Pregnancy and diseases of the cardiovascular system. Functional state of the cardiovascular system during pregnancy and childbirth
Unfortunately, heart disease occupies one of the first places among all diseases that are observed in women during pregnancy. Therefore, physicians of this pathology have long paid increased attention, this is due to the fact that the state of pregnancy very often significantly worsens the state of health future mother. Often, all this leads to very serious complications that are extremely dangerous for both the expectant mother and the unborn child. Therefore, pregnancy in women and cardiovascular diseases are very often nearby. Therefore, if there are signs of cardiovascular insufficiency in women, you should not panic, but health care needed urgently.
Today, situations are not uncommon when the issue of maintaining pregnancy is resolved both with a cardiologist and with a gynecologist not on early stage pregnancy, and even during its planning. And it's completely the right approach because you can't joke about it. No wonder the year of the fight against cardiovascular diseases in Russia was announced. It is very important how competently diagnosing heart diseases in women is carried out. vascular system.
Treatment with folk remedies often leads to negative consequences, it is always better to consult a doctor. Of course, if the treatment with folk remedies includes only various useful tinctures and products, then this is only welcome. But again, everything should be told to the doctor, only he knows how to treat.
- Gestosis, which pass in a severe course.
- Fetoplacental insufficiency.
- Chronic fetal hypoxia.
- The death of the fetus inside the womb.
- The pregnancy is terminated prematurely.
Many women in labor believe that their heart disease is dangerous only for the child, but this is not so. They themselves are in serious danger, and a fatal outcome is quite possible. Also, often heart disease, coupled with pregnancy, leads to disability.
During pregnancy, the most common diseases are:
- Heart disease (moreover, we can talk about both congenital and acquired defects, both are equally dangerous).
- Rheumatic diseases.
- Various disturbances in the rhythm of the heart.
- The heart of a woman at one time was subjected to surgical intervention.
- Diseases of the myocardium.
It is very important to remember that all these ailments must be treated on a regular basis, and the treatment period should continue throughout the pregnancy. All treatment should take place under the strict supervision of a cardiologist. Speaking of complex therapeutic measures, then they should be complex, it all depends on the severity of the disease. In most cases, the cardiologist prescribes the following medications:
- various means against arrhythmia. Each remedy must be selected individually;
- cardiac glycosides;
- drugs that have a diuretic effect;
- antiplatelet agents.
The doctor can also prescribe a diet, diet therapy in this condition is very important, you should say this more than once! However, not all diets are the same.
Management of pregnancy in women with heart disease
One of the most important factors in a pregnant woman with heart disease is that, whenever possible, the child should be kept. However, circumstances are not uncommon when the state of pregnancy has to be interrupted. Here are the main ones:
- Development of the aortic valve is insufficient.
- The heart is greatly enlarged, there is marked myocardial insufficiency and aortic valve stenosis.
- The rheumatic process functions with rhythm disturbances, blood circulation is insufficient.
- Heart after surgery
- Chronic processes in an acute form or a rheumatic process (also in an acute form).
- The presence of cardiomyopathy (if there is a severe form of the course).
- The presence of myocarditis (if there is a severe form of the course).
- Heart defects, if they are present together with atrial fibrillation.
- The interventricular septum has pronounced defects.
If we summarize all of the above, then the decision to terminate the pregnancy or abandon the child should be decided on the basis of how the existing defects are expressed, how the blood circulation is disturbed and how active the rheumatic process is. Timely laboratory diagnosis of a person who suffers from cardiovascular disease is very important.
Principles of pregnancy management (how everything should be carried out)
- the entire treatment process should be carried out jointly by a gynecologist, a cardiac surgeon and a therapist. All these specialists should be required, as various urgent conditions may arise in diseases of the cardiovascular system;
- the heart should be examined on a regular basis, since there is a risk of various cardiovascular diseases, even if there were no signs of the disease very recently. Signs of various cardiovascular diseases may not always be obvious;
- depending on the type of disease, appropriate medical preparations, which should be taken strictly according to the instructions;
- it is imperative to do an ultrasound scan of the unborn child on a regular basis, cardiotography is also necessary;
- while the question of whether to leave the child or not is being decided, planned hospitalization is shown, which usually lasts 3 months. If it's about preventive treatment, then hospitalization should last up to 8 months! If the issue of the method of childbirth is resolved, the hospitalization process must last more than 8 months. The following is very important: the methods of delivery should always be purely individual, everything is directly dependent on what disease the woman suffers from, what her state of health is, how severe the treatment of the disease is (when collecting the consultation, there must be an anesthesiologist-resuscitator).
How to conduct childbirth with heart disease
You need to have a caesarean section if:
- heart diseases are observed jointly with various obstetric pathologies, their manifestations may be different;
- there are aortic valve defects, this symptom is very common;
- circulatory rhythms are disturbed;
- there is atrial fibrillation (if it is observed in severe form) /
If no of the above contraindications are observed in the expectant mother, then we can talk about self-permission of childbirth using the natural birth canal. The risk of cardiovascular diseases in parturient women is not so great if early years carefully monitor your health, a common truth, but it should be mentioned. You should also pay attention to medical nutrition, this is also very important. So nutrition for heart disease should not include very salty and spicy foods, this is very important not only for the health of the expectant mother, but also for normal development fetus.
How to conduct natural childbirth (features of the process)
- a woman must necessarily be on her left side. In no case should you be on your back, it is extremely dangerous and can lead to the most negative consequences;
- during childbirth, it is imperative to carry out an anesthetic process (anesthesia should be prescribed taking into account the state of health of the woman in labor);
- the second stage of labor should be reduced, and this is done through the so-called "off labor". In this case, a dissection of the perineum is carried out (this is done so that the child is born faster). If we are talking about severe cases, then there is the use of special obstetric forceps;
- a cardiologist and an anesthesiologist-resuscitator should monitor the woman in labor at the same time;
- the cardiovascular system of the woman in labor must necessarily be under the close supervision of specialists, the condition of the fetus must also be constantly monitored;
- hyperbaric oxygen therapy is a very favorable area for childbirth in such conditions.
Conclusion
Expectant mothers should know that significant changes occur in the body during pregnancy (and we are talking not only about women with cardiovascular diseases, but also about healthy ones). The minute volume of the heart increases greatly (its increase can reach 80%), but than The closer the birth, the smaller the volume. The volume of extracellular fluid also becomes much larger.
Pregnancy at all stages of its development has the peculiarity of worsening the course of cc, this is fraught with the most extreme conditions. Nobody wants to scare anyone, but deaths among the fair sex, who are preparing to become a mother with heart disease, unfortunately, are far from rare. The risk of cardiovascular diseases in women does not always depend on age, problems with blood vessels can occur according to the most different reasons. For example, failure of the cardiac outlet is common.
PREGNANCY AND CARDIOVASCULAR DISEASES.
Cardiovascular diseases in pregnant women are
take the first place among all extragenital pathology.
The frequency of detection of heart disease in them ranges from 0.4
up to 4.7%. Recently, there has been an increase in the number of
pregnant and parturient women suffering from CVD, which is explained next
reasons: early diagnosis heart disease, extension
indications for maintaining pregnancy, an increase in the group of women
women operated on the heart, and the number of seriously ill women
chins who either themselves or with the permission of doctors decide to save
hurt pregnancy, being confident in the success of medical
science and practice.
During pregnancy, the cardiovascular system is healthy
women is undergoing significant changes. Increases-
sya (up to 80%) minute volume of the heart, especially at 26-28 weeks
delah, with a gradual decline to childbirth. At 30-50% of age -
no BCC due to BCP, reaching a maximum by 30-36 weeks. At 5-6
liters increases the volume of extracellular fluid. Created
additional load on the CCC, and, as a result,
30% of healthy pregnant women have a systolic murmur over
pulmonary artery and the apex of the heart, the 2nd tone increases
above the pulmonary artery, excitability and conduction are disturbed
bridge of the heart muscle, arrhythmias occur.
Among the heart diseases that complicate pregnancy, more often
all there are rheumatism, acquired and congenital
heart defects, anomalies in the development of the main vessels,
myocardial lesions, operated heart, cardiac disorders
rhythm. Developing pregnancy worsens the course of CVD and may
can lead to the development of extreme conditions requiring
carrying out urgent measures not only from the obstetrician, but also
from the therapist, cardiologist, surgeon. Fairly high lethality
ness of pregnant women, women in childbirth, puerperas suffering from
heart defects, pulmonary hypertension, complex congenital
malformations, acute and chronic CHF.
Rheumatism is a systemic connective tissue disease with
predominant lesion of the cardiac system, more common
occurs in young women; caused by β-hemolytic
group A streptococcus. In the pathogenesis of the disease,
chenie allergic and immunological factors. Taking into account
clinical manifestations and laboratory data distinguish between
active and inactive phases and 3 degrees of process activity:
1 is the minimum, 2 is the average and 3 is the maximum degree. by locale-
zations of an active rheumatic process allocate carditis without
valvular disease, recurrent carditis with valvular disease, kar-
children without cardiac manifestations, arthritis, vasculitis, nephritis and
etc. In pregnant women, rheumatism occurs in 2.3 - 6.3%, and
its exacerbation occurs in 2.5 - 25% of cases, most often in
the first 3 and in the last 2 months of pregnancy, as well as during those
the first year after childbirth.
