Mrs. Ramya, a 23-year-old primigravida at 36 weeks and 2 days of gestation, was admitted due to breathlessness, palpitations, and easy fatigability, diagnosed with mitral valve stenosis and atrial fibrillation with a history of rheumatic fever. She is currently being treated and is planned for a regional anesthesia-assisted cesarean section. Her condition is classified as NYHA class 2, without evidence of heart failure.

1. A CASE OF MITRAL
STENOSIS IN PREGNANCY

2. • Name- Mrs Ramya
• Age- 23 yrs
• Address- BERHAMPUR
• Occupation- house wife
• Obstetric score- Primigravida
• Lmp-June 10th
2021
• DOA- 20/02/2022 , admitted TO OBG WARD for safe confinement.

3. CHIEF COMPLAINTS
• A young lady presented with history of amenorrhea 36 WEEKS + 2 DAYS
• breathlessness on exertion since 3 months of duration.
• Palpitations since 2 month duration
• Easy fatigability since 2 weeks duration.

4. HISTORY OF PRESENT ILLNESS
• The young pregnant lady was apparently normal 3 months back after which she developed
Breathlessness , gradual in onset , progressive in nature, aggravated on exertion & relived on rest.
• Patient was initially comfortable at rest ,had history of mild limitation of activity which now is
progressed to moderate limitation .Progressed to breathing difficulty to les than ordinary activity.
• Palpitations is of 2 month duration, insidious in onset, aggravated on exertion and decreased on
rest.
• Feeling generalized weakness for the past 2 weeks, tiredness increased on activity and feels better
on rest

5. HISTORY OF PRESENT ILLNESS(contd..)
• there is no history of fever , blood in sputum(pink frothy sputum) ,
no history of breathlessness on lying supine or disturbed sleep.
• no h/o chest pain , sweating, swelling of legs, giddiness ,
• no h/o suggestive of squatting or cyanotic spells.
• no history of change in voice or difficulty in swallowing.
• no h/o recurrent respiratory tract infections, sore throat.

6. Past History:
• Patient gives a history of fever with sore throat and joint pain. pain involving both the
knee at 12 years of age. She was hospitalized for the same & diagnosed to have
rheumatic fever with arthritis and was advised pencillin prophylaxis once in 21 days. She
took the injection for five years and then discontinued on her own.
• Not a k/c/o DM/HTN/TB/Epilepsy/TIA /asthma

7. PRESENT HISTORY:
• Patient is booked & immunized
• She developed difficulty in breathing & palpitations in the 2nd trimester for which
cardiologist opinion was sought & she was investigated & diagnosed to have mitral
stenosis & started on medications

8. MENSTRUAL HISTORY
• Menarche-12 year
• LMP-June 10th
2021
• EDD-MARCH 17th
2022
• GA-36 weeks + 2 DAYS
• Previous menstrual cycle regular,3-4days every 30 days with average flow
OBSTETRIC HISTORY
• Married for 1 year
• Primigravida , spontaneous conception
• Husband’s occupation- mechanic
• No h/o consanguineous marriage
• No h/o contraceptive usage

9. HISTORY OF PRESENT PREGNANCY
• 1st
TRIMESTER
• Spontaneously conceived, pregnancy diagnosed by urine pregnancy test kit at home after having
missed period of 2 weeks.
• H/o intake of folic acid.
• No H/o nausea, vomiting, pain abdomen, bleeding PV& urinary complaints.
• No h/o difficulty in breathing, easy fatiguability, no syncopal attack, chest pain, orthopnoea,
palpitation.

10. 2nd
TRIMESTER
• 1 ANC visit
• h/o intake of iron & calcium tablets.
• she took 2 doses of injection TT.
• quickening felt at 5th month
• no h/o bleeding, leaking PV.
• Anomaly scan done revealed to be normal.
• She developed difficulty in breathing & palpitations in the 2nd trimester
for which cardiologist opinion was sought & she was investigated &
diagnosed to have mitral stenosis & started on medications

11. 3rd TRIMESTER
• h/o intake of iron & calcium tablets.
• Fetal movement well perceived
• No h/o bleeding, leaking PV.
• Growth scan done

12. DRUG HISTORY:
• Folic acid 0.5 mg & iron tablets 100mg
• T.Dytor 10 mg BD
• T. Digoxin 0.25 mg OD
• T.metoprolol 25 mg BD
• Inj.LMWH 40 mg sc OD
• Syr KCL 2TSP OD
• Tab Pendidts 400 mg BD

13. SURGICAL HISTORTY:
No surgical h/o in past
PERSONAL HISTORY:
patient takes mixed diet
normal bowel & bladder habits
reduced sleep and appetite since 2 months duration.
No h/o substance abuse.
FAMILY HISTORY:
No H/O similar events in the family
No H/O any heart disease or sudden death in the family.

