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Cardiac disease is one of the commonest causes of indirect maternal deaths globally. This brief report is a reminder that isolated maternal tachycardia at rest is a clinical alert and warrants a detailed history in relation to cardiac disorders, thorough clinical examination of all organ systems, relevant investigations such as imaging, and expert advice to avoid serious adverse events. We reflect on a belatedly investigated persistent maternal tachycardia resulting in a fatal postpartum collapse due to mitral stenosis. The lost window of opportunity for appropriate investigation and management of the tachycardia provides an insight into many similar maternal deaths in South Africa. Key clinical messages regarding persistent maternal tachycardia are presented for midwives and doctors caring for pregnant women.

In view of the continuing worldwide spread of COVID-19 infection, the increased morbidity and mortality from the disease during pregnancy, and the current efficacy and safety of vaccines in non-pregnant individuals, vaccines should not be withheld from women simply because of pregnancy or lactation. All pregnant women, especially healthcare professionals, should be offered vaccination and counselled about its advantages and disadvantages by their maternity care providers. Complete eradication of COVID-19 infection will be possible if potential niduses of the infection, which may act as sources for future outbreaks, are protected against the pathogen. However, if a hypothetical medication is the only means yet proven of limiting severe compromise to maternal health, access to the medication should be at the pregnant woman's discretion. Shared decision-making requires physicians to actively engage with their patients and share their knowledge about the subject matter.

Women with persistent vomiting during pregnancy need early referral to appropriate health facilities. Delayed referral and inappropriate management may lead to metabolic encephalopathy from a variety of causes, including electrolyte derangements or thiamine deficiency (Wernicke's encephalopathy) (WE). We present a case of persistent vomiting in pregnancy in which there was delayed referral, inappropriate treatment and failure to associate neurological signs such as terminal neck stiffness with WE, resulting in poor fetomaternal outcomes. In this report, we discuss the following lessons: (i) the need for early transfer of a patient with persistent vomiting and enigmatic clinical features to a higher healthcare facility; (ii) failure to associate neurological signs with complications of hyperemesis gravidarum/WE; (iii) lack of thiamine supplementation; and (iv) the advantages of magnetic resonance imaging over a computed tomography scan in the diagnosis of WE.

Severe hypertension is a major cause of morbidity and mortality. The South African Saving Mothers report (2011 - 2013) indicates that cerebral injury due to severe hypertension is resulting in avoidable maternal deaths. This demands that management of severe hypertension in pregnancy needs to be improved. A rapid-acting antihypertensive is recommended for the initial management of severe hypertension during pregnancy. A single dose of a rapid-acting agent may be ineffective, in which case incremental doses of the same medication or another antihypertensive may be required for adequate blood pressure control. To ensure that appropriate antihypertensives at the correct doses are administered, the use of a guideline in a dynamic checklist format is advocated and discussed in this article. It is envisaged that the use of dynamic checklists will be valuable to all healthcare professionals providing care during pregnancy and the puerperium.

Background: Outcomes of HIV-positive pregnant patients admitted to intensive care units (ICUs) are controversial., Objective: To determine maternal and fetal outcomes of HIV-positive patients admitted to ICUs., Methods: Pregnant patients admitted to ICUs were enrolled in the study. On admission, they were classified as having low (<50%) or high (≥50%) risk of death by GRAMPT stratification score. The primary maternal outcome was death or hypoxic-ischaemic brain injury (HIBI), while fetal outcomes recorded were Apgar score, birth weight, and delivery of the fetus to facilitate maternal care., Results: There were 84 admissions to the ICUs: 66 (78.6%) were post-partum and 18 (21.4%) antepartum. The HIV sero-status was as follows: 11 (13.1%) HIV status unknown; 42 (50%) HIV-negative and 31 (36.9%) HIV-positive. The most common pre-ICU admission diagnoses were pneumonia (19.4%) in HIV-positive patients and eclampsia (31%) in HIV-negative patients. Maternal outcomes showed a worsening trend among the HIV-positive women when compared with those who were HIV-negative (high GRAMPT, 1.91 relative risk of death/HIBI in HIV-positive; 95% CI 0.57 - 6.44). Forty-two patients gave birth within 24 hours prior to ICU admission; 3 gave birth while in ICU and none gave birth within 24 hours following ICU discharge. Outcomes of the 45 infants born to HIV-positive women were worse than for those born to HIV-negative patients (except for Apgar scores 1 - 6). Performance of the GRAMPT model for prediction of maternal mortality/HIBI was best in hypertensive patients (ROC: AUC 0.72; 95% CI 0.48 - 0.96)., Conclusion: With the exception of Apgar scores 1 - 6, all outcomes showed worsening trends among infants born to HIV-positive mothers. Large multicentre studies are needed to confirm our findings.