Acquired rheumatic heart disease is
75-90% of all heart lesions in pregnant women. Of all the forms
rheumatic origin is most often observed
mitral defects in the form of a combination of insufficiency and stenosis
left atrioventricular orifice, i.e. in the form of a combination
mitral valve disease or mitral disease. However
V clinical picture diseases usually predominate
ki or mitral stenosis, or insufficiency of bicuspid-
chat valve. Therefore, the terms "mitral stenosis" or
"mitral insufficiency" refers not only to pure
forms of defects, but also those forms of combined lesion of the
pans, in which there is a dominance of the sign of
ka. Clinical symptoms of mitral stenosis and mitral
insufficiency depend on the stage of the disease according to the class
sifications of A.N.Bakulev and E.A.Damir 1st grade - full compensation,
2nd grade - relative circulatory failure. 3st.-
the initial stage of severe circulatory failure.
4th grade - severe circulatory failure, 5th grade - distant
rheic period of circulatory insufficiency. Generally accepted
that bicuspid valve insufficiency is small
degree or combined mitral valve disease with a predominance
insufficiency usually has a favorable prognosis. Aortal-
nye defects are much less common than mitral and
predominantly combined with other vices. More often
the predominance of aortic valve insufficiency is found
pan and less often stenosis. The prognosis for aortic stenosis is more
favorable than in aortic valve insufficiency.
Congenital heart defects and anomalies of the main vessels
At present, more than 50 forms have been described. Frequency vrozh-
congenital heart defects in pregnant women ranges from 0.5 - 10%
from all heart diseases. Most often in pregnant women,
there is an atrial septal defect, non-closure of the arte-
rial duct and ventricular septal defect. Blah
Thanks to the improvement of diagnostic technology, many
roki are detected even before the onset of pregnancy, which gives
the ability to resolve issues of saving or interrupting
changes. Women with an atrial septal defect
(9-17%), non-closure of the arterial duct and an inter-
ventricular septum (15-29%) are quite well tolerated
pregnancy and childbirth. With classic "blue" vices: tet-
Rade of Fallot, Eisenmeiger's syndrome, aortic coarctation, stenosis
the mouth of the pulmonary artery develop very formidable complications,
which leads to death in 40-70% of pregnant women.
In addition to these defects, the course of pregnancy and childbirth can be
false myocarditis, myocardial dystrophy, myocarditis
cardiosclerosis, cardiac arrhythmias. In the village
during the winter, more and more pregnant women are
who underwent heart surgery before pregnancy and even during
pregnancy. Therefore, the concept of the so-called operation
rirovanny heart in general and during pregnancy in particular.
It should be remembered that not always corrective
heart surgery leads to the elimination of organic changes
nenies in the valvular apparatus or the elimination of congenital anoma-
ley development. Often, after surgical treatment,
there is a recurrence of the underlying disease, for example, in the form of resteno-
for commissurotomy. Therefore, the question of the possibility of saving
of pregnancy and the admissibility of childbirth should be decided in-
individually before pregnancy, depending on the general condition
patient.
Every pregnant woman suffering from CVD should
be hospitalized at least 3 times during pregnancy.
First up to 12 weeks. preferably a specialized hospital
for a thorough cardiological and rheumatological examination
research and resolve the issue of the possibility of prolonging the
precariousness. If 3 and 4 risk levels are detected, an interruption is shown
pregnancy after cardiac and antirheumatic therapy
FDI. The second hospitalization should be carried out during the period of
large hemodynamic loads on the heart 28-32 weeks. For
surveys and prof. treatment. Interruption during this period is
laterally. The third mandatory hospitalization must be
2 weeks before childbirth for examination and preparation for childbirth, expressing
childbirth plan boots.
Term delivery (spontaneous or with labor induction) is acceptable
in cases admissible in those cases when prenatal
preparation managed to significantly improve hemodynamic
indicators for a healthy fetus. Due to the deterioration
solving the condition of a pregnant woman often raises the question of early
nominal delivery. Best result gives labor induction
at 37-38 weeks. The delivery plan is drawn up consultatively
with the participation of an obstetrician, cardiologist and resuscitator. Choice of method
strictly individual for each patient, depending on
obstetric and somatic situation. Indications for caesarean section
sections are strictly limited. The period of exile for all women in labor
need to be shortened. In women with mitral stenosis AND NOT-
SUFFICIENCY of blood circulation of any degree, with endocardi-
volume with decompensation phenomena in previous births - overlay
weekend obstetrical forceps. And the rest have no production
rhineotomy.
After the birth of the fetus and the discharge of the placenta, there is
a rush of blood to the internal organs (and primarily to the or-
ganam abdominal cavity) and a decrease in BCC in the vessels of the brain
brain and coronary. In order to prevent deterioration of the
it is necessary immediately after the birth of the child to introduce cardio-
tonic agents. Parents with heart disease may
be discharged from the rod.home no earlier than 2 weeks later. after
delivery in a satisfactory condition under the supervision of cardio-
log at the place of residence.
BENIGN TUMORS OF THE UTERINE.
In progress practical activities to every obstetrician-gi-
a non-cologist has to meet patients with uterine fibroids - one
of the most common tumors of the genital organs of women
tires. Among gynecological patients, uterine fibroids are observed
in 10-27%. Myoma of the uterus is a benign tumor developing
yasya in the muscular membrane of the uterus - myometrium. The term "myoma"
atki" is the most accepted because it gives an idea
leniye about development of a tumor from a myometrium. uterine fibroids are
from myomatous nodes of various sizes, located
in all layers of the myometrium.
The etiology of this disease is currently represented
lyatsya as dishormonal disease. In experiments, she
develops with prolonged and continuous administration of estrogen-
nyh hormones. "Growth zones" when activated by estrogen pre-
suffer several successive stages of development: 1st.
the formation of an active growth germ 2st. rapid tumor growth
whether without signs of differentiation. 3st. expansive growth
tumors with their differentiation and maturation. As a rule, ak-
active zones are located next to the vessels and are characterized by
high level of metabolism. Specific receptor proteins, enter-
solder in connection with hormones forming an estrogen-receptor complex.
Each uterine fibroid is multiple. located
myomatous nodes mainly in the body of the uterus (95%) and much
to less often in the neck (5%). In relation to the muscular wall of the body
uterus, there are three forms of myomatous nodes: subperitoneal,
intermuscular and submucosal. The growth of myomatous nodes occurs
dit towards the abdominal cavity or uterine cavity. Myomatous
nodes located closer to the internal os of the uterus, can
grow in the direction of the side wall of the small pelvis, located
between the sheets of the broad ligament of the uterus (intraligamentary).
The fastest growing are intermuscular and submucosal
nodes. According to morphological features, simple myoma is distinguished
uterus, developing as a benign muscular gi-
perplasia, proliferative myoma, true benign
The clinical picture of uterine fibroids largely depends on
age of the patient, duration of the disease, localization of fibroids
pelvic nodes, concomitant genital and extragenital
pathology and other factors.
The premorbid background in patients with uterine myoma is often aggravated
gynecological and extragenital diseases. Among
transferred gynecological diseases are dominated by inflammatory
litelnye diseases of the genital organs, dysfunctional ma-
precise bleeding, endometriosis. Uterine fibroids are often combined
lurks with cystic changes in the ovaries and hyperplastic
mi changes in the endometrium.
In the initial stages of tumor development, which, as a rule,
coincides with the reproductive period of a woman's life, appear
prolonged and profuse menstruation. At an older age,
acyclic bleeding may be observed, which is characteristic
thorns for submucosal localization of the node, intermuscular fibroids
uterus with DMK. Menorrhagia in patients with uterine myoma may be
due to the increase in the inner surface, with which
desquamation of the endometrium occurs during menstruation. Not-
the usefulness of the myometrium and vessels located in the muscle
layer, endometrial hyperplasia and an increase in its fibrinolytic
chesky activity. Increased blood loss during menstruation
tions, as well as joining acyclic bleeding with
lead to iron deficiency anemia.
Often, patients with uterine fibroids complain of
whether. Pain has a different origin. Constant aching
pain in the lower abdomen, lower back is most often associated with
stretching of the peritoneum with the growth of subperitoneally located nodes
fishing, pressure of myomatous nodes on the nerve plexuses of the small
pelvis. Sometimes pains are caused by dystrophic, necrotic
some changes in the myomatous uterus. Contraction
various pains during menstruation are characteristic of the submucosa
localization of the tumor, the birth of a submucosal node. Location-
myoma nodes in the lower third of the uterus, on its anterior
or rear surfaces may be accompanied by a violation
functions of the bladder or rectum. The most frequent
a complication of uterine fibroids is node necrosis due to
disruption of his diet. Another complication is torsion
legs of the subperitoneal node.
