case presentation.mitral stenosis in pregnancypptx

Case presentation of MS in pregnancy

1. A CASE OF MITRAL STENOSIS IN PREGNANCY

2. Name- Mrs Ramya Age- 23 yrs Address- BERHAMPUR Occupation- house wife Obstetric score- Primigravida Lmp -June 10 th 2021 DOA- 20/02/2022 , admitted TO OBG WARD for safe confinement.

3. CHIEF COMPLAINTS A young lady presented with history of amenorrhea 36 WEEKS + 2 DAYS breathlessness on exertion since 3 months of duration. Palpitations since 2 month duration Easy fatigability since 2 weeks duration.

4. HISTORY OF PRESENT ILLNESS The young pregnant lady was apparently normal 3 months back after which she developed Breathlessness , gradual in onset , progressive in nature, aggravated on exertion & relived on rest. Patient was initially comfortable at rest ,had history of mild limitation of activity which now is progressed to moderate limitation .Progressed to breathing difficulty to les than ordinary activity. Palpitations is of 2 month duration, insidious in onset, aggravated on exertion and decreased on rest. Feeling generalized weakness for the past 2 weeks, tiredness increased on activity and feels better on rest

5. HISTORY OF PRESENT ILLNESS(contd..) there is no history of fever , blood in sputum(pink frothy sputum) , no history of breathlessness on lying supine or disturbed sleep. no h/o chest pain , sweating, swelling of legs, giddiness , no h/o suggestive of squatting or cyanotic spells. no history of change in voice or difficulty in swallowing. no h/o recurrent respiratory tract infections, sore throat.

6. Past History: Patient gives a history of fever with sore throat and joint pain. pain involving both the knee at 12 years of age. She was hospitalized for the same & diagnosed to have rheumatic fever with arthritis and was advised pencillin prophylaxis once in 21 days. She took the injection for five years and then discontinued on her own. Not a k/c/o DM/HTN/TB/Epilepsy/TIA /asthma

7. PRESENT HISTORY: Patient is booked & immunized She developed difficulty in breathing & palpitations in the 2nd trimester for which cardiologist opinion was sought & she was investigated & diagnosed to have mitral stenosis & started on medications

8. MENSTRUAL HISTORY Menarche-12 year LMP-June 10 th 2021 EDD-MARCH 17 th 2022 GA-36 weeks + 2 DAYS Previous menstrual cycle regular,3-4days every 30 days with average flow OBSTETRIC HISTORY Married for 1 year Primigravida , spontaneous conception Husband’s occupation- mechanic No h/o consanguineous marriage No h/o contraceptive usage

9. HISTORY OF PRESENT PREGNANCY 1 st TRIMESTER Spontaneously conceived, pregnancy diagnosed by urine pregnancy test kit at home after having missed period of 2 weeks. H/o intake of folic acid. No H/o nausea, vomiting, pain abdomen, bleeding PV& urinary complaints. No h/o difficulty in breathing, easy fatiguability, no syncopal attack, chest pain, orthopnoea, palpitation.

10. 2 nd TRIMESTER 1 ANC visit h/o intake of iron & calcium tablets. she took 2 doses of injection TT. quickening felt at 5th month no h/o bleeding, leaking PV. Anomaly scan done revealed to be normal. She developed difficulty in breathing & palpitations in the 2nd trimester for which cardiologist opinion was sought & she was investigated & diagnosed to have mitral stenosis & started on medications

11. 3rd TRIMESTER h/o intake of iron & calcium tablets. Fetal movement well perceived No h/o bleeding, leaking PV. Growth scan done

12. DRUG HISTORY: Folic acid 0.5 mg & iron tablets 100mg T.Dytor 10 mg BD T. Digoxin 0.25 mg OD T.metoprolol 25 mg BD Inj.LMWH 40 mg sc OD Syr KCL 2TSP OD Tab Pendidts 400 mg BD

13. SURGICAL HISTORTY: No surgical h/o in past PERSONAL HISTORY: patient takes mixed diet normal bowel & bladder habits reduced sleep and appetite since 2 months duration. No h/o substance abuse. FAMILY HISTORY: No H/O similar events in the family No H/O any heart disease or sudden death in the family.

