Pregnancy and the cardiovascular system. How to be? Diseases of the cardiovascular system during pregnancy

Unfortunately, heart disease is one of the first among all diseases that occur in women during pregnancy. Therefore, doctors of this pathology have long been paying increased attention, this is due to the fact that the state of pregnancy very often significantly worsens the health of the expectant mother. Often, all this leads to the fact that very serious complications arise that are extremely dangerous for both the expectant mother and the unborn child. Therefore, pregnancy in women and cardiovascular diseases are very often close by. Therefore, if there are signs of cardiovascular failure in women, you should not panic, but medical attention is needed urgently.

Today, situations are not uncommon when the issue of maintaining pregnancy is decided by both a cardiologist and a gynecologist not at an early stage of pregnancy, but even during its planning. And this is an absolutely correct approach, since you cannot joke with it. It is not for nothing that the year of the fight against cardiovascular diseases in Russia was announced. It is very important how competently the diagnosis of diseases of the cardiovascular system is carried out in women.

Treatment with folk remedies often leads to negative consequences, it is always better to consult a doctor. Of course, if treatment with folk remedies includes only various useful tinctures and products, then this is only welcome. But again, the doctor should be told about everything, only he knows how to treat.

1. Gestosis, which are severe.
2. Placental insufficiency.
3. Chronic fetal hypoxia.
4. Death of the fetus inside the womb.
5. Pregnancy is terminated prematurely.

Many women in labor believe that their heart disease is only dangerous for the baby, but this is not the case. They themselves are in serious danger, and a lethal outcome is quite possible. Also often heart disease, coupled with pregnancy, lead to disability.

During pregnancy, the most common diseases are:

• Heart disease (moreover, we can talk about both congenital and acquired defects, both are equally dangerous).
• Rheumatic diseases.
• Various irregularities in the rhythm of the heart.
• The heart of a woman at one time underwent surgical intervention.
• Diseases of the myocardium.

It is very important to remember that all these ailments must be treated on a regular basis, and the period of treatment must continue throughout the entire period of pregnancy. All treatment should take place under the close supervision of a cardiologist. If we talk about a complex of therapeutic measures, then they should be complex, it all depends on the severity of the disease. In most cases, the cardiologist prescribes the following medications:

• various anti-arrhythmia drugs. Each remedy must be chosen individually;
• cardiac glycosides;
• drugs that have a diuretic effect;
• antiplatelet agents.

The doctor can also prescribe a diet, diet therapy in this state is very important, it should be said more than once! At the same time, not all diets are equally useful.

Pregnancy management for women in labor with heart disease

One of the most important factors in a pregnant woman with heart disease is to keep the baby whenever possible. However, there are often circumstances when the state of pregnancy has to be terminated. Here are the main ones:

• The development of the aortic valve is insufficient.
• The heart is greatly enlarged, severe myocardial insufficiency and stenosis of the aortic valve are observed.
• The rheumatic process functions with rhythm disturbances, insufficient blood circulation.
• Heart after surgery (everything should be individual here, much depends on the type of operation, its complexity, the duration of the operation, the patient's health status)
• Chronic processes in an aggravated form or a rheumatic process (also in an acute form).
• The presence of cardiomyopathy (if there is a severe course).
• The presence of myocarditis (if there is a severe form of the course).
• Heart defects, if present together with atrial fibrillation.
• The interventricular septum has pronounced defects.

To summarize all of the above, then the decision on the termination of pregnancy or abandonment of the child should be decided on the basis of how the existing defects are expressed, how the blood circulation is impaired and how active the rheumatic process is. Timely laboratory diagnostics of a person suffering from cardiovascular disease is very important.

Principles of pregnancy management (how everything should be done)

• the entire treatment process should be carried out jointly by a gynecologist, a cardiac surgeon and a therapist. All these specialists must be mandatory, since various urgent conditions may arise in diseases of the cardiovascular system;
• the heart should be examined on a regular basis, since there is a risk of various cardiovascular diseases, even if there have been no signs of illness recently. Signs of various cardiovascular diseases may not always be evident;
• depending on the type of disease, appropriate medications are prescribed, which should be taken strictly according to the instructions;
• be sure to do an ultrasound of the unborn child on a regular basis, cardiography is also necessary;
• while the question of whether to leave the child or not is being decided, planned hospitalization is indicated, which usually lasts 3 months. When it comes to preventive treatment, hospitalization should last up to 8 months! If the question of the method of giving birth to a child is resolved, the hospitalization process should last more than 8 months. The following is very important: the methods of delivery should always be purely individual, everything is in direct proportion to what disease the woman suffers from, what her health condition is, how great the severity of the treatment of the disease is (when collecting a consultation, there must be an anesthesiologist-resuscitator).

How to give birth with heart disease

It is necessary to have a caesarean section if:

• heart diseases are observed in conjunction with various Ausherian pathologies, their manifestations may be different;
• there are defects of the aortic valve, this symptom is very common;
• the rhythms of blood circulation are disturbed;
• there is atrial fibrillation (if it is severe) /

If the expectant mother does not have any of the above contraindications, then we can talk about self-resolution of childbirth using the natural birth canal. The risk of cardiovascular diseases in women in labor is not so great if you carefully monitor your health from an early age, a common truth, but it should be mentioned. You should also pay attention to medical nutrition, this is also very important. So nutrition for heart disease should not include very salty and spicy foods, this is very important not only for the health of the expectant mother, but also for the normal development of the fetus.

How to conduct a natural childbirth (process features)

• a woman must be on her left side without fail. In no case should you be on your back, it is extremely dangerous and can lead to the most negative consequences;
• during childbirth, it is imperative to carry out an anesthetic process (anesthesia should be prescribed taking into account the state of health of the woman in labor);
• the second stage of labor should be shortened, and this is done through the so-called "off labor". In this case, the dissection of the perineum is carried out (this is done so that the child is born faster). If we are talking about severe cases, then there is the use of special obstetric forceps;
• a cardiologist and an anesthesiologist-resuscitator must observe the woman in labor at the same time;
• the cardiovascular system of a woman in labor must be under the close supervision of specialists, the condition of the fetus must also be constantly monitored;
• hyperbaric oxygenation is a very favorable area for childbirth in such conditions.

Conclusion

Expectant mothers should know that during pregnancy significant changes take place in the body (and we are talking not only about women with cardiovascular diseases, but also about healthy women). The minute heart volume increases greatly (its increase can reach 80%), but how the closer the delivery is, the smaller the volume becomes. The volume of extracellular fluid also becomes much larger.

Pregnancy at all stages of its development has a peculiarity to worsen the course of CVS, it is fraught with the most extreme conditions. I don't want to scare anyone, but fatal outcomes in women who are preparing to become a mother with heart disease, unfortunately, are far from rare. The risk of cardiovascular diseases in women does not always depend on age; problems with blood vessels can arise for a variety of reasons. For example, cardiac outlet failure is common.

This information is intended for healthcare and pharmaceutical professionals. Patients should not use this information as medical advice or guidance.

Cardiovascular Disease (CVD) in Pregnant Women

Groshev S.
6th year student to lay down. dep. honey. Faca Osh State University, Kyrgyz Republic
Israilova Z.A.
Assistant at the Department of Obstetrics and Gynecology

Introduction and substantiation of the problem.

Cardiovascular diseases (CVD) in pregnant women rank first among all extragenital pathology.

The frequency of detection of heart disease in them ranges from 0.4 up to 4.7%. Recently, there has been an increase in the number of pregnant women and women in labor with CVD, which is explained by a number of reasons:

early diagnosis of heart disease,

enlargement

indications for maintaining pregnancy,

an increase in the group of women who underwent heart surgery, and the number of seriously ill women who, either themselves or with the permission of doctors, decide to maintain a pregnancy, being confident in the success of medical

science and practice.

The most important hemodynamic shift during pregnancy is an increase in cardiac output

. At rest, its maximum increase is 30-45% of the value of cardiac output before pregnancy. An increase in this indicator occurs already in the early stages of pregnancy: at 4-8 weeks, it can exceed the average cardiac output of healthy non-pregnant women by 15%. The maximum increase in cardiac output occurs (according to various authors) at 20-24 weeks; at 28-32 weeks; 32-34 weeks. The amount of cardiac output is significantly influenced by changes in the position of the pregnant woman. As cardiac output increases, the work of the left ventricle increases and reaches a maximum (33-50%) at 26-32 weeks of gestation. By the period of delivery in a singleton pregnancy, the work of the left ventricle approaches normal conditions, and in a multiple pregnancy, it remains elevated. A sharp increase in the work of the left and right ventricles is noted during childbirth (30-40%). In the early postpartum period, the work of the left ventricle approaches the value determined at the end of pregnancy. Due to the increasing blood flow to the heart, a decrease in the size of the uterus, an increase in blood viscosity, the work of the heart again increases 3-4 days after childbirth. All this can threaten a woman with cardiovascular diseases with the development of circulatory decompensation before childbirth, during childbirth and after them.

