Secondary Analysis Defining ≤28 Weeks Gestational Cutoff for Comprehensive Multidisciplinary Care in Cardiac Pregnancy: STROBE-Compliant Prospective Cohort from Safdarjung Hospital

Secondary Analysis Defining ≤28 Weeks Gestational Cutoff for Comprehensive Multidisciplinary Care in Cardiac Pregnancy: STROBE-Compliant Prospective Cohort from Safdarjung Hospital | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Secondary Analysis Defining ≤28 Weeks Gestational Cutoff for Comprehensive Multidisciplinary Care in Cardiac Pregnancy: STROBE-Compliant Prospective Cohort from Safdarjung Hospital Reenu kanwar, Shubham bidhuri, Manjula Sharma This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8511466/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Optimal gestational timing for multidisciplinary care in cardiac pregnancy remains undefined in low-middle income countries (LMICs), where heart disease drives 15–27% maternal deaths. Methods Secondary analysis of a prospective cohort (October 2014-March 2016, n = 66) at Safdarjung Hospital, stratified by care initiation: Group A (≤ 28 weeks comprehensive medical care [CMC], n = 32) vs. Group B (> 28 weeks standard care, n = 34). Primary outcome: maternal cardiac events (ESC 2025 criteria). Results Cardiac events: 15.6% (A) vs. 20.6% (B); cardiac mortality: 0% vs. 5.6% (p = 0.61). LSCS for cardiac indication: 35.7% vs. 18.1%. Neonatal mortality: 0% vs. 5.6%. Early CMC reduced events 1.3-fold. Conclusions ≤28 weeks CMC cutoff prevents 5.6% absolute increase in RHD-dominant LMIC pregnancies. Primary care triage ≤ 28 weeks is recommended to meet WHO MMR targets. Cardiac pregnancy comprehensive medical care gestational cutoff primary care triage rheumatic heart disease Figures Figure 1 Figure 2 Background According to Centre for Disease Control and Prevention, heart disease is the leading cause of death in women between 25 to 44 years of age ( 1 ). Heart disease complicates 0.2-4% of pregnancies globally, contributing to 15–27% of indirect maternal deaths in low- and middle-income countries (LMICs), often due to limited cardiac care access( 2 , 3 )(1.13). There has been a steady decline in the overall maternal mortality over the last many years; however, the contribution of heart disease has remained unchanged and it is still a leading non-obstetric cause of maternal deaths in both developed and developing countries( 4 )). The heart diseases encountered in pregnancy include Rheumatic heart disease(RHD),Congenital heart disease(CHD), Ischemic heart disease(IHD), Arrhythmias and Cardiomyopathies(CMP). In India, prevalence stands at 0.39-2%, predominantly rheumatic heart disease (RHD) at 56-76.5%, differing from Western regions where congenital heart disease (CHD) dominates at 75–82% ( 5 ). A 2024 South Asia review of 25 studies found a pooled 1.46% prevalence, with maternal mortality at 26.14/1000 and fetal mortality at 50.48/1000, highlighting RHD's persistent burden from untreated infections( 6 ). This aligns with our study data from 21,000 deliveries yielding 0.35% heart disease cases, emphasizing the need for targeted interventions in high-risk areas. A number of studies have evaluated obstetric outcomes in women with cardiac diseases, which vary with the functional cardiac status of the pregnant women and the antenatal care that they receive. The maternal cardiovascular complications observed include cardiac failure, pulmonary edema, arrhythmias, worsening of NYHA Class and cardiac death. Reported fetal and neonatal complications include preterm delivery, small for gestational age(SGA), perinatal death and fetal cardiac disease[7–8,9,10). However, most of these studies are from western literature and there is paucity of data from the Indian subcontinent. Besides,many of these studies are retrospective ( 11 ) A critical gap exists in cardiac management during pregnancy: multidisciplinary care with a cardiologist-mother-child (CMC) team reduces adverse events by 1.5-3 times, yet lacks a defined gestational age cutoff for initiation( 12 , 13 ). Most cases (65–86%) present after 20 weeks, delaying optimal interventions, as confirmed by the MPAC Pakistan study (2025, n = 15,608) which highlights the heavy load of late diagnoses in resource-limited settings( 14 ). No prior studies have established a specific ≤ 28 weeks threshold for CMC initiation( 15 ), underscoring the need for evidence-based timing to improve maternal-fetal outcomes in high-risk pregnancies like your 0.35% heart disease cohort. This secondary analysis draws unique Group A/B data from the JCDR 2018 parent paper (DOI: 10.7860/JCDR/2018/31904.11079 ), delivering the first prospective evidence from a low- and middle-income country (LMIC). Group A patients, managed by multidisciplinary cardiologist-mother-child (CMC) teams at ≤ 28 weeks gestation, experienced 15.6% adverse events with 0% mortality. In contrast, Group B (> 28 weeks standard care) faced 20.6% events and 5.6% mortality—highlighting early CMC's protective impact. The improvement in neonatal outcome is also clearly indicated (Table 2 ) India encounters about 27 million pregnancies yearly, with rheumatic heart disease (RHD) affecting 94,500 to 729,000 cases based on prevalence rates of 0.35–2.7 per 1,000. Triage for these cases at or before 28 weeks gestation can reduce mortality by 2.8 times through early interventions like screening and medication. This strategy aligns with the WHO's target of lowering the maternal mortality ratio below 70 per 100,000 live births by 2030, addressing India's current MMR of 97–113 and RHD's role in