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 Table of Contents  
Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 55-62

Critical analysis of all pregnancies with heart disease, misses and near misses over 1-year period along with expert group so as to optimize outcome and improve patient care – Need-based analysis

1 Department of Obstetrics and Gynaecology, King Georges Medical University, Lucknow, Uttar Pradesh, India
2 Department of Critical Care Medicine, King Georges Medical University, Lucknow, Uttar Pradesh, India
3 Department of Cardiology, King Georges Medical University, Lucknow, Uttar Pradesh, India
4 Department of Paediatrics, King Georges Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication28-Jun-2019

Correspondence Address:
Dr. Shuchi Agrawal
A-704, Type V Faculty Flats, Jagat Narayan Road, KGMU Campus, Lucknow - 226 003, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/heartindia.heartindia_15_19

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Introduction: Cardiac disorders complicate approximately 1%–3% of pregnancies and present a real challenge to treating healthcare providers.Maternal mortality may be as high as 7% when New York Heart Association (NYHA) Classes III and IV patients are combined. In contrast, Classes I and II combined yield a mortality of 0.5%. Similarly, fetal mortality maybe as high as 30% in Class III and IV patients, in contrast to 2% for Classes I and II. Managing pregnant patients with complex cardiac disease mandates participation from a multidisciplinary team early in the pregnancy. Audit of misses and near misses helps to determine causes of maternal mortality and morbidity and identify gaps in care.
Aims and Objectives: To assess burden of maternal cardiac disease and its influence on maternal and fetal outcome. To assess gaps in multidisciplinary care and to analyze causes associated with increased morbidity and mortality.
Methods: A retrospective analysis of all pregnant patients with heart disease admitted to department of obstetrics and gynecology at tertiary care center from January 2017 to January 2018.
Results: Of 9563 deliveries, there were 108 cases of pregnancy with heart disease (1.12%). Majority of patients in study cohort belonged to low socioeconomic status and had rural background. 36 patients (33.33%) were primi-gravida; majority presented for antenatal care in the third trimester. 82 (75.92%) in functional Class (NYHA) I – II, predominant cardiac lesion was rheumatic valvular disease diagnosed in 101 patients (93.5%); 60 patients (58.82%) had vaginal delivery, 63 (64%) were delivered before 37 weeks and 6 patients had medical termination of pregnancy. 10 patients (9.2%) developed cardiac failure and 8 (7.4%) had atrial fibrillation. There were 4 maternal death and 8 near misses.
Conclusion: The present study highlights need of training of physicians and obstetrician working at peripheral centres for early diagnosis, timely referral and strengthening pre-pregnancy counselling.

Keywords: Fetal outcome, heart disease, maternal outcome, pregnancy

How to cite this article:
Agrawal S, Agrawal A, Bhandari M, Siddiqui SS, Koonwar S. Critical analysis of all pregnancies with heart disease, misses and near misses over 1-year period along with expert group so as to optimize outcome and improve patient care – Need-based analysis. Heart India 2019;7:55-62

How to cite this URL:
Agrawal S, Agrawal A, Bhandari M, Siddiqui SS, Koonwar S. Critical analysis of all pregnancies with heart disease, misses and near misses over 1-year period along with expert group so as to optimize outcome and improve patient care – Need-based analysis. Heart India [serial online] 2019 [cited 2022 Aug 18];7:55-62. Available from: https://www.heartindia.net/text.asp?2019/7/2/55/261831

  Introduction Top

Cardiac disorders complicate approximately 1%–3% of pregnancies and present a real challenge to treating obstetricians and other healthcare providers.[1] Although rheumatic heart disease (RHD) has decreased significantly in developed countries, it is still prevalent in developing countries where it remains an important cause of maternal morbidity and mortality.[2],[3] In India, RHD contributes to approximately 69% of cardiac disorders seen in pregnancy, and most cases present as mixed mitral valve disease.[1]

Incidence and prevalence of cardiovascular disease (acquired and congenital) in pregnancy is increasing because of improvement in diagnosis and treatment. There is also a rise in incidence of coronary artery disease (CAD) in pregnant females because of increasing age in pregnancy.