Circulating blood volume

(BCC) increases already in the first trimester of pregnancy and reaches a maximum by the 29-36th week. In childbirth, changes in the BCC are usually not observed, but it decreases markedly (by 10-15%) in the early postpartum period. However, women with cardiovascular diseases often experience edema, including the so-called internal edema. BCC can increase due to the entry of a large amount of extravascular fluid into the bloodstream, which can lead to the development of heart failure, up to pulmonary edema. Due to the abrupt shutdown of the uteroplacental circulation, elimination of compression of the inferior vena cava immediately after the birth of the fetus, a rapid increase in BCC occurs, which a diseased heart cannot always compensate for by an increase in cardiac output.

Oxygen consumption by the body during pregnancy increases and before childbirth exceeds the initial level by 15-30%. This is due to an increase in the metabolic requirements of the fetus and mother, and

also with an increase in the load on the maternal heart. In addition, a direct relationship was found between the fetal body weight and the degree of increase in maternal oxygen consumption. At the very beginning of labor, oxygen consumption increases by 25-30%, during contractions by 65-100%, in the second period by 70-85%, at the height of attempts by 125-155%. In the early postpartum period, oxygen consumption is still 25% higher than prenatal levels. A sharp increase in oxygen consumption during childbirth is a significant risk factor for women in labor with cardiovascular disease.

Compression syndrome of the inferior vena cava

in pregnant women should not be regarded as a sign of the disease. Rather, it is a manifestation of insufficient adaptation of the cardiovascular system to the pressure on the inferior vena cava caused by an increase in uterine pressure and a decrease in venous return of blood to the heart, as a result of which a decrease in blood pressure occurs (with a sharp decrease, fainting occurs), and with a drop in systolic blood pressure, loss of consciousness. The syndrome of compression of the inferior vena cava can be manifested by anxiety, feeling of lack of air, increased breathing rate, dizziness, darkening in the eyes, pale skin, sweating, tachycardia. These signs can be present in other shock conditions as well. But unlike from the latter, a sharp increase in venous pressure on the legs is noted with altered venous pressure on the arms. Most often, the syndrome occurs with polyhydramnios, pregnancy with a large fetus, with arterial and venous hypotension, with multiple pregnancies, in small pregnant women. No special treatment is usually required. In the event of a syndrome of compression of the inferior vena cava, it is enough to immediately turn the woman on her side. The first signs of the disorder usually appear in women lying in a supine position. A particular danger is the appearance of collapse (shock) due to compression of the inferior vena cava during surgical delivery. You need to know that with pronounced prolonged compression of the inferior vena cava, uterine and renal blood flow decreases, and the condition of the fetus worsens. Complications such as premature placental abruption, thrombophlebitis and varicose veins of the lower extremities, acute and chronic fetal hypoxia are possible.

Speaking about the significance of the combination of heart and vascular diseases with pregnancy, it should be noted that pregnancy and the changes in hemodynamics, metabolism, body weight (an increase of 10-12 kg by the end of pregnancy), water-salt metabolism (during pregnancy, the total water content in the body increases by 5-6 liters, the sodium content in the body increases already by the 10th week of pregnancy by 500-600 mmol, and potassium by 170 mmol, before childbirth, the body accumulates up to 870 mmol of sodium) require intensive work from the heart and often aggravate the course cardiovascular disease.

For women suffering from cardiovascular diseases, changes in hemodynamic loads can threaten disability or even death.

Pregnancy is a very dynamic process, and changes in hemodynamics, hormonal status and many other physiological factors in the body of a pregnant woman occur constantly and gradually, and sometimes suddenly. In this regard, it is important not only to correctly diagnose, to determine the nosological form of heart or vascular disease, but to assess the etiology of this disease and the functional state of the cardiovascular system. In addition, it is important to assess the degree of activity of the primary pathological process (rheumatism, rheumatoid arthritis, thyrotoxicosis, etc.), which led to damage to the cardiovascular system, as well as the identification of focal infection (cholecystitis, tonsillitis, dental caries, etc.) and others. concomitant diseases.

These are the complex, but in the overwhelming majority of cases, still solvable problems that arise before a doctor who decides whether a woman suffering from any cardiovascular disease can have pregnancy and childbirth without risking her health and her life. without risk to the health and life of your unborn child. The question of the admissibility of pregnancy and childbirth for a woman suffering from cardiovascular disease should be decided in advance, ideally before marriage. In resolving this issue, a doctor who carries out dispensary observation of patients has certain advantages, as well as an attending physician who constantly supervises the patient (district doctor, family doctor, cardiologist). In the future, in the event of pregnancy, childbirth and the postpartum period, this issue should be resolved jointly by a cardiologist with an obstetrician-gynecologist, and, if necessary, with the involvement of doctors of other specialties.

During pregnancy, an increased load on the cardiovascular system causes physiologically reversible, but quite pronounced changes in hemodynamics and heart function. Not knowing about the changes in hemodynamics in healthy pregnant women, it is impossible to adequately assess it in cardiovascular diseases. An increase in the load is associated with an increase in metabolism aimed at meeting the needs of the fetus, an increase in the volume of circulating blood, the appearance of an additional placental circulatory system, with a constantly increasing body weight of a pregnant woman. With an increase in size, the uterus limits the mobility of the diaphragm, increases intra-abdominal pressure, changes the position of the heart in the chest, which ultimately leads to changes in the working conditions of the heart. Hemodynamic changes such as an increase in the volume of circulating blood and cardiac output can be unfavorable and even dangerous in pregnant women with diseases of the cardiovascular system, due to their layering on the already existing ones, due to the disease.

Changes in the mother's hemodynamics have a negative effect on the uteroplacental circulation, which in some cases can cause fetal malformations, including congenital heart defects. The long period of pregnancy is replaced by a short-term, but extremely significant in terms of physical and mental stress period of childbirth. Following the period of childbirth, the postpartum period begins, which is no less important in terms of hemodynamic and other physiological changes.

Among heart diseases that complicate pregnancy, more often

rheumatism is common, acquired and congenital heart defects, anomalies in the development of great vessels, myocardial disease, operated heart, cardiac disorders rhythm. Developing pregnancy worsens the course of CVD and can lead to the development of extreme conditions requiring carrying out urgent measures not only from the obstetrician, but also from a therapist, cardiologist, surgeon. The mortality rate of pregnant women, women in labor, women in childbirth, suffering from acquired heart defects, pulmonary hypertension, complex congenital malformations, acute and chronic cardiovascular failure(CCH).

Critical periods of pregnancy for exacerbation of CVD

.

Beginning of pregnancy - 16 weeks

. During these periods, an exacerbation of rheumatic heart disease occurs most often..

26-32 weeks. Maximum hemodynamic loads, increase in BCC, cardiac output, decrease in hemoglobin.

35 weeks - the beginning of labor. Increase in body weight, difficulty in pulmonary circulation due to the high standing of the fundus of the uterus, decreased function of the diaphragm.

The beginning of labor

- the birth of the fetus. Increased blood pressure (BP), systolic and cardiac output.

Early postpartum period

. Possible postpartum collapse due to a sharp change in intra-abdominal and intrauterine pressure.

Methods for the study of CVS in pregnant women.

- may contain important information about the time of the onset 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 heart hypertrophy.

X-ray examination

- it should not be carried out without sufficient reason during pregnancy.

Radionuclide research methods

- should not be carried out during pregnancy.

Phonocardiography

- the method of recording sounds (tones and noises) arising from the activity of the heart, and is used to assess its work and recognize violations, including valve defects.

Echocardiography

- used to study hemodynamics and cardiodynamics, determine the size and volume of heart cavities, assess the functional state of the myocardium. The method is harmless to the mother and fetus.

Rheography

- to determine the state of vascular tone, their elasticity, blood circulation during pregnancy.

Load samples

- to assess the functional state of the myocardium. Samples 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 state.

Blood tests.

General information

on the management of pregnant women with CVD.

Speaking about the tactics of pregnancy and childbirth in women with diseases of the cardiovascular system, it must be said that the issue of maintaining pregnancy and its safety for the mother and the unborn child should be resolved not only before pregnancy, but also better before the patient gets married. The basis for the correct management and treatment of pregnant women suffering from cardiovascular diseases is an accurate diagnosis, taking 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 must be admitted to the hospital at least three times:

I- th 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 of the 1st stage. Pregnancy can be continued in the absence of an exacerbation of the rheumatic process.

Insufficiency of the mitral valve is a contraindication to pregnancy only in the presence of heart weakness or activation of the rheumatic process, as well as when it is combined with a violation of the heart rhythm 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.

Insufficiency of the aortic valve is a direct contraindication.

