Maternal outcome with mitral stenosis with pulmonary hypertension

1. Welcome to case presentation…
Welcome

2. Presented By -
Dr. Seebat masrur
indoor medical officer
cardiology department
tmc & rch

3. maternal outcome in mitral valve
disease with pulmonary hypertension.

4. Particulars of the patient
Name: : Mrs Maya
Age: 36 years
Sex: Female
Religion: Islam
Marital status: Married
Occupation: Housewife
Address: Shahajadpur Sirajgonj
Date of admission: 06th March”21
Date of Examination: 06th March”21

5. PRESENTING COMPLAINTS :
• History of Amenorrhoea for 38 weeks .
• Exertional fatigue and palpitation for several years more marked
during pregnancy period.

6. History of present illness
• According to the statement of the patient, she was amenorrheic for 9
months. She continued her antenatal check-up with an obstetrician
outside the TMSS Medical College & Rafatullah Community Hospital. Her
whole pregnancy period was uneventful except exertional fatigue and
palpitation. This palpitation was not associated with chest pain, heat
intolerance, syncopal attack , increase frequency of micturition and
headache. Her last USG report shows full term pregnancy with breech
presentation . She also mentioned that she was a patient of valvular heart
disease.

7. 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 normal vaginal delivery without any
complications. In the meantime, she conceived twice which resulted
in miscarriages. After 15 years she conceived accidentally and
continued her pregnancy.

8. Continue.......
By reviewing Ultrasonogram and Echocardiography reports, the
attending physician referred her to higher center(Dhaka) for better
management. But belonging to a lower middle-class family, she was
unable to seek services from Dhaka. So, with great hope she
admitted herself under Unit-1(Green) of Gynecology & Obstetrics
department of TMSS Medical College & Rafatullah Community
Hospital for better management.

9. Historyof past illness:
• She had history of 2 incidents of Miscarriages.
• Rheumatic Valvular Heart Disease for 5 years.
• She had no history of DM, HTN, Bronchial asthma and Thyroid
diseases
Drug history:
She had taken Iron, folic acid and Calcium tablets regularly in her
pregnancy . Betaloc 25mg, Penvik 250mg, Diretic 20/50mg for heart
disease.

10. Family history:
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

11. Obstetrichistory
Married for : 16 years
Para: 2 + 2(miscarriages)
Gravida: 4th
ImmunizationHistory
She was immunized according to EPI schedule and completed Tetanus
vaccine according to schedule.

12. Socio-economichistory:
She came from lower middle-class family.
Personal history:
• She is a housewife. No history of Smoking, Alcohol abuse or
Betel nuts chewing. Her husband is a private job holder.

13. General examination:
• Appearance: Ill looking
• Body built : Average(Weight-56 kg, Height 5 feet 1 Inch)
• Co-operation: Co-operative
• Decubitus: On choice
• Nutrition: Average
• Anemia: Mildly anemic
• Jaundice: Absent
• Cyanosis: Absent

14. General examination(Continue…)
• Koilonychia: Absent
• Leukonychia: Absent
• Clubbing: Absent
• Dehydration: Absent
• Oedema: Absent
• Pulse: 102 beats per min, Regular

15. General examination(Continue…)
• 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: Not enlarged
• Breast examination: Shows normal pregnancy changes
• Skin condition : Normal

16. systemic examination:

17. Cardiovascular System Examination
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. No radio-femoral delay

18. Continued:
2. Blood pressure: 110/70 mm of Hg
3. JVP: Not raised.
4. Examination of the precordium:
a)Inspection:
Size & Shape: Normal
Visible pulsation: Apical impulse visible in mitral area. Epigastric
pulsation present
Venous engorgement: Absent
No scar mark, No deformity.

19. Continued:
b) Palpation:
 Apex beat: left 5th ICS, 9cm lateral from midline and tapping in
nature.
 Thrill: Absent
 Left parasternal heave: Present
 Pulmonary component of second heart sound: Palpable.
 Liver : Not enlarged

20. Continued:
c) Percussion: Not Done
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.

21. Continued:
• Opening snap and presystolic accentuation present.
• An Early Diastolic 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

22. OBSTETRIC examination
Per-abdominal examination
 Inspection:
• Abdomen was enlarged and pyriform in shape.
• Umbilicus was centrally placed and everted .
• Striae gravidarum and Linea nigra present.

23. • Palpation:
Fundal height: 36 weeks in size.
Fundal grip : Smooth, hard and globular structure which signify foetal
head.
Lateral grip : Smooth, curved and resistant structure felt on left side of
the abdomen which signify back of the foetus.
Knob like irregular structure felt on right side of the abdomen, those
directed foetal limbs.
1st Pelvic grip : Broad, soft ,irregular parts seemed as foetal buttock
2nd Pelvic grip: The presenting part was not engaged.

24. Auscultation:
• Fetal Heart Rate :140 beats/ min.

25. peR Vaginal examination
not done.

