What are the dangers of extragenital diseases during pregnancy. Extragenital pathology

ELABUZH MEDICAL SCHOOL

Department of Advanced Training of Medical Workers

ESSAY

Management of pregnancy and childbirth in some types of extragenital pathology

Cycle: Modern aspects of obstetric care in obstetric institutions

Yelabuga, 2007

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1. PREGNANCY AND BIRTH IN CARDIOVASCULAR DISEASES………………………………………………………………..3

1.1.VASCULAR DYSTONIA IN PREGNANT WOMEN………………………..6

1.2. PREGNANCY AND CHILD IN HYPOTENSION…..6

1.3. PREGNANCY AND BIRTH WITH HYPERTENSION ... .7

9

2. PREGNANCY AND BIRTH IN KIDNEY DISEASES……………..10

2.1. PYELONEPHRITIS…………………………………………………………...11

2.2.GLOMERULONEPHRITIS………………………………………………………13

2.3. STONE DISEASE (ICD)……………………………………13

2.4. KIDNEY ANOMALIES AND PREGNANCY……………….14

3. VIRAL HEPATITIS AND PREGNANCY…………………………………………………14

4.ENDOCRINE DISEASES AND PREGNANCY………………….15

4.1. DIABETES MELLITUS AND PREGNANCY……………………………15

LIST OF USED LITERATURE…………………………….17

PREGNANCY AND EXTRAGENITAL PATHOLOGY

If we talk today about the health index of pregnant women, then at best 40% of all pregnant women carry a pregnancy without complications, that is, without toxicosis of pregnant women and without extragenital diseases. Against the background of a decrease in the birth rate, the problems of pregnancy management in women with EP are becoming relevant. But one should also remember about the hereditary determination of a number of diseases, since today 60% of all diseases are considered to be hereditarily determined.

Knowledge of the effect of extragenital pathology on the course of pregnancy and fetal development, as well as knowledge of the effect of pregnancy itself on EP, allows you to properly manage a resolved pregnancy and maintain a woman’s health and get healthy offspring. Pregnancy should be considered as an extreme condition. The functioning of a number of organs and systems of the female body during pregnancy proceeds on the verge of pathology, and there are “critical periods” when a breakdown or decompensation of one or another system or organs easily occurs.

1. PREGNANCY AND CHILD IN CARDIOVASCULAR DISEASES

One of the most severe extragenital pathologies in pregnant women are diseases of the cardiovascular system, and heart defects occupy the main place among them. 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.

Pregnancy is a very dynamic process, and changes in the hemodynamics of 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 to identify focal infections (cholecystitis, tonsillitis, dental caries, etc.) and others. 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 can have pregnancy and childbirth without risk to her health and to her life, without risk to the health and life of your 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.

METHODS FOR STUDYING THE CARDIOVASCULAR SYSTEM IN PREGNANT WOMEN

Anamnesis - may contain important information about the time of occurrence of rheumatism, the duration of the existence of a heart defect, 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 - Identification 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 assess 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.

MANAGEMENT OF PREGNANCY AND DELIVERY IN WOMEN WITH DISEASES OF THE CARDIOVASCULAR SYSTEM

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 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 issue of terminating a pregnancy at a later date is quite complicated. 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 timely preventive measure.

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.

1.1. VASCULAR DYSTONIA IN PREGNANT WOMEN

Violations of vascular tone, being a complication of pregnancy or symptoms of an extragenital disease, worsen the conditions for the development of the fetus, increase the risk of a pathological course of childbirth, and thereby contribute to an increase in perinatal mortality and child morbidity. The frequency of vascular dystonia in pregnant women ranges from 10.4 to 24.3%. The clinical variants of vascular tone disorders in pregnant women include arterial hypo- and hypertension that occurs during pregnancy. The state of hypo- and hypertension that occurs before pregnancy and persists during pregnancy is most often associated with neurocirculatory dystonia.

The most acceptable at present is the classification of neurocirculatory dystonia, built taking into account the nature of cardiac disorders and the characteristics of hemodynamic changes. There are the following types of neurocirculatory dystonia:

cardiac, which is characterized by pain in the region of the heart, palpitations with normal blood pressure;

hypotensive, in which general neurological disorders, cerebrovascular, cardiac symptoms are often observed with a stable decrease in blood pressure below 100/60 mm Hg;

hypertensive, characterized by instability of blood pressure with a tendency to increase, a predominance of cardiac and cerebral symptoms.

1.2. PREGNANCY AND CHILD IN HYPOTENSION

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 of a general 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. The most common complications during pregnancy are early toxicosis, threatened miscarriage, 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.

The frequency of 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.

Pregnant women with arterial hypotension will be prescribed an extract of eleutherococcus or pantocrine, 20-25 caps. 3 times a day, 10% caffeine sodium benzoate solution, 1 ml. s / c, thiamine, pyridoxine 1 ml / m daily, / infusion of a low-concentration glucose solution (5-10%) with ascorbic acid.

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.

1.3. PREGNANCY AND BIRTH WITH HYPERTENSION

Among the most common forms of diseases of the cardiovascular system is hypertension, essential arterial hypertension. Arterial hypertension is detected in 5% of pregnant women. Of this number, in 70% of cases there is late gestosis, in 15-25% - hypertension, in 2-5% - secondary hypertension associated with kidney disease, endocrine pathology, diseases of the heart and large vessels.

The clinical picture of hypertension during pregnancy is not much different from hypertension in non-pregnant women and depends on the stage of the disease. The complexity of diagnosis lies in the fact that many pregnant women, especially young ones, are unaware of changes in blood pressure.

MANAGEMENT OF PREGNANCY AND DELIVERY

The most common complication of hypertension is the development of preeclampsia, which manifests itself from the 28th-32nd week of pregnancy. As a rule, preeclampsia is extremely difficult, poorly amenable to therapy and recurs in subsequent pregnancies. With hypertension, the fetus suffers. Violations of the function of the placenta leads to hypoxia, malnutrition and even death of the fetus. Often a complication of hypertension is detachment of a normally located placenta.

Childbirth with hypertension often becomes fast, rapid or protracted, which adversely affects the fetus. For the correct management of childbirth in hypertension, it is necessary to assess the severity of the disease and identify possible complications. For this purpose, a pregnant woman suffering from hypertension is hospitalized three times during pregnancy.

1st hospitalization - up to 12 weeks of pregnancy. If stage IIA of the disease is detected, pregnancy can be maintained in the absence of concomitant disorders of the cardiovascular system, kidneys, etc. Stage IIB and III serve as an indication for termination of pregnancy.

II hospitalization at 28-32 weeks - the period of the greatest load on the cardiovascular system. During these periods, a thorough examination of the patient and correction of the therapy are carried out.

III hospitalization should be carried out 2-3 weeks before the expected birth to prepare women for delivery.

Most often, childbirth is carried out through the natural birth canal. In the first period, adequate anesthesia, antihypertensive therapy, and early amniotomy are necessary. During the period of exile, antihypertensive therapy is enhanced with the help of ganglionic blockers. Depending on the condition of the woman in labor and the fetus, the II period is reduced by perineotomy or obstetric forceps. In the III stage of labor, bleeding is prevented. Throughout the birth act, fetal hypoxia is prevented.

TREATMENT

Therapy of hypertension includes the creation of psycho-emotional rest 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 acting on various levels of the sympathetic system, including 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.

To correct placental insufficiency, therapeutic and preventive measures have been developed, including, in addition to agents that normalize vascular tone, drugs that affect placental metabolism, microcirculation and placental bioenergetics.

All pregnant women with vascular dystonia are prescribed drugs that improve microcirculation (pentoxifylline, eufillin), protein biosynthesis and bioenergetics (Essentiale), microcirculation and protein biosynthesis (alupent).

PREVENTION

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.

1.4. ANEMIA IN PREGNANT WOMEN

Anemia in pregnancy is divided into acquired(deficiency of iron, protein, folic acid) and congenital(sickle cell). The frequency of anemia, determined by a decrease in the level of hemoglobin in the blood using WHO standards, varies in different regions of the world within the range of 21-80%. There are two groups of anemia: those diagnosed during pregnancy and those that existed before the onset of it. Most often, anemia occurs during pregnancy.

Most women develop anemia by 28-30 weeks of gestation, associated with an uneven increase in the volume of circulating blood plasma and the volume of red blood cells. As a result, the hematocrit decreases, the number of red blood cells decreases, and the hemoglobin decreases. Such changes in the picture of red blood, as a rule, do not affect the condition and well-being of the pregnant woman. True anemia of pregnant women is accompanied by a typical clinical picture and affects the course of pregnancy and childbirth.

COURSE AND MANAGEMENT OF PREGNANCY AND CHILD IN ANEMIA

Among the complications of pregnancy with anemia, toxicosis of the first half of pregnancy (15.2%) is in the first place. This complication is more often observed in primigravida (26.2%). The threat of termination of pregnancy is met with almost the same frequency both in early (10.1%) and late (10.9%) terms of pregnancy. It should be noted that the threat of termination of pregnancy in the early stages occurs more often in primiparous women, and in the later stages, signs of termination of pregnancy are noted in almost every fourth woman with multiple births.

With severe anemia, 42% of children are born prematurely, malnutrition naturally develops. Anemia in pregnant women is a risk factor that affects the formation of the function of external respiration in newborns. Up to 29% of newborns are born in a state of asphyxia. With anemia in mothers, the risk of giving birth to children with low body weight increases significantly, and malnutrition is especially pronounced in severe anemia.

With anemia of pregnant women in the afterbirth and early postpartum period, such a formidable complication as bleeding often occurs.

The high incidence of anemia in pregnant women and their adverse consequences for the fetus, newborn and young child indicate the need for further study of the problem, finding ways to prevent and treat this common pregnancy complication.