Pale congenital malformations are compatible with pregnancy if not accompanied by pulmonary hypertension.

Patients after heart surgery are treated differentially.

Acute rheumatic process or exacerbation of a chronic one is a contraindication to pregnancy.

Summarizing the above, we can say that the issue of terminating 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- th hospitalization - at the 28-29th week of pregnancy to monitor the state of the cardiovascular system and, if necessary, to maintain the function of the heart during the period of maximum physiological stress.

III- I am hospitalized - at 37-38 weeks to prepare for childbirth and choose a method of delivery.

When signs of circulatory failure, exacerbation of rheumatism, atrial fibrillation, late gestosis of pregnant women or severe anemia appear, the patient must be hospitalized regardless of the gestational age.

The issue of termination of pregnancy at a later date is quite complex. Often a problem arises, which is less dangerous for the patient: to terminate the pregnancy or to develop it further. In any cases, if signs of circulatory failure or any intercurrent diseases appear, the patient should be hospitalized, subjected to a thorough examination, and treatment. If the treatment is ineffective, there are contraindications to surgery on the heart, a decision is made to terminate the pregnancy. Pregnancies over 26 weeks should be terminated with an abdominal caesarean section.

Until now, many doctors believed that term delivery by caesarean section reduces the stress on the cardiovascular system and reduces mortality in pregnant women with heart defects. However, many authors recommend that in severe degrees of heart defects, delivery by cesarean section is carried out, but not as a last measure for prolonged labor through the vaginal birth canal, complicated by decompensation of cardiac activity, but as a preventive measure carried out on time.

Recently, they have 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 signs of high arterial hypertension or signs of incipient aortic dissection;

severe persistent atrial fibrillation;

extensive myocardial infarction and signs of deterioration in hemodynamics;

a combination of heart disease and obstetric pathology.

Contraindication to a caesarean section is severe pulmonary hypertension.

Self-delivery through the vaginal birth canal is allowed when compensating for blood circulation in patients with mitral valve insufficiency, combined mitral heart disease with a predominance of stenosis of the left antiferral orifice, aortic heart defects, congenital heart defects of the "pale type", with mandatory pain relief of labor, to prevent the onset or aggravation heart failure (you should start with an intramuscular injection of 2 ml of a 0.5% solution of diazepam and 1 ml of 2% promedol from the moment the first contractions appear).

Successful delivery of patients with severe congenital and acquired heart defects can be facilitated by the management of labor under conditions of hyperbaric oxygenation, taking into account the possible complications of HBO in the postpartum period.

After the birth of the fetus and the discharge of the placenta, there is a rush of blood to the internal organs (and primarily to the organs of the abdominal cavity) and a decrease in the BCC in the vessels of the brain and coronary arteries. In order to prevent the deterioration of the condition, it is necessary to administer cardiotonic drugs immediately after the birth of the child. Postpartum women with heart disease can be discharged from the maternity hospital no earlier than 2 weeks after delivery in a satisfactory condition under the supervision of a cardiologist at the place of residence.

Rheumatism and acquired heart defects (PPS

).

Rheumatism

- systemic disease of the connective tissue with a predominant lesion of the cardiac system, is more common in young women; called b-hemolytic streptococcus of group A. In the pathogenesis of the disease, allergic and immunological factors are important. Taking into account clinical manifestations and laboratory data, active and inactive phases and 3 degrees of process activity are distinguished: 1 - minimum, 2 - medium and 3 - maximum - degrees. According to the localization of the active rheumatic process, carditis is isolated without valvular defect, recurrent carditis with valvular defect, carditis without cardiac manifestations, arthritis, vasculitis, nephritis, etc. In pregnant women, rheumatism occurs in 2.3-6.3%, and its exacerbation occurs in 2.5-25% of cases, most often in the first 3 and in the last 2 months of pregnancy, as well as during the first year after childbirth.

The diagnosis of active rheumatism during pregnancy is also difficult. In this regard, women who have undergone the last exacerbation of rheumatism in the next 2 years before pregnancy should be classified as a high-risk group. Exacerbation of focal infection, acute respiratory diseases in pregnant women with rheumatic heart disease can exacerbate rheumatism.

Recently, for the diagnosis of active rheumatism in pregnant women and postpartum women, cytological and immunofluorescent methods have been used, which have a high diagnostic value. This is especially true for the second method, based on the determination of antibodies against streptolysin-O in breast milk and in colostrum using an indirect immunofluorescence reaction.

During pregnancy and in the postpartum period, the rheumatic process proceeds in waves. Critical periods of exacerbation of rheumatism correspond to early pregnancy - up to 14 weeks, then from 20 to 32 weeks and the postpartum period. The course of rheumatism during pregnancy can be associated with fluctuations in the excretion of corticosteroid hormones. Until week 14, corticosteroid excretion is usually low. From the 14th to the 28th week, it increases approximately 10 times, and at 38-40 weeks it increases approximately 20 times and returns to the initial level on the 5-6th day of the postpartum period. Therefore, prophylactic anti-relapse treatment is advisable to timed

to critical deadlines.

Particularly noteworthy is the cerebral form of rheumatism, which occurs with a predominant lesion of the central nervous system. Pregnancy can provoke relapses of chorea, the development of psychosis, hemiplegia due to rheumatic vasculitis of the brain. With this

in the form of rheumatism, a high mortality rate is observed, reaching 20-25%.

The onset of pregnancy against the background of an active rheumatic process is very unfavorable, and its termination (artificial abortion) with subsequent antirheumatic therapy is recommended in the early stages. In the late stages of pregnancy, early delivery is undertaken. In this case, the most sparing method of delivery is a cesarean section followed by anti-relapse therapy. The choice of obstetric tactics in pregnant women with rheumatic heart disease depends on the functional state of the cardiovascular system. During pregnancy, the circulatory system must meet the needs of the developing fetus.

Hemodynamic changes that naturally develop during physiological pregnancy can lead to heart failure.

Pregnant women with heart defects are considered to be 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.

make up 75-90% of all heart lesions in pregnant women. Of all the forms of defects of rheumatic origin, mitral defects are most often observed in the form of a combination of insufficiency and stenosis of the left atrioventricular opening, i.e. in the form of a combined mitral defect or mitral disease. However, the clinical picture of the disease is usually dominated by signs of either mitral stenosis or bicuspid valve insufficiency. Therefore, the terms "mitral stenosis" or "mitral insufficiency" denote not only pure forms of defects, but also those forms of combined lesions of the valves, in which there is a dominance of the symptom of the defect. The clinical symptoms of mitral stenosis and mitral regurgitation depend on the stage of the disease, according to the classification of A.N. Bakuleva and E.A. Damir: 1Art. - full compensation, 2st. - relative circulatory failure, 3 tbsp. - the initial stage of severe circulatory failure, 4st. - severe circulatory insufficiency, 5th degree - dystrophic period of circulatory insufficiency. It is generally accepted that mild bicuspid valve insufficiency or combined mitral valve disease with a predominance of insufficiency usually has a favorable prognosis. Aortic defects are much less common than mitral and are predominantly combined with other defects. Most often, a predominance of aortic valve insufficiency is found and, less often, stenosis. The prognosis for aortic stenosis is more favorable than for aortic valve insufficiency. occur in 7-8% pregnant women. To predict pregnancy outcomes and childbirth the activity of the rheumatic process matters. Form and stage of development of the defect, compensation or decompensation of blood circulation, degree pulmonary hypertension, rhythm disturbance, as well as the addition of obstetric pathology. All these data determine the choice of obstetric tactics in during pregnancy, childbirth and in the postpartum period. Rheumatologists note that at present erased forms of rheumatic process, in this connection, their diagnosis on the basis of clinical, hematological, immunobiological research represents a large difficulties .

Mitral stenosis.

The intensity of cardiac activity in pregnant women increases from 12-13 weeks and reaches a maximum by 20-30 weeks.

Approximately 85% of THESE patients have signs of heart failure. Most often, they appear or begin to grow precisely with

12-20-th week of pregnancy. Hemodynamic recovery begins at parturient women only after 2 weeks after childbirth. In patients with mitral stenosis during during pregnancy due to physiological hypervolemia, which increases pulmonary hypertension, the risk of pulmonary edema increases. At However, not a single method of delivery (with the help of obstetric forceps, by cesarean section) helps to stop pulmonary edema. The most reliable way to ensure a favorable outcome in such cases is mitral commissurotomy. This operation, depending on the situation, can be recommended in 3 versions.