Diagnosis in most patients is not difficult.
ness, because in a routine gynecological examination, determine
the enlarged uterus with a nodular surface is divided
ness. When a node is born or when a node is born, examination with
the power of mirrors allows you to make a diagnosis. With more complex
cases, the diagnosis of uterine fibroids allows you to put probing
curettage of the endometrium, ultrasound, hysterography or hysterography
roscopy.
Treatment of uterine fibroids currently occurs in 2
directions: 1 conservative methods. 2 operational methods.
When deciding on the method of treatment, age is taken into account
patient, premorbid background, concomitant extragenital and
gynecological diseases, hormonal disorders, character-
tumor growth rate and its localization.
Indications for starting conservative treatment are:
small tumor size, stable size, moderate menopause
ragia. Conservative therapy is also subject to patients with myo-
my uterus with the presence of severe forms of extragenital diseases
vaniya, which is contraindicated in surgery. To conservative
methods include hormone therapy, vitamin therapy.
Contraindication to conservative treatment are the following
blowing conditions: submucosal uterine fibroids, intermuscular lo-
node localization with centripetal growth and sharp deformation
uterine cavity, necrosis of the myomatous node, suspicion of malignancy
qualitative degeneration of uterine fibroids, a combination of uterine fibroids
kis tumors of the genital organs of another localization. Testimony
to radical surgical treatment of patients with uterine myoma
serve rapid growth and big sizes tumors expressed
anemization of the patient in the absence of the effect of hemostatic
therapy, submucosal uterine fibroids, cervical fibroids, necrosis
node, dysfunction of the bladder and rectum. Hee-
surgical intervention, especially in young women,
capabilities should be conservative. With concomitant
pathology of the cervix and the elderly, the volume of the operation should be
Is pregnancy possible with diseases of the cardiovascular system. It is possible, but before that it is necessary to consult a doctor, especially if you suffer from rheumatic heart disease, he must give you permission to plan a pregnancy. In case you have good health, and you get tired, while shortness of breath and palpitations rarely occur only during physical exertion, you will not have problems with bearing and giving birth to a healthy child.
If you constantly, even when calm, have shortness of breath and it begins to increase when you quickly begin to move, perform light work. It is better not to take risks with pregnancy, it is very dangerous for both you and the baby. Even termination of pregnancy in this case is a dangerous procedure.
With the development of pregnancy, a lot of stress goes on the cardiovascular system of a woman, because all systems work doubly, because a woman must provide the fetus with a full life. A pregnant woman increases her body weight, the blood also increases in volume, and the growing uterus begins to push the diaphragm up, because of this, changes occur in the position of the heart. In the body, changes in the hormonal background begin to occur. Such changes in a woman's body greatly burden the cardiovascular system, when the period begins to increase, the loads become even greater.
During labor, the cardiovascular system is very much overstrained, especially when the second period of attempts begins. Also, after childbirth, the cardiovascular system will have to endure the load. Because with the rapid emptying of the uterus, blood begins to redistribute, because of this, changes in hormones occur again.
What is the risk of cardiovascular disease for pregnant women?
Women begin to experience complications different nature during pregnancy, in labor and the postpartum period, both the life of the woman and the child are endangered here. It is very dangerous that the fetus lacks blood circulation for the first time of the month, especially this problem occurs in the second half and during childbirth.
Is pregnancy possible in women with rheumatism
Rheumatism is an immune-toxic disease that affects the joints and heart valves. Rheumatism appears due to B-hemolytic streptococcus, most often affects women at a young age.
During pregnancy, the rheumatic process begins to worsen. Especially for the first month then during childbirth. What complications occur in pregnant women with rheumatic fever?
1. Pregnancy is often terminated prematurely.
2. Toxicosis continues in the later lines.
3. The fetus lacks oxygen (hypoxia).
4. Uteroplacental blood flow is disturbed.
Pregnancy with heart disease
Women who have heart disease require urgent hospitalization, according to indications, be sure to three times during pregnancy:
1. At 12 weeks, a pregnant woman should undergo a complete cardiological examination in the hospital, and here the question will already be raised of leaving the child or it would be better to terminate the pregnancy.
2. At 32 weeks, a woman should undergo a heart check, if necessary, heart therapy, because it is during this period that the most loads on the heart.
3. The last heart check should be two weeks before the actual
childbirth in order to prepare well for them.
A pregnant woman with cardiovascular problems should remember that the whole outcome depends on her behavior, especially on her lifestyle. If a woman receives the necessary drugs that support and facilitate the work of the heart, follows the regime, listens to the recommendations of the doctor, the pregnancy will end safely and the woman will be able to give birth without problems.
What to do if pregnancy is contraindicated for a woman?
First you need to cure the defect, possibly with the help of a surgical method, often it helps a woman return to a full life. But still, such a woman is at risk, so she will need to be observed by a cardiac surgeon throughout her pregnancy.
Is pregnancy possible with hypertension
Up to 15% of pregnant women suffer from hypertension, high blood pressure. Often women do not know what they have high blood pressure. For the first months, most often it is reduced or normalized, this will complicate the task.
Hypertension is dangerous because up to 70% is complicated by toxicosis in the later lines. During childbirth, hypertensive encephalopathy may appear, with this disease a headache appears and vision is very impaired. Retinal detachment and cerebral hemorrhage are considered very dangerous complications.
How to prevent hypertension in pregnant women? Constantly and carefully observed by a doctor, weekly. If the pressure is high, urgently go to the hospital in the maternity ward.
Also, hypertension can have its own stages of development, it depends on this whether it is possible to maintain a pregnancy:
Stage 1 - pregnancy is possible, gestation and childbirth are successful.
Stage 2 - pregnancy is allowed only if the woman has not experienced hypertension crises before and both her liver and kidneys are fully functional.
2 B and 3 stage pregnancy is completely prohibited.
Pregnant women who suffer from hypertension are sent to the maternity hospital three weeks in advance, where they should be provided with both physical and emotional peace.
So, pregnancy with cardiovascular disease is possible, but here you need to be very careful. Before planning, he was definitely examined by a cardiac surgeon, if you need to undergo the necessary course of treatment. If you suddenly serious illness and in no case should you carry and give birth to a child, because this threatens both your health and the child, it is best to think about other ways. It's not worth the risk. It is very important for pregnant women who suffer from cardiovascular diseases to constantly control their state of health, undergo the necessary course of treatment and not forget about preventive methods.
The spectrum of cardiovascular diseases is quite wide. Among them are acquired and congenital malformations of the heart and large vessels, rheumatism, myocarditis, cardiomyopathy and other myocardial diseases, rhythm and conduction disturbances, and hypertension. The most common pathology of these are heart defects.
What is dangerous heart disease?
Heart disease aggravates the course of pregnancy, causing an increase in the frequency premature birth lagging intrauterine development of the fetus. At the same time, in a significant part of patients with an increase in the duration of pregnancy, symptoms of cardiovascular insufficiency increase, which sometimes becomes life-threatening for a woman.
At the heart of numerous forms of the disease is a violation of blood circulation. As a result, the flow of oxygen-rich arterial blood to organs and tissues decreases, which leads to oxygen deficiency in the body of the pregnant woman and the woman in labor, as well as in the body of the fetus.
In the process of pregnancy development, the load on the cardiovascular system increases, and in severe forms of the defect, complications may occur - pulmonary edema, congestion in the liver, multiple tissue edema.
Management of pregnancy in women with heart defects
Over the past decades, thanks to the advances in cardiology and especially cardiac surgery, as well as the possibility of early diagnosis of the disease, including intrauterine ultrasound diagnosis, it has become possible to treat an exacerbation of the rheumatic process, and most importantly, to surgically correct heart disease during pregnancy and the postpartum period. Considering the complexity of the problem, specialized maternity hospitals for pregnant women with cardiovascular diseases have been created in Moscow and a number of large Russian cities. In Moscow, since 1965, such an institution has been the maternity hospital at the city clinical hospital No. 67, where most of the pregnant women suffering from one or another disease of the cardiovascular system are observed.
The presence of a consultative and diagnostic center often makes it possible to detect a heart defect in a patient or to clarify the form of the defect and the stage of its development. In the departments of pathology, pregnant women receive the necessary treatment, including surgical care in leading cardiosurgical institutions in Moscow. Timely surgical treatment makes it possible to correct the existing cardiac pathology, significantly reduce the risk of future childbirth and successfully complete the postpartum period.
Regardless of the severity of the pathology of the heart, patients with such diseases are hospitalized three times during pregnancy. The first time a woman enters the hospital at 8-10 weeks to clarify the diagnosis and decide whether the pregnancy can be continued (the need to terminate the pregnancy occurs if there are signs of heart failure, exacerbation of rheumatism at the beginning of pregnancy; if the pregnancy has not been terminated, then after 12 weeks, an appropriate treatment). The second time a pregnant woman is hospitalized at 28-30 weeks - during the period of the greatest load on the heart, and the third - 3 weeks before childbirth - to prepare for them.