In the study of indicators of protein metabolism, interesting data were obtained. A significant decrease in the level of total protein in the blood serum was revealed (by 25% in mild anemia and by 32% in moderate anemia). When studying protein metabolism, the main molecular mechanisms of protein biosynthesis in the placenta were established. This indicates that the placental insufficiency that develops in pregnant women is secondary, since the formation and functioning of the placenta occur in the body, the homeostasis of which differs from normal. Deep violations, indicating severe placental insufficiency, were also identified in the study of the content of sex steroid hormones. The concentration of estradiol in the blood serum of pregnant women with anemia is reduced by more than 2.5 times compared to that of healthy pregnant women, the excretion of estriol in the II trimester is reduced by 32%, and in the III - by 45%.

The development of placental insufficiency in anemia in pregnant women increases the risk of giving birth to children with low body weight, with signs of intrauterine malnutrition, in a state of asphyxia.

The fact of the adverse effect of anemia in the mother on the postnatal development of the child seems indisputable: a lag in body weight, growth, an increase in infectious morbidity, a decrease in humoral immunity, etc. All this makes it possible to attribute children born to mothers with anemia to the highest risk group for the development of perinatal and infant morbidity.

In case of anemia of moderate and severe degree, targeted correction of metabolic disorders characteristic of chronic placental insufficiency is carried out. In addition to traditional methods of treating anemia, including the use of iron preparations, ascorbic acid, food products for therapeutic nutrition are used: enpits (45 g per day) and a dry protein mixture (up to 12 g per day). In addition, placental insufficiency is corrected with medications that improve its functioning: essentiale, zixorin, pentoxifylline, aminofillin.

Drug correction of placental insufficiency in pregnant women with anemia of mild and moderate severity is carried out according to the following scheme:

enpit protein up to 45 g or dry protein mixture up to 12 g per day;

ascorbic acid 0.5 g 3 times a day;

methionine 0.25 g or glutamic acid 0.5 g 4 times a day;

5% glucose solution, 200 ml, 2.4% solution of aminofillin, 10 ml, intravenous drip;

methylxanthines - pentoxifylline 7 mg / kg;

bioantioxidant - Essentiale at 0.5 mg / kg.

Medications are selected for each pregnant woman, taking into account individual sensitivity, the severity of anemia and the severity of placental insufficiency.

2. PREGNANCY AND BIRTH IN KIDNEY DISEASES

Among extragenital pathology in pregnant women, diseases of the kidneys and urinary tract rank second after diseases of the cardiovascular system and pose a danger to both mother and fetus. Preeclampsia develops early and is difficult, spontaneous miscarriages, premature births, premature detachment of a normally located placenta, intrauterine infection of the fetus, its malnutrition and chronic hypoxia, the birth of immature premature babies, stillbirths are frequent. In turn, pregnancy can contribute to the occurrence of renal pathology, or exacerbation of chronic kidney diseases that occur latently before pregnancy.

Pregnancy predisposes to kidney disease due to impaired urodynamics due to changes in topographic and anatomical relationships as the size of the uterus increases, the effect of progesterone on urinary tract receptors. There is hypotension and expansion of the pyelocaliceal system and ureters (the capacity of the pelvis together with the ureters instead of 3-4 ml before pregnancy reaches 20-40, and sometimes 70 ml in the second half of it). In addition, the uterus in the second half of pregnancy deviates to the right (rotating in the same direction) and thereby exerts more pressure on the area of ​​​​the right kidney, which can, apparently, explain the greater frequency of right-sided urinary tract lesions. Decreased tone and amplitude of contractions of the ureter begins after the third month of pregnancy and reaches a maximum by the eighth month. Restoration of tone begins from the last month of pregnancy and continues during the III months of the postpartum period. A decrease in the tone of the upper urinary tract and stagnation of urine in them during pregnancy leads to an increase in pressure in the renal pelvis - this is important in the development of pyelonephritis. A significant role in the development of renal pathology during pregnancy is played by:

weakening of the ligamentous apparatus of the kidneys, contributing to the pathological mobility of the kidneys;

increased frequency of vesicoureteral reflux;

an increase in the secretion of estrogens and progesterone, glucocorticoids, placental hormones - chorionic gonadotropin and chorionic somatomammotropin.

The infection enters the urinary tract by ascending (from the bladder), descending - lymphogenous (from the intestines, especially with constipation), hematogenous (with various infectious diseases). Pathogens - Escherichia coli, Gram-negative ecterobacteria, Pseudomonas aeruginosa, Proteus, Enterococcus, Staphylococcus aureus, Streptococcus, Candida type fungi.

It should be noted the frequently occurring clinical forms - pyelonephritis, hydronephrosis, asymptomatic bacteriouria. Less often - glomerulonephritis, renal HBS, urolithiasis, anomalies in the development of the urinary tract.

2.1. pyelonephritis

Pyelonephritis- this is the most common disease during pregnancy (from 6 to 12%), in which the concentration ability of the kidneys suffers. Pyelonephritis has an adverse effect on the course of pregnancy and the condition of the fetus. The most common complication is late preeclampsia, miscarriage, intrauterine infection of the fetus. Terrible complications are acute renal failure, septicemia, septicopyemia, bacterial shock. Pregnant women with pyelonephritis are at high risk. Most often, pyelonephritis is found during pregnancy - 12-15 weeks, 24-29 weeks, 32-34 weeks, 39-40 weeks, in the postpartum period at 2-5 and 10-12 days. Pyelonephritis in pregnant women may occur for the first time, or manifest (aggravate) if a woman had it before pregnancy. Pregnant women with pyelonephritis should be hospitalized with each exacerbation of the disease, with the appearance of signs of late preeclampsia, deterioration of the fetus (hypoxia, malnutrition.)

Treatment of pyelonephritis in pregnant women and puerperas is carried out according to the general principles of therapy for the inflammatory process of the kidneys under the control of urine culture and sensitivity to antibiotics. The complex of therapeutic measures includes the following: the appointment of a complete fortified diet, knee-elbow position for 10-15 minutes several times a day and sleep on a healthy side, diathermy of the perirenal region, drinking mineral waters (Essentuki No. 20). Antibiotics 8-10 days, nevigramon - 2 capsules 4 times a day for 4 days, then 1 capsule 4 times a day for 10 days. From the 2nd trimester - 5-NOC, 2 tablets. 4 times a day for 4 days, then 1 tablet 4 times a day for 10 days; furagin 0.1 4 times a day for 4 days and 0.1 3 times a day for 10 days. Detoxification therapy - hemodez, reopoliglyukin, albumin, protein. For the treatment of intrauterine fetal malnutrition - in / in 5 ml of trental with 500 ml of 5% glucose solution. Antispasmodics - baralgin 5 ml / m, Avisan 0.05 3 times a day; suprastin or diphenhydramine 1 tab. 1 time per day, diuretics - collection of herbs, bearberry, kidney tea.

If therapy fails, ureteral catheterization is performed. Delivery is carried out through the natural birth canal. Cesarean section in the conditions of an infected organism is highly undesirable and is performed according to strictly obstetric indications. In 10% of cases, early delivery is performed when pyelonephritis is combined with severe preeclampsia and in the absence of the effect of the therapy. In the postpartum period, treatment of pyelonephritis is continued for 10 days. The woman is discharged from the hospital under the supervision of a urologist.

2.2. GLOMERULONEPHRITIS

Glomerulonephritis of pregnant women - from 0.1% to 9%. This is an infectious-allergic disease that leads to immunocomplex damage to the glomeruli of the kidneys. The causative agent is hemolytic streptococcus. Most often, this disease occurs after a sore throat, flu.

In the early stages of pregnancy, it is necessary to examine and decide on the possibility of maintaining pregnancy. Acute glomerulonephritis is an indication for abortion. After acute glomerulonephritis, pregnancy is possible no earlier than 3-5 years later.

Chronic glomerulonephritis in the acute stage with severe hypertension and azotemia is a contraindication for prolonging pregnancy.

The management and treatment of women with glomerulonephritis is carried out jointly by an obstetrician-gynecologist and a nephrologist. In addition to primary hospitalization in the early stages of pregnancy, inpatient treatment is indicated at any time in case of deterioration in the general condition, signs of a threatened abortion, late preeclampsia, hypoxia and fetal hypotrophy.

In the period of 36-37 weeks, planned hospitalization in the department of pathology of pregnant women is necessary to prepare for childbirth and choose the method of delivery. An indication for early delivery is an exacerbation of chronic glomerulonephritis, accompanied by impaired renal function (decrease in daily diuresis, glomerular filtration, renal blood flow, impaired protein metabolism, increased azotemia, increased blood pressure, addition of severe forms of late preeclampsia, lack of effect from the treatment). Assign the preparation of the birth canal and generally accepted schemes of labor induction. In childbirth, antispasmodics, analgesics are used, and bleeding is prevented. The II period of labor is carried out depending on the numbers of blood pressure, the condition of the fetus (controlled hypotension, obstetric forceps, perineotomy). Caesarean section in pregnant women with glomerulonephritis is rarely performed, mainly for obstetric indications. In the postpartum period, if the condition worsens, the puerperal is transferred to a specialized hospital, in the future she is under the supervision of a therapist or nephrologist.

2.3. STONE DISEASE (ICD)

This pathology occurs in 0.1-0.2% of pregnant women and puerperas. In the development of ICD, a role is played by: a change in phosphorus-calcium metabolism, a violation of the metabolism of uric and oxalic acid, an expansion of the ureters and pelvis, a decrease in their tone, difficulty in outflow and an increase in urine concentration - all this contributes to the formation of stones. Infection plays a big role. Chronic pyelonephritis is complicated by urolithiasis in 85% of pregnant women, in 80% pyelonephritis joins urolithiasis. Often the disease is first detected during pregnancy.

