A case of G4 P1 L1 A2 at G.A 12 wk 6 days with h/o double valve replacement on anticoagulant prophylaxis for termination of pregnancy

1. A CASE OF G4P1L1A2
AT G.A 12 WK 6 DAYS
WITH H/O DOUBLE VALVE
REPLACEMENT FOR
TERMINATION OF PREGNANCY
BY DR. CHINMAYA
KUMAR PANDA
CHAIRPERSON ASSO. PROF DR SUJATA
SINGH
ASST. PROF DR.

2. MY CASE
Mrs DB 26 Yr. Hindu Female
from Bhuban Dhenkanal
admitted to O&G dept. on 29.4.19
CHIEF COMPLAINS:
Patient came for termination of pregnancy

3. H/O PRESENT ILLNESS
Patient came for medical termination of pregnancy as she was a
known case of severe cardiac disease(RHD with severe MR and
severe AR ) with H/O cardiac surgery (Double Valve Replacement
& Cardiopulmonary Bypass) done 2 years back and was currently
on anticoagulant prophylaxis
There was no h/o chest pain/respiratory distress at rest but
these appeared on exertion
There was no h/o nocturnal dyspnoea, cough, haemoptysis,
pedal oedema, neurological deficit, syncope

4. MENSTRUAL HISTORY
LMP: 30.1.19
EDD:6.11.19
GA:12 wk. 6 days
PMC: for 3-4 days with 28-32 days duration, regular, average
flow.
Age of menarche: 11 Yrs.

5. OBSTETRICS HISTORY
Married for 9 years
Gravida 4 Para 1 Abortion 2 Living 1
1st pregnancy- Female child, 8yr back, vaginal delivery, term, living,
immunised, uneventful
2nd pregnancy-induced abortion(MTP kit) , at 8 weeks GA, 7 years back,
suction & evacuation not done
3rd pregnancy- induced abortion(MTP kit), at 8 weeks GA, 6 years back,
suction & evacuation not done
4th pregnancy- continuing, spontaneous conception
Antenatal check-up done 3 times by a local physician
Ultrasound- on 30.04.19

6. PAST HISTORY
Patient is a known case of severe RHD with severe MR,AR
detected 2 years back and operated on 18.4.2017 (Double Valve
Replacement & Cardiopulmonary Bypass) and was on anticoagulant
prophylaxis for prosthetic valves
tab Acetrom (nicoumalone 2mg) one tab OD
Tab Amifru (furosemide 40mg + amiloride 5mg) half tab OD to
decrease preload
Tab Pentid (Penicillin g 400) 1 tab BD
There was no h/o rheumatic fever, congenital rubella, congenital heart
disease, syphilis, thyroid disorder, consumption of appetite
suppressant drugs, anti-depressants, blood transfusion, sore throat,
migratory polyarthritis, SLE
Not a known case of T.B, Asthma, D.M, Hypertension

7. FAMILY HISTORY
No first degree or second degree relative of the patient had
cardiac disease

8. PERSONAL HISTORY
She had a non consanguineous marriage
Studied up to standard 7th
Low socio-economic status
Is a home-maker
Bowel bladder sleep appetite habits were normal
Mixed Indian diet
Not addicted to chewing tobacco, smoking, alcohol

9. GENERAL EXAMINATION
Patient conscious, oriented, afebrile, thin built, normal gait
Weight 48kg, height 162 cm, BMI 18.4
No pallor ,icterus ,oedema ,lymphadenopathy, cyanosis, clubbing
PR=124 per min, good volume, regular, no radio-femoral delay
BP= 110/84 mmHg on right arm supine position
RR= 16/min thoraco-abdominal

10. CONT.…
Tongue, teeth, gum, tonsil were normal
Neck veins, glands were not enlarged
JVP not raised
No thyromegaly
B/L breast were normal
No engorged leg veins

11. SYSTEMIC EXAMINATION
CVS:
Inspection: No chest deformity or precordial bulge
One scar mark on sternal region at the site of previous cardiac surgery
Palpation: Apex beat is in the left 5th intercostal space ½ inch medial to left mid
clavicular line. No thrill
Percussion: No abnormality
Auscultation: Prosthetic valve click heard, no murmur

12. RESPIRATORY SYSTEM: Bilateral vesicular breath sound, no added
sounds
CNS: Conscious, oriented to time place person, no neural deficit,
power tone reflexes co-ordination are normal