In the process of observation and treatment in the pregnancy pathology department, a woman and her relatives are informed in detail about the nature of the disease, the prognosis for the health of the mother and fetus, and the method of delivery. In especially severe cases of the disease, a woman is offered termination of pregnancy in the interests of her health.
Childbirth in women with heart defects
The nature of delivery in patients with cardiovascular diseases depends on the form of heart disease, on the stage of development of the disease, as well as on the obstetric situation - the size of the pelvis, the size of the fetus, fetal presentation and placenta. For most women with heart defects, vaginal delivery is preferable, given the simultaneous large release of blood from the uterus into the bloodstream during cesarean section and the increased load on the cardiovascular system of the woman in labor. In moderate heart diseases, interventions are used that exclude attempts during the third stage of labor (obstetrical forceps, vacuum extraction). Indication for operative delivery are severe forms of heart failure and valve prostheses in the heart.
Childbirth in women with cardiovascular disease is usually carried out in a semi-sitting position or lying on its side. This reduces the flow of venous blood to the heart, and the pregnant uterus squeezes less one of the large venous collectors - the inferior vena cava.
In pregnant women with heart disease, the following complications occur:
- premature birth. It should be noted that it is quite difficult for patients suffering from heart disease to choose drugs that help maintain pregnancy, since most of these drugs affect the smooth muscles of not only the uterus, but also the heart and blood vessels, worsening the work of the heart.
- bleeding complicating the postpartum period, since with heart failure the liver suffers, which normally produces substances involved in the process of blood clotting.
Heart disease can be complicated by the occurrence of acute heart failure during childbirth.
Doctors closely monitor the condition of the woman in labor: they determine the pulse rate, respiratory rate, and regularly measure blood pressure. For patients at risk of arrhythmias, childbirth is carried out under cardiac monitoring. They also monitor the amount of urine excreted, since its decrease indicates congestion.
Since altered valves are more susceptible to infection, antibiotics are usually used during childbirth. Since women with pathology of the cardiovascular system are at risk for bleeding, immediately after childbirth, this complication is prevented by intravenous administration. METHYLERGOMETRIN, which improves not only uterine contractions, but also the blood supply to the lungs.
After childbirth, depending on the type of heart disease, it is recommended for some women in labor, and for some it is contraindicated to put weight on the stomach - the doctor who observes the woman during childbirth knows this in advance.
Childbirth and caesarean section are carried out with careful anesthesia to avoid the progression of heart failure and pulmonary edema. For anesthesia, both relatively new methods are used - epidural anesthesia, and endotracheal anesthesia, which has been used for many decades.
Pregnancy with hypertension
Quite often, a woman suffering from hypertension finds out about her disease only at the antenatal clinic during the first measurement of blood pressure. feature this disease is the addition of gestosis 1 , more often developing by the 28-30th week of pregnancy. This complication is manifested by edema, increased blood pressure, the appearance of protein in the urine. The first manifestations of preeclampsia in women with hypertension require urgent hospitalization in the department of pregnancy pathology for appropriate treatment. The progression of gestosis adversely affects the intrauterine development of the fetus, leads to a delay in its growth, and in severe cases, to its intrauterine death. The neglected course of preeclampsia in the second half of pregnancy threatens the woman's health and can lead to a serious complication in the form of a convulsive seizure - eclampsia, which is unsafe for a woman's life. To prevent such severe complication need to visit regularly women's consultation from early pregnancy and timely treatment in a maternity hospital.
This information is intended for healthcare and pharmaceutical professionals. Patients should not use this information as medical advice or recommendations.
Groshev S. Introduction and justification of the problem. Cardiovascular diseases (CVD) in pregnant women rank first among all extragenital pathologies. early diagnosis of heart disease, expansion an increase in the number of women undergoing heart surgery and the number of seriously ill women who, either on their own or with the permission of doctors, decide to keep the pregnancy, being confident in the success of the medical The most important hemodynamic shift during pregnancy is the increase cardiac output Volume of circulating blood The consumption of oxygen by the body during pregnancy increases and before childbirth exceeds the initial level by 15-30%. This is due to an increase in the metabolic needs of the fetus and mother, and Compression syndrome of the inferior vena cava Speaking about the significance of the combination of heart and vascular diseases with pregnancy, it should be noted that pregnancy and the resulting changes in hemodynamics, metabolism, body weight (increase by 10-12 kg by the end of pregnancy), water-salt metabolism (during pregnancy, the total water content in the body increases by 5-6 l, the sodium content in the body increases already by the 10th week of pregnancy by 500-600 mmol, and potassium by 170 mmol, up to 870 mmol of sodium accumulates in the body before childbirth) require increased work from the heart and often aggravate the course cardiovascular disease. For women suffering from cardiovascular diseases, changes in hemodynamic loads can threaten disability or even death. Pregnancy is a very dynamic process, and changes in hemodynamics, hormonal status and many other physiological factors in the body of a pregnant woman occur constantly and gradually, and sometimes suddenly. In this regard, it is important not only to make a correct diagnosis, to determine the nosological form of heart or vascular disease, but to assess the etiology of this disease and the functional state of the cardiovascular system. In addition, it is important to assess the degree of activity of the primary pathological process(rheumatism, rheumatoid arthritis, thyrotoxicosis, etc.), which led to damage to the cardiovascular system, as well as the detection of focal infection (cholecystitis, tonsillitis, dental caries, etc.) and other concomitant diseases. These are the complex, but in the vast majority of cases, still solvable problems that arise before the doctor, who decides whether a woman suffering from any cardiovascular disease, have pregnancy and childbirth without risk to their health and life, without risk to the health and life of their unborn child. The issue of the permissibility of having a pregnancy and childbirth for a woman suffering from cardiovascular diseases should be decided in advance, ideally before marriage. In resolving this issue, the doctor who carries out dispensary observation of patients, as well as the attending physician who constantly monitors the patient (district doctor, family doctor, cardiologist) has certain advantages. In the future, in the event of pregnancy, childbirth and the postpartum period, this issue should be resolved jointly by a cardiologist with an obstetrician-gynecologist, and, if necessary, with the involvement of doctors of other specialties. During pregnancy, an increased load on the cardiovascular system causes physiologically reversible, but quite pronounced changes in hemodynamics and heart function. Without knowing about the changes in hemodynamics in healthy pregnant women, it is impossible to adequately assess it in cardiovascular diseases. An increase in load is associated with an increase in metabolism aimed at meeting the needs of the fetus, an increase in the volume of circulating blood, the appearance of additional placental system blood circulation, with a constantly increasing body weight of the pregnant woman. With an increase in size, the uterus limits the mobility of the diaphragm, increases intra-abdominal pressure, changes the position of the heart in the chest, which ultimately leads to changes in the working conditions of the heart. Such hemodynamic changes as an increase in the volume of circulating blood and cardiac output can be unfavorable and even dangerous in pregnant women with diseases of the cardiovascular system, due to their layering on the already existing ones, caused by the disease. A change in hemodynamics in the mother has a negative effect on the uteroplacental circulation, which in some cases can cause fetal malformations, including birth defects hearts. A long period pregnancy is replaced by a short, but extremely significant period of childbirth in terms of physical and mental stress. Following the period of childbirth, the postpartum period begins, which is no less important in terms of hemodynamic and other physiological changes. Among the heart diseases that complicate pregnancy, more often Critical periods pregnancy to exacerbate CVD Start of pregnancy - 16 weeksCardiovascular disease (CVD) in pregnant women
The student of 6 course to lay down. otd. honey. Faculty of Osh State University, Kyrgyz Republic
Israilova Z.A.
Assistant of the Department of Obstetrics and Gynecology
26-32 weeks. Maximum hemodynamic loads, increase in BCC, cardiac output, decrease in hemoglobin.
35 weeks - start of labor. Increase in body weight, difficulty in pulmonary circulation due to the high standing of the uterine fundus, decreased diaphragm function.
Start of labor
- the birth of the fetus. An increase in blood pressure (BP), systolic and cardiac output.Early postpartum period
. Possible postpartum collapse due to a sharp change in intra-abdominal and intrauterine pressure.Methods for studying CCC in pregnant women.
- may contain important information about the time of occurrence of rheumatism, the duration of the existence of heart disease, the number of rheumatic attacks suffered, circulatory disorders, etc.Electrocardiography
- registration of electrical phenomena that occur in the heart muscle when it is excited.Vectorcardiography
- detection of signs of hypertrophy of the heart.X-ray examination
- without sufficient grounds, it should not be carried out during pregnancy.Radionuclide research methods
- should not be used during pregnancy.Phonocardiography
- a method of recording sounds (tones and noises) resulting from the activity of the heart, and is used to evaluate its work and recognize disorders, including valve defects.echocardiography
- used to study hemodynamics and cardiodynamics, determine the size and volume of the cavities of the heart, assess the functional state of the myocardium. The method is harmless to mother and fetus.Rheography
- to determine the state of vascular tone, their elasticity, blood supply during pregnancy.Loaded samples
- to assess the functional state of the myocardium. Tests with a load on a bicycle ergometer up to a heart rate of 150 per minute are also used in pregnant women.Studies of the function of external respiration and acid-base status.