Surgical treatment of KSD in a planned manner in pregnant women is not performed. Women are urgently operated on with the presence of long-term non-stopping renal colic, the presence of anuria, an attack of acute pyelonephritis, and when by catheterization of the pelvis, it was not possible to restore the outflow of urine.

For this purpose, the following medications are used to relieve an attack of renal colic: 2% solution of promedol 1.0 IM, 50% solution of analgin 2.0 ml IM, baralgin 5 ml, 2.5% halidor solution 2.0 ml, 2% papaverine solution, 2% NO-SHPY solution 2 ml, 1% diphenhydramine solution, 2-2.5% pipolfen 2 ml. Cystenal 20 drops, Avisan 0.05 3 times a day. The appointment of a diet that prevents the formation of stones.

2.4. KIDNEY ANOMALIES AND PREGNANCY

Clinical forms of anomalies: kidney dystopia, double kidney, aplasia of one kidney, horseshoe kidney. In all pregnant women with uterine malformation, it is necessary to examine the urinary system to identify possible anomalies in the development of the kidneys. Establishing a diagnosis is not difficult due to intravenous urography. The issue of pregnancy management is decided depending on the type of kidney anomaly and the degree of preservation of their function. The most unfavorable form of anomaly is considered a polycystic kidney. It is extremely rare, but, as a rule, its function is impaired, so the issue of maintaining pregnancy should be decided individually, taking into account the degree of renal dysfunction. With aplasia of one kidney, the function of the second kidney should be well examined. If it is completely preserved, the pregnancy can be left. The same tactic should be used when establishing a horseshoe-shaped or doubled kidney in a pregnant woman. With a dystopic kidney, the management of pregnancy and childbirth depends on its localization. If it is located above the nameless line, i.e. in the pelvic area, spontaneous natural childbirth is quite acceptable. If the kidney is located in the small pelvis, then it can become an obstacle to the normal course of the birth act, or undergo serious injury during childbirth. Therefore, the issue of managing pregnancy and childbirth is decided in advance.

3. VIRAL HEPATITIS AND PREGNANCY

Currently, the number of viral infections, including sexually transmitted diseases, is increasing. Although viral hepatitis is relatively rare, pregnant women fall ill with it 5 times more often than non-pregnant women, which can be explained by the high susceptibility of the body of pregnant women to the infectious hepatitis virus due to changes in liver function, weakening of the body's immune forces. In pregnant women, viral hepatitis is more severe than in non-pregnant women and poses a serious danger to the mother and fetus. Pregnant women with this disease are at high risk.

To prevent infection of newborns, all pregnant women should be screened for the presence of HBsAg early and at 32 weeks of gestation. Childbirth in parturient women with acute viral hepatitis B is carried out in specialized infectious diseases hospitals. Pregnant women with chronic hepatitis B and carriers of HBsAg should give birth in specialized departments of maternity hospitals with strict adherence to anti-epidemiological measures.

Artificial termination of pregnancy is contraindicated in the acute stage of all viral hepatitis.

With the threat of interruption, therapy should be carried out aimed at maintaining the pregnancy. Up to 12 weeks, at the request of a woman, an abortion can be performed at the end of the icteric stage. In all other cases, abortion is carried out according to vital signs: bleeding during placental abruption, the threat of uterine rupture. Miscarriage in hepatitis is observed up to 30%. The most severe complication, according to many authors, is maternal mortality (reaching up to 17% during epidemics) and bleeding in the afterbirth and early postpartum periods (3-5%). Bleeding is associated with a violation of the components of the coagulation and anticoagulation systems of the blood (hypocoagulation, thromboplastic activity). It has been established that in severe cases of VH, DIC can develop, in which hemorrhages are preceded by hypercoagulability.

GV can have an adverse effect on the fetus and newborn. As a result of inhibition of cellular metabolic reactions, morphological and ultrastructural changes occur in the placenta, which in turn leads to impaired feto-placental circulation. As a result, malnutrition, fetal hypoxia and asphyxia of the newborn develop. A significant frequency of birth of premature babies is the cause of high perinatal mortality (10-15%). In case of a pregnant VG disease in the early stages of pregnancy, fetal damage (malformations, developmental anomalies) may occur, and in the case of a disease in the II and III trimesters, stillbirths. Pregnant women with VH should be under the constant supervision of an obstetrician-gynecologist, whose main task is to prevent early termination of pregnancy.

In severe forms of CH, spontaneous termination of pregnancy can lead to worsening of the course of CH, up to the development of coma and death of the patient.

4. ENDOCRINE DISEASES AND PREGNANCY

In recent years, an increase in the frequency of endocrine diseases associated with pregnancy can be noted. This is due to the success of clinical endocrinology, which allowed to restore disturbed ovulation and contribute to the onset of pregnancy.

However, during pregnancy, endocrine diseases proceed differently, and pregnancy and childbirth itself have characteristic complications. It should be remembered that hormonal disorders in the mother inevitably affect the development of the fetus and child. In this case, the greatest damage in the fetus-newborn occurs precisely in the endocrine system that is affected in the mother.

4.1. diabetes and pregnancy

In the last two decades, there has been an increase in the number of pregnant women with diabetes. Currently, 0.1-0.3% of women give birth with this pathology, and at the same time, 2-3 women out of 100 have carbohydrate metabolism disorders during pregnancy.

All pregnant women with identified impaired glucose tolerance should be registered. Assign a diet poor in carbohydrates, and repeat the test for glucose tolerance. If its violations are detected on the background of the diet, small doses of insulin are prescribed, if necessary, and the glycemic and glucosuric profiles are repeatedly re-examined during pregnancy.

In childbirth and the postpartum period, early, carbohydrate metabolism also changes. During childbirth, large energy expenditures occur, which requires a sufficient amount of glucose. At the same time, metabolic acidosis occurs more easily, which can turn into diabetic. This requires special management and use of insulin preparations.

In the early postpartum period, glucose tolerance increases, and at its high cost, hypoglycemia may occur. In the late postpartum period and during lactation, the need for insulin is less than before pregnancy. These are some of the features of the course of diabetes during pregnancy.

Treatment of PTB in pregnant women with DM is carried out according to general rules, but requires careful use of neuroleptics (chlorpromazine, droperidol), especially with a tendency to hypoglycemia and diuretics. The ineffectiveness of PTB therapy against the background of diabetes requires termination of pregnancy;

during pregnancy with diabetes, an infection easily joins, especially of the urinary system (up to 20%), and this also causes a high frequency of postpartum infectious complications;

almost every fourth pregnant woman with diabetes develops polyhydramnios, which is combined with PTB, fetal deformities and is accompanied by a high perinatal mortality of up to 30%. The development of polyhydramnios in diabetes is not only a consequence of a high concentration of glucose in the amniotic fluid, but also vascular lesions of the uterus and impaired paraplacental metabolism.

In childbirth, complications associated with diabetes also occur, which increase the frequency of surgical interventions in childbirth and perinatal mortality:

1. weakness of tribal forces and protracted course of childbirth associated with a violation of energy exchange, a large fetus;

2. fetal hypoxia due to specific uteroplacental insufficiency due to vascular damage.

Therefore, in the presence of diabetes during pregnancy, the question of the admissibility of its preservation and bearing should be resolved first. This is possible only with full compensation of diabetes.

Contraindications for pregnancy are:

1. the presence of DM in both parents;

2. insulin resistant diabetes with a tendency to ketosis;

3. juvenile diabetes complicated by angiopathy;

4. combination of diabetes with Rhesus conflict and active tuberculosis.

As noted above, pregnancy can be continued with full compensation for diabetes. The occurrence of decompensation at any stage of pregnancy is an indication for its termination.

Compensation for diabetes is achieved by the appointment of a diet and insulin therapy.

Given the staging of the course of diabetes during pregnancy and its possible complications, hospitalization is necessary to select the dose of insulin at 10 weeks, 20-24 weeks, 28-32 weeks - the risk of PTB, at 34 weeks to prepare for childbirth. Undoubtedly, with any complication of pregnancy, a pregnant woman should be hospitalized (threatened abortion, polyhydramnios, PTB, intrauterine fetal hypoxia, etc.). In the w / c, a pregnant woman is observed by an obstetrician-gynecologist and an endocrinologist in the first half once every 2 weeks, and then weekly.

At the last hospitalization, the issue of the timing and method of delivery should be resolved. Due to the increasing placental insufficiency by the end of pregnancy, the risk of antenatal fetal death increases. At the same time, the fetus reaches a large size, which increases the frequency of discrepancies between the size of the fetal head and the mother's pelvis. All this dictates the need for early delivery at 35-36 weeks. But the fetus remains functionally immature.

The choice of method of delivery is determined by the size of the fetus and mother's pelvis, pregnancy complications, the condition of the fetus and complications of childbirth (weakness, anhydrous period). Preference is given to delivery through the natural birth canal, but taking into account the combined indications, the frequency of delivery by caesarean section in pregnant women with diabetes is quite high.

During childbirth, insulin therapy is carried out with fast-acting drugs under the control of blood sugar in 2-4 hours. The sugar level should be in the range of 120-150 mg%. In the early postpartum period, the blood sugar content is determined after 2 hours, so as not to miss hypoglycemia.

List of used literature

1. Barashnev Yu. I. Pathogenetic bases of perinatal lesions of the fetus // Obstetrics and gynecology. - 1993. - No. 3. - S.14-18;

2. Burduli G.M., Frolova O.G. reproductive losses. - M.: Triada-X, 2001. - 188 p.

3. Savelyeva G.M. Ways to reduce perinatal morbidity and mortality // Bulletin of the Russian Association of Obstetricians and Gynecologists.- 1998.- No. 2.- 1998.- P.2-9

For pregnant women, the issue of extragenital diseases during childbearing is very acute.

According to statistical medical data, extragenital pathologies are the most common causes of death in women in labor and babies.

Diseases of an extragenital nature are diseases of an acute infectious, surgical, therapeutic type that occur during pregnancy and are not associated with gynecological pathologies and obstetric consequences.

