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1. CASE OF MS POSTED FOR LSCS PRESENTER : DR. KARANBIR SINGH MODERATOR : DR. PAYAL JAIN MAM Total no of slides : 44

2. CLINICAL PROFILE : Name- Mrs Rashmi W/O - Yogesh Age- 28 years Address- Pakwara Occupation- Housewife Gravid status- Primigravida Period of gestation- 3 7 weeks

3. CHIEF COMPLAINT : H/O Amenorrhea since 9 months. Patient is admitted with active labour pain at full term for institutional delivery. Easy fatigability since 5 months. Breathlessness since 4 months.

4. HISTORY OF PRESENTING ILLNESS Breathlessness was gradual in onset , progressive in nature, aggravated on exertion and relieved on rest. Patient was comfortable at rest, but mild physical activity results in fatigue and palpitation.(NYHA II) There is no history of fever, hemoptysis, orthopnea, PND, chest pain or syncopal attacks. No history of change in voice or difficulty in swallowing. No history of recurrent respiratory tract infection. No history suggestive of squatting or cyanotic spells.

5. PAST HISTORY No H/O Hypertension, Diabetes mellitus, Epilepsy . No H /O Tuberculosis, Asthma , Thyroid disorders. No H/O Blood transfusions. No H/O surgeries in past.

6. OBSTETRIC HISTORY Non- consanguinons marriage. Marital life- 2 years Conceived spontaneously 1 year after marriage .

7. OBSTETRIC HISTORY Conceived spontaneously . 1 st Trimester UPT + ve 2 weeks after missing periods. Antenatal Check ups done. Folic acid prophylaxis taken No H/O excessive nausea and vomiting No H/O of pain ab d omen No H/O bleeding P/V and spotting PV No H/O radiation exposure No H/O drug intake USG scan @ 11 weeks: Normal

8. 2nd Trimester : She was able to perceive fetal movements at 2 2 weeks of gestation, anomaly scan was normal . N o history of headache, swelling of legs, blurring of vision, no history of bleeding PV . She developed breathing difficulty and palpitations during second trimester and the cardiologist opinion was sought and diagnosed with Mitral Stenosis and prescribed medications. [2D ECHO : MILD MS] She is in regular follow up with both the doctors.

9. 3rd Trimester : Fetal movements are well perceived Iron and calcium tablets taken Growth scan done and showed normal development. No H/O GDM/GHTN/Bleeding PV/Leaking PV

10. MENSTRUAL HISTORY LMP : 26 Dec 2023 Menarche : 13 yrs Cycles : 28 days 2-3 pads/day Flow : 3-4 days No H/o dysmenorrhea No clots

11. DRUG HISTORY Folic acid and iron tablets Tab. Metoprolol 25 mg BD T ab . Dytor 10 mg BD Syp. KCL 2 tsp OD Inj. LMWH 40 mg SC OD.

12. PERSONAL HISTORY : Diet- Vegetarian Appetite-good Sleep-adequate Bowel & Bladder- Regular No h/o any addictions

13. GENERAL EXAMINATION After obtaining consent, patient was examined in a well-lit, silent room. Patient conscious, oriented to time, place and person. Average built. Ht-1 57 cm , Wt- 55 kg BMI- 22 kg/m 2 Pallor- absent No icterus, cyanosis, clubbing, lymphadenopathy . Spine – NAD JVP not elevated METS less than 4. Modified Allens test N Grade 1 Reperfusion within 5secs

14. VITALS Pulse rate :86 bpm, regular rhythm, Low volume, Normal character, Condition of Arterial wall- palpable. No radio-radial , radio-femoral delay. BP: 124/74mmHg, left arm in supine position. RR: 23/min SpO2: 98% on Room air Temperature- 98.6 F

15. AIRWAY EXAMINATION Mouth opening - > 3 fingers Malampatti grading - II Neck Flexion/ Neck Extension- Adequate No loose teeth No artificial teeth

16. OBSTETRIC EXAMINATION • INSPECTION: Abdomen longitudinally enlarged, umbilicus in midline. Linea niagra present. No scars visible. PALPATION: FUNDAL GRIP: Hard, globular, ballotable mass felt suggestive of head. • LATERAL GRIP: Hard, resistant, curved structure felt on the left side probably the back. Irregular firm nodules felt on the right side probably limbs. • PELVIC GRIP: Broad, soft , rounded, non-ballotable structure felt suggestive of breech. • AUSCULTATION: FHR 160/min heard above and left of umbilicus.

17. SYSTEMIC EXAMINATION: CVS Examination: INSPECTION: Apical impulse seen at the left 5th ICS in mid clavicular line. No precordial bulge, no visible pulsations or distended veins seen. No scars seen. PALPATION: Apex beat confirmed at left 5th ICS in midclavicular line. No parasternal heave. No chest wall tenderness.

18. AUSCULTATION: MITRAL AREA: Loud S1 heard followed by S 2. Opening snap heard. A low-pitched rough rumbling mid-diastolic murmur of grade 4 intensity heard over mitral area in left lateral position with bell of stethoscope heard at end of expiration. S1 and S2 heard in all other areas with no added sounds or murmur.

19. CNS Examination: Patient conscious, oriented to time, place and person. RESPIRATORY SYSTEM: Bilateral air entry-present, clear and equal on both sides, No adventitious sounds

20. LAB INVESTIGATIONS Routine Investigations Hb: 12.5g/dl TLC: 8800 cells/mm3 Platelets: 1.45,000/mm3 RFT: Urea/Creat: 30mg/dl/0.8mg/ dI Uric acid - 6.5 Sodium - 140 mEq /I Potassium - 4.2 mEq /I Chloride - 101 mEq /I LFT: Sgot/sgpt: 48/45 Total billirubin:1.1 Direct/indirect bilirubin: 0.6/0.4 INR :1.5 PT :15 secs Viral marker: negative Blood group : o+ve ECG: HR 80 BPM , N sinus rhytm , P mitrale in lead II USG scan showed breech presentation.

21. chest X-ray : Straightening of the lt border of cardiac silhouette ,prominent pulmonary arteries , increased CT ratio 2D ECHO : MV Area 1.5 cm 2 , Transmitral gradient 5 mmhg , LVEF 55% , No RWMA

22. DIAGNOSIS A 28 YEARS OLD PRIMI WITH 3 7 WEEKS OF PERIOD OF GESTATION WITH BREECH PRESENTATION WITH K/C/ MILD MS WITH NYHA II POSTED FOR LSCS. (ASA III) TECHNIQUE OF ANAESTHESIA : Combined Spinal Epidural Anesthesia