The management of cardiac disease in pregnancy should start with a detailed evaluation, ideally before or at least in early pregnancy. This is important to predict potential complications, which in turn help the clinician to take necessary actions at appropriate time such as avoiding pregnancy at first place, and if pregnancy occurs, then timely termination of pregnancy or need of surgical or therapeutic intervention if required. Few studies have been done to estimate the risk of mortality and morbidity in pregnant females with cardiac disease. Siu et al.[4] developed a scoring (CARPREG) which was widely used to assess risk in pregnancy. Although this score was adequate for congenital heart diseases, valvular heart disease (VHD), myocardial diseases, and arrhythmias, it is not useful for prosthetic heart valves, aortopathies, and pulmonary artery hypertension (PAH). Thus, Silversides et al. presented a more comprehensive risk score, CARPREG II. The CARPREG II score is based on predictors which are given a maximum of 3 and minimum of 1 point based on the pathology and severity of cardiac disease (Prior cardiac events or arrhythmias, baseline New York Heart Association (NYHA) Class III/IV or cyanosis, mechanical valve, ventricular dysfunction, highrisk leftsided valve diseases/left ventricular outflow tract obstruction, PAH, CAD, highrisk aortopathies, late pregnancy assessment, and no prior cardiac intervention with decreasing weightage). The other risk scores are ZAHARA score and modified WHO classification.[4],[5]

Maternal mortality may be as high as 7% when NYHA Class III and IV patients are combined. In contrast, Class I and II when combined have mortality of only 0.5%. Similarly, fetal mortality maybe as a high as 30% in Class III and IV patients, in contrast to 2% for Classes I and II.[3] The high maternal morbidity and mortality is due to compromised cardiac function and inability to cope with the physiological adaptations of pregnancy, stress of labor, and hemodynamic changes of the puerperium.[2] Only a few studies have focused specifically on pregnancy outcome in women with VHD,[6],[7],[8] especially in lower income countries.[9]

In many instances, lack of financial support and lack of information about the risks of pregnancy in women with heart disease lead to late presentation, and also, social and cultural drawbacks preclude any appropriate preventive strategy. Clinical assessment remains a key factor in timely referral and appropriate management. Managing pregnant patients with complex cardiac disease mandates participation from a multidisciplinary team early in the pregnancy so that best course of management can be discussed and planned.

Audit of misses which as per WHO is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. And, near misses which is surrogate of maternal death is defined as “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of termination of pregnancy.” Helps to identify gaps in point of care and improve the quality of service aimed at reduction of maternal morbidity and mortality.

Aims and objectives

  • To assess the burden of maternal cardiac disease and its influence on maternal and fetal outcome
  • To assess gaps in multidisciplinary approach
  • To analyze causes associated with increased morbidity and mortality.

  Methods Top

A retrospective analysis of all pregnant patients with heart disease admitted to department of obstetrics and gynecology at tertiary care center from January 2017 to January 2018.

Inclusion criterion

All patients with cardiac disease were included in our study.

Exclusion criteria included

Patients with hypertensive heart disease and known case of cardiomyopathies were excluded from the study.

Clinical data were recorded on a structured format including demographic details, such as the age, occupation, education and marital status, parity, planned or unplanned pregnancy, and contraception used or not. NYHA class at booking, gestational age at first visit, history of cardiac complications before pregnancy, cardiac medications and anticoagulation, prior history of cardiac surgery/interventions, and nature of the cardiac lesion were noted. Moreover, associated comorbid conditions such as anemia and diabetes were also noted.

Patients' antenatal course, labor, delivery details and postnatal course and complications were systematically recorded. Treatment history, maternal and fetal outcome data were obtained. Various factors like development of arrhythmia, deterioration in NYHA Class, non-cardiac complications were taken in to account to assess maternal outcome.

Most importantly, misses and near-miss cases were recorded and analyzed along with expert group to find gaps in patient's care, associated avoidable factors of heart disease in pregnancy, and predictors of adverse outcome. Statistical analysis was done using the SPSS software (SPSS Version 17 of IBM, USA).

  Results Top

In present study, we analyzed data of 9563 deliveries during the study period, of which there were 108 cases of pregnancy with heart disease (1.12%).