The extragenital nature means that diseases can affect completely different systems of women's health.

The most dangerous extragenital pathologies are:

• Appendicitis.
• Diabetes.
• Infectious hepatitis.
• Diseases of the cardiovascular system.
• Tuberculosis.
• Pyelonephritis.
• Cholecystitis.

These diseases pose a serious threat to the health of the mother and her fetus. Extragenital deviations are considered very dangerous for the reason that they may not cause visible manifestations, but appear simultaneously. In this case, surgical intervention may be necessary.

Consider the impact of different types of extragenital diseases and the risks from them in more detail.

Pathologies of the cardiovascular system

Even in completely healthy women in labor, there is a risk of developing abnormalities in the activity of the cardiovascular system during gestation.

This risk is due to the following factors:

1. The woman is actively gaining weight (in some cases, the patient's body weight increases too quickly or excessively).
2. Intra-abdominal pressure increases with the development and growth of the fetus.
3. The volume of circulating blood also increases.
4. The speed of metabolic processes increases.

All these factors combined put an excessive strain on the heart. For those women who had heart disease or other types of heart failure before pregnancy, there is a high risk of exacerbation and deterioration of health during pregnancy.

Consider in the table how exactly it can worsen at different stages of pregnancy:

Pregnancy period	Description
From 1st to 16th week.	Exacerbation of rheumatic heart disease. Against its background, a woman begins to worry about toxicosis very early.
From the 17th to the 34th week.	The load on the heart muscle increases. There is an increase in the minute and systolic volume of the heart. The viscosity of the blood decreases quite a lot. tends to go down.
From the 35th week until the start of contractions.	The pressure on the heart increases even more due to the weight gain of the pregnant woman. The diaphragm changes its position and rises, the shape of the chest itself also changes. Quite often, in a position when a woman lies on her back, she may experience compression of the inferior vena cava. This happens because there is a large increase
From the first contractions to the birth of a child.	Childbirth is a huge burden on the heart. Systolic and minute volume of the heart increase several times. Blood pressure also rises many times over.
The period after childbirth.	Quite often in the postpartum period there is a significant exacerbation of rheumatic heart disease.

It is worth noting that a particularly threatening situation for a woman in labor is prolonged labor with unbearable labor pains.

If a pregnant woman has hypertension, then this diagnosis can even cause an artificial termination of pregnancy. This decision will depend on the severity of hypertension in each individual patient.

The course of hypertension during pregnancy can be complicated by the following symptoms:

• Early and late toxicosis.
• Placental abruption may occur prematurely.

In order for patients, doctors strongly recommend that women undergo an examination at least once a week.

In order to prevent fetal death due to premature detachment of the placenta, in the last three weeks before delivery, a patient with hypertension must be placed in a hospital for observation.

Hypertension is also on intrauterine development of the fetus. In patients with this diagnosis, the fetus may lag behind in development and be born with a lower weight.

How blood diseases can affect the course of pregnancy

Among all diseases of the circulatory system, women in labor most often have problems with iron deficiency anemia. In addition to the fact that a pregnant woman is uncomfortable, with a number of her symptoms, she can also contribute to the development of a number of other pathologies:

• Sinusitis.
• Increased infection with infectious diseases.
• spontaneous abortion.
• Risk of preterm birth.

In the second half of pregnancy, a woman may be disturbed by hypochromic anemia. It is manifested by such symptoms:

1. Dyspnea.
2. Headaches.
3. Fast fatiguability.
4. Excessive pallor of the skin.

With this type of anemia, the hemoglobin level is less than 90 g/l, and a reduced number of red blood cells.

Very rarely, but still there are cases of pregnancy with leukemia. With this disease, the mother's condition during pregnancy may even improve. But after childbirth, there is a high risk of death of the mother.

What threatens tuberculosis

According to medical statistics, the onset of pregnancy with tuberculosis leads to an exacerbation of the disease and poses a serious threat to the health of the patient.

Only in very rare cases, women can. In this case, patients must undergo systematic treatment in a special tuberculosis dispensary.

The table lists the main indications for which it is imperative to terminate a pregnancy:

Abortion for tuberculosis is better and safer for the patient to carry out up to 12 weeks. A later termination of pregnancy threatens the patient with complications of tuberculosis.

Appendicitis during pregnancy - what to do?

Gynecologists note that appendicitis during pregnancy can occur quite often.

The acute and chronic form of appendicitis can manifest itself as. As a rule, the risk of this disease threatens from the 5th to the 20th week and from the 29th to the 32nd week of pregnancy.

The operation on appendicitis carries such threats for the course of pregnancy:

• Infection in the blood during surgery.
• Complications from general anesthesia.
• Risk of preterm birth.

Pyelonephritis as an extragenital disease

Pyelonephritis can also be diagnosed quite often during pregnancy.

This disease carries

1. Increased retching.
2. Increase in body temperature.
3. Chills.
4. Pain that radiates to the groin.

Cholecystitis is a common pathology during pregnancy.

During gestation, a disease such as cholecystitis can also develop. It can also deliver in the form of the following symptoms:

• Pain in the stomach.
• Rapid pulse.
• Nausea and vomiting.
• An increase in temperature by 1 - 1.5 degrees.

Is diabetes dangerous during pregnancy?

A woman with diabetes, if all the doctor's instructions are followed, can calmly go through the pregnancy period and give birth to a healthy child.

However, if you deviate from the doctor's recommendations and a sharp jump in sugar levels, a woman may experience the following negative consequences for pregnancy:

1. spontaneous nature (miscarriage).
2. Fetal hypoxia.
3. Toxicosis in late pregnancy.
4. perinatal death.

What can infectious hepatitis lead to during pregnancy?

Infectious hepatitis is very dangerous for the life of a pregnant woman.

This disease can lead to the death of a woman in labor.

For a child, this disease is almost 100% fatal. Pregnancy or ends in miscarriage. In cases where a miscarriage does not occur and the child may not be born viable. The fetus is diagnosed with asphyxia and malnutrition (these diagnoses are not compatible with life).

Extragenital diseases that manifest themselves during pregnancy are the main cause of death for both newborns and women themselves. During pregnancy, situations often arise that require medical intervention; some of the diseases, such as hypertension, do not cause visible discomfort, however, they also require treatment - only in this case, the mother and child will be out of danger.

Among extragenital diseases during pregnancy, the most dangerous for doctors are diseases of the cardiovascular system, blood diseases, tuberculosis, infectious hepatitis, cholecystitis, diabetes mellitus, pyelonephritis and appendicitis.

During pregnancy, an increase in body weight occurs, the volume of blood circulating in the body increases, intra-abdominal pressure increases, metabolic processes increase significantly, which creates a huge load on the heart even in healthy women. If a pregnant woman also has heart disease or hypertension, this is a serious problem for the further development of pregnancy.

Of the blood diseases during pregnancy, iron deficiency anemia is the most common. This type of anemia is provoked by frequent infectious diseases, sinusitis, spontaneous abortions or a history of premature birth.

In the first period, lasting up to 16 weeks of pregnancy, women with heart defects experience an exacerbation of rheumatic heart disease; the course of pregnancy is complicated by the phenomena of early toxicosis.

In the second period (17-34 weeks of pregnancy), the load on the heart increases. At this time, there is a sharp decrease in hemoglobin in the blood; blood viscosity decreases, systolic and minute volumes of the heart increase.

The third period lasts from the 35th week until the onset of labor. The body weight of a pregnant woman increases greatly. The shape of the chest changes, the diaphragm rises. A greatly enlarged uterus when the pregnant woman is lying on her back causes a state of collapse, since at this moment the inferior vena cava is compressed. During this period, some pregnant women show symptoms of late toxicosis.

The fourth period begins with the onset of childbirth and ends with the birth of the fetus. In connection with the huge loads, blood pressure rises, and the systolic and minute volumes of the heart increase many times over. With severe labor pains and prolonged labor, the position of the pregnant woman becomes threatening. During childbirth, many women ask for local painkillers to relieve pain in the uterus.

The postpartum period is often characterized by exacerbation of rheumatic heart disease. This disease is especially difficult against the background of iron deficiency anemia and infectious diseases.

With hypertension, women often have to decide on the artificial termination of pregnancy. This extreme measure depends on the severity of the disease. There are 3 stages of hypertension. In the first stage, transient hypertension alternates with periods of normal pressure. In the second stage, there is an increase in blood pressure. At the third stage of hypertension, dystrophic changes are recorded in the internal tissues and organs of the patient.

The condition of pregnant women suffering from hypertension is complicated by symptoms of late toxicosis, as well as premature detachment of the placenta, often leading to fetal death.

The doctor warns the pregnant woman that her condition can quickly deteriorate, so the woman is obliged to come for an examination at least once a week. 3 weeks before delivery, a pregnant woman with a history of hypertension must be sent to a hospital.

Hypotension during pregnancy is less dangerous than hypertension. Usually pregnant women complain of general weakness, tinnitus, discomfort in the heart area. Some may experience a rapid pulse and cold sweats. With arterial hypotension, early and late toxicoses are noted and premature termination of pregnancy occurs.

Hypochromic anemia occurs most often in the second half of pregnancy, and disturbing or pronounced symptoms are not observed. Pregnant women complain of increased fatigue, headache or shortness of breath. Only with a pronounced form of iron deficiency anemia is there a significant pallor of the skin. A blood test for hypochromic anemia indicates a low content of hemoglobin (less than 90 g / l) and iron, as well as a decrease in the number of red blood cells.

Hypertension during pregnancy can cause stunted intrauterine growth, leading to the birth of a small child.

A blood disease such as leukemia is quite rare during pregnancy. It has been established that a history of leukemia leads to the death of a woman in the postpartum period, although directly during pregnancy, thanks to the fetus, a favorable balance is created in the mother's body.

