4. A 36 years old
pregnant women
was admitted in
RCH
• Picture was taken with the consent of
the patient
5. Particulars of the patient
Name: : Mrs Maya
Age: 36 years
Sex: Female
Religion: Islam
Occupation: Housewife
Marital status: Married for 16yrs
Address: Shahajadpur Sirajgonj
Date of admission: 06th March”21 at 12:32 pm
Date of Examination: 06th March”21 at 12:50 pm
6. CHIEF COMPLAINTS :
• History of amenorrhoea for 38 weeks .
• Exertional fatigue and palpitation for several years more
marked during pregnancy period.
7. History of present illness
• According to the statement of the patient, she was
reasonably well 9 months back. Then she developed
amenorrhea. She continued her antenatal check-up with a
gynecologist outside the TMSS Medical College & RCH.
Her whole pregnancy period was uneventful except
exertional fatigue and palpitation. Her last USG report
shows full term pregnancy with breech presentation . She
also mentioned that she was a patient of valvular heart
with Pulmonary Hypertension.
8. Continue.......
She had previously attempted several times for
interventional management for valvular heart
disease. But it was not possible due to some
reasons. She also mentioned that she delivered a
male baby 15 years back by NVD without any
complications. In the meantime, she conceived twice
which resulted in miscarriages. After 15 years she
conceived accidentally and continued her pregnancy.
9. Continue.......
By seeing USG report , the attending physician referred her
to higher center(Dhaka) for better management. But
belonging to a low-income family, She was unable to seek
services from Dhaka. So, with great hope she admitted
herself under Unit-1(Green) of gynecology department of
TMSS Medical College & RCH in hope for better
management.
10. History of past illness:
• She had history of 2 incidents of Miscarriages.
• Rheumatic Valvular Heart Disease for 5 years.
• She had no history of DM,HTN, BA, and Thyroid
diseases
Drug history:
She had taken Iron, folic acid and Calcium tablets
regularly in her pregnancy . Ecosprin 75 mg, Betaloc
25mg, Penvik 250mg, Diretic 20/50mg for heart
disease.
11. Familyhistory:
She comes from a lower middle-class family. Both of her parents
are alive. She has one sister & two brothers. All are apparently
healthy.
Menstrual history:
• Menarche: At 13 yrs .
• Menstrual period: 4-5 days.
• Menstrual cycle: Regular
• Menstrual flow: Average
• LMP:16th July 2020
• EDD:8th March 2021
• Contraceptive History: OCP, Barrier Method
12. Obstetric history
Married for : 16 years
Para: 2 + 2(miscarriages)
Gravida: 4th
Immunization History
She was immunized according to EPI schedule and
completed Tetanus vaccine schedule.
13. Socio-economic history:
She came from lower middle-class family.
Personal history:
• She is a housewife. No history of smoking,
Alcohol abuse or beetle nuts chewing. Her
husband is a private job holder.
14. General examination:
• Appearance: Ill looking
• Body built : Average
• Co-operation: Co-operative
• Decubitus: On choice
• Nutrition: Average
• Anemia: Mildly anemic
• Jaundice: Absent
• Cyanosis: Absent
16. • Blood pressure: 110/70 mm of Hg
• Temperature: 98˚F.
• Respiratory rate: 18 breaths per min
• Neck vein: Not engorged
• Thyroid gland: Not enlarged
• Lymph node: No lymphadenopathy
• Breast examination: Shows normal pregnancy changes
• Skin condition : Normal
18. Cardiovascular system:
1.Arterial pulse:
a.Rate: 102 beats/ min
b.Rhythm: Regular
c.Volume & character: Low volume
d.Symmetry: All peripheral pulses are bilaterally
symmetrically palpable.
e.Condition of the vessel wall: Normal
f.Radio-femoral delay: Absent
19. Continued:
2. Blood pressure: 110/70 mm of Hg
3. JVP: Not raised.
4. Examination of precordium:
a)Inspection:
Shape: normal
Visible pulsation: Apical impulse visible in mitral area. Epigastric
pulsation present
Venous engorgement: absent
No scar mark, No deformity.
20. Continued:
b) Palpation:
Apex beat: left 5th ICS, 9cm lateral from midline and
taping in nature.
Thrills: Absent
Left parasternal heave: Present
Pulmonary component of second heart sound:
Palpable.
Liver : Not enlarged
21. Continued:
c) Percussion:
d) Auscultation:
1st heart sound: Loud in mitral area
2nd heart sound: Pulmonary component of 2nd heart sound was
loud.