Blood studies.
General information
for the management of pregnant women with CVD.Speaking about the tactics of pregnancy and childbirth in women with diseases of the cardiovascular system, it must be said that the issue of maintaining pregnancy and its safety for the mother and unborn child should be decided not only before pregnancy, but also better before the patient's marriage. The basis for the correct management and treatment of pregnant women suffering from cardiovascular diseases is an accurate diagnosis that takes into account the etiology of the disease.
Large loads on the cardiovascular system during pregnancy occur at the 7-8th obstetric month of pregnancy and during childbirth. Therefore, pregnant women should be hospitalized at least three times:
I- hospitalization - at the 8-10th week of pregnancy to clarify the diagnosis and resolve the issue of the possibility of maintaining pregnancy.
With mitral stenosis I st. Pregnancy can be continued in the absence of exacerbation of the rheumatic process.
Mitral valve insufficiency is a contraindication to pregnancy only in the presence of cardiac weakness or activation of the rheumatic process, as well as when it is combined with heart rhythm disturbance and circulatory failure.
Aortic valve stenosis - pregnancy is contraindicated in case of signs of myocardial insufficiency, with a significant increase in the size of the pregnant woman's heart.
Aortic valve insufficiency is a direct contraindication.
Congenital malformations of the pale type are compatible with pregnancy unless accompanied by pulmonary hypertension.
Patients after heart surgery are treated differently.
Acute rheumatic process or exacerbation of a chronic one is a contraindication to pregnancy.
Summarizing the above, we can say that the issue of termination of pregnancy up to 12 weeks is decided depending on the severity of the defect, the functional state of the circulatory system and the degree of activity of the rheumatic process.
II- hospitalization - at the 28-29th week of pregnancy to monitor the state of the cardiovascular system and, if necessary, to maintain heart function during the period of maximum physiological stress.
III- i hospitalization - at 37-38 weeks to prepare for childbirth and choose the method of delivery.
If there are signs of circulatory failure, exacerbation of rheumatism, the occurrence of atrial fibrillation, late gestosis of pregnant women or severe anemia, the patient must be hospitalized regardless of the duration of pregnancy.
The question of termination of pregnancy for more later dates is quite complex. Not infrequently, a problem arises, which is less dangerous for the patient: to terminate the pregnancy or to develop it further. In any case, if signs of circulatory failure or any intercurrent diseases appear, the patient should be hospitalized, subjected to a thorough examination, treatment. With the ineffectiveness of treatment, the presence of contraindications to surgical intervention on the heart, a decision is made to terminate the pregnancy. Pregnancies beyond 26 weeks should be terminated by abdominal caesarean section.
Until now, many physicians believed that delivery at term by caesarean section reduces the burden on the cardiovascular system and reduces the mortality of pregnant women suffering from heart defects. However, many authors recommend that, in severe degrees of heart defects, delivery by caesarean section should be performed, but not as a last resort for protracted births through the natural birth canal, complicated by cardiac decompensation, but as a preventive measure carried out on time.
Recently expanded somewhat indications for caesarean section in patients with cardiovascular diseases. These include the following:
circulatory failure II-B - III stage;
rheumatic heart disease II and III degree of activity;
pronounced mitral stenosis;
septic endocarditis;
coarctation of the aorta or the presence of signs of high arterial hypertension or signs of incipient aortic dissection;
severe persistent atrial fibrillation;
extensive myocardial infarction and signs of hemodynamic deterioration;
combination of heart disease and obstetric pathology.
A contraindication to caesarean section is severe pulmonary hypertension.
Self-delivery through the natural birth canal is allowed with compensation of blood circulation in patients with mitral valve insufficiency, combined mitral heart disease with a predominance of stenosis of the left antriventricular orifice, aortic heart defects, congenital heart defects of the "pale type", with mandatory anesthesia for childbirth, to prevent the onset or aggravation heart failure (should start with the / m injection of 2 ml of a 0.5% solution of diazepam and 1 ml of 2% promedol already from the moment the first contractions appear).
Successful delivery of patients suffering from severe congenital and acquired heart defects can be facilitated by conducting labor under hyperbaric oxygen therapy, taking into account possible complications of HBOT in the postpartum period.
After the birth of the fetus and the discharge of the placenta, there is a rush of blood to the internal organs (and primarily to the abdominal organs) and a decrease in BCC in the vessels of the brain and coronary. In order to prevent deterioration of the condition, it is necessary to administer cardiotonic agents immediately after the birth of the child. Women in childbirth with heart disease can be discharged from the maternity hospital no earlier than 2 weeks after delivery in a satisfactory condition under the supervision of a cardiologist at the place of residence.
Rheumatism and Acquired Heart Disease (ACD)
).Rheumatism
- systemic connective tissue disease with a predominant lesion of the cardiac system, more common in young women; called b-group A hemolytic streptococcus. Allergic and immunological factors are important in the pathogenesis of the disease. Taking into account clinical manifestations and laboratory data, there are active and inactive phases and 3 degrees of process activity: 1 - minimal, 2 - medium and 3 - maximum - degrees. According to the localization of the active rheumatic process, carditis without valvular disease, recurrent carditis with valvular disease, carditis without cardiac manifestations, arthritis, vasculitis, nephritis, etc. are distinguished. In pregnant women, rheumatism occurs in 2.3-6.3%, and its exacerbation occurs in 2.5-25% of cases, most often in the first 3 and last 2 months of pregnancy, as well as during the first year after childbirth.The diagnosis of active rheumatism during pregnancy is also difficult. In this regard, women who have experienced the last exacerbation of rheumatism in the next 2 years before pregnancy should be classified as a high-risk group. Exacerbation of focal infection, acute respiratory diseases in pregnant women with rheumatic heart disease can exacerbate rheumatism.
Recently, cytological and immunofluorescent methods, which have a high diagnostic value, have been used to diagnose active rheumatism in pregnant women and puerperas. This is especially true for the second method, based on the detection of antibodies against streptolysin-O in breast milk and colostrum using an indirect immunofluorescence reaction.
During pregnancy and in the postpartum period, the rheumatic process proceeds in waves. Critical periods of exacerbation of rheumatism correspond to the early stages of pregnancy - up to 14 weeks, then from 20 to 32 weeks and the postpartum period. The course of rheumatism during pregnancy can be associated with fluctuations in the excretion of corticosteroid hormones. Until the 14th week, corticosteroid excretion is usually at a low level. From the 14th to the 28th week, it increases by about 10 times, and on the 38th-40th week it increases by about 20 times and returns to its original level on the 5th-6th day of the postpartum period. Therefore, it is advisable to time preventive anti-relapse treatment
to critical times.Of particular note is the cerebral form of rheumatism, which occurs with a predominant lesion of the central nervous system. Pregnancy can provoke relapses of chorea, the development of psychosis, hemiplegia due to rheumatic vasculitis of the brain. With this
form of rheumatism, there is a high mortality rate, reaching 20-25%.The occurrence of pregnancy against the background of an active rheumatic process is very unfavorable, and in the early stages it is recommended to terminate it (artificial abortion) followed by antirheumatic therapy. In the later stages of pregnancy, early delivery is undertaken. In this case, the most sparing method of delivery is caesarean section followed by anti-relapse therapy. The choice of obstetric tactics in pregnant women with rheumatic heart disease depends on the functional state of the cardiovascular system. During pregnancy, the circulatory system must meet the needs of the developing fetus.
Hemodynamic shifts naturally developing during physiological pregnancy can lead to heart failure.
Pregnant women with heart defects are at high risk of maternal and perinatal mortality and morbidity. This is explained by the fact that pregnancy imposes an additional burden on the cardiovascular system of women.
account for 75-90% of all heart lesions in pregnant women. Of all the forms of defects of rheumatic origin, mitral defects are most often observed in the form of a combination of insufficiency and stenosis of the left atrioventricular orifice, i.e. in the form of combined mitral defect or mitral disease. However, the clinical picture of the disease is usually dominated by signs of either mitral stenosis or bicuspid valve insufficiency. Therefore, the terms "mitral stenosis" or "mitral insufficiency" refer not only to pure forms of defects, but also to those forms of combined valve damage in which the sign of the defect dominates. Clinical symptoms of mitral stenosis and mitral insufficiency depend on the stage of the disease, according to A.N. Bakuleva and E.A. Damir: 1Art. - full compensation, 2st. - relative insufficiency of blood circulation, 3st. - the initial stage of severe circulatory failure, 4st. - severe circulatory failure, stage 5 - dystrophic period of circulatory failure. It is generally accepted that mild bicuspid valve insufficiency or combined mitral valve disease with a predominance of insufficiency usually has a favorable prognosis. Aortic defects are much less common than mitral and are predominantly combined with other defects. Most often, the predominance of aortic valve insufficiency and less often stenosis is found. The prognosis for aortic stenosis is more favorable than for aortic valve insufficiency. found in 7-8% pregnant. To predict pregnancy outcomes and childbirth the activity of the rheumatic process matters. Form and stage of defect development, compensation or decompensation of blood circulation, degree pulmonary hypertension, rhythm disturbance, as well as the addition of obstetric pathology. All these data determine the choice of obstetric tactics during during pregnancy, childbirth and the postpartum period. Rheumatologists note that obliterated forms of rheumatic fever currently predominate. process, in this connection, their diagnosis on the basis of clinical, hematological, immunobiological research presents great difficulties .mitral stenosis.