14. GENERAL EXAMINATION patient is conscious , well oriented to time, place and person, average built, and well nourished Ht - 154 cm, Wt - 64 kg, Pre Pregnancy weight-59 kg , BMI- 21.7 kg/m2, Weight gain- 6 kg HEAD TO TOE EXAMINATION No pallor ,icterus , cyanosis , clubbing of fingers and lymphadenopathy b/l pitting pedal oedema + JVP not raised thyroid appears normal on examination

15. VITALS Temperature- 98.2F measured in axilla BP- 110/60 mm of Hg on right arm in left lateral position PR- 81/min, irregularly irregular in rhythm, varied volume and normal in character with pulse deficit of 10/min, no radio radial, radio femoral delay in the right hand. All peripheral pulses felt. R/R- 20/min, thoraco abdominal,no accessory muscles of respiration are used.

16. AIRWAY EXAMINATION No gross facial dymorphism B/L nasal passage patent (no DNS) Mouth opening- 3 fingers MPG-Grade 2 Tongue-normal in appearance No loose teeth or artificial tooth or buck teeth ThyroMentalDistance-10 cm TMJ- mobile , >1 figure can be inserted in front of tragus Full range of neck movement

17. SPINE EXAMINATION No kyphosis/scoliosis or any obvious deformity Skin-normal, no scars, no swelling/local tenderness, no local raise of temperature. Palpation-intervertebral spaces well identified.

18. SYSTEMIC EXAMINATION CARDIOVASCULAR SYSTEM JVP not raised Inspection- no deformity, no dilated veins seen. Palpation -apex beat at left 5 th ICS lateral to the left MCL, tapping in character. Diastolic thrill palpable in mitral area in left lateral position, no parasternal heave percussion of heart borders not done. Auscultation- over mitral area -Loud S 1 heard followed by S2 .Opening snap heard .A low pitched rough rumbling middiastolic murmur heard over mitral area in left lateral position. No parasternal heave or palpable heart sound. S1,S2 heard in rest of the auscultatory areas with no murmur.

19. SYSTEMIC EXAMINATION RESPIRATORY SYSTEM Trachea centrally placed Chest normal in shape and B/L symmetrical on inspection No use of accessory muscles , no nasal flaring B/L normal vesicular breath sounds + No added sounds

20. SYSTEMIC EXAMINATION CENTRAL NERVOUS SYSTEM Conscious, oriented Cranial nerves intact Power 5/5 B/L in upper and lower limbs Tone-normal No signs of cerebellar dysfunction higher mental function normal with no sensory or motor deficit All reflexes are within normal limit

21. ABDOMINAL EXAMINATION INSPECTION - uniformly distended, ovoid in longitudinal axis umbilicus central & flat linea nigra & striae gravidarum seen no dilated vein around umblicus , no scar marks PALPATION- fundal height corresponds to 28 wks of gravid uterus abdominal circumference =30 inches FH= 28 cm cephalic presentation

22. Auscultation- fetal heart sound heard by stethoscope, fhr-144/min, regular, heard over left spino -umbilical line

23. INVESTIGATIONS Blood group- O + ve Hb-10.4g% PCV-39 TLC-9500/mm3 TPC-2.4 lac/mm3 75gm GCT-70 mg/dl S.Na-137 meq /l, S.K-4.2meq/l S.protein-6.9 , S. albumin-3.2 S.TSH- 3.8 mIU / ml S.urea-28 mg/dl S.creatinine-0.7mg/dl HIV, HBsAg, HCV- negative Urine albumin- negative ECG(01/08/21) - Bifid P wave in lead ii ,iii and iv. Irregular R-R interval ECHO (01/08/21 )- Normal LV Function(EF-57%) LA size-43 mm RA sze –normal MVA-1.4cm2 IMPRESSION- RHD, moderate MS with AF, Normal LV systolic

24. SUMMARY Mrs. Ramya 23 year old female, primigravida at 36 weeks+2 days of gestation got admitted on 01/08/2020 with complaints of breathlessness since 3 months, palpitations since 2 months and easy fatigability since 1 weeks , diagnosed to have mitral valve stenosis in atrial fibrillation and is being treated for the same with a past history of rheumatic valvular heart disease without evidence of heart failure admitted for safe confinement. PROVISINAL DAIGNOSIS: primigravida 36w+2d newly detected mitral stenosis with past history of rheumatic fever (NYHA CLASS 2, METs 6, no CHF or PAH) ASA Grade - II Plan : c-section My PLAN FOR ANAESTHESIA: Regional anaesthesia ( epidural anaesthesia )