Murmur: There is a mid diastolic murmur in the mitral area
which is low pitch, localized, rough rumbling which is best heard
in left lateral position breath hold after expiration with the bell of
the stethoscope. Murmur grade is 3/4.
22. Continued:
Opening snap and presystolic accentuation present.
• An ejection systolic murmur in the 2nd left intercostal
space is present.
• Another systolic murmur is present in tricuspid area
which is best heard in breath hold after inspiration.
Murmur grade is 3/6.
• Bilateral basal crepitation: Absent
23. Examination of Respiratory System
• Respiratory rate: 18 breaths per min
• 1. Inspection :
• Shape of the chest: elliptical shaped
• Movement of the chest : Symmetrical
• Visible pulsation: Apical impulse visible in mitral area.
• Intercostal indrawing: absent
• Subcostal recession: absent
• No deformity.
• No scar mark.
24. Continue
2. Palpation :
• Position of the trachea : Central
• Apex beat: left 5th ICS, 9cm lateral from midline and taping in
nature.
• Chest expansion: Symmetrical on both side
• Total chest expansion: 3 cm.
• Vocal fremitus : Normal
26. Abdominal examination
Inspection:
• Abdomen was enlarged and pyriform in shape
• Umbilicus was centrally placed and everted
• Striae gravidarum and Linea nigra present.
27. • Palpation:
Fundal height: 38 weeks size correspond to the period of
amenorrhea.
Fundal grip : Smooth, hard and globular mass suggestive of
head.
Lateral grip : Smooth, curved and resistant feeling
suggestive of back on left side.
Small knob like irregular parts suggestive of limb on right side.
Pelvic grip : Broad, soft and irregular mass suggestive of
breech.
The presenting part was not engaged.
30. Examination of Nervous system
• Higher psychic function :
• Orientation : Oriented
• Intelligence : Good
• Speech : Normal
• Consciousness : Conscious
• Memory : Intact
• Cranial nerves : Yields no abnormality
31. Cerebellar function : Yields no abnormality
Motor function :
Bulk of the muscle : Normal
Tone of the muscle : Normal
Co-ordination of movement : Normal
Reflexes : Superficial & deep reflexes are normal
Involuntary movements : Absent
Sensory function : Intact
32. • Signs of meningeal irritation :
• Neck rigidity : Absent
• Kernigs sign : Absent
• Brudzinski’s sign : Absent
Other systemic examination reveals normal findings.
33. Salient features:
Mrs. Maya, 36yrs, 4th gravida , para 2+2(miscarriage), non-diabetic,
normotensive , was admitted at her 38th weeks of pregnancy with the
plan to have delivery via caesarean section. She continued her
antenatal check-up with a gynecologist outside the TMSS Medical
College & RCH. Her whole pregnancy period was uneventful except
exertional fatigue and palpitation. She mentioned that she was a
patient of valvular heart disease with Pulmonary Hypertension.
34. ContinueD.......
She also mentioned that she delivered a male baby 15
years back by NVD without any complications. Her last
USG report shows full term delivery with breech
presentation. By seeing the report, the attending physician
referred her to higher center (Dhaka) for better
management. But with great hope she admitted herself
under Unit-1(Green) of gynecology department of TMSS &
RCH for better management.
35. ContinueD.......
On General Examination she was mildly pale , her pulse
was 102 bpm, regular, low volume. B.P is 110/70 mm of Hg,
JVP not raised. On examination of CVS- visible pulsation
present in mitral and epigastric areas, apex beat left 5th ICS,
9cm lateral from midline and taping in nature, left
parasternal heave present, pulmonary component of
second heart sound was palpable.
36. ContinueD.......
On Auscultation, 1st heart sound was loud in mitral area.
Pulmonary component of 2nd heart sound was also loud.
There was a mid diastolic murmur in the mitral area which
is low pitched, localized, rough rumbling, best heard in left
lateral position breath hold after expiration with the bell of
the stethoscope. Murmur grade was 3/4.
37. Opening snap and presystolic accentuation was present.
An ejection systolic murmur in the 2nd left intercostal
space was present. Another systolic murmur was present
in tricuspid area which was best heard in breath hold after
inspiration. Murmur grade was 3/6. Bilateral basal
crepitation absent.