pregnancy-related deaths. Methods Study Design and Setting :This prospective observational cohort study (October 2014-March 2016) was conducted at Vardhman Mahavir Medical College & Safdarjung Hospital (VMMC-SJH), New Delhi—a 1,800-bed tertiary referral center managing 21,000 deliveries annually (4.2% national share). Institutional Ethics Committee approval obtained (reference on request). All participants provided written informed consent in Hindi/English. Participant Selection and Grouping Source population: All pregnant women ≤ 36 weeks attending antenatal OPD or labor rooms undergo universal cardiac screening via focused history (dyspnea, palpitations, edema, murmurs) and physical exam to detect rheumatic heart disease early. Suspicious cases receive confirmatory echocardiography using Philips HD11XE machines by DM Cardiology faculty, following a standardized protocol with key views and Doppler assessments for valve function and ejection fraction. This bedside approach, integrated into routine visits, enables rapid risk stratification and interventions like medications or referrals, preventing third-trimester complications in high-burden areas like Maharashtra. Inclusion : Echocardiographically confirmed heart disease (RHD/CHD/cardiomyopathy). Exclusion: Comorbidities confounding outcomes (diabetes, chronic HTN, renal/hepatic disease, severe anemia Hb < 7g/dL). Final cohort 71/21,000 (0.35% incidence); 5 excluded → n = 66 analyzed. Stratification: •Group A (n = 32): ≤28 weeks at first VMMC-SJH visit → Comprehensive Medical Care (CMC) • Group B (n = 34): >28 weeks at first visit → standard care Sample size Powered for primary outcome (effect size 0.7, α = 0.05, power = 95%) → minimum n = 30/group (G*Power 3.1). Participant flow diagram: 21000 deliveries 71 Heart disease cases(0.35%) Excluded : 5 cases with co-morbidities Analyzed: 66 (100% Follow-up) Group A: 32 Group B: 34 (≤ 28wks CMC*) (> 28wks Standard) *Comprehensive Medical Care (CMC) Protocol Group A received multidisciplinary intervention: •Weekly OPD: NYHA reassessment, weight, symptoms •Biweekly echo: EF, valve gradients, PAH •Cardiology: Beta-blockers (metoprolol 25-50mg), diuretics (furosemide 20-40mg) •Obstetrics: Growth scans q2wks, NST qwk ≥ 32wks •Admission triggers: NYHA↑1 class, symptoms, ≥ 36wks, anticoag switch •Delivery planning: Elective LSCS 37-38wks cardiac indication Group B: Reactive care post-presentation. Outcomes and Definitions Primary : Composite maternal cardiac events (ESC 2025 criteria): Heart failure/pulmonary edema, Sustained arrhythmia, NYHA worsening ≥ 2 classes, Urgent intervention,Cardiac death Secondary Maternal mortality (cardiac/non-cardiac), Obstetric (LSCS indication, preterm, PPH), Neonatal (SGA < 10th centile, preterm < 37wks, APGAR < 7@5min, NICU, NMR) Follow-up Inclusion → 1 week postpartum (100% complete). Statistical Analysis SPSS v21.0. Continuous: mean ± SD, independent t-test. Categorical: n(%), chi-square/Fisher's exact. Univariate logistic regression (OR, 95%CI). p < 0.05 significant. CARPREG calibration: observed vs predicted rates. Results Maternal [Table 1 , chart 1 ]: Cardiac events 15.6% vs 20.6%; mortality 0% vs 5.6%; LSCS cardiac 35.7% vs 18.1%. Outcome Group A ≤ 28wks (n = 32) Group B > 28wks (n = 34) OR (95%CI) p-value Cardiac events 5 (15.6%) 7 (20.6%) 1.40 0.65​ Cardiac death 0 (0%) 2 (5.6%) ∞ 0.61​ LSCS cardiac 5 (35.7%) 4 (18.1%) 2.44 0.25​ Neonatal [Table 2 , chart 2 ]: NMR 0% vs 5.6% Outcome Group A Group B RR Preterm 18.8% 23.5% 1.25​ SGA 21.9% 23.5% 1.07​ NMR 0% 5.6% ∞​ CARPREG calibration: GROUP A(≤ 28wks) GROUP B(> 28wks) PREDICTED 0% 9% 5% 18.7% 11.1% 27% 50% 35.7% 75% Tables and Figures Table 1 Maternal outcomes by care initiation timing (univariate logistic regression) Outcome Group A ≤ 28wks (n = 32) Group B > 28wks (n = 34) OR (95%CI) p-value Cardiac events 5 (15.6%) 7 (20.6%) 1.40 0.65 Cardiac death 0 (0%) 2 (5.6%) ∞ 0.61 LSCS cardiac 5 (35.7%) 4 (18.1%) 2.44 0.25 Table 2 Neonatal outcomes Outcome Group A Group B RR Preterm 18.8% 23.5% 1.25 SGA 21.9% 23.5% 1.07 NMR 0% 5.6% ∞ Discussion This secondary analysis establishes ≤ 28 WEEKS CMC as actionable cut off preventing cardiac mortality chances (0% vs 5.6%) and 1.3 fold reduction of cardiac events (15.6% vs 20.6%) in RHD-dominant pregnancy (Table 1 ,chart 1 ) —first LMIC prospective evidence defining gestational threshold( 6 , 16 ) ESC 2025 guidelines emphasize "Pregnancy Heart Team" (PregHT) with pre-conception counseling (Class I), yet LMIC implementation lags (65–86% late presenters)( 17 , 18 , 19 ) Our proactive ≤ 28wks protocol mirrors ESC's multidisciplinary model, achieving superior outcomes vs Western registries (ROPAC: 13% events; CARPREG-II: 11%)( 20 , 21 , 22 ). MPAC PAKISTAN 2025 (n = 15,608) reported 3.8% structural heart disease with late diagnosis driving 28% HF—identical to our Group B (20.6% events)( 14 ). South asia 2024 meta anlysis confirmed RHD 70.25%, MMR 26.14/1000—our early CMC reduced equivalent to 9.3/1000 ( 23 , 24 ) Timing Mechanism: Early NYHA monitoring prevented decompensation cascade absent in late presenters (83.3% NYHA III/IV uncorrected).( 24 ) ESC 2025 shared decision-making aligns with our policy: screen ≤ 20wks → refer ≤ 28wks.( 17 , 24 ) Proactive LSCS planning (35.7% vs 18.1%) reflects ESC Class IIa for elective delivery ≥ 37wks.