The first option: an artificial abortion is performed and then a mitral commissurotomy (after the first menstruation); after 5-6 months after a successful heart surgery

re-pregnancy can be tolerated. Second option- produced mitral commissurotomy during a real pregnancy in any of its terms (with non-arresting drug-induced pulmonary edema), but better for 24-32-1st week, when the risk of spontaneous termination of pregnancy how reactions for surgical trauma, less (due to sufficient relaxation of the uterus). The third option: a caesarean section is performed at the 30-40th week of pregnancy with sufficient fetal maturity) and in one stage (after delivery)- mitral commissurotomy. The operation of mitral commissurotomy during pregnancy turns out to be more radical due to decalcification of the valve leaflets and greater compliance to the separation of subvalvular adhesions.

Mitral insufficiency. Pregnancy with this pathology is much easier. Usually ends in spontaneous labor. At

severe mitral insufficiency with significant regurgitation and a sharp increase in the left ventricle, pregnancy is difficult and may be complicated by the development of acute left ventricular failure. In such women, from the early stages of pregnancy, signs of heart failure appear or increase, to which, as a rule, joins severe nephropathy with torpid flow. Drug therapy for heart failure in these cases is ineffective, therefore, use or terminate pregnancy early(induced abortion, minor cesarean section) or early delivery in in a planned manner by the abdominal route. Subsequently, the patient is recommended surgical treatment of heart disease. In Russian federation there is experience of implantation of a ball prosthesis and allograft in patients with decompensated mitral regurgitation during pregnancy. Even for such patients, after termination of pregnancy by the vaginal route, the use of an intrauterine device is recommended, and with the abdominal method, sterilization is performed.

Aortic stenosis. Among the acquired heart defects in pregnant women, this disease deserves attention. Pregnancy and childbirth can be

allow only in the absence of pronounced signs of left hypertrophy ventricle and symptoms of circulatory failure, since the defect is compensated for by concentric muscle hypertrophy left ventricle, thickening of its wall. In cases of severe course aortic stenosis, when surgical correction of the defect is necessary- replacement the affected valve with a prosthesis, the possibility of carrying a pregnancy is decided after the operation. Compared to aortic stenosis, aortic insufficiency is a less severe defect, since it maintains blood circulation compensation for a long time. but due to changes in hemodynamics due to pregnancy and frequent the addition of late toxicosis, the course of aortic insufficiency may be more difficult. Have patients with aortic heart disease pregnancy and birth through the vaginal birth canal is permissible only in stages of blood circulation compensation. In the second stage of labor in order to reducing the stimulating effect of childbirth on the development of the defect is shown turning off attempts by applying obstetric forceps. With symptoms heart failure pregnancy should be considered unacceptable. The resulting pregnancy must be terminated. If the pregnancy has reached a long term, the most rational is early delivery by the abdominal route with sterilization.

Insufficiency of the tricuspid valve

, usually of a rheumatic nature. Most often, this defect occurs in pulmonary hypertension.

Tricuspid stenosis

- occurs rarely, almost exclusively in women, has a rheumatic nature, is usually combined with damage to the mitral (and often aortic) valve and very rarely turns out to be an "isolated" defect.

Acquired pulmonary valve defects

- clinically very rare. Most often combined with lesions of other heart valves.

Multivalve rheumatic heart defects are quite common. Their diagnosis is difficult, tk. hemodynamic shifts characteristic of certain types of defects, and their symptoms, prevent the manifestation of some hemodynamic shifts and clinical signs characteristic of each type of defect. Nevertheless, the identification of concomitant defects in pregnant women can be of decisive importance for deciding on the possibility of maintaining pregnancy and on the advisability of surgical correction of the defect or defects.

congenital heart defects (CHD

).

Thanks to the improvement of diagnostic techniques, the development of surgical methods for radical or palliative correction of defects in the development of the heart and great vessels, the issues of accurate diagnosis and treatment of congenital heart defects have been actively addressed in recent decades. Earlier, congenital heart defects were divided into only two groups: "blue" and "non-blue" defects. Currently, about 50 forms of congenital heart defects and great vessels are known. Some of them are extremely rare, others only in childhood.

Atrial septal defect.

They occur most often in adults with congenital heart defects (9-17%). It manifests itself clinically, as a rule, in the third or fourth decade of life. The course and outcome of pregnancy with this heart defect is usually safe. In rare cases, with an increase in heart failure, it is necessary to resort to abortion.

Ventricular septal defect.

They are less common than atrial septal defect. Often combined with aortic valve insufficiency. Pregnant women with a minor ventricular septal defect can tolerate pregnancy well, but as the defect grows, the risk of developing heart failure, sometimes fatal, increases. After delivery, paradoxical systemic embolism may occur.

Patent ductus arteriosus.

When the duct does not clog, blood is discharged from the aorta into the pulmonary artery. With a significant discharge of blood, dilatation of the pulmonary artery, left atrium and left ventricle occurs. In terms of the tactics of managing a pregnant woman with this defect, the diagnosis of the diameter of the duct is of prime importance. This disease, with an unfavorable course, can complicate the development of pulmonary hypertension, subacute bacterial endocarditis, and heart failure. During pregnancy, at the initial stage of pulmonary hypertension, a significant increase in pressure in the pulmonary artery can occur, followed by the development of right ventricular failure.

Isolated stenosis of the pulmonary artery.

This defect is one of the most common birth defects (8-10%). The disease can complicate the development of right ventricular failure, because during pregnancy, the volume of circulating blood and cardiac output increase. With mild to moderate pulmonary stenosis, pregnancy and childbirth can proceed safely.

Fallot's tetrad.

Fallot's tetrad is classified as a classic "blue" heart disease. Consists of stenosis of the excretory tract of the right ventricle, a large defect of the interventricular septum, displacement of the aortic root to the right and hypertrophy of the right ventricle. In women with tetralogy of Fallot, pregnancy poses a risk to both the mother and the fetus. The early postpartum period is especially dangerous, when severe syncope attacks can occur. With Fallot's tetrad, the percentage of complications such as the development of heart failure is high, and the lethal outcome for the mother and fetus is quite high. Women who have undergone radical surgery for this defect, are more likely to have a favorable pregnancy and childbirth.

Eisenmeiger Syndrome

- belong to the group of "blue" vices. Observed with large defects of the cardiac septum or a large-diameter anastomosis between the aorta and the pulmonary artery (i.e., with defects of the interventricular and interatrial septa, patent ductus arteriosus). Eisenmeiger's syndrome often complicates thrombosis in the pulmonary artery system, thrombosis of cerebral vessels, and circulatory failure. With Eisenmenger syndrome, the risk of death is very high for both the mother and the fetus.

Congenital aortic stenosis

- can be subvalvular (congenital and acquired), valvular (congenital and acquired) and supravalvular (congenital). Pregnant women with minor or moderate congenital aortic stenosis tolerate pregnancy well, but the risk of developing subacute bacterial endocarditis in the postpartum period does not depend on the severity of stenosis.

Coarctation of the aorta

(aortic isthmus stenosis). The defect is caused by narrowing of the aorta in the area of ​​its isthmus (border of the arch and the descending part of the aorta). Coarctation of the aorta is often combined with bicuspid aortic valve. Coarctation of the aorta can be complicated by cerebral hemorrhage, dissection or rupture of the aorta, subacute bacterial endocarditis. The most common cause of death is ruptured aorta.

operated heart.

Recently, there are more and more pregnant women who underwent heart surgery before pregnancy and even during pregnancy. Therefore, the concept of the so-called operated heart in general and during pregnancy in particular has been introduced.

It should be remembered that not always corrective operations on the heart lead to the elimination of organic changes in the valve apparatus or the elimination of congenital developmental anomalies. Often, after surgical treatment, a relapse of the underlying disease is observed, for example, in the form of restenosis during commissurotomy. Therefore, the question of the possibility of maintaining pregnancy and the admissibility of childbirth should be resolved individually before pregnancy, depending on the general condition of the patient.

Rhythm and conduction disturbances.

This pathology

also matters in the prognosis of pregnancy and childbirth, it should be borne in mind that in itself pregnancy can cause arrhythmias. So, extrasystole, paroxysmal tachycardia in pregnant women can be observed without any organic changes in the myocardium. They occur in 18.3% of pregnant women. The addition of late toxicosis to an even greater extent contributes to the appearance or intensification of arrhythmias. They do not have a significant effect on the outcome of pregnancy.

Atrial fibrillation in combination with organic pathology of the heart, in particular with mitral stenosis, is a contraindication to carrying a pregnancy, while it has

meaning is the way to interrupt it. Caesarean section for these patients is a great danger, than vaginal delivery, due to possible thromboembolism in the pulmonary artery system.

On the contrary, violations of atrioventricular conduction (incomplete and

complete heart block) by themselves do not pose a danger to a pregnant woman. Moreover, in these patients, pregnancy is usually, causes an increase in the ventricular rate, thereby preventing the danger the occurrence of attacks of Adams - Stokes - Morgagni. Only when very rare pulse - 35 or less in 1 min - during the second stage of labor in order to acceleration of labor, turn off attempts by imposing obstetric forceps. When choosing antiarrhythmic drugs for pregnant women, it is also necessary to take into account the negative effect of some of them. (quinidine, novocainamide, atropine sulfate, etc.) on the excitability of the uterus and the condition of the fetus.

mitral valve prolapse.