38. Abdomen was enlarged and pyriform in shape. Umbilicus was
centrally placed and everted. Striae gravidarum and Linea nigra
present. Fundal height of 38 weeks size correspond to the
period of amenorrhea. Fundal grip was Smooth, hard and
globular mass suggestive of head. Lateral grip was Smooth,
curved and resistant feeling suggestive of back on left side.
Small knob like irregular parts suggestive of limb on right
side. Pelvic grip was Broad, soft and irregular mass
suggestive of breech. The presenting part was not
engaged.
39. Continue.......
fetal parts were easily palpable, presentation was breech .
Fetal heart rate was 140 bpm.
Other systemic examination reveals no abnormality.
40. Clinical Diagnosis
4th Gravida of 38th weeks pregnancy with Mitral Stenosis
with Tricuspid regurgitation with Pulmonary Hypertension.
41. Investigations
• ECG
• USG of Pregnancy Profile
• Echocardiography
• RT PCR for COVID-19: Negative
• Blood grouping and Rh typing : O (+)ve
• HBsAg: Negative
• RBS: 5.8 mmol/L
43. Continue
1. ECG:
• Sinus tachycardia
• P mitralae
• Right ventricular hypertrophy
• Right axis deviation
44.
45. ECHOCARDIOGRAPHY
Echo- 2D:
• Thickening, fibrosis and calcification of mitral leaflets
• Diastolic doming of Anterior Mitral Leaflet (AML)
• Both commissure are fused.
• LA seems to be dilated.
46.
47. Continued
Echo- M mode:
• There is dilatation of left atrium (56mm)
• Dilated RA and RV
• Reduced EF slope.
• Mitral valve area is 0.9 cm2
• TAPSE 17 mm
Echo- CD:
• Color flow mosaic passing from LA to LV.
• Color flow mosaic passing from RV to RA.
48.
49. USG of pregnancy profile
• Single live pregnancy of about 37 weeks and
2 days with breech presentation.
50. Confirmed diagnosis:
4th Gravida of 38th weeks pregnancy with Severe
Mitral Stenosis with Severe Tricuspid regurgitation
with severe Pulmonary Hypertension.
53. Continue
After that gynecology and obstetrics department promptly
sought cardiac consultation. Cardiology department visited
the patient, reviewed the case carefully made a
preoperative risk assessment by CARPREG score which
was 1 that correspond to cardiac risk 27%. After that a
through discussion with patient`s husband about the risks &
benefits of patient was done. Then cardiology department
gave an opinion for cesarean section after three days of
preoperative patient preparation, under G/A and with the
presence of Cardiologist, Anesthesiologist and Obstetrician.
54. Pre-Operative Patient preparation
• Inj. Furosemide 20 mg, 2 ample IV bid for 3 days.
• Tab Spirocard 100 mg once daily
• Tab Betaloc 25 mg 1+0+1
• Tab Penvik 250 mg 1+0+1
• Inj Pantoprazol 40mg….1 vial 12 hrly.
• No fluid was given prior to operative procedure.
55. Per operative
• Elective LUCS was done with GA on 09.03.21 during
office time in presence of Cardiologist, Anesthetics and
Obstetrician. Caesarean section took 23 mins. There
was no complications during procedure. Fetal expulsion
occurred within 2 mins. A male baby was born weighting
2.16 kg and the APGAR score was 8/10 .
• Per operative 1L fluid was given.
• Advised to collect 1 units of fresh human whole blood .
• An informed written consent was taken before surgery.
56. Post-operative
• Inf. Hartsol 500 ml+ 2 amp LINDA DS was given in 12 hours
• Inj. Furosemide 20 mg, 2 ample IV bid for 3 days then converted
to oral furosemide 40 mg
• Inj. Enoxaparine 40 mg… S/C x bid for 3 days
• Inj. Ceftriaxone 1gm…12 hourly for 5 days
• Inj. Pantoprazol 40mg….1 vial 12 hrly
• Tab. Spirocard 100 mg once daily
• Tab. Betaloc 25 mg 1+0+1
• Tab. Penvik 250 mg 1+0+1
57. Advice on discharge
She was discharged on 20th March 2021 with
Advice for mother
• Avoid heavy exertion.
• Avoid extra salt.
• Keep water intake to 1.5 L/day.
• Avoid coitus for 6 weeks.
• Avoid OCP, Injection, Norplant, Copper-T. Use Barrier
method.
58. Advice for Baby
• Exclusive breast feeding for 6 months.
• Give the baby vaccination according to EPI schedule .
• Advised for follow up after 14 days both Gynae & Obs and
Cardiology OPD.