14. GENERAL EXAMINATION
• patient is conscious , well oriented to time, place and person,
• average built, and well nourished
• Ht- 154 cm, Wt- 64 kg,
• Pre Pregnancy weight-59 kg ,
• BMI- 21.7 kg/m2,
• Weight gain- 6 kg
HEAD TO TOE EXAMINATION
• No pallor ,icterus , cyanosis , clubbing of fingers and lymphadenopathy
• b/l pitting pedal oedema +
• JVP not raised
• thyroid appears normal on examination

15. VITALS
• Temperature- 98.2F measured in axilla
• BP- 110/60 mm of Hg on right arm in left lateral position
• PR- 81/min, irregularly irregular in rhythm, varied volume and
normal in character with pulse deficit of 10/min, no radio radial,
radio femoral delay in the right hand. All peripheral pulses felt.
• R/R- 20/min, thoraco abdominal,no accessory muscles of respiration
are used.

16. AIRWAY EXAMINATION
• No gross facial dymorphism
• B/L nasal passage patent (no DNS)
• Mouth opening- 3 fingers
• MPG-Grade 2
• Tongue-normal in appearance
• No loose teeth or artificial tooth or buck teeth
• ThyroMentalDistance-10 cm
• TMJ- mobile , >1 figure can be inserted in front of tragus
• Full range of neck movement

17. SPINE EXAMINATION
• No kyphosis/scoliosis or any obvious deformity
• Skin-normal, no scars, no swelling/local tenderness, no local raise of temperature.
• Palpation-intervertebral spaces well identified.

18. SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
• JVP not raised
Inspection- no deformity, no dilated veins seen.
Palpation-apex beat at left 5th
ICS lateral to the left MCL, tapping in character.
Diastolic thrill palpable in mitral area in left lateral position, no parasternal heave
percussion of heart borders not done.
Auscultation- over mitral area
-Loud S 1 heard followed by S2 .Opening snap heard .A low pitched
rough rumbling middiastolic murmur heard over mitral area in left lateral position.
• No parasternal heave or palpable heart sound.
• S1,S2 heard in rest of the auscultatory areas with no murmur.

19. SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
• Trachea centrally placed
• Chest normal in shape and B/L symmetrical on inspection
• No use of accessory muscles , no nasal flaring
• B/L normal vesicular breath sounds +
• No added sounds

20. SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM
• Conscious, oriented
• Cranial nerves intact
• Power 5/5 B/L in upper and lower limbs
• Tone-normal
• No signs of cerebellar dysfunction
• higher mental function normal with no sensory or motor deficit
• All reflexes are within normal limit

21. ABDOMINAL EXAMINATION
INSPECTION-
uniformly distended, ovoid in longitudinal axis
umbilicus central & flat
linea nigra & striae gravidarum seen
no dilated vein around umblicus, no scar marks
PALPATION-
fundal height corresponds to 28 wks of gravid uterus
abdominal circumference =30 inches
FH= 28 cm
cephalic presentation

22. Auscultation-
• fetal heart sound heard by stethoscope, fhr-144/min, regular, heard over left spino-umbilical
line

23. INVESTIGATIONS
• Blood group- O +ve
• Hb-10.4g%
• PCV-39
• TLC-9500/mm3
• TPC-2.4 lac/mm3
• 75gm GCT-70 mg/dl
• S.Na-137 meq /l, S.K-4.2meq/l
• S.protein-6.9 , S. albumin-3.2
• S.TSH- 3.8 mIU/ ml
• S.urea-28 mg/dl
• S.creatinine-0.7mg/dl
• HIV, HBsAg, HCV- negative
• Urine albumin- negative
• ECG(01/08/21)-
• Bifid P wave in lead ii ,iii and iv.
• Irregular R-R interval
• ECHO (01/08/21)-
Normal LV Function(EF-57%)
LA size-43 mm
RA sze –normal
MVA-1.4cm2
IMPRESSION- RHD, moderate MS
with AF, Normal LV systolic

24. SUMMARY
• Mrs. Ramya 23 year old female, primigravida at 36 weeks+2 days of gestation got admitted
on 01/08/2020 with complaints of breathlessness since 3 months, palpitations since 2
months and easy fatigability since 1 weeks , diagnosed to have mitral valve stenosis in atrial
fibrillation and is being treated for the same with a past history of rheumatic valvular heart
disease without evidence of heart failure admitted for safe confinement.
• PROVISINAL DAIGNOSIS: primigravida 36w+2d newly detected mitral stenosis with past
history of rheumatic fever (NYHA CLASS 2, METs 6, no CHF or PAH)
• ASA Grade -II
• Plan : c-section
• My PLAN FOR ANAESTHESIA: Regional anaesthesia ( epidural anaesthesia)