title: Preconception counseling, predicting risk and outcomes in women with mWHO 3 and 4 heart disease.
abstract: OBJECTIVE
  All women with CHD, especially those with more severe disease, should be offered preconception counseling (PCC), to discuss the risk of complications and to plan a future pregnancy. Several scoring system have been devised to estimate the risk of adverse events in pregnancies complicated by maternal heart disease (HD) and while comparisons have been made across the whole population, none have focused on the high-risk population.
  
  
  METHODS
  Retrospective cohort study that included women classed as modified WHO (mWHO) 3 and 4 who had a pregnancy from at least 20weeks gestation between 1994 and 2015 managed within our institution. We assessed how well the quoted risk (at PCC) of an adverse event (maternal or fetal) related to the actual rate of occurrence. We calculated NYHA and CARPREG scores for all patients, and the clinician assessment of percentage risk, to predict the occurrence of an adverse outcome.
  
  
  RESULTS
  We identified 76 mWHO 3 and 4 women who had a total of 102 pregnancies. However, only in 63 pregnancies had the woman attended PCC. Both maternal and fetal adverse events were common. NYHA did not significantly predict any adverse events, whilst a CARPREG score of >3 score predicted heart failure and mWHO4 score predicted maternal death. However, the best prediction of adverse outcomes was a composite quoted risk (percent) given at PCC.
  
  
  CONCLUSIONS
  Women must have access to PCC as those with worse CARPREG and mWHO scores encounter greater adverse events.
authors.affiliation: Academic Department of Obstetrics and Gynaecology, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK. Electronic address: mrc100@ic.ac.uk.
authors.forename: Matthew
authors.initials: M
authors.lastname: Cauldwell
authors.affiliation: Adult Congenital Heart Centre, The National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Ghonim
authors.affiliation: Adult Congenital Heart Centre, The National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
authors.forename: Anselm
authors.initials: A
authors.lastname: Uebing
authors.affiliation: Adult Congenital Heart Centre, The National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
authors.forename: Lorna
authors.initials: L
authors.lastname: Swan
authors.affiliation: Academic Department of Obstetrics and Gynaecology, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Steer
authors.affiliation: Adult Congenital Heart Centre, The National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Gatzoulis
authors.affiliation: Academic Department of Obstetrics and Gynaecology, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK. Electronic address: mark.johnson@imperial.ac.uk.
authors.forename: Mark R
authors.initials: MR
authors.lastname: Johnson
mesh_terms: D000328:Adult; D015331:Cohort Studies; D037001:Directive Counseling / Q000379:methods*; D005260:Female; D006331:Heart Diseases / Q000175:diagnosis / Q000453:epidemiology / Q000503:physiopathology; D006801:Humans; D016742:Preconception Care / Q000379:methods*; D011247:Pregnancy; D011249:Pregnancy Complications, Cardiovascular / Q000175:diagnosis / Q000453:epidemiology / Q000503:physiopathology; D018566:Pregnancy, High-Risk; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D006113:United Kingdom / Q000453:epidemiology
keywords: Counseling; Preconception; Pregnancy; Risk prediction; mWHO3; mWHO4