26. Examination of Respiratory System
• Respiratory rate: 18 breaths per min
• 1. Inspection :
• Size & Shape of the chest: Normal
• Movement of the chest : Symmetrical
• Visible pulsation: Apical impulse visible in mitral area.
• Intercostal indrawing: Absent
• Subcostal recession: Absent
• No deformity.
• No scar mark.

27. Continue
2. Palpation :
• Position of the trachea : Central
• Apex beat: left 5th ICS, 9cm lateral from midline and tapping in nature.
• Chest expansion: Symmetrical on both side
• Chest expansibility: 3 cm.
• Vocal fremitus : Normal

28. Continue
• 3. Percussion : Resonant
• 4. Auscultation:
Breath sound : Vesicular
Vocal resonance : Normal
Bilateral basal crepitation: Absent

29. Alimentary System Examination
• Lips, gums, teeth, tongue, oral cavity- Normal
• Abdomen
• Inspection
• Abdomen was enlarged and pyriform in shape.
• Umbilicus was centrally placed and everted .
• Striae gravidarum and Linea nigra present.

30. • Palpation & Percussion was not done due advanced pregnancy.
• Auscultation
• Bowel Sound-Normal
• Foetal Heart Sound- 140 beats/ min

31. Examination of Nervous system
• Higher psychic function :
• Orientation : Oriented
• Intelligence : Normal
• Speech : Normal
• Consciousness : Conscious
• Memory : Intact
• Cranial nerves : Yields no abnormality

32. CONTINUE
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

33. CONTINUE
• Signs of meningeal irritation :
• Neck rigidity : Absent
• Kernigs sign : Absent
• Brudzinski’s sign : Absent
Other systemic examination revealed normal findings.

34. Salient features:
Mrs. Maya, 36yrs, 4th gravida , para 2+2(miscarriages), non-diabetic,
normotensive patient, was admitted at her 38th weeks of pregnancy
with the plan to have delivery via caesarean section. She continued
her antenatal check-up with an obstetrician outside the TMSS Medical
College & Rafatullah Community Hospital. Her whole pregnancy
period was uneventful except exertional fatigue and palpitation. This
palpitation was not associated with chest pain, heat intolerance,
syncopal attack , increase frequency of micturition and headache. She
mentioned that she was a patient of valvular heart disease.

35. ContinueD.......
She also mentioned, she delivered a male baby 15 years back by
normal vaginal delivery without any complications. Her last USG
report shows full term pregnancy with breech presentation. By
seeing all the reports, the attending physician referred her higher
center (Dhaka). But she admitted herself under Unit-1(Green) of
Gynecology and Obstetric department of TMSS Medical College &
Rafatullah Community Hospital.

36. ContinueD.......
On General Examination she was mildly anaemic , her pulse was
102 bpm, regular, low volume. B.P was 110/70 mm of Hg, JVP not
raised. On examination of CVS- visible pulsation present in mitral
and epigastric areas, apex beat in left 5th ICS, 9cm lateral from
midline and tapping in nature, left parasternal heave present,
pulmonary component of second heart sound was palpable.

37. 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.

38. Continued…
Opening snap and presystolic accentuation was present. An early
diastolic 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.

39. Continued…
On Obstetric examination -Abdomen was enlarged and pyriform in
shape. Umbilicus was centrally placed and everted. Striae
gravidarum and Linea nigra present. Fundal height of 36 weeks in
size. Fundal grip was Smooth, hard and globular structure which
signify foetal head. Lateral grip was Smooth, curved and resistant
structure felt on left side of abdomen which signify back of the
foetus. Small knob like irregular structure felt on right side of
abdomen those directed foetal limbs.1st Pelvic grip was broad, soft
and irregular part seemed as foetal buttock. 2nd pelvic grip: The
presenting part was not engaged.

40. Continue.......
Fetal heart rate was 140 bpm.
Other systemic examination revealed no abnormality.

41. Clinical Diagnosis
4th Gravida of 38th weeks Pregnancy and Mitral Stenosis with
Tricuspid regurgitation with Pulmonary Hypertension.

42. Investigations
• ECG
• USG of Pregnancy Profile
• Echocardiography
• CBC: Hb% 9.4 gm/dl
• Serum Electrolyte: Normal
• Serum creatinine :0.97 mg/dl
• RBS: 5.8 mmol/L
• Liver function test: Normal

43. Continue
• Urine R/M/E :Pus cell :2-4/ HPF,RBS : Nill ,Epithelial cell : 5-7
/HPF
• RT PCR for COVID-19: Negative
• Blood Grouping and Rh typing : O (+)ve
• HBsAg: Negative

44. ECG:
• Sinus tachycardia
• P mitralae
• Right ventricular
hypertrophy
• Right axis
deviation

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. • Parasternal Long Axis View
thickening, fibrosis &
Calcification of both anterior
and posterior mitral leaflets

47. • Parasternal Long axis view LA
is dialated which is about 56.5
mm.