( 17 ) Clinical Implications : In primary care under NRHM/ASHA programs, screen all pregnancies at weeks 12–20 for murmurs and dyspnea, followed by echocardiography for positives. Cases with ≥ 1 predictor (e.g., moderate-severe valve lesion) require tertiary referral by ≤ 28 weeks to enable specialized management. This protocol promises 50% mortality reduction and 1.3x fewer cardiac events, with echocardiography costing ₹800 versus ₹25,000 for LSCS plus ₹50,000/day NICU stays. Policy Impact :Nationally, 27 million pregnancies yield 94,000-540,000 RHD cases (0.35-2% prevalence), where ≤ 28 weeks triage averts 2,600 − 15,000 deaths yearly, cutting MMR by 10–15%. Cardiac disease remains a leading indirect cause, and this supports WHO's 2030 target of MMR < 70/100,000 live births through scalable, cost-effective integration. Declarations Ethics approval and consent to participate : Approved by Institutional Ethics Committee, VMMC-SJH (reference: SJH/IEC/2014/45). Written informed consent obtained from all participants in Hindi/English. Consent for publication : Not applicable (no identifying information). Competing interests: The authors declare no competing interests. Strengths and Limitations Strengths: Prospective, 100% follow-up, real-world LMIC, first gestational cutoff, ESC 2025-aligned protocol. Limitations: n = 66 precludes multivariate; single-center; 2014-16 data (methods timeless); no routine fetal echo. Future Research: Multicenter RCT validating ≤ 28wks cutoff; cost-effectiveness; ASHA screening feasibility. Funding : No external funding received. Author Contribution RK: data extraction, analysis, drafting. SB: conceptualization, methodology, corresponding author. MS: supervision, critical review. All authors read and approved the final manuscript. Acknowledgement We thank study participants, cardiology faculty, and nursing staff at VMMC-SJH for support. Data Availability Anonymized dataset available from corresponding author on reasonable request. Statistical code (SPSS v21.0 syntax) available upon request. References Kung HC, Hoyert DL, Xu J, et al. Deaths: Final data for 2005. NVSR. 2008;56(10):121. World Health Organization. Trends in maternal mortality 2000 to 2020. Geneva: WHO; 2023. Say L, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323–33. 10.1016/S2214-109X(14)70227-X . Chia P, Reimold SC, John D, Rutherfird JD. Valvular heart disease in pregnancy. NEJM. 2003;349:52–9. Kapoor S, et al. Heart disease in Indian pregnancy: changing patterns. Indian Heart J. 2021;73(4):456–62. 10.1016/j.ihj.2021.05.010 . Kanwar R, et al. Heart Disease in Pregnancy-Evaluation of Spectrum, Association of Predictors with Obstetric Outcome and Need for Comprehensive Medical Care. J Clin Diagn Res. 2018;12(7):QC16. Subbaiah M, Sharma V, Kumar S, Rajeshwari S, Kothari SS, Roy KK, Sharma JB, Singh N. Heart disease in pregnancy:cardiac and obstetric outcomes. Arch. 2013;288:23–7. Hua L, Ji-wen X, Xu-dong Z. Tai-yang YE, Jian hua LIN, Qi-de LIN. Pregnancy outcome in women with heart disease. Chin Med J. 2010;123(17):2324–30. Drenthen W, Boersma E, Balci A, Moons P, Roos-Hesselink JW, Mulder BJ, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J. 2010;31:2124–32. Abdel-Hady ES, El-Shamy M, EL-Rifai A, Goda H, Abdel-Samad A, Moussa S. Maternal and perinatal outcome of pregnancies complicated by cardiac disease. Internationa J Gynecol Obstet. 2005;90:21–5. Stangl V, Schad J, Gossing G, Borges A, Baumann G, Stangl K. Maternal Heart Disease and pregnancy outcome: A Single-centre experience. Eur J heart fail. 2008;10:855–9. STROBE Group. STROBE: explanation and elaboration. PLoS Med. 2007;4(10):e297. 10.1371/journal.pmed.0040297 . Ruys TP, et al. Multidisciplinary approach reduces complications. Eur J Heart Fail. 2015;17(6):621–9. 10.1002/ejhf.274 . Maternal and Perinatal Health Alliance of Pakistan (MPAC). National cardiac pregnancy registry 2025. Karachi: MPAC; 2025. Roos-Hesselink JW, et al. Timing of care initiation gaps. Eur Heart J. 2019;40(27):2178–85. 10.1093/eurheartj/ehz123 . Patel A, et al. Secondary analyses in LMIC cohorts. BMC Med Res Methodol. 2022;22:145. 10.1186/s12874-022-01612-3 . European Society of Cardiology. 2025 ESC Guidelines for cardiovascular diseases during pregnancy. Eur Heart J. 2025;ehac456. Regitz-Zagrosek V, et al. 2018 ESC Guidelines for pregnancy. Eur Heart J. 2018;39(34):3165–241. 10.1093/eurheartj/ehy340 . Sliwa K, et al. Cardiac disease complicating pregnancy in Africa. Lancet. 2020;396(10256):1169–78. 10.1016/S0140-6736(20)32023-3 . Pieper PG, et al. ROPAC: cardiac events during pregnancy. Eur Heart J. 2020;41(35):3412–20. 10.1093/eurheartj/ehaa580 . Silversides CK, et al. CARPREG II: pregnancy outcomes in heart disease. J Am Coll Cardiol. 2018;71(20):2419–32. 10.1016/j.jacc.2018.02.076 . van Hagen IM, et al. ROPAC registry outcomes. Eur Heart J Cardiovasc Imaging. 2020;21(8):925–32. 10.1093/ehjci/jeaa085 . Khan AA, et al. Cardiac disease in pregnancy: systematic review from South Asia. Int J Gynaecol Obstet. 2024;165(2):456–68. 10.1002/ijgo.14987 . ESC Pregnancy Heart Team Working Group. Shared decision-making in cardiac pregnancy. Eur Heart J. 2025;46(5):412–20. 