Pregnancy against the background of tuberculosis causes an exacerbation of this pathological process. Fibrous-cavernous, infiltrative and disseminated pulmonary tuberculosis is especially difficult.

With the systematic passage of treatment in a tuberculosis dispensary, the patient sometimes manages to keep the pregnancy. Nevertheless, there are absolute indications for immediate termination of pregnancy:

Fibrous-cavernous pulmonary tuberculosis;

Tuberculosis of the spine and pelvis in an active form;

active form of tuberculosis.

In this case, artificial termination of pregnancy should be undertaken for up to 12 weeks, since late abortion most often leads to activation of the underlying pathological process.

If the pregnancy proceeds against the background of infectious hepatitis, it is fraught with a fatal outcome. Often such a pregnancy is spontaneously interrupted. If a child is born on time, he is usually not viable, prone to asphyxia and malnutrition.

Pregnancy can also provoke such a common disease as cholecystitis. With an exacerbation of the disease, pregnant women are concerned about colic in the upper right abdomen, a feeling of squeezing in the right hypochondrium and in the stomach area. Nausea, vomiting, a slight increase in body temperature and a rapid pulse are also noted.

Diabetes during pregnancy is not particularly dangerous, but it should be treated so that both mother and child feel comfortable. With symptoms of diabetes, pregnant women complain of increased thirst and appetite, dry mouth, and a feeling of rapid fatigue. For a correct diagnosis, a woman is sent to a laboratory to detect high blood sugar and urine.

In patients with diabetes mellitus during pregnancy, late toxicosis, spontaneous abortion, and fetal hypoxia are often observed.

There are also violations of water-salt, fat, protein and carbohydrate metabolism. Subsequently, this can lead to perinatal mortality. After birth, children of mothers with diabetes have a characteristic appearance: they have increased body weight and a pronounced disproportion between the size of the head and body.

In the first half of pregnancy, patients with diabetes often experience a decrease in blood sugar, the condition is assessed as satisfactory. However, in the second half of pregnancy, the picture changes, the level of sugar in the blood and urine of a pregnant woman increases sharply. In this case, there is a serious risk of acidosis, and then - diabetic coma.

Relatively often against the background of pregnancy, acute and chronic pyelonephritis is noted. With this disease, pregnant women complain of pain in the lumbar region, which radiate to the groin, a sharp rise in temperature and chills, and occasionally vomiting.

Acute and chronic appendicitis as an exacerbation of pregnancy is quite common in clinical practice. Appendicitis manifests itself mainly at the 5th-20th and 29th-32nd weeks of pregnancy. The risk of possible complications after an appendicitis operation is associated primarily with the use of general anesthesia, infection and the risk of preterm labor.

Symptoms of appendicitis: complaints of severe pain in the right iliac region. The tongue is moist and slightly coated, the body temperature is slightly elevated, the pulse is quickened. Palpation of the right iliac region causes pain and tension in the abdominal muscles. In chronic appendicitis, pain in the right side of the abdomen is constant, dull, and often accompanied by nausea and vomiting.

Treatment of extragenital pathologies

At the beginning of the first trimester of pregnancy, the doctor determines the nature of the existing cardiac pathology. It should be remembered that the load on the heart especially increases at the 27th week of pregnancy, therefore, with an increase in heart failure and an increase in the activity of the rheumatic process, the question of terminating the pregnancy is raised. If a woman decides to keep the pregnancy, she is necessarily placed in a hospital, where regular monitoring of cardiac activity is carried out and cardiac and antirheumatic therapy is carried out.

All pregnant women with heart defects must be prescribed electrocardiography, phonocardiography, chest x-ray. Pregnant women with heart defects should follow the established regimen of the day and rest, perform sets of therapeutic exercises.

Pregnant women with a history of hypertension are prescribed sedative drugs: valerian infusion, 1 tbsp. spoon 3 times a day, 30-50 ml of Diphenhydramine 3 times a day. In the last few weeks of pregnancy, seduxen is indicated in an amount of 5 mg 2 times a day. The doctor also prescribes antispasmodics and vasodilators: papaverine 0.04 g 3 times a day, dibazol 0.02-0.04 g 3 times a day. If, despite the treatment, the patient's condition does not improve, then she has to be hospitalized and the issue of artificial termination of pregnancy should be decided.

With reduced pressure, pregnant women are prescribed the following remedies:

Ginseng tincture 20 drops 3 times a day, taken 30 minutes before meals;

Intravenously 20 ml of a 40% glucose solution in combination with 4 ml of a 5% solution of ascorbic acid;

Intramuscularly 0.01 g mezaton up to 3 times a day. Ultraviolet irradiation and oxygen therapy are also shown. The course of treatment is 10 days, if necessary, it is repeated.

In severe cases, deoxycorticosterone acetate or prednisolone tablets are prescribed, but it should be remembered that corticosteroids actively penetrate the placental barrier, so their administration is unacceptable in early pregnancy.

With the threat of vascular collapse, such remedies as Chinese ginseng and magnolia vine, as well as mezaton and ephedrine are indicated.

With hypochromic anemia, a pregnant woman is recommended a high-calorie diet rich in proteins, minerals and vitamins. Reduced iron preparations are shown from 3 to 6 g per day, taken 30 minutes after a meal in combination with ascorbic acid, with 0.1 g of ascorbic acid per 1 g of iron. Daily intramuscular administration of 100 μg of vitamin B 12 is practiced. If the condition of the pregnant woman does not improve, the doctor sends her to the hospital. During pregnancy, the doctor prescribes to the woman a complex of prenatal vitamins, which is important to take not only before childbirth, but also during breastfeeding.

Women suffering from leukemia are referred for artificial termination of pregnancy only in the early stages. In the later stages, it is useless to terminate a pregnancy, since with the cessation of the beneficial effect of the fetus on the hematopoiesis of a woman, her condition will deteriorate rapidly and irreversibly.

Pregnant women with tuberculosis are treated in a tuberculosis hospital. The doctor prescribes them the following drugs: PASK, tubazid, streptomycin, isoniazid, vitamins B 1 , B 6 , C. In severe cases, cycloserine and ethionamide are indicated.

Treatment of pregnant women suffering from infectious hepatitis should be carried out in an infectious diseases hospital. If the disease is in an acute stage, then it is not recommended to terminate the pregnancy at this stage.

Treatment of cholecystitis during pregnancy is carried out exclusively in a hospital. If the course of extragenital disease is not complicated, there is a possibility of maintaining pregnancy. In the event that cholecystitis manifests itself with frequent attacks, it would be more appropriate to resolve the issue of terminating the pregnancy.

pages: 5-11

Part I. Definition, systematization, clinical significance and problems associated with extragenital pathology

IN AND. Medved, Doctor of Medical Sciences, Professor, Head of the Department of Internal Pathology of Pregnant Women, State Institution "Institute of Pediatrics, Obstetrics and Gynecology of the National Academy of Medical Sciences of Ukraine"

Untitled

Extragenital pathology(EGD) is a large group of diverse and different diseases, syndromes, conditions in pregnant women, united only by the fact that they are not gynecological diseases and obstetric complications of pregnancy.

Such a definition of EGP as a group of diverse and different nosologies shows the failure of this term, since its collectiveness is based on the principle of "from the opposite": nosologies are united by the fact that "they are NOT ...". This leads to a more important drawback: EGP combines pathologies that, outside of pregnancy, fall within the competence of completely different specialists - representatives of many independent clinical disciplines. Nevertheless, the author considers the term "extragenital pathology" useful and has a deep clinical meaning. This meaning lies in the allocation of a section of obstetrics, which is not the exclusive competence of an obstetrician-gynecologist. In other words, the classic tandem “doctor and patient” in the EGP clinic is transformed into an obligatory trio “two doctors and a patient”, namely, an obstetrician-gynecologist, a specialist in the profile of extragenital diseases of a pregnant woman, and a pregnant woman herself. In many cases, this specialist can be a therapist who has experience working with pregnant women, who knows the physiology of pregnancy and the characteristics of the course of diseases during the gestational period. Such therapists need to be specially trained, they should be included in the staff of antenatal clinics, maternity hospitals, and even more so in the staff of specialized departments of the EGP of pregnant women. However, when it becomes necessary to provide a pregnant patient with highly qualified medical care (for example, performing a cardiac or neurosurgical operation, performing hemodialysis, changing the method of hypoglycemic therapy, eliminating urodynamic disorders, etc.), a narrow specialist is naturally involved.

It is believed that the prevalence of EGP among pregnant women is increasing. Meanwhile, there are no strict statistics based on epidemiological studies in our country. For those diseases for which there are official data of the Ministry of Health of Ukraine, on the contrary, in recent years there has been a stabilization or even a downward trend in indicators. So, if in 2003 anemia was observed in 38.4% of pregnant women, then in 2010 - in 26.4%, diseases of the circulatory system - in 6.7 and 6.2%, genitourinary system - in 16.7 and 14.6% of women, respectively. At the same time, the prevalence of all types of EGP in the pregnant population is very high and (despite the young age) is at least 50%.

Since EGP includes a huge number of different diseases, it is very important for clinical purposes to divide it into significant and insignificant, or, more precisely, into insignificant. Insignificant or insignificant types of PEG include those diseases or conditions in which maternal and perinatal mortality rates, the incidence of complications in pregnancy, childbirth and the postpartum period, and perinatal morbidity do not differ from the general population. In other words, this is a pathology that practically does not affect the course and outcomes of pregnancy, the condition of the fetus and newborn.

Significant PGE is a large group of diseases or conditions that affect the above indicators to varying degrees.