The intensity of cardiac activity in pregnant women increases from 12-13 weeks and reaches a maximum by 20-30 weeks.Approximately 85% of THESE patients have signs of heart failure. Most often they appear or begin to grow precisely with
12-20-th week of pregnancy. Hemodynamic recovery begins at puerperas only after 2 weeks after childbirth. In patients with mitral stenosis, during pregnancy due to physiological hypervolemia, which exacerbates pulmonary hypertension, increased risk of pulmonary edema. At In this case, no method of delivery (with the help of obstetric forceps, by caesarean section) helps to stop pulmonary edema. The most reliable way to ensure a favorable outcome in such cases is a mitral commissurotomy. This operation, depending on the situation, can be recommended in 3 options.The first option: an artificial abortion is performed and then a mitral commissurotomy (after the first menstruation); after 5-6 months. after successful heart surgery
re-pregnancy is possible. Second option- produced mitral commissurotomy during real pregnancy in any of its terms (with intractable drug-induced pulmonary edema), but better on 24-32-th week, when the risk of spontaneous abortion like reactions for surgical trauma, less (due to sufficient relaxation of the uterus). Third option: a caesarean section is performed at the 30-40th week of pregnancy with sufficient maturity of the fetus) and one-stage (after delivery)- mitral commissurotomy. The operation of mitral commissurotomy during pregnancy is more radical due to decalcification of the valve leaflets and greater susceptibility to separation of subvalvular adhesions.mitral insufficiency. Pregnancy with this pathology is much easier. Usually ends in spontaneous delivery. At
pronounced mitral insufficiency with significant regurgitation and a sharp increase in the left ventricle, pregnancy is difficult and may be complicated by the development of acute left ventricular failure. In such women, signs of heart failure appear or increase from early pregnancy, to which, as a rule, severe nephropathy with a torpid course joins. Medical therapy heart failure in these cases is ineffective, therefore, apply or terminate pregnancy in the early stages(induced abortion, small caesarean section) or early delivery in in a planned manner by the abdominal route. Subsequently, the patient is recommended surgical treatment of heart disease. In Russian federation available experience of ball prosthesis and allograft implantation in patients with decompensated mitral regurgitation during pregnancy. Even for such patients, after abortion by the vaginal route, the use of an intrauterine device is recommended, and sterilization is performed with the abdominal method.aortic stenosis. Among the acquired heart defects in pregnant women, this disease deserves attention. Pregnancy and childbirth can
allow only in the absence of pronounced signs of hypertrophy of the left ventricle and symptoms of circulatory failure, since the defect is compensated for by concentric muscle hypertrophy left ventricle, thickening of its wall. In cases of severe aortic stenosis, when surgical correction of the defect is necessary- replacement affected valve with a prosthesis, the possibility of carrying a pregnancy is decided after surgery. Aortic insufficiency is less severe than aortic stenosis because German long time circulatory compensation is maintained. However due to changes in hemodynamics due to pregnancy and frequent accession late toxicosis course of aortic insufficiency may be heavier. At patients with aortic heart disease, pregnancy and births through the natural birth canal are allowed only in stages of circulatory compensation. In the second stage of labor in order to reduction of the stimulating effect of childbirth on the development of the defect is shown turning off attempts by applying obstetric forceps. For symptoms heart failure pregnancy should be considered unacceptable. The resulting pregnancy is to be terminated. If the pregnancy has reached a long term, the most rational is early delivery by abdominal route with sterilization.Tricuspid valve insufficiency
, usually rheumatic in nature. Most often, this defect occurs in pulmonary hypertension.Tricuspid valve stenosis
- is rare, almost exclusively in women, has a rheumatic nature, is usually combined with damage to the mitral (and often aortic) valve and very rarely turns out to be an "isolated" defect.Acquired valvular disease of the pulmonary artery
- are rarely seen clinically. Most often combined with lesions of other heart valves.Multivalvular rheumatic heart disease is quite common. Their diagnosis is difficult, because. hemodynamic shifts characteristic of certain types of defects, and their symptoms, prevent the manifestation of some hemodynamic shifts and clinical signs characteristic of each type of defect. However, the identification of concomitant malformations in pregnant women may be of decisive importance for making a decision on the possibility of maintaining the pregnancy and on the advisability of surgical correction of the defect or malformations.
congenital heart defects (CHDs)
).Thanks to the improvement of diagnostic techniques, the development of surgical methods for the radical or palliative correction of defects in the development of the heart and great vessels, the issues of accurate diagnosis and treatment of congenital heart defects have been actively addressed in recent decades. Previously, congenital heart defects were divided into only two groups: "blue" and "non-blue" defects. Currently, about 50 forms of congenital heart defects and major vessels are known. Some of them are extremely rare, others only in childhood.
Atrial septal defect.
Meet most often in adults with congenital heart defects (9-17%). It manifests itself clinically, as a rule, in the third or fourth decade of life. The course and outcome of pregnancy with this heart disease is usually favorable. In rare cases, with an increase in heart failure, it is necessary to resort to termination of pregnancy.Ventricular septal defect.
Less common than atrial septal defect. Often associated with aortic valve insufficiency. Pregnant women with a minor ventricular septal defect can tolerate pregnancy well, but as the defect increases, the risk of developing heart failure, sometimes fatal, increases. Postpartum paradoxical systemic embolism may occur.Open ductus arteriosus.
When a duct is blocked, blood flows from the aorta into the pulmonary artery. With a significant discharge of blood, dilatation of the pulmonary artery, left atrium and left ventricle occurs. In terms of tactics of managing a pregnant woman with this defect, the diagnosis of the diameter of the duct is of primary importance. This disease, with an unfavorable course, can complicate the development of pulmonary hypertension, subacute bacterial endocarditis, and heart failure. During pregnancy, when initial stage pulmonary hypertension, a significant increase in pressure in the pulmonary artery can occur with the development of then right ventricular failure.The isolated stenosis of a pulmonary artery.
This defect is among the most common congenital defects (8-10%). The disease can complicate the development of right ventricular failure, because. Pregnancy increases blood volume and cardiac output. With mild to moderate pulmonary stenosis, pregnancy and childbirth can proceed safely.Tetralogy of Fallot.
Fallot's tetrad is classified as a classic "blue" heart disease. Consists of right ventricular outflow tract stenosis, large ventricular septal defect, displacement of the aortic root to the right, and right ventricular hypertrophy. In women with Fallot's tetralogy, pregnancy poses a risk to both mother and fetus. Especially dangerous is the early postpartum period, when severe syncopal attacks can occur. With Fallot's tetrad, the percentage of complications such as the development of heart failure is high, and the lethal outcome for the mother and fetus is quite high. Women who have undergone radical surgery for this defect, are more likely to have a favorable course of pregnancy and childbirth.Eisenmeiger syndrome
- belong to the group of "blue" defects. Observed with large defects of the cardiac septum or fistula large diameter between the aorta and the pulmonary artery (i.e., with defects in the interventricular and interatrial septa, open ductus arteriosus). Eisenmeiger's syndrome often complicates thrombosis in the pulmonary artery system, thrombosis of cerebral vessels, and circulatory failure. With Eisenmenger's syndrome, the risk of death for both the mother and the fetus is very high.congenital aortic stenosis
- can be subvalvular (congenital and acquired), valvular (congenital and acquired) and supravalvular (congenital). Pregnant women with mild or moderate congenital aortic stenosis tolerate pregnancy well, but the risk of developing subacute bacterial endocarditis in the postpartum period does not depend on the severity of stenosis.Coarctation of the aorta
(stenosis of the isthmus of the aorta). The defect is caused by narrowing of the aorta in the area of its isthmus (the border of the arch and the descending part of the aorta). Coarctation of the aorta is often combined with a bicuspid aortic valve. Aortic coarctation can be complicated by cerebral hemorrhage, aortic dissection or rupture, and subacute bacterial endocarditis. The most common cause of death is aortic rupture.operated heart.
Recently, there are more and more pregnant women who have undergone heart surgery before pregnancy and even during pregnancy. Therefore, the concept of the so-called operated heart in general and during pregnancy in particular has been introduced.
It should be remembered that not always corrective heart surgery leads to the elimination of organic changes in the valvular apparatus or the elimination of congenital anomalies development. Often, after surgical treatment, a relapse of the underlying disease is observed, for example, in the form of restenosis during commissurotomy. Therefore, the question of the possibility of maintaining pregnancy and the admissibility of childbirth should be resolved individually before pregnancy, depending on general condition sick.