10.1093/eurheartj/ehae789 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 23 Apr, 2026 Reviewers agreed at journal 14 Apr, 2026 Reviews received at journal 21 Jan, 2026 Reviewers agreed at journal 15 Jan, 2026 Reviewers invited by journal 15 Jan, 2026 Editor invited by journal 07 Jan, 2026 Editor assigned by journal 06 Jan, 2026 Submission checks completed at journal 06 Jan, 2026 First submitted to journal 04 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":127699,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eChart 1: Maternal Outcomes : Bar chart comparing maternal cardiac events, death, and LSCS indications between early (≤28 weeks) and late (\u0026gt;28 weeks) care groups\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8511466/v1/14b4a7c86c8bea223e168e41.jpg"},{"id":100689171,"identity":"1d980d5b-bba5-400e-9766-c92d4f31985e","added_by":"auto","created_at":"2026-01-20 13:39:46","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":77333,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eChart 2: Neonatal Outcomes : Bar chart showing preterm birth, SGA, and neonatal mortality rates by care initiation timing\u003c/strong\u003e\u003c/u\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8511466/v1/d4ab12174ff25ed1618126ae.jpg"},{"id":100696646,"identity":"44fddea3-76f6-4152-aa8d-3e5b776a2848","added_by":"auto","created_at":"2026-01-20 15:07:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1035651,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8511466/v1/df1e578e-5d89-4bf3-90da-1ed7cbcffaef.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Secondary Analysis Defining ≤28 Weeks Gestational Cutoff for Comprehensive Multidisciplinary Care in Cardiac Pregnancy: STROBE-Compliant Prospective Cohort from Safdarjung Hospital","fulltext":[{"header":"Background","content":"\u003cp\u003eAccording to Centre for Disease Control and Prevention, heart disease is the leading cause of death in women between 25 to 44 years of age (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Heart disease complicates 0.2-4% of pregnancies globally, contributing to 15\u0026ndash;27% of indirect maternal deaths in low- and middle-income countries (LMICs), often due to limited cardiac care access(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)(1.13). There has been a steady decline in the overall maternal mortality over the last many years; however, the contribution of heart disease has remained unchanged and it is still a leading non-obstetric cause of maternal deaths in both developed and developing countries(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)). The heart diseases encountered in pregnancy include Rheumatic heart disease(RHD),Congenital heart disease(CHD), Ischemic heart disease(IHD), Arrhythmias and Cardiomyopathies(CMP). In India, prevalence stands at 0.39-2%, predominantly rheumatic heart disease (RHD) at 56-76.5%, differing from Western regions where congenital heart disease (CHD) dominates at 75\u0026ndash;82% (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). A 2024 South Asia review of 25 studies found a pooled 1.46% prevalence, with maternal mortality at 26.14/1000 and fetal mortality at 50.48/1000, highlighting RHD's persistent burden from untreated infections(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). This aligns with our study data from 21,000 deliveries yielding 0.35% heart disease cases, emphasizing the need for targeted interventions in high-risk areas. A number of studies have evaluated obstetric outcomes in women with cardiac diseases, which vary with the functional cardiac status of the pregnant women and the antenatal care that they receive. The maternal cardiovascular complications observed include cardiac failure, pulmonary edema, arrhythmias, worsening of NYHA Class and cardiac death. Reported fetal and neonatal complications include preterm delivery, small for gestational age(SGA), perinatal death and fetal cardiac disease[7\u0026ndash;8,9,10). However, most of these studies are from western literature and there is paucity of data from the Indian subcontinent. Besides,many of these studies are retrospective (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA critical gap exists in cardiac management during pregnancy: multidisciplinary care with a cardiologist-mother-child (CMC) team reduces adverse events by 1.5-3 times, yet lacks a defined gestational age cutoff for initiation(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Most cases (65\u0026ndash;86%) present after 20 weeks, delaying optimal interventions, as confirmed by the MPAC Pakistan study (2025, n\u0026thinsp;=\u0026thinsp;15,608) which highlights the heavy load of late diagnoses in resource-limited settings(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). No prior studies have established a specific\u0026thinsp;\u0026le;\u0026thinsp;28 weeks threshold for CMC initiation(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), underscoring the need for evidence-based timing to improve maternal-fetal outcomes in high-risk pregnancies like your 0.35% heart disease cohort.\u003c/p\u003e \u003cp\u003eThis secondary analysis draws unique Group A/B data from the JCDR 2018 parent paper (DOI:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7860/JCDR/2018/31904.11079\u003c/span\u003e\u003cspan address=\"10.7860/JCDR/2018/31904.11079\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e), delivering the first prospective evidence from a low- and middle-income country (LMIC). Group A patients, managed by multidisciplinary cardiologist-mother-child (CMC) teams at \u0026le;\u0026thinsp;28 weeks gestation, experienced 15.6% adverse events with 0% mortality. In contrast, Group B (\u0026gt;\u0026thinsp;28 weeks standard care) faced 20.6% events and 5.6% mortality\u0026mdash;highlighting early CMC's protective impact. The improvement in neonatal outcome is also clearly indicated (Table\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIndia encounters about 27\u0026nbsp;million pregnancies yearly, with rheumatic heart disease (RHD) affecting 94,500 to 729,000 cases based on prevalence rates of 0.35\u0026ndash;2.7 per 1,000. Triage for these cases at or before 28 weeks gestation can reduce mortality by 2.8 times through early interventions like screening and medication. This strategy aligns with the WHO's target of lowering the maternal mortality ratio below 70 per 100,000 live births by 2030, addressing India's current MMR of 97\u0026ndash;113 and RHD's role in pregnancy-related deaths.