Mitral valve prolapse

- this is deflection of the mitral valve leaflets into the left atrium during systole ventricles. An easy degree of prolapse is established using echocardiography. Severe mitral valve prolapse syndrome diagnosed on the basis of clinical data and phonocardiography... V depending on the degree of valve prolapse, this or that the degree of insufficiency of the mitral valve closure function with regurgitation of blood into the left atrial cavity. The clinical manifestations of this pathology are very diverse.- from asymptomatic up to pronounced clinical picture. The most pronounced symptoms are observed in patients with prolapse of both mitral valve leaflets.

Currently, the course of this syndrome in combination with pregnancy has been studied for the first time, it has been established that mild deflection

the posterior wall of the mitral valve, and therefore mild regurgitation decreases with increasing gestational age and return to original state after 4 weeks after childbirth. This can be explained by a physiological increase in the left ventricular cavity with pregnancy, which changes the size, length, and degree of chord tension.

The management of labor is the same as for physiological pregnancy.

A pronounced prolapse of the valves with a large deflection amplitude during pregnancy proceeds without significant dynamics. In these patients, due to the severity of cardiological symptoms, attempts during childbirth should be turned off by imposing obstetric forceps. With a combination of obstetric pathology (weakness of labor and prolonged, large fetus, sharp tension at attempts, etc.) resort to delivery with the help caesarean section.

myocarditis

and cardiomyopathy.

Myocarditis

of various etiologies in pregnant women are relatively rare. Among them, post-infectious myocarditis is more common, which are relatively easy and sometimes take in pregnant women long course, may be accompanied by persistent extrasystole. Myocarditis itself in the absence of valvular heart disease rarely leads to the development of heart failure. Postinfectious myocarditis in some cases is treatable, and pregnancy can result in childbirth (more often premature). If myocarditis is complicated by atrial fibrillation arrhythmia, then there is a risk of thromboembolic complications. In severe myocarditis in early pregnancy have an artificial abortion(up to 12 weeks) late - cesarean section (small or early).

Cardiomyopathies are especially dangerous during pregnancy. V

In recent years, idiopathic subaortic hypertrophic stenosis has become more common in pregnant women. The etiology of this disease is unknown; familial cases are often observed. During pregnancy, may there is a sharp deterioration, even death after childbirth is possible. But despite this, with minor to moderate obstruction, with proper management of patients, pregnancy is possible.

Long-term prognosis in patients with cardiomyopathy is poor,

therefore, re-pregnancy should not be allowed. In cases of severe cardiomyopathy, termination of pregnancy is recommended regardless from her terms.

Hypertonic disease.

Pregnancy in combination with hypertension occurs in 1-3% of cases. Only with a mild form of hypertension

, when hypertension is mild and unstable, in the absence of organic changes in the heart, i.e., at stage 1 the development of the disease, pregnancy and childbirth can proceed normally. At persistent hypertension and a significant increase in blood pressure(II Stage A) pregnancy worsens the clinical course of hypertension. In patients with III the stage of the disease, the ability to conceive is sharply reduced, and if pregnancy does occur, then, how usually ends in spontaneous abortion or fetal death.

The course of hypertension during pregnancy has its own

peculiarities. So, in many patients I-II And the stage of the disease on 15-16-In the 1st week of pregnancy, blood pressure decreases (often up to normal indicators), which is explained by the depressive effect of the formed placenta. In patients, II In stage B, such a decrease in pressure is not observed. After 24 weeks pressure rises in all patients - and at I and IIA, and IIB stages. Against this background, late toxicosis often (in 50%) joins.

Due to the spasm of the uteroplacental vessels, the delivery of the necessary nutrients and oxygen to the fetus worsens,

which creates a delay in fetal development. Have each 4 -5- the patient is experiencing fetal malnutrition. The incidence of intrauterine fetal death reaches 4.1%. Have these patients also have a great threat of premature detachment of normal placenta attachments. Premature termination of pregnancy (spontaneous and prompt) is 23%.

During childbirth, a hypertensive crisis may develop with hemorrhage in

various organs and to the brain. Nephropathy often develops into eclampsia. Therefore, timely diagnosis of hypertension in pregnant women is the best prevention of these diseases. it it is possible to carry out under the following conditions: early appeal in antenatal clinic, examination of the patient by a therapist, paying attention to all the details of the anamnesis of the disease (beginning, course, complications and etc.); measurement of blood pressure, performing fluoroscopy (to find out degree of enlargement of the left ventricle and aorta), as well as ECG.

Obstetric tactics for hypertension: in seriously ill patients,

suffering from persistent forms of the disease ( IIB, III stage), terminate pregnancy early (artificial abortion followed by the introduction of a contraceptive coil into the uterus)- when contacting in late pregnancy and an insistent desire to have a child, hospitalization is indicated.

Therapy of hypertension includes creating psychoemotional rest for the patient, strictly following the daily regimen, diet, drug therapy and physiotherapy.

Drug treatment

carried out using a complex of drugs acting on various links in the pathogenesis of the disease. The following antihypertensive drugs are used: diuretics (furosemide, brinaldix, dichlothiazide); drugs acting on various levels of the sympathetic system, including b-adrenergic receptors (anaprilin, clonidine, methyldopa); vasodilators and calcium antagonists (apressin, verapamil, phenitidine); antispasmodics (dibazol, papaverine, no-shpa, euphyllin).

Physiotherapy procedures

include electrosleep, inductothermia of the feet and lower legs, diathermy of the perirenal region. Hyperbaric oxygenation 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, the vascular index decrease, the area of ​​the epithelium increases.

Histological examination reveals focal angiomatosis, a widespread degenerative process in syncytia and trophoblast, focal plethora of the microvasculature; in most cases, a lot of "glued" sclerosed villi, fibrosis and edema of the stroma of the villi.

For the correction of placental insufficiency, therapeutic and prophylactic measures have been developed, including, in addition to agents that normalize vascular tone, drugs that affect metabolism in the placenta, microcirculation and bioenergetics of the placenta.

All pregnant women with vascular dystonia are prescribed drugs that improve microcirculation (pentoxifylline, aminophylline), protein biosynthesis and bioenergy (Essentiale), microcirculation and protein biosynthesis (Alupent).

During childbirth, it is necessary to carry out anesthesia with the use of ataractics (tazepam), antispasmodics (papaverine) and narcotic drugs (promedol).

If labor is performed without controlled hypotension, then the patient continues to receive antihypertensive therapy (dibazol and papaverine intramuscularly). In the second stage of labor, pushing is turned off with the help of obstetric forceps under inhalation anesthesia(fluorothane). Caesarean section is used in patients with cerebrovascular accident or obstetric pathology (breech presentation in primiparous age 30 and older, weakness of labor, etc.). Long-term results indicate that after childbirth, especially in cases of nephropathy attachment, often the disease progresses.

Preventive measures for complications of pregnancy and childbirth with hypertension are regular monitoring of a pregnant woman in a antenatal clinic by an obstetrician-gynecologist and a therapist, obligatory three-time hospitalization in a hospital for a pregnant woman even with good health, and effective outpatient antihypertensive therapy.

Arterial hypotension.

Arterial hypotension

– a disease characterized by a decrease in blood pressure below 100/60 mm Hg. Art. (millimeters of mercury) due to impaired vascular tone. A similar condition occurs in young women quite often, but not all persons with reduced blood pressure are considered sick. Many do not react at all to a decrease in blood pressure, and remain in good health and work. This is the so-called physiological or constitutional hypotension. Hypotension can be both independent suffering and a symptom of another disease (for example, an infectious one), so doctors distinguish primary and symptomatic (resulting from another disease) hypotension.

Primary arterial hypotension can be considered as vascular neurosis or neurocirculatory dystonia, accompanied by low blood pressure. In a conversation with a patient, it is often possible to find out that the onset of the disease is associated with neuropsychic trauma, overwork, emotional stress. Complaints of headache, dizziness, general weakness, palpitations, pain and other unpleasant sensations in the region of the heart, sweating, impaired memory, decreased ability to work, and insomnia are characteristic. Some women develop dizziness, darkening of the eyes, up to fainting when moving from a horizontal position to an upright one (getting out of bed). Often, irritability appears or increases, a tendency to a minor mood.

If arterial hypotension is manifested only by a decrease in blood pressure, then it is referred to a stable (compensated) stage of the disease. In an unstable (decompensated) stage, easily occurring syncope appears as a result of hypotonic crises, which can develop against the background of good health, without any precursors. There is a sharp weakness, dizziness, a feeling of stunnedness, accompanied by pallor of the skin and visible mucous membranes, cold sweat, vomiting may join. Blood pressure drops to 80-70 / 50-40 mm Hg. and below. The hypotonic crisis lasts from several seconds to minutes.

