Anju S’s research while affiliated with Madras Medical College and other places

Background Even though many risk assessment tools in pregnant women with valvular heart disease (VHD) are available, validation studies are few that assess their performance in diverse settings, which is needed prior to the application of routine clinical practice. Objectives To validate and establish the clinical utility of two risk stratification tools – DEVI (VHD-specific tool) and CARPREG-I in predicting adverse cardiac events in pregnant patients with VHD. Methods This cohort study involved consecutive pregnancies complicated with VHD enrolled in the prospective MPAC registry from July 2016 to December 2019(1). The ability to discriminate those with and without adverse cardiac outcomes was assessed using the area under the curve for both the DEVI and CARPREG-1 scores. Performance was assessed through discrimination and calibration characteristics. Clinical utility was evaluated with Decision Curve Analysis. Results Among 1029 pregnancies complicated with heart disease in the MPAC registry cohort, 604(52.3%) with valvular heart disease were included in this analysis. One or more composite adverse cardiac events occurred in 70 (11.6%) pregnancies during antenatal or the early postpartum period. Mitral regurgitation was the most common lesion (67.7%). In assessing the pregnancy outcomes, those who continued past 20 weeks were included, with the majority (92.0%) delivered at term, and the cesarean rates were 33.6% (n=203). The most common adverse event was heart failure (n=32, 5.3%), most of which (68.6%) occurred in the postnatal period. There were 11 maternal deaths (1.8%) during the study period, six among those with mechanical heart valves (four prosthetic valve thrombosis), two among those with severe mitral stenosis and pulmonary hypertension and two with severe mitral regurgitation and infective endocarditis. The area under the receiver operating characteristic curve (AUC) was 0.766, with 95% confidence intervals (CI) 0.703- 0.828 for DEVI and 0.703 (95%CI 0.644- 0.763) for CARPREG-I models. Calibration plots suggested that the DEVI score overestimates risk at higher probabilities, whereas the CARPREG-I score underestimates the risk at most probabilities. Decision curve analysis demonstrated that both models were useful across predicted probability thresholds between 10% and 60%. Conclusion In this external validation study in pregnant women with primary rheumatic VHD, DEVI and CARPREG-I scores showed good discrimination ability and clinical utility across various probabilities. Both can be used to classify those who develop adverse cardiac outcomes during pregnancy and childbirth. However, both models need recalibration to improve the agreement between the predicted and observed events prior to routine application in diverse clinical settings.Figure 1.a and b ROC and Decision Curves

Introduction Congenital heart disease (CHD) is becoming an increasingly important cause of heart disease in pregnancy in low -middle income countries (LMICs). Preconception and contraception counselling based on risk stratification has the potential to reduce maternal complications. Data is lacking from LMICs on the availability and effectiveness of preconception counselling (PCC) in women with CHD (WWCHD). Methods Madras Medical College Pregnancy and Cardiac disease (M-PAC) Registry is a single center prospective observational registry conducted at a tertiary referral institution in South India from July 2016 to December 2019. Baseline features and feto-maternal outcomes were compared in WWCHD with and without PCC. Predictors of post-delivery contraception were identified. Results Of the 107 eligible pregnancies with data on counselling, only 49.5% had received PCC. Pregnancies involving women with corrected CHDs (62.3% vs 33.3%; P = 0.006) and cyanotic CHD (20.8% vs 11.1%; P = 0.042) were more likely to get PCC. High risk mWHO categories were non-significantly less likely to get PCC (32% vs 39%). Primary outcome of death or heart failure was non-significantly low in the PCC group (3.8% vs 7.4% P = 0.4). Patients with high risk m WHO categories were less likely to get Tier I contraceptives post-delivery (46% vs 79.7% P = 0.004). Conclusion Preconception and post conception counselling, which have the potential to improve outcome in WWCHD, are being underused in LMICs. Health care systems should ensure multidisciplinary pregnancy and heart team approach to offer timely lesion specific pre-conceptional counselling, shared decision making and appropriate peri-pregnancy care for WWCHD.