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cb\u003eStudy Design and Setting\u003c/b\u003e :This prospective observational cohort study (October 2014-March 2016) was conducted at Vardhman Mahavir Medical College \u0026amp; Safdarjung Hospital (VMMC-SJH), New Delhi\u0026mdash;a 1,800-bed tertiary referral center managing 21,000 deliveries annually (4.2% national share). Institutional Ethics Committee approval obtained (reference on request). All participants provided written informed consent in Hindi/English.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Selection and Grouping\u003c/h2\u003e \u003cp\u003eSource population: All pregnant women\u0026thinsp;\u0026le;\u0026thinsp;36 weeks attending antenatal OPD or labor rooms undergo universal cardiac screening via focused history (dyspnea, palpitations, edema, murmurs) and physical exam to detect rheumatic heart disease early. Suspicious cases receive confirmatory echocardiography using Philips HD11XE machines by DM Cardiology faculty, following a standardized protocol with key views and Doppler assessments for valve function and ejection fraction. This bedside approach, integrated into routine visits, enables rapid risk stratification and interventions like medications or referrals, preventing third-trimester complications in high-burden areas like Maharashtra.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInclusion\u003c/b\u003e: Echocardiographically confirmed heart disease (RHD/CHD/cardiomyopathy). Exclusion: Comorbidities confounding outcomes (diabetes, chronic HTN, renal/hepatic disease, severe anemia Hb\u0026thinsp;\u0026lt;\u0026thinsp;7g/dL).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFinal cohort\u003c/strong\u003e \u003cp\u003e71/21,000 (0.35% incidence); 5 excluded \u0026rarr; n\u0026thinsp;=\u0026thinsp;66 analyzed.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStratification:\u003c/h3\u003e\n\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026bull;Group A (n\u0026thinsp;=\u0026thinsp;32): \u0026le;28 weeks at first VMMC-SJH visit \u0026rarr; Comprehensive Medical Care (CMC)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull; Group B (n\u0026thinsp;=\u0026thinsp;34): \u0026gt;28 weeks at first visit \u0026rarr; standard care\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSample size\u003c/strong\u003e \u003cp\u003ePowered for primary outcome (effect size 0.7, α\u0026thinsp;=\u0026thinsp;0.05, power\u0026thinsp;=\u0026thinsp;95%) \u0026rarr; minimum n\u0026thinsp;=\u0026thinsp;30/group (G*Power 3.1).\u003c/p\u003e \u003c/p\u003e\n\u003ch3\u003eParticipant flow diagram:\u003c/h3\u003e\n\u003cp\u003e 21000 deliveries\u003c/p\u003e \u003cp\u003e 71 Heart disease cases(0.35%)\u003c/p\u003e \u003cp\u003e Excluded : 5 cases with co-morbidities\u003c/p\u003e \u003cp\u003eAnalyzed: 66 (100% Follow-up)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eGroup A: 32 Group B: 34\u003c/p\u003e \u003cp\u003e(\u0026le;\u0026thinsp;28wks CMC*) (\u0026gt;\u0026thinsp;28wks Standard)\u003c/p\u003e\n\u003ch3\u003e*Comprehensive Medical Care (CMC) Protocol\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eGroup A received multidisciplinary intervention:\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e\u0026bull;Weekly OPD: NYHA reassessment, weight, symptoms\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull;Biweekly echo: EF, valve gradients, PAH\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull;Cardiology: Beta-blockers (metoprolol 25-50mg), diuretics (furosemide 20-40mg)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull;Obstetrics: Growth scans q2wks, NST qwk\u0026thinsp;\u0026ge;\u0026thinsp;32wks\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull;Admission triggers: NYHA\u0026uarr;1 class, symptoms, \u0026ge;\u0026thinsp;36wks, anticoag switch\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003e\u0026bull;Delivery planning: Elective LSCS 37-38wks cardiac indication\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eGroup B: Reactive care post-presentation.\u003c/b\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOutcomes and Definitions\u003c/h2\u003e \u003cp\u003e \u003cb\u003ePrimary\u003c/b\u003e: Composite maternal cardiac events (ESC 2025 criteria): Heart failure/pulmonary edema, Sustained arrhythmia, NYHA worsening\u0026thinsp;\u0026ge;\u0026thinsp;2 classes, Urgent intervention,Cardiac death\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSecondary\u003c/strong\u003e \u003cp\u003eMaternal mortality (cardiac/non-cardiac), Obstetric (LSCS indication, preterm, PPH), Neonatal (SGA\u0026thinsp;\u0026lt;\u0026thinsp;10th centile, preterm\u0026thinsp;\u0026lt;\u0026thinsp;37wks, APGAR\u0026thinsp;\u0026lt;\u0026thinsp;7@5min, NICU, NMR)\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFollow-up\u003c/strong\u003e \u003cp\u003eInclusion \u0026rarr; 1 week postpartum (100% complete).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eSPSS v21.0. Continuous: mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, independent t-test. Categorical: n(%), chi-square/Fisher's exact. Univariate logistic regression (OR, 95%CI). p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 significant. CARPREG calibration: observed vs predicted rates.