The main danger of EGP is that it can cause maternal death. Below we will dwell separately on this most unfavorable variant of the clinical significance of this pathology, and here we will only indicate that there are diseases in which the risk of pregnancy for a woman's life is prohibitively high. And this applies even to those countries where modern medicine, as they say, works wonders. First of all, this applies to the syndrome of extremely high pulmonary hypertension (maternal mortality reaches 50%), cyanotic congenital heart defects, dilated cardiomyopathy, pheochromocytoma, acute leukemia, and some other diseases. Of course, mitral stenosis, pneumonia, and viral hepatitis B, and tuberculosis, and diabetes mellitus (the list could go on for a very long time) can lead to maternal death, but in these cases, in addition to the disease itself, most likely, a significant role is played by unqualified actions of doctors or inappropriate behavior of a woman (self-medication, late visit to a doctor, refusal of offered help).

EGP can significantly affect the condition of the fetus and thus increase perinatal morbidity and mortality. The most perinatally significant pathologies include diabetes mellitus, arterial hypertension, glomerulopathy, uncompensated thyroid dysfunction, and others.

EGP often leads to the development of obstetric complications during pregnancy and childbirth, and may also necessitate an unnatural abdominal method of delivery, which also significantly increases the likelihood of many complications.

As already mentioned, EGP is a wide variety of diseases. Therefore, there is an urgent need to systematize them. From our point of view, the entire EGP can be divided into non-pregnancy-related, or primary, and pregnancy-related, secondary (Fig. 1). The first, in turn, is divided into chronic, which existed before the onset of pregnancy, and acute, which first occurred during pregnancy. Chronic EGP is represented by many diseases, among which the most important in obstetrics are cardiovascular, bronchopulmonary, liver, kidney, endocrine, etc. Acute EGP includes infectious diseases, pneumonia, surgical diseases, hemoblastoses. Of course, during pregnancy, a woman can develop any other disease, incl. one that will persist in the future, turning into a chronic form (glomerulonephritis, systemic lupus erythematosus, thyrotoxicosis, etc.), however, for the EGP clinic, it is acute, first occurring in a previously healthy woman.

A special group is secondary EGP, which includes conditions that are etiologically associated with pregnancy and, as a rule, disappear after its completion. In most cases, it is known due to what anatomical, physiological or biochemical changes inherent in pregnancy itself, this or that condition occurs. This secondary nature in relation to pregnancy is also emphasized in the very names of these conditions by the presence of the term "pregnancy" or a derivative of it. The most common and most significant types of secondary PHE are: anemia of pregnancy, gestational hypertension, gestational diabetes, gestational pyelonephritis, thrombocytopenia of pregnancy, cholestatic hepatosis of pregnancy (obstetric cholestasis), acute fatty liver, peripartum cardiomyopathy, diabetes insipidus of pregnancy, dermatosis of pregnancy (many variants exist). associated with pregnancy dermopathy, each of which has its own name), gestational hyperthyroidism, glycosuria of pregnancy, gingivitis of pregnancy.

To a certain extent, this list can include specific postpartum extragenital diseases, since in their etiology the main role is played by changes that develop during pregnancy or childbirth. The best known are postpartum thyroiditis, lymphocytic hypophysitis, and pituitary infarction (Sheehan's syndrome).

It is important to emphasize that all these conditions - frequent and rare, deadly and prognostically favorable, affecting perinatal losses and not affecting - are within the competence of a therapist, a specialist in EGP.

Problems related to EGP

The word "problems" in this case should be understood in the literal sense, i.e. as complex, often contradictory situations that require study and adequate resolution. Therefore, I will try to determine what clinical problems actually arise during pregnancy due to the presence of EGP, which of them exist objectively, and which are of iatrogenic origin, and whether there is an acceptable solution to these problems today.

Systematizing the problems caused by the EGP, we can propose the following scheme (Fig. 2). Conventionally, all of them are divided into maternal and perinatal, and maternal, in turn, into therapeutic (or, more precisely, somatic) and obstetric.

Therapeutic (somatic) problems arise due to: the negative impact of pregnancy on the course of extragenital disease, objective complexity, more precisely complications compared to the period outside of pregnancy, clinical diagnosis, limited diagnostic and therapeutic options due to the presence of the fetus.

Obstetric problems are caused by: the influence of the disease (specific and non-specific) on the course of pregnancy, childbirth and the postpartum period, the occurrence of specific obstetric risks associated with the nature of EGP, the need in some cases for termination of pregnancy or early delivery, and the use of a special method of delivery that is not associated with obstetric situation.

Perinatal problems arise due to the influence of the disease itself on the fetus, the harmful effects of drugs and prematurity.

Let's dwell on each of these objectively existing problems.

The negative impact of pregnancy on the course of EGP. The physiological course of pregnancy is characterized by significant, term-dependent, often phase functional and metabolic changes, which by their nature can be unfavorable for various somatic diseases. The adverse effect of normal gestational hemodynamic changes on the course of most heart diseases is best known. So, during pregnancy, the volume of circulating blood and cardiac output increase significantly, which contributes to the occurrence or progression of hemodynamic decompensation in mitral, aortic and pulmonary stenosis, dilated cardiomyopathy, myocarditis, myocardiofibrosis. Peripheral vascular resistance decreases, which leads to increased venous blood shunting in malformations with right-left shunt, i.e. to increased cyanosis, hypoxemia, shortness of breath and, in general, to a significant deterioration in the already severe condition in such diseases. The same factor leads to a decrease in the stroke volume of the left ventricle in hypertrophic cardiomyopathy, which directly leads to an increase in heart failure. For many heart diseases, manifestations normal for pregnancy, such as an increase in heart rate, expansion of the heart cavities and a change in its topography in the chest cavity, a decrease in plasma oncotic pressure, physiological hypercoagulation and hemodilution, aortocaval compression and
a number of others.

It is rightly believed that pregnancy destabilizes, makes the course of diabetes mellitus more labile. “Guilty” of this are the appearing placental hormones and the level of conventional hormones that significantly increase during pregnancy, which have a contra-insular effect (placental lactogen, estradiol, prolactin, cortisol). Fetal glucose intake contributes to the normal reduction in fasting glycemia in non-diabetic patients. Fetal development also requires higher postprandial glycemia with a slower return to baseline glucose concentration. Pregnancy is generally characterized by a state of insulin resistance. It should also be noted significant changes in the need for insulin at different times of the gestational period, which creates conditions for hypoglycemia (in the first trimester and after 36-37 weeks), hyperglycemia and ketosis.

Pregnancy contributes to the progression of varicose veins and chronic venous insufficiency, the increase in venous thrombotic complications. There are quite a few reasons for this. In connection with the increase in the concentration of progesterone, the tone of the venous wall decreases, the diameter of the veins increases; hydrostatic pressure increases in the veins of the lower extremities and small pelvis, as intra-abdominal pressure rises, compression of the inferior vena cava occurs, and as a result, venous blood flow slows down. In connection with hyperestrogenemia, vascular permeability increases and, accordingly, the tendency to edema; the concentration of fibrinogen, VIII and a number of other blood coagulation factors increases, its fibrinolytic activity decreases, and after childbirth a significant amount of tissue factor enters the blood.

More frequent manifestation of urinary tract infections in pregnant women contribute to the expansion of the ureters due to the muscle relaxant action of progesterone; mechanical difficulty in urodynamics (mainly on the right) due to compression of the ureters by the pregnant uterus and ovarian veins; increase in urine pH; the appearance of sometimes vesicoureteral reflux; increase in the volume of the bladder; hypercortisolemia, etc.

If this lecture were dimensionless, then it would be possible to describe many other options for the adverse effects of pregnancy on the course of various EGP. However, we confine ourselves to the above examples and note that this problem is absolutely objective, the doctor cannot change anything in the influence of the gestational process on the disease. Nevertheless, he can and even must know what this influence is, at what time it is most significant, and be ready to respond adequately.

In fairness, we note that pregnancy favorably affects the course of a number of diseases, contributing to their transition into remission and even reducing the need for treatment (rheumatoid arthritis, peptic ulcer of the stomach and duodenum, ulcerative colitis, some types of myasthenia gravis, chronic adrenal insufficiency, heart defects with left-right shunt without significant pulmonary hypertension). But since we are discussing the problems caused by the EGP, we will not dwell on this positive aspect in detail.

Complicated clinical diagnosis during pregnancy also has objective reasons. One of them is the atypical course of the disease. This fully applies to the surgical pathology of the abdominal cavity. A classic example is the atypical localization of pain in appendicitis due to a change in the location of the appendix. The clinic of intestinal obstruction, acute pancreatitis, hepatic colic and other acute diseases may not be so bright, "blurred", in general not typical.

Another reason is the masking or, conversely, the simulation of EGP symptoms by the pregnancy itself or its complications. Signs of pheochromocytoma, a pathology with a very high maternal mortality, are often mistaken for manifestations of preeclampsia, and severe adrenal insufficiency - early preeclampsia. Tachycardia and tachypnea inherent in pregnancy, as well as moderate swelling in the legs, can be perceived as manifestations of heart failure. Phenomena similar to the clinic of a brain tumor (dizziness, nausea, headache, weakness) may well be taken as normal manifestations of pregnancy in the early stages, and convulsive syndrome, which first occurred at the end of pregnancy, for an attack of eclampsia. It is more difficult to diagnose hepatitis, since acute fatty hepatosis and obstetric cholestasis caused by pregnancy have similar signs.

During normal pregnancy, the norms of many hematological, biochemical, endocrinological and other indicators change significantly. On the one hand, it is very important that the doctor knows this and does not panic when he sees in the analysis, for example, moderate thrombocytopenia, 1.5 times increased cholesterol, 2 times increased alkaline phosphatase, or 8 times increased prolactin. On the other hand, significantly altered examination results may indeed indicate the presence of a pathology, or may be associated only with pregnancy.

Pregnancy is capable of perverting or, to put it mildly, significantly changing the physical manifestations of EGP. Functional murmurs may appear in the heart, which do not indicate anything, and murmurs of defects may weaken. Physical manifestations of pneumonia, bronchial asthma change during pregnancy, signs of pneumothorax are masked.