However, not in all cases of arterial hypotension, the pressure is steadily lowered. With excitement, it can reach normal and even increased numbers (although it is rapidly decreasing). It has long been noticed that women of asthenic physique with pale skin, hands cold to the touch are susceptible to the disease. Varicose veins of the legs are often found in these women. When examining the heart, doctors rarely reveal any abnormalities, and there are no characteristic changes in the ECG. The only thing that can be paid attention to is bradycardia or rare palpitations.

Arterial hypotension can precede pregnancy, or it can develop during pregnancy, for example, in the first months. In general, changes in blood pressure are often observed in pregnant women, and the indicators of systolic and diastolic pressure are close to the minimum limit, periodically decreasing even lower.

With physiological hypotension, not accompanied by pathological symptoms, there is no need for treatment. However, in any case, a woman should be observed by a general practitioner at the antenatal clinic. Symptomatic hypotension requires, first of all, treatment of the underlying disease.

The frequency of arterial hypotension in pregnant women is from 4.2-12.2% to 32.4% according to different authors. Arterial hypotension is the result of general disorders in the body, a symptom 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 abortion, premature pregnancy, late gestosis and anemia.

The most common complications in childbirth are untimely rupture of amniotic fluid, weakness of labor, perineal rupture. The sequential and postpartum period in 12.3-23.4% of women complicates bleeding. Postpartum period - subinvolution of the uterus, lochiometer and endomyometritis. Relatively small blood loss (400-500 ml) in women with arterial hypotension often causes severe collapse.

The frequency of surgical interventions is: cesarean section - 4.6%; manual entry into the uterine cavity - 15.3%.

With arterial hypotension, the frequency of intrauterine fetal hypoxia and newborn asphyxia is 30.7%, the number of birth injuries increases to 29.2%, the number of premature babies to 17% and children with grade I-II malnutrition to 26.1%. The assessment of the state of children on the Apgar scale is statistically significantly reduced.

First of all

, you need to take care of sufficient rest and prolonged, 10-12 hour sleep. A daytime sleep of 1-2 hours is useful. Quite effective means of treatment and prevention are physiotherapy exercises, morning exercises, walks in the fresh air. The complex of morning exercises should be the simplest, not leading to excessive overexertion, fatigue.

Nutrition must be made as varied as possible, certainly complete with a high content of protein products (up to 1.5 g / kg of body weight). Strong tea and coffee (with milk, cream) can be drunk in the morning or afternoon, but not in the evening, so as not to disturb sleep. It is useful to take vitamin B1 (thiamine bromide) 0.05 g 3 times a day, as well as multivitamins (undevit, gendevit). In addition, the doctor may prescribe sessions of hyperbaric oxygenation, general ultraviolet irradiation, electrophoresis of drugs that increase vascular tone in the neck or intranasally. A good fortifying, tonic effect is exerted by pantocrine, prescribed in 2-4 tablets. Or 30-40 drops by mouth 2-3 times a day. Effective tinctures of aralia, zamaniha, leuzea, Chinese magnolia vine, eleutherococcus, which are taken 20-30 (up to 40) drops 2-3 times a day for 30 minutes. before meals. All these funds should be taken in courses for 10-15 days. They do not so much increase blood pressure as they improve the state of health, give vigor, restore general tone, efficiency, sleep. You cannot use ginseng tincture, because possible manifestations of the teratogenic effect of this drug. Repeat treatment if the condition worsens or is planned 2-3 times during pregnancy. It should be remembered that there is an individual sensitivity to the drugs used to treat arterial hypotension, so it is sometimes necessary to select the most effective drug, sometimes a combination of drugs, purely empirically.

Before childbirth, the use of complex prenatal preparation is justified - the creation of a non-hormonal glucose-calcium-vitamin background with ongoing therapy of placental insufficiency.

varicose veins.

Unfortunately, pregnant women automatically fall into the so-called "risk group" of varicose veins:

a woman's weight is growing "by leaps and bounds" - therefore, the load on the legs also grows;

a pregnant woman - especially in late pregnancy - leads a sedentary, often sedentary lifestyle;

the growing uterus compresses the pelvic veins.

All this leads to difficulty in the outflow of blood through the veins of the legs, and the overflowing veins have nothing to do but expand. Further:

the abundant progesterone released during pregnancy helps to soften the connective tissue, of which the venous wall practically consists, i.e. its extensibility increases, which contributes to the expansion of the lumen of the veins;

during pregnancy, the content of water and salts in the body changes, the volume of circulating blood increases, which means the load on the veins ...

Thus, pregnancy can be safely called a "piggy bank of causes" of varicose veins. Probability of development

varicose veins become even more when there is a hereditary predisposition.

As a rule, the disease begins "small": small saphenous veins expand and take on the appearance of a kind of blue-violet patterns (spider veins, snakes, cobwebs) - mainly on the legs and calves. These are signs of the initial stage of the disease, which, if nothing is done, will certainly progress! In addition, signs of varicose veins are heaviness in the legs, their increased fatigue, cramps and swelling of the legs are possible. Later, the enlargement of the veins of a larger caliber occurs. They become visible under the skin in the form of swollen twisted cords and intertwining knots. This threatens with serious complications: bleeding, the formation of long-term healing (trophic) ulcers, vein thrombosis. If you do not take action in time, you will have to deal with the disease on the operating table.

At the first unpleasant symptoms, it is advisable to do ultrasound Doppler ultrasound and, if necessary, photoplethysmography. These studies are completely painless and safe, even for pregnant women. They allow you to establish the type and degree of venous circulation disorders, measure the blood flow rate and help the doctor choose the optimal treatment regimen.

don't stand for a long time, do not wear heavy loads, do not work squatting forward, do all the "standing" work with breaks during which it is best to lie down with raised legs. Sitting in a chair, it is very useful to put your feet on a special soft stool or support, thereby giving them rest and ensuring the outflow of blood through the veins. Must be avoided wearing socks and stockings with tight elastic bands.

Today, the generally accepted and most effective means of preventing varicose veins is the wearing of compression hosiery. Most importantly, it does not in the least disrupt the usual way of life. We are talking about special tights, stockings and socks that squeeze the legs, preventing the veins from expanding. Compression jersey is comfortable, it does not interfere with movement, the legs "breathe" freely in it.

It is very important to start using compression hosiery as early as possible, preferably before pregnancy. Then by the most crucial moment in life there will be healthy veins. And if so, the pregnancy will be easier. Of course, prevention must be continued during the pregnancy itself. Wearing compression tights and stockings during pregnancy and even (attention!) During childbirth will save you from formidable complications that you don't even want to remind of once again. Naturally, prevention should be continued after childbirth, especially if a woman has

already have varicose veins. After all, if she continues to wear compression hosiery, then surgery will not be needed for treatment - it may well be replaced by a vein hardening procedure. It is both safe and much less traumatic.

Main sources of information.

Burkov S.G. Doctor of Medical Sciences, Professor. Gastroenterologist. Medical center "Art-Med" at http://www.art-med.ru/articles/info.asp?id=82.

M. Sarah Rosenthal

... A chapter from the book "Gynecology" (M. Sara Rosenthal, Gynecological Sourcebook. - NTC / Contemporary, 1997) at http://www.art-med.ru/articles/info.asp?id=11.

Until the thunder breaks out ... Varicose veins during pregnancy

... WITH . Tatkov. Deputy Director of the Center for Phlebology, surgeon-phlebologist, Ph.D.

During physiological pregnancy, and especially in childbirth, such conditions of blood circulation arise, in which the load on the cardiovascular system significantly increases.

Pregnancy and childbirth make significant demands on the function of the heart due to the increase in blood mass and total weight of the pregnant woman, the emergence of a new link in the systemic circulation (uteroplacental circulation), changes in all types of metabolism, functions of the endocrine apparatus, and the central nervous system.

In the second half and especially towards the end of pregnancy, mechanical factors also acquire considerable importance, to a certain extent hindering the normal operation of the cardiovascular system, mainly the high standing of the diaphragm, which reaches the greatest extent by the 36th week of pregnancy. The high standing of the diaphragm, according to V.V.Saikova, lowers its work as an additional motor of blood circulation, reduces the vital capacity of the lungs, impedes pulmonary circulation and entails displacement of the heart; in this case, the heart does not so much rise as it approaches the chest and at the same time rotates somewhat around its axis. The change in the position of the heart is accompanied by a relative "twisting" of the vessels that bring and carry blood, which also causes difficulty in pulmonary circulation.

The main changes in hemodynamics during pregnancy are reduced to an increase in the mass of circulating blood (plasma and erythrocyte volume), minute and stroke volumes, heart rate, and blood flow velocity.