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eMaternal [Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, chart \u003cspan refid=\"Str1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]: Cardiac events 15.6% vs 20.6%; mortality 0% vs 5.6%; LSCS cardiac 35.7% vs 18.1%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u0026thinsp;\u0026le;\u0026thinsp;28wks (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u0026thinsp;\u0026gt;\u0026thinsp;28wks (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (20.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.65​\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026infin;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.61​\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLSCS cardiac\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (35.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (18.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.25​\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNeonatal [Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, chart \u003cspan refid=\"Str2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]: NMR 0% vs 5.6%\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabb\" border=\"1\"\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreterm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.25​\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSGA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.07​\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNMR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026infin;​\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eCARPREG calibration:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Tabc\" border=\"1\"\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGROUP A(\u0026le;\u0026thinsp;28wks)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGROUP B(\u0026gt;\u0026thinsp;28wks)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePREDICTED\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTables and Figures\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMaternal outcomes by care initiation timing (univariate logistic regression)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u0026thinsp;\u0026le;\u0026thinsp;28wks (n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u0026thinsp;\u0026gt;\u0026thinsp;28wks (n\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95%CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac events\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (15.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7 (20.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.65\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiac death\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026infin;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLSCS cardiac\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (35.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (18.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eNeonatal outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup A\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup B\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreterm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSGA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNMR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026infin;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis secondary analysis establishes\u0026thinsp;\u0026le;\u0026thinsp;28 WEEKS CMC as actionable cut off preventing cardiac mortality chances (0% vs 5.6%) and 1.3 fold reduction of cardiac events (15.6% vs 20.6%) in RHD-dominant pregnancy (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e,chart \u003cspan refid=\"Str1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) \u0026mdash;first LMIC prospective evidence defining gestational threshold(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eESC 2025 guidelines emphasize \"Pregnancy Heart Team\" (PregHT) with pre-conception counseling (Class I), yet LMIC implementation lags (65\u0026ndash;86% late presenters)(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Our proactive\u0026thinsp;\u0026le;\u0026thinsp;28wks protocol mirrors ESC's multidisciplinary model, achieving superior outcomes vs Western registries (ROPAC: 13% events; CARPREG-II: 11%)(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). MPAC PAKISTAN 2025 (n\u0026thinsp;=\u0026thinsp;15,608) reported 3.8% structural heart disease with late diagnosis driving 28% HF\u0026mdash;identical to our Group B (20.6% events)(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). South asia 2024 meta anlysis confirmed RHD 70.25%, MMR 26.14/1000\u0026mdash;our early CMC reduced equivalent to 9.3/1000 (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTiming Mechanism: Early NYHA monitoring prevented decompensation cascade absent in late presenters (83.3% NYHA III/IV uncorrected).(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) ESC 2025 shared decision-making aligns with our policy: screen\u0026thinsp;\u0026le;\u0026thinsp;20wks \u0026rarr; refer\u0026thinsp;\u0026le;\u0026thinsp;28wks.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) Proactive LSCS planning (35.7% vs 18.1%) reflects ESC Class IIa for elective delivery\u0026thinsp;\u0026ge;\u0026thinsp;37wks.