Rhythm and conduction disturbances.
This pathology
also matters in prognosis of pregnancy and childbirth, it should be borne in mind that in itself pregnancy can cause arrhythmias. So, extrasystole, paroxysmal tachycardia in pregnant women can be observed without any organic changes in the myocardium. They occur in 18.3% of pregnant women. The addition of late toxicosis further contributes to the appearance or intensification of arrhythmias. There is no significant effect on the outcome of pregnancy.Atrial fibrillation in combination with organic pathology of the heart, in particular with mitral stenosis, is a contraindication to pregnancy, while it has
meaning how to interrupt it. Caesarean section for these patients is a great danger, than delivery through the natural birth canal, due to the possible thromboembolism in the pulmonary artery system.On the contrary, disturbances of atrioventricular conduction (incomplete and
complete heart block) by themselves do not pose a danger to a pregnant woman. Moreover, in these patients pregnancy is usually, causes an increase in the ventricular rate, thereby preventing the danger occurrence of attacks of Adams - Stokes - Morgagni. Only with very rare pulse - 35 or less in 1 min - during second stage of labor for acceleration of labor activity turn off attempts with the help of imposition obstetric forceps. When choosing antiarrhythmic drugs for pregnant women, it is also necessary to consider negative action some of them (quinidine, novocainamide, atropine sulfate, etc.) on uterine excitability and the condition of the fetus.mitral valve prolapse.
Mitral valve prolapse
- This deflection of the mitral valve leaflets into the left atrium during systole ventricles. A mild degree of prolapse is established using echocardiography. Severe mitral valve prolapse syndrome diagnosed on the basis of clinical findings and phonocardiography. IN Depending on the degree of prolapse of the valves, one or another the degree of insufficiency of the closing function of the mitral valve with regurgitation of blood into the cavity of the left atrium. The clinical manifestations of this pathology are very diverse.- from asymptomatic to pronounced clinical picture. The most pronounced symptoms are observed in patients with prolapse of both leaflets of the mitral valve.At present, for the first time, the course of this syndrome in combination with pregnancy has been studied; it has been established that mildly pronounced deflection
posterior wall of the mitral valve, and hence mild regurgitation decreases with increasing gestational age and return to baseline after 4 weeks after childbirth. This can be explained by the physiological increase in the cavity of the left ventricle with pregnancy, which changes the size, length and degree of tension of the chords.The tactics of conducting labor is the same as in physiological pregnancy.
A pronounced prolapse of the valves with a large amplitude of deflection during pregnancy proceeds without significant dynamics. In these patients, due to the severity of cardiac symptoms, attempts during childbirth must be turned off by applying obstetric forceps. With a combination of obstetric pathology (weak labor and prolonged, large fetus, sudden stress at attempts, etc.) resort to delivery with the help caesarean section.myocarditis
and cardiomyopathy.Myocarditis
of various etiology in pregnant women are observed relatively rarely. Among them, post-infectious myocarditis is more common, which proceed relatively easily and in pregnant women are sometimes taken long course, may be accompanied by persistent extrasystole. Myocarditis itself, in the absence of valvular heart disease, rarely leads to development of heart failure. Post-infectious myocarditis in some cases can be treated, and pregnancy can end in childbirth. (more premature). If myocarditis is complicated by atrial fibrillation arrhythmia, there is a risk of thromboembolic complications. In severe myocarditis in early pregnancy perform an induced abortion(up to 12 weeks) in the later stages - caesarean section (small or early).Of particular danger during pregnancy are cardiomyopathies. IN
last years in pregnant women, idiopathic subaortic hypertrophic stenosis began to be detected more often. The etiology of this disease is unknown, familial cases are often observed. During pregnancy, it may step on sharp deterioration states, even death after childbirth is possible. But despite this, with mild to moderate obstruction, with proper management of patients, pregnancy is possible.Long-term prognosis in patients with cardiomyopathy is unfavorable,
therefore, re-pregnancy should not be allowed. In cases of severe cardiomyopathy, termination of pregnancy is recommended regardless from her timing.Hypertonic disease.
Pregnancy in combination with hypertension occurs in 1-3% of cases. Only when mild form hypertension
, when hypertension is mild and unstable, in the absence of organic changes in the heart, i.e. at stage 1 development of the disease, pregnancy and childbirth can proceed normally. At persistent hypertension and a significant increase in blood pressure(II Stage A) pregnancy worsens the clinical course of hypertension. In patients with III the stage of the disease, the ability to conceive is sharply reduced, and if pregnancy does occur, then, How rule ends spontaneous abortion or fetal death.The course of hypertension during pregnancy has its own
peculiarities. So, in many patients I-II And the stage of the disease 15-16-1st week of pregnancy, blood pressure drops (often to normal values), which is explained by the depressor effect of the formed placenta. In sick people II In stage B, no such decrease in pressure is observed. After 24 weeks pressure rises in all patients - and at I and IIA, and IIB stages. Against this background, late toxicosis often (in 50%) joins.In connection with the spasm of the uteroplacental vessels, the delivery of necessary nutrients and oxygen to the fetus worsens,
which creates a delay in fetal development. At each 4 -5- The patient has fetal hypotrophy. The frequency of intrauterine fetal death reaches 4.1%. At these patients are also at high risk of developing premature detachment normal attachment of the placenta. Premature termination of pregnancy (spontaneous and operative) is 23%.During childbirth, a hypertensive crisis may develop with hemorrhage in
various organs and brain. Nephropathy often turns into eclampsia. Therefore, timely diagnosis of hypertension in pregnant women is the best prevention of these diseases. This possible under the following conditions: early negotiability in antenatal consultation, examination of the patient by a general practitioner paying attention to all the details of the disease history (beginning, course, complications and etc.); measurement of blood pressure, performing fluoroscopy (to determine degree of enlargement of the left ventricle and aorta), as well as an ECG.Obstetric tactics in hypertension: in seriously ill patients,
suffering from persistent forms of the disease ( IIB, III stage), abortion is performed at an early stage (artificial abortion followed by the introduction of a contraceptive spiral into the uterus)- upon contact in the late stages of pregnancy and the persistent desire to have a child, hospitalization is indicated.Therapy of hypertension includes the creation of psycho-emotional peace for the patient, strict adherence to the daily regimen, diet, drug therapy and physiotherapy.
Medical treatment
carried out using a complex of drugs acting on various links in the pathogenesis of the disease. Apply the following antihypertensive drugs: diuretics (furosemide, brinaldix, dichlothiazide); drugs that act on various levels of the sympathetic system, including b-adrenergic receptors (anaprilin, clonidine, methyldopa); vasodilators and calcium antagonists (apressin, verapamil, fenitidine); antispasmodics (dibazole, papaverine, no-shpa, eufillin).Physiotherapy procedures
include electrosleep, inductothermy of the feet and legs, diathermy of the perirenal region. Hyperbaric oxygen therapy has a great effect.Micromorphometric studies of the placenta revealed changes in the ratio of the structural elements of the placenta. The area of the intervillous space, stroma, capillaries, vascular index decrease, the area of the epithelium increases.
Histological examination noted focal angiomatosis, widespread dystrophic process in syncytium and trophoblast, focal plethora of the microvasculature; in most cases, a lot of "glued" sclerotic villi, fibrosis and edema of the stroma of the villi.
For correction placental insufficiency therapeutic and preventive measures have been developed, including, in addition to agents that normalize vascular tone, drugs that affect the metabolism in the placenta, microcirculation and bioenergetics of the placenta.
All pregnant women with vascular dystonia are prescribed drugs that improve microcirculation (pentoxifylline, eufillin), protein biosynthesis and bioenergetics (Essentiale), microcirculation and protein biosynthesis (alupent).
During childbirth, it is necessary to conduct anesthesia with the use of ataractics (tazepam), antispasmodics (papaverine) and narcotic drugs (promedol).
If delivery is performed without controlled hypotension, then the patient continues to receive antihypertensive therapy (dibazole and papaverine intramuscularly). In the second stage of labor, the attempts are turned off with the help of obstetric forceps under inhalation anesthesia(halothane). Caesarean section is used in patients with cerebrovascular accident or obstetric pathology ( breech presentation in primiparous aged 30 years and older, weakness of labor activity, etc.). Long-term results indicate that after childbirth, especially in cases of accession of nephropathy, often the disease progresses.Preventive measures for complications of pregnancy and childbirth with hypertension - regular monitoring of a pregnant woman in a women's consultation by an obstetrician-gynecologist and a general practitioner, mandatory three-time hospitalization of a pregnant woman even with good health and effective outpatient antihypertensive therapy.
Arterial hypotension.
