwa K, Hilfiker-Kleiner D, Petrie MC, Mebazaa A, Pieske B, Buchmann E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of peripartum cardiomyopathy: A position statement from the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy. Eur J Heart Fail 2010;12:767-78.
3.	Porak C. Reciprocal influence of pregnancy and heart diseases. Paris: G. Bailliere; 1880.
4.	Ritchie C. Clinical contribution to the patho-diagnosis and treatment of certain chronic diseases of the heart. Edinb Med J 1850;2:2.
5.	Gouley BA. Idiopathic myocardial degeneration associated with pregnancy and especially the peripartum. Am J Med Sci 1937;19:185-99.
6.	Demakis JG, Rahimtoola SH, Sutton GC, Meadows WR, Szanto PB, Tobin JR, et al. Natural course of peripartum cardiomyopathy. Circulation 1971;44:1053-61.
7.	Rosen SM. Puerperal cardiomyopathy. Br Med J 1959;2:5-9.
8.	Perrine RP. An obscure myocardiopathy in postpartum Saudi Arabs. Trans R Soc Trop Med Hyg 1967;61:834-8.
9.	Wang SY, Hsu SR, Su SL, Tu ST. Sheehan's syndrome presenting with early postpartum congestive heart failure. J Chin Med Assoc 2005;68:386-91.
10.	Hull E, Hafkesbring E. Toxic postpartal heart disease. New Orleans Med Surg J 1937;89:550-7.
11.	Cenac A, Djibo A. Postpartum cardiac failure in Sudanese-Sahelian Africa: Clinical prevalence in western Niger. Am J Trop Med Hyg 1998;58:319-23.
12.	Sanderson JE, Adesanya CO, Anjorin FI, Parry EH. Postpartum cardiac failure--heart failure due to volume overload? Am Heart J 1979;97:613-21.
13.	Meadows WR. Idiopathic myocardial failure in the last trimester of pregnancy and the puerperium. Circulation 1957;15:903-14.
14.	Walsh JJ, Burch GE, Black WC, Ferrans VJ, Hibbs RG. Idiopathic myocardiopathy of the puerperium (postpartal heart disease). Circulation 1965;32:19-31.
15.	Sakakibara S, Sekiguchi M, Konno S, Kusumoto M. Idiopathic postpartum cardiomyopathy: Report of a case with special reference to its ultrastructural changes in the myocardium as studies by endomyocardial biopsy. Am Heart J 1970;80:385-95.
16.	Stuart KL. Cardiomyopathy ofpregnancy and the puerperium. Q J Med 1968;37:463-78.
17.	Woolford RM. Postpartum myocardosis. Ohio State Med J 1952;48:924-30.
18.	Danbauchi SS. Echocardiographic features of peripartum cardiac failure: The Zaria syndrome. Trop Doct 2002;32:24-7.
19.	Lucas AO. It Was the Best of Times: From Local to Global Health. Ibadan, Nigeria: BookBuilders; 2010.
20.	Abrahams DG. An unusual form of heart-disease in West Africa; its relation to endomyocardial fibrosis. Lancet 1959;2:111-2.
21.	Abrahams DG, Alele CA. A clinical study of hypertensive disease in West Africa. West Afr Med J 1960;9:183-93.
22.	Abrahams DG, Alele CA, Barnard BG. The systemic blood pressure in a rural West African community. West Afr Med J 1960;9:45-58.
23.	Abrahams DG, Barton CJ, Cockshott WP, Edington GM, Weaver EJ. Annular subvalvular left ventricular aneurysms. Q J Med 1962;31:345-60.
24.	Abrahams DG. Endomyocardial fibrosis of the right ventricle. Q J Med 1962;31:1-20.
25.	Abrahams DG, Cockshott WP. Multiple non-luetic aneurysms in young Nigerians. Br Heart J 1962;24:83-91.
26.	Abrahams DG, Parry EH. Hypertension due to renal artery stenosis caused by abdominal aortic aneurysm. Successful treatment by nephrectomy. Circulation 1962;26:104-7.
27.	Abrahams DG, Parry EH. Chronic pericardial effusion complicating endomyocardial fibrosis. Circulation 1963;28:221-31.
28.	Abrahams DG, Parry EH. The mechanism of arterial oxygen desaturation in right ventricular endomyocardial fibrosis. Evidence in favour of the existence of an azygos pulmonary venous shunt. Clin Sci 1963;24:69-80.
29.	Parry EH, Abrahams DG. The function of the heart in endomyocardial fibrosis of the right ventricle. Br Heart J 1963;25:619-29.
30.	Parry EH, Abrahams DG. The natural history of endomyocardial fibrosis. Q J Med 1965;34:383-408.
31.	Parry EH. Endomyocardial thickening. Br Med J 1965;1:921.
32.	Davidson NM, Trevitt L, Parry EH. Perpartum cardiac failure. An explanation for the observed geographic distribution in Nigeria. Bull World Health Organ 1974;51:203-8.
33.	Davidson NM, Parry EH. Proceedings: Postpartum hypertension and aetiology of peripartum cardiac failure. Br Heart J 1975;37:784.
34.	Davidson NM, Hudson B, Parry EH. Defaulters from follow-up after pre-partum cardiac failure. Trop Geogr Med 1975;27:109-14.
35.	Fillmore SJ, Parry EH. The evolution of peripartal heart failure in Zaria, Nigeria. Some etiologic factors. Circulation 1977;56:1058-61.
36.	Ladipo GO, Froude JR, Parry EH. Pattern of heart disease in adults of the Nigerian Savanna: A prospective clinical study. Afr J Med Med Sci 1977;6:185-92.