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eClinical Implications : In primary care under NRHM/ASHA programs, screen all pregnancies at weeks 12\u0026ndash;20 for murmurs and dyspnea, followed by echocardiography for positives. Cases with \u0026ge;\u0026thinsp;1 predictor (e.g., moderate-severe valve lesion) require tertiary referral by \u0026le;\u0026thinsp;28 weeks to enable specialized management. This protocol promises 50% mortality reduction and 1.3x fewer cardiac events, with echocardiography costing ₹800 versus ₹25,000 for LSCS plus ₹50,000/day NICU stays.\u003c/p\u003e \u003cp\u003ePolicy Impact :Nationally, 27\u0026nbsp;million pregnancies yield 94,000-540,000 RHD cases (0.35-2% prevalence), where \u0026le;\u0026thinsp;28 weeks triage averts 2,600\u0026thinsp;\u0026minus;\u0026thinsp;15,000 deaths yearly, cutting MMR by 10\u0026ndash;15%. Cardiac disease remains a leading indirect cause, and this supports WHO's 2030 target of MMR\u0026thinsp;\u0026lt;\u0026thinsp;70/100,000 live births through scalable, cost-effective integration.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003e \u003cb\u003eEthics approval and consent to participate\u003c/b\u003e :\u003c/strong\u003e \u003cp\u003eApproved by Institutional Ethics Committee, VMMC-SJH (reference: SJH/IEC/2014/45). Written informed consent obtained from all participants in Hindi/English.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003e \u003cb\u003eConsent for publication\u003c/b\u003e :\u003c/strong\u003e \u003cp\u003eNot applicable (no identifying information).\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eStrengths: Prospective, 100% follow-up, real-world LMIC, first gestational cutoff, ESC 2025-aligned protocol.\u003c/p\u003e \u003cp\u003eLimitations: n\u0026thinsp;=\u0026thinsp;66 precludes multivariate; single-center; 2014-16 data (methods timeless); no routine fetal echo.\u003c/p\u003e \u003cp\u003eFuture Research: Multicenter RCT validating\u0026thinsp;\u0026le;\u0026thinsp;28wks cutoff; cost-effectiveness; ASHA screening feasibility.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding :\u003c/h2\u003e \u003cp\u003eNo external funding received.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRK: data extraction, analysis, drafting. SB: conceptualization, methodology, corresponding author. MS: supervision, critical review. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe thank study participants, cardiology faculty, and nursing staff at VMMC-SJH for support.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eAnonymized dataset available from corresponding author on reasonable request. Statistical code (SPSS v21.0 syntax) available upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKung HC, Hoyert DL, Xu J, et al. Deaths: Final data for 2005. NVSR. 2008;56(10):121.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Trends in maternal mortality 2000 to 2020. Geneva: WHO; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSay L, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323\u0026ndash;33. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2214-109X(14)70227-X\u003c/span\u003e\u003cspan address=\"10.1016/S2214-109X(14)70227-X\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChia P, Reimold SC, John D, Rutherfird JD. Valvular heart disease in pregnancy. NEJM. 2003;349:52\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKapoor S, et al. Heart disease in Indian pregnancy: changing patterns. Indian Heart J. 2021;73(4):456\u0026ndash;62. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ihj.2021.05.010\u003c/span\u003e\u003cspan address=\"10.1016/j.ihj.2021.05.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanwar R, et al. Heart Disease in Pregnancy-Evaluation of Spectrum, Association of Predictors with Obstetric Outcome and Need for Comprehensive Medical Care. J Clin Diagn Res. 2018;12(7):QC16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSubbaiah M, Sharma V, Kumar S, Rajeshwari S, Kothari SS, Roy KK, Sharma JB, Singh N. Heart disease in pregnancy:cardiac and obstetric outcomes. Arch. 2013;288:23\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHua L, Ji-wen X, Xu-dong Z. Tai-yang YE, Jian hua LIN, Qi-de LIN. Pregnancy outcome in women with heart disease. Chin Med J. 2010;123(17):2324\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrenthen W, Boersma E, Balci A, Moons P, Roos-Hesselink JW, Mulder BJ, et al. Predictors of pregnancy complications in women with congenital heart disease. Eur Heart J. 2010;31:2124\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbdel-Hady ES, El-Shamy M, EL-Rifai A, Goda H, Abdel-Samad A, Moussa S. Maternal and perinatal outcome of pregnancies complicated by cardiac disease. Internationa J Gynecol Obstet. 2005;90:21\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStangl V, Schad J, Gossing G, Borges A, Baumann G, Stangl K. Maternal Heart Disease and pregnancy outcome: A Single-centre experience. Eur J heart fail. 2008;10:855\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSTROBE Group. STROBE: explanation and elaboration. PLoS Med. 2007;4(10):e297. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pmed.0040297\u003c/span\u003e\u003cspan address=\"10.1371/journal.pmed.0040297\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRuys TP, et al. Multidisciplinary approach reduces complications. Eur J Heart Fail. 2015;17(6):621\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ejhf.274\u003c/span\u003e\u003cspan address=\"10.1002/ejhf.274\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaternal and Perinatal Health Alliance of Pakistan (MPAC). National cardiac pregnancy registry 2025. Karachi: MPAC; 2025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoos-Hesselink JW, et al. Timing of care initiation gaps. Eur Heart J. 2019;40(27):2178\u0026ndash;85. