HYDERABAD: Akhila, 22, was 35 weeks pregnant and also suffered with shortness of breath, dry cough, cold and mild fever for 10 days. She was initially evaluated by Dr MSS Mukarjee and his team who diagnosed severe mitral valve prolapse. She tested negative for Covid-19. She suffered heart failure, severe mitral regurgitation and severe anemia with Hb count of 6.7gm%. She also had low BP (70/50mmHg) with low oxygen levels on arrival at ER. The patient was found to be unfit for less invasive procedures after echocardiographic assessment due to unfavorable valve anatomy. These patients pose a high risk of mortality during labor and in the postnatal period.
A decision for a rare simultaneous combined surgery was taken - Caesarean section [CS] followed by mitral valve repair. This was a better option as she cannot go through normal labour, and she is a not fit for general anaesthesia. If she had only heart operation she may lose the child. Though there was a high risk, it was decided to perform both operations simultaneously after detailed multidisciplinary discussion. Management of anaesthesia for such cases is a challenge, as there is a risk of worsening cardiac failure at multiple stages, increased risk of uterine bleeding and increased maternal and fetal morbidity and mortality. Steroids were given for fetal lung maturity and fetal and maternal monitoring was done in ICU. A total of 4 pints blood transfusions were given before and during surgery. On 16 November, 2020 under antibiotic prophylaxis, central and femoral invasive lines were secured and patient was ventilated.
Dr Prabha Agarwal, Sr Consultant-Gynecology and Dr. Krishna Prasad Sr Consultant- CT Surgery simultaneously successfully performeda Caesarean section followed by emergent mitral valve replacement. She delivered a healthy male baby with birth weight 2.75 kg with minimal distress. Baby was handed over to the neonatology team. Blood loss was on average 500–800 ml. Uterine incision and abdomen was closed after meticulous hemostasis. Thereafter, median sternotomy was performed and the patient was fully heparinized for Mitral Valve Repair. She had a leaking mitral valve so she was connected to a heart lung machine and a complex repair of the valve was done.
Repairing the valve will give her the advantage of not needing to use blood thinning medications for rest of her life. Taking these medicines would also mean she will not be able to give milk to her child. Further because it is her own valve the repair will last longer for her and will help her have a normal life and a longer life too. In medical literature there are cases of valve replacement but no episodes of Mitral valve repair being done along with caesarean section. The two surgeries took 5-6 hours for successful completion. These patients are also at increased risk of bleeding and inability to tolerate both surgeries, further due to pregnancy there will be excess body water which can cause lung problems.
Postoperatively, patient was taken to the intensive care unit for monitoring on inotropic support, which was tapered off gradually and she was extubated within 24 hours. No unusual bleeding was encountered in the postoperative period. The new born was managed in the neonatal ICU without complication.