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Heart Disease in Pregnancy: Validity of CARPREG Score in local populationEliza M.N (1), Quek Y.S. (1), Woon S.Y. (1), Ravichandan N. (2), Ravichandran J. (1)

1. Hospital Sultanah Aminah Johor Bahru, Malaysia 2. Singapore General Hospital

Objectives Results Conclusions

References

Report of Confidential enquiry into maternal deaths in 1997-

2000 showed that the commonest cause of death is due to

medical disorders in pregnancy which consists of 20.6%.

Heart disease in pregnancy is the leading cause of death due

to medical disorders especially due to valvular lesions and

followed by congenital heart disease. There are four

predictors used to determine mortality associated with heart

disease, called CARPREG score. They are prior cardiac

event ( heart failure/ stroke ), baseline NYHA >II, left heart

obstruction ( mitral area <2cm, aortic area < 1.5cm or peak

left ventricular outflow gradient > 30mmhg by ECHO ) and

reduced systemic ventricular ejection fraction ( < 40% ) .

This study is to asses the validity of a risk score index

(CARPREG) in predicting maternal and perinatal outcome in

pregnant patients with heart diseases in our population.

The main finding of this study is that pregnant women with

various forms of heart disease experience an overall low risk of

cardiac complications if their CARPREG score is low. This

cardiac event observed was lower than most studies done.

In our study we categorized patients according to the

previous validated carpreg score, however some limitations of

the carpreg score must be recognized. Lesion specific

predictors need to be incorporated in the scoring and prior

cardiac event such as arrhythmia would be too vague as the

outcome for treated and treated event was not mentioned

specifically. As for NYHA class, it would patient and the

doctors own evaluation which may sometimes be inaccurate.

Several limitations of our study also needs to be considered

as some patients who were discharged home may have had a

cardiac event which have been missed.

In conclusion, the cardiac events observed in our study was

relatively lower compared to the standard outcome in the

CARPREG scoring system, thus a different method or scoring

system is required in our local setting. More research and

bigger studies need to be done to assess the validity of this

scoring system and other scoring system as well .

Results

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Methods

A prospective observational study in pregnant women

diagnosed with heart disease for 1 year duration involving 150

patients managed by combine obstetrician and cardiologist.

Patients went through CARPREG risk scoring and their

cardiac events were observed. The rate of cardiac

complications according to the CARPREG score for a patient

with a score of 0,1 and >1 was 5%, 27% and 75% respectively.

The demographic data for all these patients were also

observed.

Majority of our patients were grouped in Carpreg 0 (Figure 1).

Among 150 cases recruited, 61 of them were congenital heart disease

with 89 acquired heart disease (Table 1). Occurrence of cardiac

events in relation to carpreg score category were as in Table 2.

1. Jastrow N, Meyer P, Kahiry P, et al. Prediction of complications in pregnant women with cardiac diseases referred to a tertiary center. Int. J Cardiol 2011;151:209-213.

2. Ruth C., Swan L., Steera PJ. Cardiac disease in pregnancy. Curr Opinion Obstet Gynecol 2009;21:508-513.

3. Willem D., Eric B., Balci A., et al. Predictors of pregnancy complications in women with congenital heart disease. European Heart J 2010;31:2124-2132.

4. Samuel CS, Sermer M, Colman JM, et al. Prospective Multicenter Study of Pregnancy Outcomes in Women with Heart Disease. Am Heart Assoc Circulation 2001; 104:515-521.

5. Paul K., Ouyang DW., Fernandes SM., et al. Pregnancy Outcomes in Women with Congenital Heart Disease. Am J Heart Assoc 2006; 113:517-524.

Table 1. Carpreg Score in different cardiac disease

Carpreg Score Congenital

(n = 61)

Acquired

(n = 89)

Total

(n = 150)

0 53 (86.9) 60 (67.4) 113 (75.3)

1 4 (6.6) 20 (22.5) 24 (16)

2 4 (6.6) 9 (10.1) 13 (8.7)

Data presented as n (%)

Table 2. Carpreg Score and Cardiac Events

Data presented as n (%)

Carpreg

Score 0

Carpreg

Score 1

Carpreg

Score 2

Total

Presence of Cardiac Event

Yes 1 (0.9) 3 (12.5) 4 (30.8) 8 (5.3)

No 112 (99.1) 21 (87.5) 9 (69.2) 142 (94.7)

Onset of Cardiac Event

Antepartum 1 (100) 1 (33.3) 3 (75) 5 (62.5)

Postpartum 0 (0) 2 (66.7) 1 (25) 3 (37.5)

Maternal mortality 0 (0) 1 (4.2) 1 (7.7) 2 (1.3)

Ocurrence of cardiac events were further subcategorized

into congenital or acquired heart disease in relation to

carpreg score category (Table 3 & 4).

Table 3. Cardiac Events in Acquired Heart Disease

Data presented as n (%)

Carpreg

Score 0

Carpreg

Score 1

Carpreg

Score 2

Total

Presence of Cardiac Event

Yes 1 (1.7) 3 (15.0) 1 (11.1) 5 (5.6)

No 59 (98.3) 17 (85.0) 8 (88.9) 84 (94.4)

Onset of Cardiac Event

Antepartum 1 (100) 1 (33.3) 1 (100) 3 (60)

Postpartum 0 (0) 2 (66.7) 0 (0) 2 (40)

Type of Cardiac Event

Heart Failure 1 (1.1) 2 (2.2) 1 (1.1) 4 (5.4)

Maternal Mortality 0 (0) 1 (1.1) 0 (0) 1 (1.1)

Table 4. Cardiac Events in Congenital Heart Disease

Carpreg

Score 0

Carpreg

Score 1

Carpreg

Score 2

Total

Presence of Cardiac Event

Yes 0 (0) 0 (0) 3 (75) 3 (4.9)

No 53 (100) 4 (100) 1 (25) 58 (95.1)

Onset of Cardiac Event

Antepartum NA* NA* 2 (66.7) 2 (66.7)

Postpartum NA* NA* 1 (33.3) 1 (33.3)

Type of Cardiac Event

Heart Failure NA* NA* 2 (66.7) 2 (66.7)

Maternal Mortality NA* NA* 1 (33.3) 1 (33.3)Data presented as n (%). * Not applicable

All these cardiac event was heart failure , however there

was one maternal death and this occurred postpartum in the

CARPREG 1 group. The patient was a 33 year old

primigravida who was diagnosed to have chronic rheumatic

heart disease and had severe aortic stenosis. She was

admitted from 30 weeks onwards and was on beta blockers,

aspirin and metoprolol. The pregnancy ended up with an

IUD and was delivered via caeserian section. She

succumbed to the illness during postpartum.