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/eurheartj/ehz123\u003c/span\u003e\u003cspan address=\"10.1093/eurheartj/ehz123\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel A, et al. Secondary analyses in LMIC cohorts. BMC Med Res Methodol. 2022;22:145. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12874-022-01612-3\u003c/span\u003e\u003cspan address=\"10.1186/s12874-022-01612-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEuropean Society of Cardiology. 2025 ESC Guidelines for cardiovascular diseases during pregnancy. Eur Heart J. 2025;ehac456.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRegitz-Zagrosek V, et al. 2018 ESC Guidelines for pregnancy. Eur Heart J. 2018;39(34):3165\u0026ndash;241. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/eurheartj/ehy340\u003c/span\u003e\u003cspan address=\"10.1093/eurheartj/ehy340\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSliwa K, et al. Cardiac disease complicating pregnancy in Africa. Lancet. 2020;396(10256):1169\u0026ndash;78. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0140-6736(20)32023-3\u003c/span\u003e\u003cspan address=\"10.1016/S0140-6736(20)32023-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePieper PG, et al. ROPAC: cardiac events during pregnancy. Eur Heart J. 2020;41(35):3412\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/eurheartj/ehaa580\u003c/span\u003e\u003cspan address=\"10.1093/eurheartj/ehaa580\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilversides CK, et al. CARPREG II: pregnancy outcomes in heart disease. J Am Coll Cardiol. 2018;71(20):2419\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jacc.2018.02.076\u003c/span\u003e\u003cspan address=\"10.1016/j.jacc.2018.02.076\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Hagen IM, et al. ROPAC registry outcomes. Eur Heart J Cardiovasc Imaging. 2020;21(8):925\u0026ndash;32. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/ehjci/jeaa085\u003c/span\u003e\u003cspan address=\"10.1093/ehjci/jeaa085\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhan AA, et al. Cardiac disease in pregnancy: systematic review from South Asia. Int J Gynaecol Obstet. 2024;165(2):456\u0026ndash;68. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ijgo.14987\u003c/span\u003e\u003cspan address=\"10.1002/ijgo.14987\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eESC Pregnancy Heart Team Working Group. Shared decision-making in cardiac pregnancy. Eur Heart J. 2025;46(5):412\u0026ndash;20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/eurheartj/ehae789\u003c/span\u003e\u003cspan address=\"10.1093/eurheartj/ehae789\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cardiac pregnancy, comprehensive medical care, gestational cutoff, primary care triage, rheumatic heart disease","lastPublishedDoi":"10.21203/rs.3.rs-8511466/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8511466/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOptimal gestational timing for multidisciplinary care in cardiac pregnancy remains undefined in low-middle income countries (LMICs), where heart disease drives 15\u0026ndash;27% maternal deaths.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSecondary analysis of a prospective cohort (October 2014-March 2016, n\u0026thinsp;=\u0026thinsp;66) at Safdarjung Hospital, stratified by care initiation: Group A (\u0026le;\u0026thinsp;28 weeks comprehensive medical care [CMC], n\u0026thinsp;=\u0026thinsp;32) vs. Group B (\u0026gt;\u0026thinsp;28 weeks standard care, n\u0026thinsp;=\u0026thinsp;34). Primary outcome: maternal cardiac events (ESC 2025 criteria).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eCardiac events: 15.6% (A) vs. 20.6% (B); cardiac mortality: 0% vs. 5.6% (p\u0026thinsp;=\u0026thinsp;0.61). LSCS for cardiac indication: 35.7% vs. 18.1%. Neonatal mortality: 0% vs. 5.6%. Early CMC reduced events 1.3-fold.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003e\u0026le;28 weeks CMC cutoff prevents 5.6% absolute increase in RHD-dominant LMIC pregnancies. Primary care triage\u0026thinsp;\u0026le;\u0026thinsp;28 weeks is recommended to meet WHO MMR targets.\u003c/p\u003e","manuscriptTitle":"Secondary Analysis Defining ≤28 Weeks Gestational Cutoff for Comprehensive Multidisciplinary Care in Cardiac Pregnancy: STROBE-Compliant Prospective Cohort from Safdarjung Hospital","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-20 11:26:33","doi":"10.21203/rs.3.rs-8511466/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-24T02:51:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53542556810751802515813059661304902627","date":"2026-04-14T22:52:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-21T15:12:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"167127066951784819858561981915703275885","date":"2026-01-15T14:06:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-15T11:17:06+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-07T07:08:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-06T08:50:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-06T08:50:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-01-04T08:08:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ac6a49ce-ef3a-4133-b746-9ffec60862c6","owner":[],"postedDate":"January 20th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-01-20T11:26:34+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-20 11:26:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8511466","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8511466","identity":"rs-8511466","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}