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1. CASE PRESENTATION A 30 YEAR OLD FEMALE WITH G 2 P 1 L 1 WITH SEVERE MS POSTED FOR EMERGENCY LSCS PRESENTED BY: Dr.G.Pramod eswar PG Resident, Dept. of Anesthesiology and Critical care, VIMSAR, Burla GUIDED BY: Dr. Bidyapati Padhan Asst Professor, Dept. of Anaesthesiology and Critical care, VIMSAR, Burla

2. PATIENT DETAILS Name-Mrs Chaitali Barik Age-30 years Sex- Female Registration no-5489/24.11.2023 Bed no- 7, labour Room Unit-3 Husband’s name- Anand Barik Occupation- House Wife Address- Bijepur, Bargarh

3. CHIEF COMPLAINTS Cessation of Menstrual cycle – 9 months Pain Abdomen – since 4 hours Shortness of Breath – since 2 weeks

4. HISTORY OF PRESENT ILLNESS The Patient with 38 weeks of gestation , was apparently alright 2 weeks back after which she complaints breathlessness which was gradually progressive, exertional. It was not associated with cough, chest pain, wheeze , stridor, URTI, angina , fever, syncope. She was having pain in lower abdomen and groin since 2 hours and pain was intermittent in frequency ,initially dull then became spasmodic in nature, increasing in intensity , severity and duration. Pain not associated with Fever, Burning micturition, Vomiting No history of bleeding or leaking per vagina.

5. MENSTUAL HISTORY She attained menarche at 13 years. Previous menstrual cycle: Regular, Normal flow, No association with pain or clot. 3-4 days Regular, Avg blood flow without any clots 30 days cycle Gestational age-38 weeks LMP- 07/03/23 EDD- 14/12/23

6. OBSTETRIC HISTORY She is married since 6 years. Obstetrics score - Gravida 2 ,Para 1,Living 1 Past obstetrics history - Delivered a Female child of Wt.2.8 kg via LSCS at term 4 years back under General anesthesia.

7. PAST HISTORY H/o of Fever with joint pain in her childhood. She diagnosed with Rheumatic Fever since 15 years of age. Diagnosed with Severe Mitral stenosis 2 years back. For which She was taken:- Tab. Metoprolol 40 mg BD Prophylactic Inj.Penidure Every 21 days Tab. Aspirin 75 mg OD No History of HTN,DM,SCD,TB,THROID DISORDER AND SEIZURE DISORDER

8. PERSONAL HISTORY Low Socio-Economic status No Addiction and habituation No H/O use of Contraceptive Pills Mixed Indian diet.

9. FAMILY HISTORY She is a Housewife. No similar history in the family . No H/O malignancy in family .

10. GENERAL EXAMINATION Patient is Conscious, Co-operative, Oriented to Time, Place and Person. Pallor- Absent Icterus- Absent Clubbing- Absent Cyanosis- Absent Pedal Edema- Present Lymphadenopathy- Absent JVP- Not Raised Temp- 98.4 F PULSE :- Rate- 106 bpm Rhythm- Regular Volume – low No Radio-radial or radio-femoral delay present. No Arterial wall thickening. All Peripheral Pulses were felt.

11. BP- 118/74mmHg in right arm in supine position. SPO2- 97% Room air RR- 20 cycles/min, regular, mostly Thoraco-abdominal Average build Weight-60 kg Height -152 cm

12. SYSTEMIC EXAMINATION CVS EXAMINATION:- INSPECTION :- No precordial deformity ,No significant pulsation or venous engorgement. PALPATION :- Apex beat at 5 th intercostal space,1/2 inch medial to left mid clavicular line, tapping in nature PERCUSSION:- Dull note from 2 nd – 5 th ICS AUSCULTATION :- S1 : Loud in Mitral Area S2 : Audible [ P2 -Loud in Pulmonary area]

13. Low pitched Mid Diastolic R umbling murmur with Presystolic accentuation in mitral area without any radiation . Best heard with the bell of the stethoscope, in left lateral position, at the height of expiration . Early Systolic murmur heard .

14. RESPIRATORY SYSTEM EXAMINATION:- INSPECTION :- No chest deformity is seen and Equal B/L Chest movement is found. PALPATION :- Trachea centrally placed. PERCUSSION :- Tympanic note AUSCULTATION:- Bilateral vesicular breath sound heard, without any added sounds CNS EXAMINATION:- Higher functions normal. No motor or sensory deficit. All Cranial nerves were intact.

15. ABDOMEN EXAMINATION- INSPECTION :- Abdomen is enlarged , Linea nigra and Stria gravidarum seen. PALPATION :- Soft ,Tender, fundal height 38 weeks size, flanks are full UMBILICUS:- Centrally placed , Everted.

16. AIRWAY EXAMINATION DENTITION- No loose or bucked tooth or artificial dentures. MOUTH OPENING - Adequate, >3 fingers. MALLAMPATI GRADING - Grade 2 THYROMENTAL DISTANCE - 7cms. NECK MOVEMENTS- Normal , not restricted SPINE EXAMINATION Normal, No kyphosis, No Scoliosis, No restrictions to Movement, No skin infections.

17. INVESTIGATIONS Hb - 9.4 gm% RBS -75mg/dl LFT, RFT- WITH IN NORMAL LIMITS S.ELECTROLYTES- WITH IN NORMAL LIMITS VIRAL MARKERS –NON REACTIVE URINE ANALYSIS- WITH IN NORMAL LIMITS

18. ECG :- LA enlargement – wide and notched P wave (P M itrale ) -most prominent in lead II CHEST XRAY :– Slight increase in the transverse diam. of heart, Straightening of the left border of heart • Double contour of the right border of heart

19. ECHO - LA-39 mm - EF- 56% - MVO-0.9 cm2 - Dilated LA and RV - Mitral leaflets are thickened, have reduced motion during diastole, and show doming - PAP 35mmhg

20. PROVISIONAL DIAGNOSIS :- A 30 YEAR OLD FEMALE WITH G 2 P 1 L 1 WITH SEVERE MS PLAN OF SURGERY :- EMERGENCY LSCS PLAN OF ANAESTHESIA :- GENERAL ANAESTHESIA WITH ENDOTRACHEAL INTUBATION WITH POSITIVE PRESSURE VENTILATION AND EPIDURAL BLOCKADE.