13. PER ABDOMINAL EXAMINATION
Inspection: Umbilicus central inverted, abdomen not enlarged, no
scar marks, no linea nigra, no engorged veins, all hernial sites
intact
Palpation: Uterus just palpable, about 12 wk. size at the time of
admission, abdomen relaxed
No organomegaly or ascites
Percussion: No fluid thrill, shifting dullness
Auscultation: Bowel sound heard

14. PELVIC EXAMINATION
PER-SPECULUM EXAMINATION: No bleeding , cervix vagina
healthy
PER-VAGINAL EXAMINATION: On bimanual examination uterus
about 12 week size, anteverted, bilateral fornix free and no
fornix tenderness
Cervix long soft, OS closed

15. PROVISIONAL DIAGNOSIS
G4P1L1A2 at Gestational Age 12 week 6 days
with H/O Cardiac surgery
on Anticoagulant Therapy
for Termination of Pregnancy

16. SUMMARY
My patient 26 yrs. HF from Dhenkanal
a G4P1L1A2 at G.A 12 week 6 days from low socio-economic status
presented to GOPD for medical termination of pregnancy
with history of prosthetic valve surgery done 2 years back and
currently on anticoagulant therapy . She was NYHA CLASS 2 as she had
slight limitation of physical activity and only exertion caused fatigue,
palpitation, dyspnoea. On examination she had tachycardia. On
bimanual examination her uterus was about12 week size
corresponding to period of amenorrhoea. Her recent USG shows a
single live intrauterine foetus at AGA 13 wks. 1 day which also
corresponded to her period of amenorrhoea

17. MANAGEMENT
Tab Acetrom 2mg 1 tab OD
Tab Pentid (Penicillin G) 1 tab BD
Tab Amifru 40 ½ tab OD
Investigations to be sent
ORA number was obtained
USG obstetric scan was done
Cardiology consultation was taken

18. INVESTIGATION
USG OBS SCAN:
Single live intra uterine foetus with CRL corresponding to G.A
13wk. 1 day
single gestational sac

19. INVESTIGATION
ECHO: MV and AV prosthesis in situ,
no para valvular leak/ collection,
acceptable gradient across prosthetic valve,
normal LV systolic function

20. INVESTIGATION
PT: Control 11.9
Test 26.5
INR 2.14
APTT: Control 26.6
Test 29.4

21. INVESTIGATION
Hb 8.8MG/DL
DC N66 L31 E2 M1
TLC 6800
TPC 2.0 Lac
PCV 28
URINE R/M No pus cell
HIV/HBsAg/HCV Negative
BLOOD GROUP AB +
FBS 88
2HR PPBS 105
S.UREA 16
S.CREATININE 0.6
S.SOD 141
S.POT 3.5
S.BILIRUBIN 0.3
SGOT 29
SGPT 23
ALK PHOS 279

22. CARDIOLOGY CONSULTATION
Tab Metoprolol Tartarate 25 mg BD given for tachycardia
Clearance for MTP obtained with mild to moderate risk to patient
Tab Acetrom to be stopped 5 day before termination
And patient to be started on Inj. LMWH 0.6 units s.c twice daily and to
be stopped about 12 hours before expected time of evacuation
After evacuation only inj. LMWH to be started after 6 hours and given
for 3 days and then Tab Acetrom to be overlapped from 4th day
onwards for three consecutive days
Then on 7th day inj. LMWH to be stopped and patient to be given only
tab Acetrom and discharged on all oral tablets

23. EXPULSION
• Tab misoprostol 200 ugm was from 5th day onwards per
vaginally with pelvic assessment every 4 hourly
After 3 dose of misoprostol patient expelled an abortus about
200 gm on 28.5.19 at 6:30 pm

24. POST EXPULSION MANAGEMENT
Patient conscious oriented afebrile
B.P 114/70 mm Hg
Pulse 98/min
Chest: B/L VBS no added sound
CVS: prosthetic valve click heard
P/A: soft NAD
P/S: no active bleeding
Rx
Inj. ampicillin 1 gm iv qid
Inj. gentamycin 80 mg iv bd
Inj. LMWH 0.6 units s.c bd
Tab metoprolol tartarate 25mg 1 tab
bd
Tab pantoprazole 1 tab od
Tab amifru40 ½ tab od
Inj. Tramadol 1 amp i.m bd

25. CONTACEPTIVE COUNSELLING
Patient was counselled for barrier method, IUCD and permanent
sterilisation
Patient opted for permanent sterilisation