[Table 1] shows analysis of demographic profile of pregnant patient with heart disease. Data revealed that Majority of patients (n = 90) were in the age group of 20–30 years Majority of patients in study cohort belonged to low socioeconomic status and had rural background. 36patients (33.33%) were primigravidae.
Table 1: Demographic profile

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Cases of heart disease diagnosed before pregnancy were 27 (25%), and cases diagnosed during current pregnancy were 77 (71.2%) while 4 (3.7%) cases were diagnosed postpartum. Majority (n = 36) presented for antenatal care in the third trimester. 82 patients (75.92%) were in NYHA I–II Class and 26 patients(24%) were in Class III–IV.

[Table 2] shows nature of cardiac disease on basis of echocardiography.
Table 2: Nature of cardiac lesion

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Predominant cardiac lesion was RHD diagnosed in 101 patients (93.5%).

Isolated mitral stenosis (MS) was seen in 30 patients (27.7%), of which 10 patients had moderately severe to critical MS (mitral valve area 0.8–1.2 cm2); 57 patients (52.7%) had combined MS and mitral regurgitation (MR). Mixed valve involvement was seen in 14 patients (12.9%). Congenital heart disease was present in 7 patients (6.4%) with atrial septal defect and ventricular septal defect being the predominant lesions. Mechanical prosthetic valves were seen in 3 patients (2.7%) while 10 patients (9.2%) had history of balloon mitral valvuloplasty.

[Table 3] shows obstetrical and neonatal outcome in recruited cohort.
Table 3: Obstetrical and Neonatal outcome

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Sixty patients (58.82%) had vaginal delivery and 38 patients (63%) went into spontaneous labor. Labor was induced in 22 patients (36.6%). In 80%, the indication for induction was postdated pregnancy. Other indications were premature rupture of membranes and intrauterine fetal demise. Of these 20 patients (19.6%) had normal vaginal delivery, 40 patients (39.21%) required instrumental delivery with outlet forceps or vacuum extractions. 42 patients (41.17%) underwent caesarean section (C/S), of which 30 patient (27.17%) had emergency C/S while 12 patients (11.11%) had an elective C/S. In elective C/S patients, the decision was based purely on the severity of their cardiac disease. Spinal anesthesia was given in 25 patients (60%) and general anesthesia in 17 patients (40%). Six patients had medical termination of pregnancy (MTP).

[Table 4] shows complication associated with cardiac disease in pregnancy.
Table 4: Complication associated with cardiac disease in pregnancy

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Cardiac complications occurred in 21 patients (19.4%) and were mainly arrhythmias and deterioration in NYHA Class. 10 patients (9.2%) developed cardiac failure and 8 patients (7.4%) had atrial fibrillation. All the patients with complication required intensive care management.

Out of 12 misses and near misses in study, 9 had severe MS combined with severe MR, 1 patient had Eisenmenger syndrome, and 2 patients had multivalvular involvement. They were managed with diuretics, oxygen, and β blockers along with other heart failure treatment regimen. 6 patients (8.3%) required vasopressors. Eight cases of near miss recovered well and were discharged after their condition was stable. Among the noncardiac complications, puerperal sepsis with multisystem organ dysfunction syndrome was seen in 5 cases, postpartum hemorrhage in 10 cases (9.2%), and anemia was associated comorbidity in 62 patients (57%). In addition to cardiac disease, 24 patients had associated medical conditions such as hypertension (HTN) (n = 16) and gestational diabetes (n = 10). 48 patients (44.4%) remained NYHA Class I throughout pregnancy and up to 48 h postpartum.

However, worsening of NYHA class was seen in 36 patients (33%), especially in the third trimester. All of them had severe MS and were in NYHA Class II/III at the time of admission and had a significant improvement after treatment given as per protocol.

Cardiac drugs required

94 patients (87%) were on penicillin prophylaxis which was continued throughout pregnancy. Seventy-one (65%) women required β blockers to control the heart rate, and 10 (9.2%) required anti-heart failure measures during pregnancy or in the immediate postpartum period.

[Table 5] shows nearmiss pathology markers and avoidable factors analysis based on data collected from facility based near miss review form as per Ministry of Health and Family Welfare Government of India.
Table 5: Near miss pathology markers and avoidable factors

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In the present study, there were 8 near miss cases Five patients had an organ system dysfunction.

Of 8 maternal nearmiss (MNM) cases, 7 patients (87.5%) were admitted for more than 8 days, 6 patients (75%) were admitted in intensive care unit for more than 5 days, and 5 patients (62.5%) were put on ventilator, 5 patients (62.5%)women required blood and blood product transfusion, and 6 patients (75%) required vasopressor support.

