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Prediction of adverse cardiac events in pregnant women with valvular rheumatic heart disease
  1. Jyoti Baghel1,
  2. Anish Keepanasseril1,
  3. Ajith Ananthakrishna Pillai2,
  4. Nivedita Mondal3,
  5. Yavanasuriya Jeganathan1,
  6. Pankaj Kundra4
  1. 1 Obstetrics & Gynaecology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
  2. 2 Cardiology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
  3. 3 Neonatology, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
  4. 4 Anaesthesiology & Critical Care, Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry, India
  1. Correspondence to Dr Anish Keepanasseril, Obstetrics & Gynecology, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry 605006, India; keepan_r{at}


Objective To assess the incidence of adverse cardiac events in pregnant women with rheumatic valvular heart disease (RHD) and to derive a clinical risk scoring for predicting it.

Methods This is an observational study involving pregnant women with RHD, attending a tertiary centre in south India. Data regarding obstetric history, medical history, maternal complications and perinatal outcome till discharge were collected. Eight-hundred and twenty pregnancies among 681 women were included in the analysis. Primary outcome was composite adverse cardiac event defined as occurrence of one or more of complications such as death, cardiac arrest, heart failure, cerebrovascular accident from thromboembolism and new-onset arrhythmias.

Results Of the 681 women with RHD, 180 (26.3%) were diagnosed during pregnancy. Composite adverse cardiac outcome during pregnancy/post partum occurred in 122 (14.9%) pregnancies, with 12 of them succumbed to the disease. In multivariate analysis, prior adverse cardiac events (OR=8.35, 95% CI 3.54 to 19.71), cardiac medications at booking (OR=0.53, 95% CI 0.32 to 0.86), mitral stenosis (mild OR=2.48, 95% CI 1.08 to 5.69; moderate OR=2.23, 95% CI 1.19 to 4.18; severe OR=7.72,95% 4.05 to 12.89), valve replacement (OR=2.53, 95% CI 1.28 to 5.02) and pulmonary hypertension (OR=6.90, 3.81 to 12.46) were predictive of composite adverse cardiac events with a good discrimination (area under the curve=0.803) and acceptable calibration. A predictive score combining these factors is proposed for clinical utility.

Conclusion Heart failure remains the most common adverse cardiac event during pregnancy or puerperium. Combining the lesion-specific characteristics and clinical information into a predictive score, which is simple and effective, could be used in routine clinical practice.

  • pregnancy
  • valvular heart disease

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  • Contributors AK and AAP conceived the study. All authors contributed to the design. JB and YJ carried out the data collection and guarantees data integrity. AK performed statistical analyses. AAP, NM and PK reviewed the analysis and AK and JB wrote the first draft. All authors contributed to revising and finalisation of the manuscript. AK (corresponding author) guarantees all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval This study was done as per the ethical standards set by the Institute Scientific Advisory and Ethical committee (Human Studies), in accordance with the 1964 Helsinki Declaration and its later amendments. Protocol of the study and waiver of consent for the collection of the details of the women from the records from 2011 to 2015 was approved by the Institute Ethics Committee (Human studies). Informed consent was obtained from women who were prospectively enrolled (approval number: JIP/IEC/2016/1079).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request to the corresponding author.

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