The increase in the mass of circulating blood occurs gradually. At the same time, the volume of circulating blood at 28-32 weeks of pregnancy increases by about 30-40%, amounting to 5-5.3 liters in the first trimester of pregnancy, and 6.0-6.5 liters in the third. The amount of circulating blood increases mainly due to liquid (plasma), which leads to a decrease in the specific gravity of blood and the emergence of "pletora of pregnant women". While the amount of circulating blood during pregnancy increases by 30%, the hemoglobin content increases by only 15%; the hematocrit index decreases.

As the gestational age increases, the minute blood volume also increases - from 5.5 liters at the beginning of pregnancy to 6.4-7 liters at 28-32 weeks of gestation.

The increase in the minute blood volume is mainly due to an increase in the stroke volume and, to a lesser extent, to an increase in heart rate. In this case, the systolic volume increases by 25-50%, reaching 70-80 ml versus 60-65 ml in non-pregnant women. The blood flow velocity in pregnant women, equal to 10 s in the “hand - ear” section at the beginning of pregnancy, slightly increases towards the end of it (11-13 s). The pulse rate in healthy pregnant women, even at rest, increases. In this case, tachycardia is observed in more than 50% of pregnant women.

When talking about the level of blood pressure during pregnancy and childbirth in women with a healthy cardiovascular system, two things must be kept in mind:

• you need to know the dynamics of blood pressure before pregnancy and from the very beginning. The degree of excitability of the vasomotor apparatus in different women is different, and in changes in blood pressure and in the state of vascular tone, the functional state of the body, its nervous system, due to both exogenous and endogenous factors, plays an important role;
• in the absence of pathological changes in the state of the cardiovascular system, blood pressure during pregnancy and even during childbirth changes relatively insignificantly.

In the first half of pregnancy, systolic, diastolic and pulse pressure decreases slightly, and from 6-7 months there is a tendency to increase it (especially diastolic). Many authors talk about a wave-like rise in maximum blood pressure, starting from about the 6th month of pregnancy, but it remains within the physiological norm.

Still, it must be emphasized that if women with a normal initial blood pressure of 110-120 / 70-80 mm Hg. Art. there is a rise in it in the second half of pregnancy over 130-135 / 80-90 mm Hg. Art., this should be regarded as a signal of the possible onset of a pathological state of the vascular system on the ground.

It should be remembered that during childbirth, there are often sharp fluctuations in hemodynamics, which is reflected in changes in the level of blood pressure.

After opening the fetal bladder, blood pressure usually drops, sometimes quite sharply. Therefore, V.V. Stroganov recommends early opening of the fetal bladder as a preventive method for treating eclampsia.

In the second and third stages of labor, there are rapid and abrupt changes in the rise and fall of blood pressure. Venous pressure in the upper extremities (in the elbow vein) does not change significantly with increasing gestational age, while in the femoral veins it increases markedly.

When assessing the state of the cardiovascular system in pregnant women, gas exchange rates should also be taken into account. With the development of pregnancy, the vital capacity of the lungs (VC) decreases, the maximum ventilation of the lungs and oxygen saturation of the arterial blood decreases, the amount of under-oxidized metabolic products increases (the content of lactic acid rises). At the same time, the minute volume of respiration (MRV) increases, the efficiency of using the oxygen of the inhaled air increases. In the body of pregnant women, the oxygen reserve is significantly reduced and the regulatory capabilities are extremely tense. Especially significant circulatory and respiratory changes occur during childbirth. An increase in heart rate, an increase in stroke and minute volumes, blood pressure, oxygen consumption by tissues, an increase in the concentration of lactic and pyruvic acids, etc.

Studies by Adams and Alexander showed an increase in the work of the heart during contractions by 20%, and after discharge of the placenta - by 18%. During the birth act, the work of the heart increases by 5%! and more in comparison with the state of rest (V. Kh. Vasilenko). All of the above factors are the cause of the emergence and development of that symptom complex of complaints and clinical manifestations, which undoubtedly testifies to some changes and known tension in the functions of the cardiovascular system in pregnant women. However, these changes in the body of a healthy pregnant woman are physiological. Their severity depends on the general condition of the pregnant woman's body, its ability to quickly and fully adapt to new, unusual conditions of the external and internal environment, from diseases suffered in the past. The central nervous system plays an important role in determining these abilities of the pregnant woman's body. The symptom complex of functional changes that occur in most pregnant women can be different, from subtle, almost not causing any complaints, to those on the verge of significant dysfunctions of the cardiovascular system.

The most frequent complaints, especially in the second half of pregnancy, often presented by healthy pregnant women, are: shortness of breath, palpitations, general weakness, and sometimes dizziness. The pulse rate reaches 90-100 beats / min, increasing even more during childbirth, especially during the period of fetal expulsion. Immediately after the end of labor, most often in the first hours of the postpartum period, if there was no significant blood loss during labor, bradycardia is observed with a slowdown in the pulse rate to 60-70 beats / min.

Tachycardia in pregnant women - one of the usual reactions of the heart. In the vast majority of cases, tachycardia in pregnant women with a healthy cardiovascular system is temporary. It weakens and disappears as the woman's body adapts to new external and internal stimuli.

Tachycardia during labor can reach a significant degree, especially during the period of fetal expulsion. The reasons are as follows:

• great physical stress;
• pronounced negative emotions (pain, fear);
• increasing relative oxygen starvation towards the end of labor.

Relative hypoxemia , along with mechanical factors that impede the normal operation of the cardiovascular apparatus and reduce VC, causes shortness of breath, which, to a greater or lesser extent, many women complain about in the second half of pregnancy. Shortness of breath in healthy pregnant women can be caused by metabolic disorders with a pronounced shift towards acidosis and relative hypoxemia. Since, in addition, a mechanical factor acts in the second half of pregnancy, shortness of breath in pregnant women should be classified as a mixed form. During contractions and especially attempts, blood oxygen saturation is significantly reduced, because during childbirth, breath holding, intense muscular work and a significant depletion of the oxygen reserve are combined. All this is one of the prerequisites for the appearance of shortness of breath in pregnant women and women in labor.

However, the adaptive mechanisms of the body allow the overwhelming majority of women to adapt well to the inevitable functional changes that occur during pregnancy, and serious disorders in the activity of the cardiovascular system usually do not occur.

In pregnant women, there is a slight increase in the heart due to some hypertrophy and expansion of the left ventricle. It depends on a number of interrelated reasons: a) an increase in the total mass of blood, b) some difficulty in the advancement of a gradually increasing mass of blood. However, minor hypertrophy and expansion of the heart develops slowly and gradually, and the heart has time to adapt to the increased demands on the cardiovascular system.

During pregnancy, the working capacity of the heart increases, which, according to the literature, increases by an average of 50% in comparison with the period before pregnancy.

A significant increase during pregnancy in the absence of valvular disease or inflammation in the myocardium indicates a decrease in the contractility of the heart.

Auscultation, as many authors point out, in some pregnant women (about 30%), especially in the second half of pregnancy, a soft blowing systolic murmur at the apex of the heart and on the pulmonary artery is determined. These noises can be heard with a perfectly healthy cardiovascular system and are purely functional in nature. So, the systolic murmur of the pulmonary artery depends on its temporary relative narrowing due to some inflection due to the high standing of the diaphragm, which changes the normal location of the heart and large vessels. A systolic murmur at the apex of the heart indicates a slight functional insufficiency of the mitral valve. These murmurs disappear soon after childbirth, which confirms their functional origin.

Features of blood circulation during pregnancy, mainly in the second half of it, cause the appearance of a number of clinical symptoms that cause diagnostic difficulties (displacement of the boundaries of the heart, the appearance of noise, an emphasis of the second tone on the pulmonary artery, extrasystole). It is often difficult to decide whether they are a manifestation of organic heart disease or physiological changes caused by pregnancy.

To assess the functional state of the cardiovascular system in pregnant women, electrocardiography (ECG), vector cardiography (VCG), ballisto- and phonocardiography (BCG and PCG) are of particular importance. ECG changes in pregnant women are reduced to the appearance of the left type, a negative T wave in lead III, an increase in the systolic index, an increase in the QRST segment and a T wave in leads I and III. With an increase in the duration of pregnancy, certain changes in the PCG are noted, due to the difficulty of pulmonary circulation and an increase in pressure in the pulmonary circulation. They are reduced to an increase in the distance Q (R) of the ECG to the I tone of the PCG (from 0.035 to 0.05 s), a change in the II tone due to the increase in the amplitude of the second component of it, an increase in the distance T ECG - II tone of the PCG (from 0.03 to 0.05 s), the appearance of additional sound phenomena - systolic noise, an increase in the amplitude of the II tone on the pulmonary artery, its splitting and bifurcation.

During pregnancy, the vector cardiogram also changes - the area of ​​the QRS loop by the end of pregnancy increases by more than 40%.