48. • Parasternal short axis view
showing planimetry of mitral
valve. Mitral valve is reduced
which is about 0.928 cm2

49. • This is color flow map of a
stenotic mitral valve from
apical 4 chamber view
showing a candle-flame
like jet.

50. Continued
Echo- M mode:
• There is dilatation of left atrium (56mm)
• Dilated RA and RV
• Reduced EF slope.
• Mitral valve area is 0.93 cm2
• TAPSE 17 mm
Echo- CD:
• Color flow mosaic passing from LA to
LV.
• Color flow mosaic passing from RV to
RA.

51. • Pic Showing Doppler, where
EF slope is reduced.

52. USG of pregnancy profile
• Single live pregnancy of about 37 weeks and 2 days with breech
presentation.

53. Confirmed diagnosis:
4th Gravida of 38th weeks Pregnancy and Severe Mitral Stenosis
with Severe Tricuspid Regurgitation with Severe Pulmonary
Hypertension.

54. Treatment

55. Treatment on Admission
• Inf. HS (500ml)…I/V @ 10 drops/mins
• Inj. Algin 5 mg…1 amp I/V 8 hrly
• Cap. Sergel 20 mg…1+0+1(30 mins B/M)
• Tab. Hemofix FZ …0+0+1
• Tab. Coralcal DX…0+0+1
• Tab. Betaloc 25 mg 1+0+1
• Tab. Penvik 250 mg 1+0+1
• Tab. Diretic 20/50 mg…0+1+0

56. Continue
After initial treatment 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 thorough 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.

57. Pre-Operative Patient preparation
• Inj. Fusid 20 mg: 2 ample IV bid at 8 am and 4 pm for 3 days.
• Tab. Spirocard 100 mg: once daily
• Tab. Betaloc 25 mg:1+0+1
• Tab. Penvik 250 mg:1+0+1
• Inj. Pantonix 40mg: 1 vial bid before meal
• Judicious fluid volume was maintained preoperatively(1ml/kg/hr)
• Inj. Ceftron 1gm:1 vial I/V was given just before operative
procedure.
• An informed written consent was taken before surgery.

58. Per operative
• Elective LSCS was done under General Anesthesia on
09.03.21 during office time with presence of Cardiologist,
Anesthesiologist and Pediatrician. Cesarean section
took 23 mins. There was no complications during
procedure. Fetal expulsion occurred within 2 mins. A male
baby was born weighing 2.44kg and the APGAR score
was 8/10 .
• IV fluid was given@1ml/kg/hr.
• Advised to collect 1 units of fresh human whole blood .

59. Post-operative
• Inf. Hartsol 500 ml+ 2 amp LINDA DS was given @ 15 drop/min in 12 hours
• Inj. Fusid 20 mg: 2 ample IV bid at 8 am and 4 pm for 3 days then converted
to oral fusid 40 mg bid
• Inj. Cardinex 40 mg: S/C x 12 hourly for 3 days
• Inj. Ceftron 1gm:12 hourly for 5 days
• Inj Filmet 500 mg..1 bottle I/V x 8 hourly upto 3rd POD
• Inj. Anadol100 mg: 12 hourly upto 2nd POD then oral.
• Inj. Pantonix 40mg:1 vial I/V bid
• Tab. Spirocard 100 mg :once daily
• Tab. Betaloc 25 mg: 1+0+1
• Tab. Penvik 250 mg: 1+0+1

60. Discharge and Advice
She was discharged on 20th March 2021 with following medications
and advice:
• Tab. Cef-3 DS 1+0+1 for 7 days.
• Tab. Napa Extend 1+1+1 for 3days.
• Tab. Pantonix 20 mg. 1+0+1 before meal for 15 days.
• Tab. Deflux 10mg 1+1+1 before meal for 10 days.
• Tab. Penvik 250mg: 1+0+1 continue
• Tab. Betaloc 25 mg: 1+0+1 continue
• Tab. Edeloss (20/50): 0+1+0 continue

61. Advice for mother
• Avoid heavy exertion.
• Avoid extra salt.
• Keep water intake to 1.5 L/day.
• Avoid coitus for 6 weeks.
• Avoid oestrogen containing preparation such OCP, Injection,
sub dermal patch, Norplant.
• Use Barrier method.
• Strictly forbidden for further conception.
• Advice for follow up after 14 days both in Cardiology and
Gynae & Obs OPD.

62. Advice for Baby
• Exclusive breast feeding for 6 months.
• Give the baby vaccination according to EPI schedule .
• Advised for follow up after 14 days in Pediatric OPD.

63. Take Home Message
• Rheumatic mitral stenosis complicating pregnancy is still a
frequent cause of death in a developing country. Patient with
severe mitral stenosis tolerate pregnancy poorly & should be
advised against pregnancy until correction of their mitral valve is
done
• But for those patient who find themselves in such unfortunate
situation like Mrs Maya, they should be treated in a
multidisciplinary approach to reduce mortality and morbidity.

65. Preoperative
Risk
Assessment