[Table 6] shows analysis of causes of maternal mortality.
Table 6: Timing of maternal death

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There were 4 maternal deaths among the 108 pregnant cardiac patients. The majority of deaths occurred in women with mitral valve disease; most of the deaths occurred in the third trimester and the postpartum period. Pulmonary edema was sinistrous event in 3 of 4 cases of maternal mortality, and all of them were intubated and required ionotropic support. One patient had cerebrovascular accident (CVA)due to embolization, and 2 patients required renal replacement therapy. On evaluation of mortality data as per WHO, maternal death surveillance and response (MDSR ) format, patientrelated factors, lack of transport facilities and poor followup were found to be contributory factors in 3 cases Managing pregnant patient.

[Table 7] shows analysis of predictors of adverse outcome, CARPREG II risk assessment score developed by Siu et al.
Table 7: Predictors of adverse outcome in study cohort

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  Discussion Top

In the present study, prevalence of heart disease was found to be 1.12% with RHD being the predominant disease (93.5%). About 44.4% patients were in NYHA 1 at the time of first presentation which is in concordance with the study of Bhatla et al. and Abdel-Hady et al.[10],[11] The mitral valve was the most common valve involved, and isolated mitral valve lesions accounted for 52.7% of our individuals. This was similar to the observations of Sheela et al.[12] and suggests that the incidence of MS in our society has not changed. Our results are in contrast to developed countries where congenital heart lesions are the dominant cardiac disease in pregnancy.[4],[13] Majority of our patients (83.33%) were below 30 years of age. In a study by Silversides,[14] the mean age of patients was 32 years.

In the present study, majority of the patients (71.2%) were diagnosed to have heart disease first time during pregnancy. As most patients remain asymptomatic before pregnancy and the underlying condition is unmasked due to hemodynamic changes of pregnancy or when disease itself is severe enough to produce symptoms.

The maternal mortality ratio (MMR) in low-to-middle income countries (LIMCs) is 14 times higher than in high-income countries. A number of deficiencies including lack of antenatal care, late booking, lack of appropriate referral systems to higher level of care, no family planning, overall poor education, and low rates of birth managed by skilled health-care attendants contribute to the high maternal death rates in LIMCs.[15] In the present study, 40.74% were unbooked and only 25% of the patients were aware of their heart disease, of which only 5 (4.6%) received appropriate prior counseling or contraception; this reinforces the need of educating prospective parents before the pregnancy and emphasizes the need to screen for heart diseases, so as to reduce the disease burden. Sixty percent of women in our study belonged to low educational status and were unaware about the risks associated with pregnancy.

In cases of heart disease instrumental delivery with forceps or vaccum is preferred, in order to prevent maternal strain and exhaustion. In the present study, 39.2% had instrumental delivery and 19.6% delivered without assistance. Patients who delivered without assistance were those who were multiparous, came in advanced labor, and those who progressed rapidly. Epidural analgesia is recommended for all patients undergoing vaginal delivery; it prevents tachycardia and avoids strain on heart. In the present study, efforts were made to give epidural analgesia in majority of women delivering vaginally and was given in 50% of cases.

The Japanese Circulation Society joint working group recommended C/S only for patients with cardiac dysfunction, patient at risk of hemodynamic instability, pulmonary HTN, uncontrolled arrhythmia, mechanical valve prosthesis, and patients with cyanosis.[16] In the present study C/S rate is 38%. In the majority (n = 30) (71.4%), the indications were purely obstetric, but in 12 (28.5%) patients, it was based on the severity of the cardiac lesion. Our results are in contrast to other studies which have reported an incidence of 16%–20%.[17] The high rate of C/S in our study is due to the fact that ours is a tertiary care center where we get referred complicated cases with associated comorbidities.

The overall C/S rate at our institute is 50%–55% (unpublished departmental data). Abdel-Hady et al. reported similar findings,[11] whereas in our study, decision for C/S was based on the severity of the disease and was jointly taken in consultation with cardiologists, anesthetist, and pediatrician, taking into account the echocardiographic findings and the clinical status of the patient.

