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 Table of Contents  
MINI REVIEW
Year : 2020  |  Volume : 17  |  Issue : 2  |  Page : 156-161

Peripartum cardiomyopathy in Nigeria: A historical perspective


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 Submission01-Jul-2020
Date of Decision01-Aug-2020
Date of Acceptance10-Aug-2020
Date of Web Publication13-Nov-2021

Correspondence Address:
Dr. Okechukwu Samuel Ogah
Department of Medicine, Cardiology Unit, University of Ibadan, Ibadan, Oyo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njc.njc_19_20

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  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 2021 Dec 4];17:156-61. Available from: https://www.nigjcardiol.org/text.asp?2020/17/2/156/330420




  Preamble Top


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 Top


HF in the puerperium was first described in the 19th 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 Top


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 Top


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

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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 Top


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

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  Eldryd Hugh Owen Parry Top


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

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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

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  Ian Fraser Brockington Top


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”

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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.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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Preamble
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Peripartum Cardi...
Derek Gordon Abr...
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