Rheumatic Heart Disease Complicating Pregnancy.pptx

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1. Rheumatic Heart disease complicating pregnancy Presenter: Dr T. Anusha(final year pg MS OBG, Government maternity hospital, koti – Osmania medical college )

2. A 2 4 year old primigravida with 33 weeks Gestational age , K/c/o Chronic Rheumatic Heart disease referred from amberpet  PHC for multidisciplinary care.

3. Mrs Vijaya , Wife of Venkata ramana , 2 4 yr old, Hindu by Religion, House wife, belonging to lower middle socioeconomic status resident of amberpet,Hyderabad

4. Presenting illness: patient referred from Amberpet PHC for multidisciplinary approach in view of heart disease complicating pregnancy She was apparently asymptomatic until 28weeks then she developed shortness of breath since 2 weeks, which was initially grade 2 and gradually progressed to grade 3 It was aggravated on lying down associated with palpitations. Patient complain of waking up from sleep after 1-2 hrs due to shortness of breath Complains of dry cough since 2 weeks, not associated with URTI symptoms

5. No complains of chest pain, hemoptysis No cyanosis, squatting episodes No complains of recurrent fevers, sore throat, joint pains, skin rashes No history of dental infections, urinary infections No complains of pedal edema, facial puffiness She was evaluated at GMH,koti as chronic rhuematic  heart disease on 2decho and started on treatment.

6. Present pregnancy details Patient was asymptomatic pre pregnancy Married for 10 months (non consanguineous) She conceived spontaneously , confirmed pregnancy by UPT at 4 months amenorrhea First trimester : She had no early antenatal visits No h/o. Excessive nausea or vomiting No complains of bleeding PV, fever with rash, exposure to teratogens or radiation No folic acid supplementation No investigations done

7. Second trimester : Patient had antenatal checkup at amberpet PHC at 20 weeks GA Started on routine: iron, folic acid, multivitamin supplements, 2 doses of Td injections Had anomaly scan at 20 weeks which was normal Quickening felt by 5 months of amenorrhea she was diagnosed as having hypothyroidism and started on tab thyronorm 25 mcg od No c/o sob,palpitations,chest pain, pedal edema No h/o raised blood pressures No h/o fever / burning micturition OGTT done at 27 weeks was normal Third trimester : She had shortness of breath from 28 weeks of gestation for which she was evaluated at gmh koti started on medical management and now symptoms resolved

8. Menstrual history : menarche at 13yrs Regular cycles , duration 4-5 days for 28 days LMP:23-4-2025 EDD: 30-1-2025 No history of using any contraceptive Past history : no history of similar complaints in the past Not known case of DM, HTN, Thyroid disorders, asthma, epilepsy, allergy No history of recurrent fevers, sore throat, joint pains, skin rashes, dental infections in childhood

9. Family history : no history of congenital heart disease in family, no any other significant family history Personal history : she is home maker with normal appetite, regular bowel and bladder habits, adequate sleep with no history of smoking, alcohol abuse or beetle nut chewing

10. General examination Patient conscious coherent and co operative Thin built, well nourished Pre pregnancy weight: 40kg height: 150cm Weight in third trimester: 50kg BMI: 20 kg/m2 GCS: E4V5M6 Normal higher mental functions Mild pallor, no pedal edema, no icterus, no koilonychia , no clubbing, no cyanosis, no lymphadenopathy Dental hygiene maintained Temp: afebrile RR: 18/min Saturations 96% on room air

11. CVS examination: Pulse rate: 108bpm Rhythm: regular Normal Volume and normal character All peripheral pulses felt, no radio radial and radio femoral delay BP: 110/70 mm hg JVP elevated 5cm

12. EXAMINATION OF CHEST: Inspection: Normal shape, no Visible pulsations, no Venous engorgement, no Scars, deformities Palpation: apex beat: felt at 4 th intercostal space 1.5cm lateral to mid clavicular line, Systolic thrill palpable at apex Parasternal heave felt along left sternal border Auscultation: S1 heard s2 split present with loud and prominent P2 Murmur: pansystolic best heard in apex radiating to axilla, and at left lower sternal border Bilateral air entry present, normal breath sounds No basal crepts Thyroid normal Breast examination: normal

13. Neurological examination: Higher mental functions normal All the cranial nerves examined and normal Superficial and deep tendon reflexes intact Power of both upper and lower limbs normal

14. Per abdomen On inspection Umblicus everted Striae gravidarum and linea nigra present hernial orifices free On palpation Symphysio fundal height: 30 cm Abdominal girth: 80cm uterus corresponds to 30 weeks, Cephalic presentation Adequate liquor No hepatomegaly On auscultation fetal heart heard on left side spinoumblical line

15. Provisional diagnosis 2 4 yr old primi with 33 weeks gestation with chronic rheumatic heart disease with singleton pregnancy for further antenatal management

16. Investigations: CBP:HB:10g, WBC:12k, PLT:2.4 lakh Blood grp: B positive LFT and RFT: normal Urine examintion : normal HIV, HBsAG , VDRL: negative TSH : 2 .9 microIU /ml FBS:80mg/dl PLBS:100 mg/dl PT, INR, Aptt: within therapeutic range

17. ECG : Incomplete Right bundle branch block Right axis deviation present No S-T changes 2DECHO : ejection fraction: 50% moderate MS, severe MR, moderate TR, moderate PAH(RVSP: 58MM HG) MVA 1.2 cm2 Dilated LA, mildly dilated RA Mild LV Systolic dysfunction NO vegetation, clots, pericardial effusion TEE : CRHD, AML doming, PML restricted Moderate MS, severe MR, dilated LA, no LA clot Moderate TR, moderate  PAH (RSVP: 58 MMHG)

18. ANTENATAL SCAN: SINGLE, CEPHALIC PLACENTA ANTERIOR UPPER MID SEGMENT AFI: 7-8 cm 31-32 WEEKS FEATL WEIGHT OF 1.8 KG FETAL DOPPLER NORMAL

19. DIAGNOSIS 2 4 YR OLD PRIMI WITH 33 WEEKS GESTATION age , with Chronic Rheumatic Heart disease (MODERATE MS, SEVERE MR, MODERATE TR, MODERATE PAH) WITH SINGLETON PREGNANCY FOR FURTHER ANC MANAGEMENT

20. TREATMENT Patient Advised Bed Rest, salt restriction Inj Benzathine penicillin 1.2 million units, im once every three weeks till 40 yrs of age Anticoagulant: Tab Warfarin 2mg OD done Beta blocker: Tab Metxl 25mg OD Diuretic : Tab Furosemide 20 Mg OD Tab Thyronorm 25mcg OD

21. Continuous PT, INR, Aptt monitoring Weekly antenatal scan with fetal doppler Cardiac status monitored to detect any deterioration Admitted at 36 weeks for monitoring and optimisation Spontaneous onset of labour at 37 weeks of gestation

22. First stage of labor Continuous maternal cardiac and vitals monitoring done along with fetal monitoring Pain management and antibiotic prophylaxis done Second stage cut short by application of forceps Active management of third stage of labor done cautiously with slow oxytocin infusion Close monitoring done for 48 hours in icu with appropriate medications

23. Patient was discharged on day 7 in stable condition after optimising cardiac medications and cardiologist consultation Followed up at 2weeks and 6 weeks postpartum

24. Thank you