Regional anesthesia, either epidural or spinal, is safe in cardiac patients presenting for C/S. In the present study, spinal anesthesia was safely used in 25 (60%) of patients who underwent C/S.[18]

Various studies have reported C/Ss with cardiac disease under spinal anesthesia with a success rate of 99%.[18]

In the present study, 92% patient had live birth, 7.8% had still birth, and 16% of the term new born were of low birth weight (<2.5 kg). A similar finding was reported by Soma-Pillay et al.[9] Small for gestational age babies were seen in 12% of women with cardiac disease as reported by Sawhney et al.[19] This suggests that cardiac disease itself could be one of the risk factors for low birth weight. In the present study, fetal outcome was good and not different from patient without heart lesion. Good fetal outcome in our study reflects good multidisciplinary care at our institute involving obstetrician, cardiologist, and pediatrician with timely decision for pregnancy termination and good neonatal care facility.

In the present study, the complications relating to cardiac disease resulting in severe morbidity and mortality was seen in 12 patients, the most common being congestive cardiac failure, followed by arrhythmia. Three patients with heart failure had severe MS, and three had multivalvular involvement. Three cases who had prosthetic valve in our study cohort had no complication due to monitored therapy. Nonvalvular factors such as anemia 62 (57%) and sepsis 5 (4.6%) were the precipitating factors for heart failure in our patients. The high incidence of right heart failure associated with MS in this study is similar to the 38% reported by Desai et al., 31% by Silversides et al., and others.[10],[14],[20],[21]

In the present study, 2 of 10 patients developed cardiac failure postdelivery which is in accordance to Abdel-Hady et al.[11] Atrial fibrillation was present in 5 patients; results of our study are in concordance with Malhotra et al. who reported a 7.3% incidence of arrhythmias.[21]

In the present study, 12% of present patients underwent palliative or valve replacement surgery before pregnancy and 2 patients underwent ballon mitral valvuloplasty during second trimester of pregnancy. All of them tolerated pregnancy well. The European task force on the management of cardiovascular diseases in pregnancy also recommends surgical correction of the valve defect before pregnancy.[22]

A near-miss describes a patient with an acute organ system dysfunction which could result in death if not treated appropriately and has been shown to be a surrogate for maternal death. Appropriate management of MNM cases is a prerequisite to reduce MMR in our country so as to achieve Millennium Development Goals as envisioned by WHO.

In the present study, near-miss data evaluation by expert group shows that there were patient-related avoidable factors in 7 of 8 cases – patients were unbooked, booked late, or did not have regular antenatal visits. Medically related avoidable factors were present in 6 of 8 cases of the near misses.

In the present study, audit of miss and near-miss cases identified delays at various levels, delay in diagnosis and treatment due to inadequate history given by patient. This is because many patients and healthcare providers overlook symptom of heart disease as normal pregnancy-related symptom, thus delaying diagnosis and treatment.

There were 4 maternal deaths in the present study. Other studies from resource-poor countries document a low but significant maternal mortality rate. Malhotra et al. reported two deaths in a series of 312 patients; Rahman et al. one death in 229 patients, and Sawhney et al. 10 in 480 patients.[19],[23]

Our study and analysis of mortality cases as per WHO MDSR format reiterate the need of early hospitalization, evaluation by a multidisciplinary approach, surgical correction before pregnancy, early diagnosis, and proper evaluation.

The outcome of pregnancy was determined by the maternal functional status in the first trimester of pregnancy. NYHA Class III and IV strongly predicted an adverse maternal outcome; I. Sawhney et al. reported a maternal mortality rate of 2% in women with cardiac disease. They studied 486 women over a period of 13 years. Ten deaths were seen, of which 8 women (80%) were in NYHA Class III or IV.8 In our study also cases who succumbed were in NYHA III and IV. In the present study, one patient who died was a known case of Eisenmenger's syndrome and presented in NYHA Class III, despite that she conceived and carried pregnancy till term, this highlights the gap in preconceptional counseling and emphasizes need of creating awareness among health care professional regarding absolute indication of MTP as in case with primary pulmonary HTN, Eisenmenger's, pulmonary venoocclusive disease.

In the present study factors, associated with adverse maternal outcome were multiparity, young age, severity of valvular lesion, NYHA functional Class III or IV,, arrhythmias and poor ejection fraction.

