Baghel J, Keepanasseril A, Pillai AA, et al. - This observational study was undertaken to determine the incidence of adverse cardiac events among pregnant women suffering from rheumatic valvular heart disease (RHD) as well as to derive a clinical risk scoring for predicting it. This study involved 820 pregnancies among 681 women. Composite adverse cardiac event (primary outcome) was defined as development of one or more of complications such as death, cardiac arrest, heart failure, cerebrovascular accident from thromboembolism and new-onset arrhythmias. The occurrence of composite adverse cardiac outcome during pregnancy/post partum was reported in 122 (14.9%) pregnancies; 12 of them succumbed to the disease. Factors that predicted composite adverse cardiac events with a good discrimination (area under the curve = 0.803) and acceptable calibration were: prior adverse cardiac events, cardiac medications at booking, mitral stenosis, valve replacement and pulmonary hypertension, as revealed in multivariate analysis. Integrating these factors, a predictive score was derived for clinical utility. Overall, findings show that heart failure continues to be the most common adverse cardiac event during pregnancy or puerperium. The predictive score derived by combining the lesion-specific features and clinical data is a simple and effective tool for use in routine clinical practice.