Arterial hypotension
– a disease characterized by a decrease in blood pressure below 100/60 mm Hg. Art. (millimeters of mercury), caused by a violation of vascular tone. A similar condition occurs in young women quite often, but not all persons with reduced blood pressure are considered sick. Many do not respond at all to a decrease in blood pressure, maintain good health and ability to work. This is the so-called physiological or constitutional hypotension. Hypotension can be either an independent suffering or a symptom of another disease (for example, infectious), so doctors distinguish between primary and symptomatic (resulting from another disease) hypotension.Primary arterial hypotension can be considered as vascular neurosis or neurocirculatory dystonia, accompanied by low blood pressure. In a conversation with a patient, it is often possible to find out that the onset of the disease is associated with neuropsychic trauma, overwork, and emotional overstrain. Typical complaints about headache, dizziness, general weakness, palpitations, pain and others discomfort in the heart area, sweating, memory loss, decreased ability to work, insomnia. Some women develop dizziness, darkening of the eyes, up to fainting when moving from a horizontal to a vertical position (getting out of bed). Often irritability appears or intensifies, a tendency to a minor mood.
If arterial hypotension is manifested only by a decrease in blood pressure, then it is referred to as a stable (compensated) stage of the disease. In the unstable (decompensated) stage, easily occurring syncope appears as a result of hypotonic crises, which can develop against the background of good health, without any precursors. Appear severe weakness, dizziness, a feeling of stupor, accompanied by pallor of the skin and visible mucous membranes, cold sweat, vomiting may join. BP drops to 80-70/50-40 mm Hg. and below. The hypotonic crisis lasts from a few seconds to minutes.
However, not in all cases arterial hypotension pressure is steadily reduced. With excitement, it can reach normal and even elevated numbers (although it quickly decreases). It has long been noted that women are susceptible to the disease asthenic physique with pale skin cold to the touch hands. These women often find varicose veins of the legs. When examining the heart, doctors rarely detect any abnormalities, and there are no characteristic changes on the ECG. The only thing that can be paid attention to is bradycardia or rare heartbeats.
Arterial hypotension may precede pregnancy, and may develop during it, for example, in the first months. In general, changes in blood pressure are often observed in pregnant women, and the indicators of systolic and diastolic pressure are close to the minimum limit, periodically decreasing even lower.
With physiological hypotension, not accompanied by pathological symptoms, there is no need for treatment. However, in any case, a woman should be observed by a general practitioner of the antenatal clinic. Symptomatic hypotension requires first treatment of the underlying disease.
The frequency of arterial hypotension in pregnant women is from 4.2-12.2% to 32.4% according to different authors. Arterial hypotension is the result of general disorders in the body, a symptom common disease when the tone of not only blood vessels, but also other organs changes. Arterial hypotension adversely affects the course of pregnancy and childbirth, the development of the fetus and newborn. Most frequent complications during pregnancy are early toxicosis, the threat of abortion, miscarriage, late preeclampsia and anemia.
The most common complications in childbirth are untimely discharge of amniotic fluid, weakness of labor, perineal ruptures. The subsequent and postpartum period in 12.3-23.4% of women complicates bleeding. postpartum period- subinvolution of the uterus, lochiometer and endomyometritis. A relatively small blood loss (400-500 ml) in parturient women with arterial hypotension often causes severe collapse.
Frequency surgical interventions is: caesarean section - 4.6%; manual entry into the uterine cavity - 15.3%.
With arterial hypotension, the frequency of intrauterine fetal hypoxia and asphyxia of the newborn is 30.7%, the number of birth injuries increases to 29.2%, the number of premature babies to 17% and children with malnutrition I-II degree to 26.1%. The assessment of the state of children according to the Apgar scale was statistically significantly reduced.
First of all
, it is necessary to take care of sufficient rest and a long, 10-12 hour sleep. Useful daily 1-2 hour sleep. Sufficiently effective means of treatment and prevention are physiotherapy exercises, morning exercises, walks in the fresh air. Complex morning exercises should be the simplest, not leading to excessive overstrain, fatigue.Nutrition must be made as varied as possible, certainly complete with a high content of protein products (up to 1.5 g / kg of body weight). Strong tea and coffee (with milk, cream) can be drunk in the morning or afternoon, but not in the evening, so as not to disturb sleep. It is useful to take vitamin B1 (thiamine bromide) 0.05 g 3 times a day, as well as multivitamins (undevit, gendevit). In addition, the doctor may prescribe sessions of hyperbaric oxygen therapy, total ultraviolet irradiation, electrophoresis medicines increasing vascular tone on the neck or intranasally. A good restorative, tonic effect is exerted by pantocrine, prescribed in 2-4 tables. Or 30-40 drops inside 2-3 times a day. Tinctures of aralia, zamaniha, leuzea, Chinese magnolia vine, eleutherococcus are effective, which are taken 20-30 (up to 40) drops 2-3 times a day for 30 minutes. before meals. All these funds should be taken in courses for 10-15 days. They do not so much increase blood pressure as they improve well-being, give vigor, restore overall tone, performance, and sleep. Ginseng tincture should not be used, because. possible manifestations of the teratogenic effect of this drug. Repeat the treatment if the condition worsens or is planned 2-3 times during pregnancy. It should be remembered that there is individual sensitivity to drugs used to treat arterial hypotension, so sometimes it is necessary to select the most effective drug purely empirically, sometimes a combination of drugs.
Before childbirth, the use of complex prenatal preparation is justified - the creation of a non-hormonal glucose-calcium-vitamin background with ongoing therapy for placental insufficiency.
varicose veins.
Unfortunately, pregnant women automatically fall into the so-called "risk group" of varicose veins:
the weight of a woman is growing "by leaps and bounds" - therefore, the load on the legs is also growing;
a pregnant woman - especially in late pregnancy - leads a sedentary, often sedentary lifestyle;
the growing uterus compresses the veins of the small pelvis.
All this leads to difficulty in the outflow of blood through the veins of the legs, and the crowded veins have no choice but to expand. Further:
progesterone secreted in abundance during pregnancy contributes to the softening of the connective tissue, of which the venous wall practically consists, i.e. its extensibility increases, which contributes to the expansion of the lumen of the veins;
during pregnancy, the content of water and salts in the body changes, the volume of circulating blood increases, which means that the load on the veins ...
Thus, pregnancy can be safely called the "piggy bank of causes" of varicose veins. Probability of development
varicose veins become even greater when there is a hereditary predisposition.As a rule, the disease begins “from a small point”: small saphenous veins expand and take on the appearance of peculiar blue-violet patterns (spider veins, snakes, cobwebs) - mainly on the shins and calves. These are signs of the initial stage of the disease, which, if nothing is done, will certainly progress! In addition, signs of varicose veins are heaviness in the legs, their increased fatigue, cramps and swelling of the legs are possible. Later there is an expansion of veins of a larger caliber. They become visible under the skin in the form of swollen tortuous strands and intertwining knots. This threatens with serious complications: bleeding, the formation of long-term non-healing (trophic) ulcers, vein thrombosis. If you do not take action in time, you will have to deal with the disease on the operating table.
At the first unpleasant symptoms it is advisable to do ultrasonic dopplerography and, if necessary, photoplethysmography. These studies are absolutely painless and safe, even for pregnant women. They allow you to determine the type and degree of venous circulation disorders, measure the speed of blood flow and help the doctor choose the optimal treatment regimen.
don't stand for a long time, do not wear heavy weights, don't work squatting, leaning forward, perform all "standing" work with breaks during which it is best to lie down with raised legs. Sitting in a chair, it is very useful to put your feet on a special soft stool or stand, thereby giving them rest and ensuring the outflow of blood through the veins. Must be avoided wearing golfs and stockings with tight elastic bands.Today, the most common and most effective way to prevent varicose veins is to wear compression stockings. Most importantly, it does not violate the usual way of life. It's about about special tights, stockings and stockings that squeeze the legs, preventing the veins from expanding. Compression knitwear is comfortable, it does not interfere with movement, the legs “breathe” freely in it.
It is very important to start using compression stockings as soon as possible, preferably before pregnancy. Then by the most crucial moment in life there will be healthy veins. And if so, then the pregnancy will proceed easier. Of course, prevention must be continued during pregnancy itself. Wearing compression tights and stockings during pregnancy and even (attention!) during childbirth will save you from formidable complications, which you don’t even want to remind you once again. Naturally, prevention should be continued after childbirth, especially if a woman has
already have varicose veins. After all, if she continues to wear compression stockings, then surgery will not be needed for treatment - it may well be replaced by a vein sclerosis procedure. It is both safe and much less traumatic.Main sources of information.
Burkov S.G. Doctor of Medical Sciences, professor. Gastroenterologist. Medical center "Art-Med" at http://www.art-med.ru/articles/info.asp?id=82.
M. Sara Rosenthal
. Chapter from the book "Gynecology" (M. Sara Rosenthal, Gynecological Sourcebook. - NTC / Contemporary, 1997) at http://www.art-med.ru/articles/info.asp?id=11.Until the thunder strikes ... Varicose veins during pregnancy
. WITH . Tatkov. Deputy Director of the Phlebology Center, phlebologist surgeon, Ph.D.