In the present study, multidisciplinary consultation was sought in all patients regarding optimal management.

  Conclusion Top

Although the incidence of RHD has decreased, it is still an important cause of maternal morbidity and mortality. The multidisciplinary management reduces the adverse events and results in satisfactory maternal and fetal outcomes. Communication between the team members is important to prevent, recognize and treat complications, to develop systematic plan for labor and postpartum care. Initial multidisciplinary planning meeting including all providers involved in care should be organized. Multidisciplinary evaluation with discussion of risk factors, appropriate family planning, and optimizing of the cardiac state before conception are advised.[22],[24]

The strength of the present study is that a thorough evaluation of miss and near miss was done with expert group to assess gap in care and take corrective actions accordingly. Various contributory factors – medical, social, economical and other factors were studied in detail. Present study highlights the need of timely diagnosis and management to optimize fetomaternal outcome, need to strengthen prepregnancy counselling in highrisk women, and need of regular review of misses and near misses.

Limitations of the study are that it is a singlecenter audit with limited time duration and a retrospective study which patients identified from the records. There is need of data collection from prospective study spanning over a few years, which would give a true picture of the improvement in obstetric care.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Konar H, Chaudhuri S. Pregnancy complicated by maternal heart disease: A review of 281 women. J Obstet Gynaecol India 2012;62:301-6.  Back to cited text no. 1
NCCEMD, Maternal, Child and Women's Health Directorate. Saving Mothers: Third Report on Confidential Enquiries into Maternal Deaths in South Africa. 2002-2004. Pretoria: Department of Health; 2006.  Back to cited text no. 2
Cotrufo M, De Feo M, De Santo LS, Romano G, Della Corte A, Renzulli A, et al. Risk of warfarin during pregnancy with mechanical valve prostheses. Obstet Gynecol 2002;99:35-40.  Back to cited text no. 3
Siu SC, Sermer M, Colman JM, Alvarez AN, Mercier LA, Morton BC, et al. Prospective multicenter study of pregnancy outcomes in women with heart disease. Circulation 2001;104:515-21.  Back to cited text no. 4
Silversides CK, Grewal J, Mason J, Sermer M, Kiess M, Rychel V, et al. Pregnancy outcomes in women with Heart disease: The CARPREG II study. J Am Coll Cardiol 2018;71:2419-30.  Back to cited text no. 5
Ben Farhat M, Gamra H, Betbout F, Maatouk F, Jarrar M, Addad F, et al. Percutaneous balloon mitral commissurotomy during pregnancy. Heart 1997;77:564-7.  Back to cited text no. 6
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Soma-Pillay P, MacDonald AP, Mathivha TM, Bakker JL, Mackintosh MO. Cardiac disease in pregnancy: A 4-year audit at Pretoria academic hospital. S Afr Med J 2008;98:553-6.  Back to cited text no. 9
Bhatla N, Lal S, Behera G, Kriplani A, Mittal S, Agarwal N, et al. Cardiac disease in pregnancy. Int J Gynaecol Obstet 2003;82:153-9.  Back to cited text no. 10
Abdel-Hady ES, El-Shamy M, El-Rifai AA, Goda H, Abdel-Samad A, Moussa S. Maternal and perinatal outcome of pregnancies complicated by cardiac disease. Int J Gynaecol Obstet 2005;90:21-5.  Back to cited text no. 11
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Silversides CK, Colman JM, Sermer M, Siu SC. Cardiac risk in pregnant women with rheumatic mitral stenosis. Am J Cardiol 2003;91:1382-5.  Back to cited text no. 14
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Sawhney H, Aggarwal N, Suri V, Vasishta K, Sharma Y, Grover A. Maternal and perinatal outcome in rheumatic heart disease. Int J Gynaecol Obstet 2003;80:9-14.   Back to cited text no. 19
Desai DK, Adanlawo M, Naidoo DP, Moodley J, Kleinschmidt I. Mitral stenosis in pregnancy: A four-year experience at King Edward VIII hospital, Durban, South Africa. BJOG 2000;107:953-8.  Back to cited text no. 20
Malhotra M, Sharma JB, Tripathii R, Arora P, Arora R. Maternal and fetal outcome in valvular heart disease. Int J Gynaecol Obstet 2004;84:11-6.  Back to cited text no. 21
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

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