Comparing the outcomes of rheumatic heart disease in pregnancy complicated with and without atrial fibrillation: A propensity score matched analysis.

BACKGROUND: Atrial fibrillation (AF) may increase the risk of adverse maternal and fetal outcomes among pregnant with rheumatic valvular lesions (RHD). We aimed to assess the rate of occurrence of AF in pregnant with RHD and its impact on cardiac and maternal-fetal outcomes compared to those without it. METHODS: The study group consisted of pregnant women with RHD and AF (cases) and a matched comparison group of pregnant women with RHD but without AF (controls) was derived from the database of pregnant women with RHD receiving care at our center between 2011 and 2021. Incidence of composite adverse outcomes(maternal death, heart failure, or thrombo-embolic events) and pregnancy outcomes were compared between them. RESULTS: Seventy-one (5.1%; 95%CI 4.1%-6.4%) pregnant women with RHD had AF during pregnancy and childbirth, most occurring in the late second or early third trimester. New-onset AF was diagnosed in 34 (47.9%) of them. After matching, the incidence of composite outcome was higher in women with AF (77.5% (95%CI 66.3%-85.7%) compared to women without AF (17.3%(95%CI 13.3%-22.1%), P < .001), with seven (9.9%) maternal deaths among cases and two (0.7%) in controls. Heart failure was the most common adverse cardiac event (26.7% vs. 4.2%, P < .001, cases vs controls). Those with AF had higher odds (adjusted OR 56.6 (14.1-226.8)) of adverse cardiac outcomes after adjusting for other risk factors. The frequency of most non-cardiac pregnancy complications was similar in both groups. However, there was a trend towards a higher rate of miscarriage (16.9% vs. 9.9%), small-for-gestational-age babies(16.3 vs. 9.0%), and cesarean rates(31.9% vs. 18.3%) women with AF compared to those who did not experience AF. CONCLUSIONS: Atrial fibrillation in pregnancy among women with RHD was associated with an increased risk of maternal morbidity and mortality, with a trend towards an increase in some non-cardiac pregnancy complications compared to those pregnant women without AF. Our study results provide background data for developing and implementing a pregnancy-specific management strategy tailored to middle-income settings.

An Analysis of the Barriers in Implementation of Labour Care Guide in India and Possible Measures to Combat Them.

Majority of the maternal deaths, still births, and neonatal deaths occurring in low- to middle-income countries are preventable through timely interventions. In this context, World Health Organization (WHO) recently came up with the Labour Care Guide (LCG). It is the revised version of the WHO partograph and focuses on timely clinical interventions and the importance of respectful maternity care. Various sections of LCG facilitate early identification of potential complications and timely referral when required. However, it was realized that there were some concerns while using the LCG at various sites particularly in developing countries like India. The present manuscript analyses the barriers in implementation of LCG and also suggests feasible measures that could be taken to overcome them.

Concurrent valve replacement and caesarean section for rheumatic mitral valve disease with refractory heart failure in late pregnancy.

Objective: To assess clinical characteristics and outcomes of women who underwent concurrent valve replacement with caesarean section for severe rheumatic mitral valve disease with refractory heart failure. Methods: All women admitted to a single centre from 2011 to 2020 with severe rheumatic mitral valve disease, having recurrent episodes of pulmonary edema on optimal medical therapy and contraindication to percutaneous balloon mitral valvotomy, who underwent concurrent valve replacement (for native valve disease) along with caesarean section, were included. Results: Among 1300 pregnancies with rheumatic heart disease, six underwent the concurrent procedure. All had replacement of mitral valve except one who had both aortic and mitral valve replacements, between 33 and 39 weeks of gestation. There were no maternal deaths, and there was one neonatal loss from late-onset sepsis. Conclusion: Pregnant women with severe rheumatic mitral valve disease with refractory heart failure, unsuitable for minimal access interventions, can be considered for a concurrent valve replacement with caesarean section.

Locked Down: Experiences of Domestic Violence in Central India.