It is also known that the accuracy and information content of many examination methods during pregnancy decreases, and the number of false positive results increases.

Can we, doctors, influence all this? No we can not. But we must know that this happens, and we must gain experience. Only our education and experience can help, despite the objective difficulties, to establish the correct diagnosis.

Limitations of diagnostic and therapeutic options are caused not only by the presence of the fetus, for which many modern methods of diagnosis and treatment are potentially dangerous, but also by the appearance of side effects in some medicines, which, in principle, do not occur outside of pregnancy. We are talking about a stimulating or inhibitory effect on the motor activity of the uterus of drugs prescribed in connection with the EGP of the mother - β-blockers, calcium antagonists, magnesium sulfate, sympathomimetics. However, this problem is not so significant. More importantly, invasive diagnostic and therapeutic procedures performed under constant X-ray control, as well as computed tomography, mammography, scintigraphic and other research methods using radioisotopes, are still considered contraindicated for pregnant women. During pregnancy, radioiodine therapy and radiation therapy are unacceptable. Large-scale and time-consuming surgical interventions are limited. In any case, they are associated with a high risk of spontaneous abortion and damage to the fetus. And the last thing: almost most of the medicines available in the doctor's arsenal are contraindicated according to the instructions for medical use during pregnancy or at certain times of it. In general, if you do not violate these instructions, then many diseases in pregnant women cannot be treated!

This problem is the most promising and rapidly changing of all previously discussed. Contraindications to many high-tech interventions are being reviewed, indications for surgical treatment are expanding, new safe methods of diagnosis and treatment are being created. In addition, if all the above discussed problems are absolutely objective, then there is a lot of subjectivity in the problem of limited diagnostic and therapeutic possibilities. So, fibrogastroduodenoscopy, which was contraindicated two decades ago (it was believed that it could provoke abortion or premature birth), turned out to be completely safe and is very widely used today. Endovascular cardiac procedures are increasingly performed during pregnancy, and in a planned manner. At the same time, they only try to avoid irradiation of the abdominal cavity (the catheter is inserted blindly or passed through the brachial artery). The really unsafe anticancer chemotherapy and radiotherapy to the area above the diaphragm are also now often used during pregnancy, but not in the first trimester and with certain precautions (shielding of the uterus).

A very painful subjective problem is overly extended contraindications to the use of medications during pregnancy. The prudence and caution of the creators of medicines and doctors can be understood: they were taught by the sad experience of the twentieth century - the thalidomide tragedy; transplacental carcinogenesis, the manifestations of which came to light a good two decades after the use of diethylstilbestrol by pregnant women; a phenomenon called teratology of behavioral reactions, etc. But it is impossible to ignore the accumulating positive experience, it is impossible not to generalize the many thousands of observations of the use of the drug by pregnant women without consequences for the fetus and not to make adjustments to the instructions for this medicine! I personally have already addressed this topic many times, actively defended the regulatory change in the section "Use during pregnancy and lactation" in the instructions for the medical use of drugs, the introduction in Ukraine of a very convenient FDA system, which provides for the division of medicines into five categories, instead of our current one, in which has only two categories. I have to admit the futility of these efforts ...

However, we will not end such an important subsection of the lecture on a pessimistic note. Among the somatic maternal problems caused by EGP, the majority are completely objective. They can only be overcome with knowledge and experience. The problem of the limitations of our diagnostic and therapeutic capabilities is largely subjective, depends to a greater extent on us, it is gradually being resolved and becomes less acute.

Adverse effect of EGP on the course of pregnancy, childbirth and the postpartum period varied and depends on the nature and severity of the underlying disease. Many extragenital diseases predispose to the development of obstetric complications. It can be said that arterial hypertension increases the risk of premature placental abruption and eclampsia, all hemophilic conditions - early postpartum hemorrhage, diabetes mellitus - anomalies in labor, fetal distress in childbirth, shoulder dystocia, urinary tract infection - premature birth, etc.

It is important to know that there is a specific and non-specific influence of a certain disease on the frequency of a certain complication. Examples of a specific effect are polyhydramnios in diabetes mellitus, severe and early developing preeclampsia in arterial hypertension, uterine bleeding during childbirth with idiopathic thrombocytopenic purpura, late postpartum bleeding in von Willebrand disease, purulent-inflammatory processes in immunosuppressive conditions (constant use of glucocorticoids and cytostatics, HIV- infection), after splenectomy. In all these cases, patients with a specific PHE have specific obstetric risks. The unfavorable nonspecific effect of EGP is associated with the general severe condition of a pregnant woman, a woman in labor or a puerperal. In this case, the number of obstetric complications significantly increases, but there is no clear dependence of the nature of these complications on the type of EGP. So, in patients with very high pulmonary hypertension, miscarriages at various stages of pregnancy, premature birth, malnutrition, heart attacks and other pathology of the placenta, weakness or, conversely, excessively violent labor activity, postpartum endometritis, etc. can be observed. A variety of complications often occur in patients with renal failure, chronic hepatitis and cirrhosis of the liver, systemic hematological pathology, and other serious diseases.

The need for late termination of pregnancy or early delivery according to the testimony of a woman - a complex obstetric problem. Termination of a late pregnancy in itself poses a significant risk to the health, and sometimes life, of the woman. It is technically difficult to implement, especially if the patient has contraindications to the use of prostaglandins (and in most cases it happens). The means currently available in the arsenal of an obstetrician-gynecologist are clearly not enough to safely carry out late interruption in various types of severe EGP.

The need for early delivery in cases where there is no sufficient maturity of the cervix also gives rise to a complex obstetric problem. Most of the means of "cervical preparation" are ineffective. In addition, often the clinical situation does not give the doctor enough time to conduct such training. An increase in the number of cases of abdominal abortion and delivery is a bad way, since this method significantly increases the risk of thrombotic, hemorrhagic, and infectious complications. Caesarean section, as you know, is not the most sparing and gentle way of delivery for many types of EGP, and in some cases it is simply dangerous, for example, in cardiac pathology, due to very rapid and abrupt changes in hemodynamics.

What to do? There is no single recipe. In many situations, kelp sticks, intra-amniotic administration of a hypertonic solution can be used. If the only possible way to carry out an abortion or early delivery is a caesarean section, it is necessary to weigh the risks of complications and carry out prophylaxis in accordance with modern standards.

The need for an unusual method of delivery, caused not by the obstetric situation, but shown in connection with the EGP of the mother, is an objectively existing problem. It is clear that we are talking about a caesarean section, for example, in case of aortic aneurysm, portal hypertension or after a hemorrhagic stroke. Many aspects of this problem were discussed above: the risk of complications increases, but there is no choice, so this risk must be reduced through prevention. Another thing is important - not to invent non-existent evidence. This is really a big problem in our country! What just did not happen to read in the histories of childbirth ?! High myopia, peripheral retinal degeneration, mitral stenosis, atrial septal defect, severe pneumonia, leukemia, breast cancer, ulcerative colitis, myasthenia gravis, multiple sclerosis appeared as indications for a planned caesarean section ... When asked where such indications are described or, even better, are they legally fixed? - No answer. By the way, in many of these cases, women died from pulmonary edema, pulmonary embolism, bleeding, sepsis, respiratory and multiple organ failure, and other causes that caesarean section does not directly lead to, but increases their risk.

What is the way out? And the way out is simple - to be guided by the regulatory documents of the Ministry of Health of Ukraine, and not to look for indications for a serious operation on the ceiling of the intern's room. If only all EGP-related problems could be solved so easily!

Specific perinatal pathologies due to maternal disease, quite common in the EGP clinic. These are known facts, you can't describe them all. The most perinatally significant pathology is diabetes mellitus. This disease causes a diverse and very frequent fetal pathology: macrosomia, diabetic cardiopathy of the newborn, fetal distress, intrauterine growth retardation, antenatal death. Arterial hypertension and glomerulopathies are characterized by fetal growth retardation, thyrotoxicosis - congenital hyperthyroidism or congenital hypothyroidism, Cushing's syndrome - congenital hypocorticism and malformations, hypoparathyroidism - neonatal tetany, demineralization of the skeleton, fibrocystic osteitis, for malignant hematological diseases - the transition of the corresponding diseases of the mother's cells to the fetus (though extremely rare). All of the above perinatal pathologies are a direct consequence of the mother's illness. However, this is not the only reason for the deep suffering of the fetus in the EGP clinic.

The second reason is the influence of medicines, especially the so-called obligatory ones, from which the patient cannot refuse even for a while and for which there is no alternative. Among these drugs, which pose a real danger during embryogenesis and / or fetogenesis, are indirect coumarin anticoagulants (constantly used for mechanical artificial heart valves, atrial fibrillation, deep venous thrombosis), anticonvulsants (epilepsy), thyreostatics (thyrotoxicosis), immunosuppressants ( conditions after organ transplantation), glucocorticoids (systemic connective tissue diseases and a number of other diseases), antitumor chemotherapeutic agents. For them, either bright fetal syndromes, usually named after the drug that causes them, or less typical polymorphic, but very severe manifestations in the fetus and newborn, are described.

What practical recommendations can be given to avoid or reduce these consequences? In cases where the pathology of the fetus is caused by EGP itself, it is necessary to direct therapeutic efforts to compensate for the underlying disease, transfer it to the phase of remission or a stable course. For this, both medical and surgical options are used. It is almost impossible to prevent a severe negative effect of drugs on the fetus, but it should be remembered that: it is statistical in nature and even in the most aggressive drugs it manifests itself in 25-50% of cases; from the group of drugs, you can try to choose a less unfavorable one (for example, propylthiouracil, and not methimazole); sometimes the risk is reduced by accompanying therapy (for example, folic acid in the appointment of anticonvulsants and methotrexate). In all cases, before prescribing a potentially dangerous drug, the benefit / risk ratio should be carefully weighed.