37.	Parry EH, Davidson NM, Ladipo GO, Watkins H. Seasonal variation of cardiac failure in northern Nigeria. Lancet 1977;1:1023-5.
38.	Davidson NM, Parry EH. Peri-partum cardiac failure. Q J Med 1978;47:431-61.
39.	Davidson NM, Parry EH. The etiology of peripartum cardiac failure. Am Heart J 1979;97:535-6.
40.	Adesanya CO, Anjorin FI, Sada IA, Parry EH, Sagnella GA, MacGregor GA. Atrial natriuretic peptide, aldosterone, and plasma renin activity in peripartum heart failure. Br Heart J 1991;65:152-4.
41.	Ford L, Abdullahi A, Anjorin FI, Danbauchi SS, Isa MS, Maude GH, et al. The outcome of peripartum cardiac failure in Zaria, Nigeria. QJM 1998;91:93-103.
42.	Brockington IF, Olsen EG, Goodwin JF. Endomyocardial fibrosis in Europeans resident in tropical Africa. Lancet 1967;1:583-8.
43.	Ive FA, Willis AJ, Ikeme AC, Brockington IF. Endomyocardial fibrosis and filariasis. Q J Med 1967;36:495-516.
44.	Brockington IF, Bohrer SP. Enlargement of the aortic shadow in Nigerian heart muscle disease. Acta Cardiol 1970;25:344-56.
45.	Brockington IF, Luzzatto L, Osunkoya BO. The heart in eosinophilic leukaemia. Afr J Med Sci 1970;1:343-52.
46.	Brockington IF. Postpartum hypertensive heart failure. Am J Cardiol 1971;27:650-8.
47.	Brockington IF, Edington GM. Adult heart disease in western Nigeria: A clinicopathological synopsis. Am Heart J 1972;83:27-40.
48.	Brockington IF, Olsen EG. Löffler's endocarditis and Davies' endomyocardial fibrosis. Am Heart J 1973;85:308-22.
49.	Brockington IF, Ikeme AC, Bohrer SP. Contributions to the diagnosis of endomyocardial fibrosis. Acta Cardiol 1973;28:255-72.
50.	Brockington IF. Heart Muscle Disease in Nigeria. Cambridge Cambridge University; 1975.
51.	Brockington IF, Edington GM, Olsen EG. Nigerian 'heart muscle disease': The late stages of untreated hypertensive heart failure? Acta Cardiol 1977;32:245-67.
52.	Talabi AI, Gaba FE, George BO. Puerperal cardiomyopathyin Lagos: 14 cases. Cardiol Trop 1985;11:73-9.
53.	Isezuo SA, Abubakar SA. Epidemiologic profile of peripartum cardiomyopathy in a tertiary care hospital. Ethn Dis 2007;17:228-33.
54.	Isezuo SA, Njoku CH, Airede L, Yaqoob I, Musa AA, Bello O. Case report: Acute limb ischaemia and gangrene associated with peripartum cardiomyopathy. Niger Postgrad Med J 2005;12:237-40.
55.	Karaye KM, Lindmark K, Henein MY. Prevalence and predictors of right ventricular diastolic dysfunction in peripartum cardiomyopathy. J Echocardiogr 2017;15:135-40.
56.	Karaye KM, Lindmark K, Henein MY. One year survival in Nigerians with peripartum cardiomyopathy. Heart Views 2016;17:55-61. [PUBMED] [Full text]
57.	Karaye KM, Lindmark K, Henein MY. Electrocardiographic predictors of peripartum cardiomyopathy. Cardiovasc J Afr 2016;27:66-70.
58.	Karaye KM, Lindmark K, Henein M. Right ventricular systolic dysfunction and remodelling in Nigerians with peripartum cardiomyopathy: A longitudinal study. BMC Cardiovasc Disord 2016;16:27.
59.	Karaye KM, Yahaya IA, Lindmark K, Henein MY. Serum selenium and ceruloplasmin in nigerians with peripartum cardiomyopathy. Int J Mol Sci 2015;16:7644-54.
60.	60Karaye KM, Lindmark K, Henein MY. Left ventricular structure and function among sisters of peripartum cardiomyopathy patients. Int J Cardiol 2015;182:34-5.
61.	Karaye KM, Henein MY. Peripartum cardiomyopathy: A review article. Int J Cardiol 2013;164:33-8.
62.	Karaye KM. Right ventricular systolic function in peripartum and dilated cardiomyopathies. Eur J Echocardiogr 2011;12:372-4.
63.	Karaye KM, Sai'du H, Habib AG. Peripartum and other cardiomyopathies in a Nigerian adult population. Int J Cardiol 2011;147:342-3.
64.	Falase AO. Peripartum heart disease. Heart Vessels Suppl 1985;1:232-5.
65.	Aliyu I. Endomyocardial fibrosis in northern Nigerian girl. Ann Med Health Sci Res 2014;4:S6-8. [PUBMED] [Full text]
66.	Antony KK. Pattern of cardiac failure in Northern Savanna Nigeria. Trop Geogr Med 1980;32:118-25.
67.	Isiguzo GC, Micheal O, Onuh JA, Muoneme AS, Bitrus NK, Okeahialam BN. Endomyocardial fibrosis: Seven decades later in the Nigerian setting. Niger J Cardiol 2015;12:45.
68.	Okeahialam B, Okeke E. Endomyocardial fibrosis in Nigeria's savannah region: A case report in a patient with sickle cell anaemia. Cardiol Trop 1997;23:119-21.