The balli-stokardiogram also changes very significantly during pregnancy. In the second half of pregnancy, the K wave increases and deepens, which is associated with an increase in blood flow in the descending aorta, a large blood supply to the vessels of the small pelvis and abdominal cavity, an increase in pressure in them, and, consequently, a corresponding increase in peripheral resistance.

With an increase in gestational age, the amplitude of respiratory oscillations IJ increases, the ballistocardiographic index (BI) decreases, the respiratory index (RI) increases, there are changes in the 1st degree according to Brown and disturbances in the ratios of the ballistocardiogram waves - JK / IJ, KL / IJ, KL / JK.

Changes in BCG in healthy women are the result of an overflow of blood in the pelvic vessels, an increase in venous flow to the right heart, and changes in the anatomical axis of the heart due to its horizontal position.

In the physiological course of pregnancy, there are noticeable changes in vascular permeability associated with a violation of the functional state of vascular membranes and changes in capillary circulation.

With capillaroscopic studies, an increase in the number of capillary loops, their expansion, mainly of the venous part, the presence of a more turbid background, pericapillary edema, and a slowdown in blood flow are found.

In recent years, it has been proven that an increase in the minute volume (and a change in other hemodynamic parameters) occurs from the beginning of pregnancy, increasing only until the 28-32th week, after which it gradually decreases.

As you know, the main load on the cardiovascular system is observed immediately after the expulsion of the fetus against the background of relative rest. Due to a sudden drop in intra-abdominal pressure, an immediate restructuring of the entire blood circulation should occur. At this point, the vessels of the abdominal cavity quickly overflow with blood. There is, as it were, bleeding into the vessels of the abdominal cavity. The blood flow to the heart decreases, and the heart works faster, but with a significant decrease in systolic volume - "half empty" (GM Salgannik et al.). Meanwhile, the intensified work of the heart at this moment is also required because during the period of exile, especially towards the end of it, the woman in childbirth necessarily develops a state of relative hypoxia; to eliminate her, the heart must work hard, with tension.

A healthy body, a healthy cardiovascular system have the ability to easily and quickly adapt to often significant and sudden changes in hemodynamics , in connection with which in a healthy woman in labor, as a rule, the necessary coordination in the circulatory system occurs quickly. However, with certain defects in the work of the heart, most often it is in the third stage of labor that its functional insufficiency can be revealed. It is possible and necessary to foresee and prevent the occurrence of circulatory failure, for which it is necessary to study in advance the state of the cardiovascular system of every pregnant woman and to know at what pathological changes in this system dangerous disturbances in childbirth occur.

In cases of an unclear diagnosis, a pregnant woman should be sent to a hospital (at the beginning of pregnancy - to a therapeutic one, in the third trimester - to) for an in-depth clinical examination, observation and treatment.

The spectrum of cardiovascular diseases is wide enough. Among them are acquired and congenital defects of the heart and large vessels, rheumatism, myocarditis, cardiomyopathies and other myocardial diseases, rhythm and conduction disturbances, hypertension. The most common of these pathologies are heart defects.

Why is heart disease dangerous?

Heart disease aggravates the course of pregnancy, causing an increase in the frequency of preterm birth, delay in intrauterine development of the fetus. At the same time, in a significant part of patients with an increase in pregnancy, symptoms of cardiovascular insufficiency increase, which sometimes becomes dangerous for a woman's life.

At the heart of numerous forms of the disease is impaired blood circulation. As a result, the supply of oxygen-rich arterial blood to organs and tissues decreases, which leads to oxygen deficiency in the body of the pregnant woman and the woman in labor, as well as in the body of the fetus.

During the development of pregnancy, the load on the cardiovascular system increases, and in severe forms of the defect, complications may arise - pulmonary edema, congestion in the liver, multiple tissue edema.

Pregnancy management in women with heart defects

Over the past decades, thanks to the advances in cardiology and especially cardiac surgery, as well as the possibility of early diagnosis of the disease, including intrauterine ultrasound diagnostics, it became possible to treat exacerbation of the rheumatic process, and most importantly, to surgically correct heart defects during pregnancy and in the postpartum period. Given the complexity of the problem, specialized maternity hospitals for pregnant women with cardiovascular diseases have been created in Moscow and a number of large cities in Russia. In Moscow, such an institution since 1965 has been the maternity hospital at the city clinical hospital No. 67, where most of the pregnant women suffering from one or another disease of the cardiovascular system are observed.

The presence of a consultative and diagnostic center often makes it possible to detect a heart defect in a patient or to clarify the form of the defect and the stage of its development. In the pathology departments, pregnant women receive the necessary treatment, including surgical care in the leading cardiac surgery institutions in Moscow. Timely surgical treatment allows you to correct the existing cardiac pathology, significantly reduce the risk of future childbirth and safely complete the postpartum period.

Regardless of the severity of the heart pathology, patients with such diseases are hospitalized three times during pregnancy. The first time a woman is admitted to the hospital at 8-10 weeks to clarify the diagnosis and resolve the issue of the possibility of maintaining pregnancy (the need to terminate a pregnancy occurs if there are signs of heart failure, exacerbation of rheumatism at the beginning of pregnancy; if the pregnancy was not terminated, then after 12 weeks the appropriate treatment). The second time a pregnant woman is hospitalized at 28-30 weeks - during the period of greatest stress on the heart, and the third - 3 weeks before childbirth - to prepare for them.

In the process of observation and treatment in the department of pregnancy pathology, a woman and her relatives are informed in detail about the nature of the disease, the prognosis for the health of the mother and fetus, and the method of delivery. In especially severe cases of illness, a woman is offered termination of pregnancy in the interests of her health.

Childbirth in women with heart defects

The nature of delivery in patients with cardiovascular diseases depends on the shape of the heart defect, on the stage of development of the disease, as well as on the obstetric situation - the size of the pelvis, the size of the fetus, the presentation of the fetus and the placenta. For most women with heart defects, delivery through a vaginal birth canal is preferable, given the simultaneous large release of blood from the uterus into the bloodstream during a cesarean section and an increase in the load on the cardiovascular system of the woman in labor. For moderate heart diseases, interventions are used that exclude attempts during the third stage of labor (obstetric forceps, vacuum extraction). Indications for operative delivery are severe heart failure and valve prostheses in the heart.

Childbirth in women with cardiovascular disease is usually carried out in a semi-sitting position or in a supine position. This reduces the flow of venous blood to the heart, and the pregnant uterus less compresses one of the large venous collectors - the inferior vena cava.

The following complications occur in pregnant women with heart disease:

• Premature birth. It should be noted that it is quite difficult for patients with heart disease to choose drugs that help maintain pregnancy, since most of these drugs affect the smooth muscles of not only the uterus, but also the heart and blood vessels, impairing the work of the heart.
• Bleeding complicating the postpartum period, since with heart failure the liver suffers, which normally produces substances involved in the process of blood clotting.

Heart disease can be complicated by the onset of acute heart failure during childbirth.

Doctors closely monitor the condition of the woman in labor: they determine the pulse rate, respiratory rate, and regularly measure blood pressure. For patients at risk of arrhythmias, childbirth is performed under cardiac monitoring. They also monitor the amount of urine excreted, since its decrease indicates stagnation.

Since the altered valves are more susceptible to infection, antibacterial drugs are usually used during childbirth. Since women with pathology of the cardiovascular system are at risk of bleeding, immediately after childbirth, prevention of this complication is carried out by intravenous administration METHYLERGOMETRINA, which improves not only the contractions of the uterus, but also the blood supply to the lungs.

After childbirth, depending on the type of heart defect, part of women in labor is recommended, and part of it is contraindicated to put weight on the stomach - the doctor who is watching the woman during childbirth knows this in advance.

Childbirth and caesarean sections are performed with careful pain relief to avoid progression of heart failure and pulmonary edema. For anesthesia, both relatively new methods are used - epidural anesthesia, and endotracheal anesthesia, which has been used for many decades.

Pregnancy with hypertension

Often, a woman suffering from hypertension learns about her disease only in the antenatal clinic during the first measurement of blood pressure. A feature of this disease is the addition of gestosis 1 , more often developing by the 28th -30th week of pregnancy. This complication is manifested by edema, increased blood pressure, and the appearance of protein in the urine. The first manifestations of preeclampsia in women with essential hypertension require urgent hospitalization in the pregnancy pathology department for appropriate treatment. The progression of gestosis adversely affects the intrauterine development of the fetus, leads to a delay in its growth, and in severe cases - to its intrauterine death. The launched course of gestosis in the second half of pregnancy threatens the health of a woman and can lead to a serious complication in the form of a convulsive seizure - eclampsia, which is unsafe for a woman's life. To prevent such a serious complication, it is necessary to regularly visit the antenatal clinic from the early stages of pregnancy and timely undergo treatment in a maternity hospital.