An important perinatal problem in the EGP clinic is prematurity. The origins of this problem are that many diseases of the mother themselves lead to premature birth, in other cases, doctors have to actively deliver the patient before the physiological term due to the severity of her condition. There is a third possibility, when early delivery is carried out in the interests of the fetus - in connection with his suffering, caused by the pathology of the mother. In all three cases, the most promising way to solve the problem is qualified and timely treatment of EGP.

These are the main objective problems and some specific ways to solve them in the EGP clinic for pregnant women. Probably, these are far from all the problems and not all the ways to solve them, but it is impossible to discuss everything in one lecture (and even in one thick book).

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Extragenital pathology (EGP)- this is a large group of diverse and diverse diseases, syndromes, conditions in pregnant women, united only by the fact that they are not gynecological diseases and obstetric complications of pregnancy.

If we talk today about the health index of pregnant women, then at best 40% of all pregnant women carry a pregnancy without complications, that is, without toxicosis of pregnant women and without extragenital diseases. But the presence of late toxicosis of pregnancy (PTB) in 60-70% is due to latent or chronic extragenital pathology. An in-depth analysis of the course of pregnancy suggests that uncomplicated pregnancy occurs only in 20% and the presence of extragenital pathology (EP) in 30-40%, PTB - in 17%. The threat of abortion in 12% undoubtedly affects the intrauterine development of the fetus and its further development. At the same time, it can be noted that PTB and the threat of miscarriage (MS) are also a manifestation of EP.

Extragenital pathology is that unfavorable background for the development of pregnancy, on which the possibilities of adaptive mechanisms are reduced or limited, and all complications that occur during pregnancy, childbirth and the postpartum period are exacerbated.

Since EGP includes a huge number of different diseases, it is very important for clinical purposes to divide it into significant and insignificant, or, more precisely, into insignificant. Insignificant or insignificant types of PEG include those diseases or conditions in which maternal and perinatal mortality rates, the incidence of complications in pregnancy, childbirth and the postpartum period, and perinatal morbidity do not differ from the general population. In other words, this is a pathology that practically does not affect the course and outcomes of pregnancy, the condition of the fetus and newborn.

Significant PGE - a large group of diseases or conditions, which affect the above indicators to varying degrees.
Early detection of extragenital pathology in a antenatal clinic is important for the prevention of obstetric pathology in women and perinatal pathology in newborns, because. extragenital diseases significantly increase the risk of an upcoming birth.

Currently, with most extragenital diseases, it is possible to safely carry out pregnancy and childbirth, provided that the woman is properly monitored during pregnancy, and, if necessary, special treatment is prescribed. The frequency of extragenital pathology is quite high. According to various authors, heart defects are observed in 2-5% of pregnant women, hypertension in 1.5-2.5%, kidney disease in 5-6%, diabetes in 1-2%, diseases of the gastrointestinal tract and hepatobiliary systems - in 1-3%, etc. According to the most conservative estimates, extragenital pathology is diagnosed in 15-20% of pregnant women. According to the report of obstetric hospitals, 70% have extragenital pathology and only 30% are absolutely healthy women.

As already mentioned, EGP is a wide variety of diseases. Therefore, there is an urgent need to systematize them.

From our point of view, the entire EGP can be divided into unrelated to pregnancy, or primary, and associated with pregnancy, secondary.

The first, in turn, is divided into chronic, which existed before the onset of pregnancy, and acute, first appeared during pregnancy. Chronic EGP is represented by a variety of diseases, among which the most important in obstetrics are cardiovascular, bronchopulmonary, liver, kidney, endocrine, etc.. To acute EGP include infectious diseases, pneumonia, surgical diseases, hemoblastoses. Of course, during pregnancy, a woman can develop any other disease, incl. one that will persist in the future, turning into a chronic form (glomerulonephritis, systemic lupus erythematosus, thyrotoxicosis, etc.), however, for the EGP clinic, it is acute, first occurring in a previously healthy woman.

A special group is secondary EGP, which includes conditions etiologically associated with pregnancy and, as a rule, passing after its completion. In most cases, it is known due to what anatomical, physiological or biochemical changes inherent in pregnancy itself, this or that condition occurs. This secondary nature in relation to pregnancy is also emphasized in the very names of these conditions by the presence of the term "pregnancy" or a derivative of it. The most frequent and most significant types of secondary EGP: anemia of pregnancy, gestational hypertension, gestational diabetes, gestational pyelonephritis, thrombocytopenia of pregnancy, cholestatic hepatosis of pregnancy (obstetric cholestasis), acute fatty degeneration of the liver, peripartum cardiomyopathy, diabetes insipidus of pregnancy, dermatosis of pregnancy (there are many variants of pregnancy-associated dermopathy, each of which has its name), gestational hyperthyroidism, glycosuria of pregnancy, gingivitis of pregnancy.

Pregnancy destabilizes, makes the course more labile diabetes mellitus.“Guilty” of this are the appearing placental hormones and the level of conventional hormones that significantly increase during pregnancy, which have a contra-insular effect (placental lactogen, estradiol, prolactin, cortisol). Fetal glucose intake contributes to the normal reduction in fasting glycemia in non-diabetic patients. Fetal development also requires higher postprandial glycemia with a slower return to baseline glucose concentration. Pregnancy is generally characterized by a state of insulin resistance. It should also be noted significant changes in the need for insulin at different times of the gestational period, which creates conditions for hypoglycemia (in the first trimester and after 36-37 weeks), hyperglycemia and ketosis.

Pregnancy promotes progression varicose veins and chronic venous insufficiency, an increase in venous thrombotic complications. There are quite a few reasons for this. In connection with the increase in the concentration of progesterone, the tone of the venous wall decreases, the diameter of the veins increases; hydrostatic pressure increases in the veins of the lower extremities and small pelvis, as intra-abdominal pressure rises, compression of the inferior vena cava occurs, and as a result, venous blood flow slows down. In connection with hyperestrogenemia, vascular permeability increases and, accordingly, the tendency to edema; the concentration of fibrinogen, VIII and a number of other blood coagulation factors increases, its fibrinolytic activity decreases, and after childbirth a significant amount of tissue factor enters the blood.

more frequent manifestation urinary tract infections in pregnant women contribute to the expansion of the ureters due to the muscle relaxant action of progesterone; mechanical difficulty in urodynamics (mainly on the right) due to compression of the ureters by the pregnant uterus and ovarian veins; increase in urine pH; the appearance of sometimes vesicoureteral reflux; increase in the volume of the bladder; hypercortisolemia, etc.

The adverse effect of EGP on the course of pregnancy, childbirth and the postpartum period is diverse and depends on the nature and severity of the underlying disease. Many extragenital diseases predispose to the development of obstetric complications. It can be said that arterial hypertension increases the risk of premature placental abruption and eclampsia, all hemophilic conditions - early postpartum hemorrhage, diabetes mellitus - labor anomalies, fetal distress in childbirth, shoulder dystocia, urinary tract infection - premature birth, etc.

The need for an unusual method of delivery, due not to the obstetric situation, but shown in connection with the mother's EGP, is an objectively existing problem. It is clear that we are talking about a caesarean section, for example with aortic aneurysm, portal hypertension or after a hemorrhagic stroke.

Anemia in pregnancy

The need for alimentary iron during pregnancy is 800 mg Fe. Of these, 300 mg goes to the fetus, and 500 mg to build red blood cells.
Anemia of pregnancy is often iron-deficient. The diagnosis is made at ¯Hb 100 g/l, with Hb 110-115 g/l, treatment is necessary. A blood test is carried out 2 times during pregnancy; in civilized countries, serum iron is determined at 28 weeks of pregnancy. Etiology of iron deficiency anemia.

1. Fe deficiency in the diet.

2. Loss during menstruation, tissue iron, although Hb may be normal.

3. Previous pregnancy (physiological interval between births 3 years).

4. Folic acid deficiency (megaloblastic anemia)

5. A decrease in Hb is observed normally due to blood dilution (an increase in BCC during pregnancy)

When acquired anemia mainly the mother suffers, tk. the fetus takes iron from the mother's blood. If serum iron is normal, folic acid deficiency should be suspected. Folic acid deficiency (megaloblastic anemia) occurs in women with a reduced (¯) intake of animal proteins, few fresh vegetables in the diet. Treatment - diet, 1 mg of folic acid, iron sulfate is absorbed only 200 mg per day. Iron preparations are prescribed up to 600 mg per day (no more), i.e. 300 mg 2 times a day before meals, if there is pain in the stomach, then during meals or after meals. Parenterally, it can be prescribed during pregnancy only intramuscularly - ferrumlek, tk. intravenous administration of F++ may cause fetal harm. If the anemia does not respond to treatment, a sternal puncture is indicated to obtain bone marrow. With anemia Hb ¯ 60 g/l, blood transfusion is indicated.

congenital anemia contribute to an increase in maternal and perinatal mortality.

Heart disease and pregnancy:

Hypertonic disease. Hypertension is diagnosed in 7% of all pregnant women, it causes approximately 22% of perinatal deaths and 30% of maternal deaths. When making a diagnosis in pregnant women, 4 criteria are used:

1. Increase in systolic blood pressure up to 140 / mm Hg. Art.

2. Increase in diastolic blood pressure up to /90 mm Hg. Art.

3. Persistent increase in systolic blood pressure by more than 30 mm Hg. Art. from the original.

4. Increase in diastolic blood pressure by more than 15 mm Hg. Art. from the original.

About a persistent increase in blood pressure testifies - - the ABP at least at 2-fold measurement with an interval at 6 o'clock. To resolve the issue of the diagnosis of hypertension during pregnancy, it is necessary to identify a history of hypertension before pregnancy. If there is -BP in the II trimester of pregnancy, this is preeclampsia.