INTRODUCTION: The National Family Health Survey (NFHS-4) data show that 31.1% of women faced domestic violence in 2015-2016, with no reduction since 2005-2006. Emerging data show that since the outbreak of the coronavirus disease (COVID-19), reports of intimate partner violence have increased worldwide because of mandatory lockdowns to curb the spread of the virus. The nature of the current pandemic, which has forced women to spend time with their abusers and restricted their mobility, has made them more vulnerable to abuse. We aimed to determine the proportion of domestic violence among Indian women during the lockdown period. METHODS: This is a cross-sectional study, conducted in June-August 2020 on married, Indian women of reproductive age who attended the obstetrics-gynecology outpatient department during the COVID-19 pandemic. The Abuse Assessment Screening questionnaire validated during NFHS-4 (2015-2016) was used as a data collection tool. Our primary objective was to determine the proportion of women presenting to the hospital who were exposed to domestic violence during the lockdown period. Analysis was done using SPSS Statistics V22.0. RESULTS: A total of 412 women were recruited for the study. The mean age was 23 years (range 19-52 years). The prevalence of domestic violence in any form was found to be 32.5%, with the majority being verbal abuse in the form of insults, threats of physical violence, or public humiliation. CONCLUSION: The results of this study indicated a high proportion of women with a history of domestic violence during the pandemic. Thus, health care policy makers and experts involved in women's care-particularly during crisis conditions such as the COVID-19 pandemic-should be aware of the extent of this problem and take measures to properly address it.

The socioeconomic apprehensions of a pregnant woman around COVID-19 - Do we need to be worried?

Introduction: Coronavirus 2019 (COVID-19) pandemic has become the most severe intercontinental health challenge and pregnant women are deemed to be a special population group. The COVID-19-related restrictions on visiting the hospital for antenatal check-up and procedures may be distressing for them. The present study aims at assessing the level of anxiety and risk perception of pregnant women during the pandemic. Materials and Methods: This cross-sectional observational study included all pregnant women who were above 18 years of age, irrespective of their gestational age. They were administered the pre-designed, pre-tested questionnaire via face-to-face interview. The effect of the COVID-19 pandemic and its influence on women's experience including her worries were collected. Data analysis was done using SPSS software version 22. Results: A total of 130 pregnant women with a mean maternal age of 26.1 ± 6.5 years were enrolled in the study. The mean gestational age of the women was 19 ± 4.7 weeks and most of them were in the second trimester (48.5%). Most of the pregnant women encountered the adverse socioeconomic influence of COVID-19 on their daily life (55.6% somewhat, 9.1% moderately so, 1.1% very much). Majority of them reported that they had limited their social activities (78.5%) and amorous relationship with their partner (30.8%). Also, around 59.2% of antenatal women experienced a moderate level and 40.7% had a mild level of anxiety. Conclusion: It is essential for obstetric providers to do prompt identification of mental health concerns in perinatal women and to liaise with mental health professionals to provide relevant interference.

Maternal Mortality in the Remote Islands of India-Unraveling the Conundrum.

Introduction: Reduction in maternal mortality has been a top priority in low- and lower middle-income countries of Asia-Pacific region. India, being one of them, has a major responsibility of reducing maternal mortality especially in light of the commitment on the part of the Sustainable Development Goals. Despite massive efforts and availability of technology needed to avert maternal deaths, the maternal mortality ratio (MMR) in India continues to be high especially in remote areas. This study aims at collecting the MMR data and analyzing in the context of island infrastructure. Material and Methods: This was a hospital-based cross-sectional study. The records of maternal deaths from January 2010 to December 2019 were collected from the medical record section and analyzed. Results: The MMR was estimated to be 95.63 per 100,000 live births. Majority of the patients were multigravida (82%) in the age group of 21 to 30 years (75%). Around 64% of them were referred cases. Majority (86%) of the deaths occurred in the postpartum period. Hemorrhage was the leading direct cause of maternal deaths (35.7%) followed by hypertensive disorders of pregnancy (HDP) (21.4%). Conclusion: Most maternal deaths are preventable. Early detection of high-risk pregnancies and early referral of such patients to a well-equipped center is the key to curb the catastrophe of mortality. Adopting methods like qSOFA (quick sequential organ failure assessment) for identifying patients requiring intensive care and miniPIERS (Preeclampsia Integrated Estimate of RiSk) model for predicting adverse outcome in HDP is the need of hour. More efforts should be made to retain the specialists in the islands.

Exploring the perspective of nursing staff or caregivers on birthing positions in Central India.

INTRODUCTION: Maternal birthing positions refer to the various physical postures a pregnant mother may assume at the time of delivery. The World Health Organisation recommends that woman should be given an opportunity to make a choice on the type of position to use during labour. Alternative birth positions are associated with lower incidence rates of performing episiotomy, less perineal tears and less use of instrumental deliveries. Nurses' perspective on women's positions has rarely been explored in India. Present study aims at assessing the knowledge regarding alternative birth positions among nursing officers. MATERIALS AND METHODS: This cross-sectional observational study was conducted on 52 nursing officers who were posted in the labour room. A pretested questionnaire was administered to them. Data analysis was done using SPSS software version 22. RESULTS: Majority (82.7%) of nursing officers felt that there is a need of giving a choice to the woman regarding alternate birth position. 76.9% of them were aware of position other than lithotomy. Around 48.1% would recommend squatting position to a woman in labour. Ease and convenience in conducting the delivery was the foremost reason chosen in advocating a birth position. Whereas overcrowding in the labour room, ignorance about alternate positions and difficulty in converting to instrumental delivery were cited as reasons of not recommending these positions. CONCLUSION: Educating nursing officers about emerging evidence regarding birthing positions will enable them to give accurate information to women.

Alternatives to Low Molecular Weight Heparin for Anticoagulation in Pregnant Women with Mechanical Heart Valves in Middle-Income Countries: A Cohort Study.

Objective: To compare cardiac complications and pregnancy outcomes in women with mechanical heart valves (MHVs) on two different anticoagulation regimens in a middle-income country. Methods: We conducted a retrospective cohort study comparing outcomes in pregnant women with MHVs that received vitamin K antagonists (VKAs) throughout pregnancy versus sequential anticoagulation (heparins in the first trimester and peripartum period and VKAs for the remainder of pregnancy), at a tertiary centre in South India, from January 2011 to August 2020. Results: We identified 138 pregnancies in 121 women, of whom 32 received VKAs while 106 were on sequential anticoagulation. There were no differences between groups with regard to maternal deaths [0 vs. 6 (5.7%), p = 0.34], thromboembolic events [2 (6.3%) vs. 15 (14.2%), p = 0.36], haemorrhagic complications [4 (12.5%) vs. 12 (11.3%), p = 0.85], cardiac events [1 (3.1% vs. 17 (16%), p = 0.07], spontaneous miscarriages [5 (15.6%) vs. 13 (12.3%), p = 0.62], stillbirths [0 vs. 5 (5.4%), p = 0.581] or neonatal deaths [2 (8.7%) vs. 1 (1.1%), p = 0.11]. Both cases of warfarin embryopathy received >5 mg warfarin in the first trimester. Thromboembolic events were associated with subtherapeutic doses of heparin in the first and third trimesters and the early postpartum period. Fetal growth restriction and preterm birth complicated 34 (29.3%) and 26 (22.4%) pregnancies respectively. Conclusion: Pregnancy complications associated with MHVs in middle-income countries may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if daily doses >5 mg and ensuring therapeutic levels of heparin during bridging in the first and third trimesters and peripartum period. Administration of low-dose aspirin should be considered as this may prevent placentally-mediated complications of pregnancy. Highlights: Pregnancy complications associated with MHVs in LMICs may be reduced by multidisciplinary surveillance, avoiding first-trimester warfarin if the daily dose is >5 mg, ensuring therapeutic levels of heparin in the first trimester and peripartum period.Placentally-mediated complications of pregnancy can be prevented by administering low-dose aspirin.Vitamin K antagonists or sequential regimen can be used as suitable alternatives to LMWH for anticoagulation in pregnant women with MHVs.

Pregnancy outcome in women with an uncorrected single ventricle: A single-centre experience from South India.

BACKGROUND: Women with an uncorrected single ventricle heart are at increased risk of adverse maternal and perinatal outcomes. METHODS: We report our experience of managing pregnant women with uncorrected single ventricles, during the time period 2011 to 2017, in a low-resource setting and compare pregnancy outcome with healthy concurrent controls. Outcomes assessed include the mode of delivery, maternal complications, neonatal death and birth weight. RESULTS: There were six pregnant women with uncorrected single ventricles who had a total of 14 pregnancies. There was one maternal death in a woman with atrioventricular-septal defect and Eisenmenger syndrome. Caesarean section rates and preterm delivery were similar, whereas perinatal loss and low-birth weight rates were higher among women with a single ventricle compared to healthy controls. CONCLUSION: Unplanned pregnancies without prenatal counselling/care pose a challenge to physicians especially in low to middle income countries and with the high risk of morbidity/mortality, pregnancy should be discouraged.

Prediction of adverse cardiac events in pregnant women with valvular rheumatic heart disease.

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.