Diseases of the cardiovascular system during pregnancy. Pregnancy and diseases of the cardiovascular system

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

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

• early diagnosis of heart disease,
• expansion of indications for the preservation of pregnancy,
• an increase in the number of women undergoing heart surgery and the number of seriously ill women who, either on their own or with the permission of doctors, decide to keep their pregnancy, confident in the success of medical science and practice.

The most important hemodynamic shift during pregnancy is the increase in cardiac output. At rest, its maximum increase is 30-45% of the cardiac output before pregnancy. The increase in this indicator occurs already in the early stages of pregnancy: on the 4-8th week 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 magnitude of cardiac output is significantly affected by changes in the position of the body of a 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 time 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 the gestation period.

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 on 3-4 days after birth. All this can threaten a woman with cardiovascular diseases with the development of circulatory decompensation before childbirth, during childbirth and after them.

Volume of circulating blood

(BCC) increases already in the first trimester of pregnancy and reaches a maximum by the 29-36th week. In childbirth, changes in BCC are usually not observed, but it decreases markedly (by 10-15%) in the early postpartum period. However, women suffering from cardiovascular diseases often have edema, including the so-called internal.

BCC can increase due to the entry into the bloodstream of a large amount of extravascular fluid, which can lead to the development of heart failure, up to pulmonary edema. Due to the abrupt shutdown of the uteroplacental circulation, the elimination of compression of the inferior vena cava, immediately after the birth of the fetus, there is a rapid increase in BCC, which the diseased heart cannot always compensate for by an increase in cardiac output.

Oxygen consumption during pregnancy increases and before childbirth exceeds the initial level by 15-30%. It's connected withan increase in the metabolic needs of the fetus and mother, andalso with an increase in the load on the maternal heart.In addition, a direct relationship was found between fetal body weight and the degreeincrease in maternal oxygen consumption.

At the very beginning of childbirth,increase in oxygen consumption by 25-30%, during contractions by 65-100%, duringthe second period by 70-85%, at the height of attempts by 125-155%. In the early postpartumperiod, oxygen consumption still remains elevated by 25% compared withprenatal level. A sharp increase in oxygen consumption during childbirthis a significant risk factor for women in labor with the diseaseof cardio-vascular system.

The syndrome of compression of the inferior vena cava in pregnant women should not be regarded as a sign diseases. Rather, it is a manifestation of insufficient adaptation of the cardiovascular due to an increase in uterine pressure, pressure on the inferior vena cava and a decrease in venous return of blood to the heart, resulting in a decrease in blood pressure (with a sharp decrease, fainting occurs), and with a fall in systolic blood pressure, loss of consciousness.

The syndrome of compression of the inferior vena cava can be manifested by anxiety, a feeling of lack of air, increased respiration, dizziness, darkening of the eyes, blanching of the skin, sweating, tachycardia. These signs can be in other shock states. But unlike the latter, a sharp increase in venous pressure in the legs is noted with an altered venous pressure in the arms.

Most often, the syndrome occurs with polyhydramnios, pregnancy with a large fetus, with arterial and venous hypotension, with multiple pregnancy, in pregnant women of small stature. Special treatment is usually not required. If a syndrome of compression of the inferior vena cava occurs, it is enough to immediately turn the woman on her side.

The first signs of the disorder usually appear in women lying on their backs. Of particular danger is the appearance of collapse (shock) due to compression of the inferior vena cava during operative delivery.

It is necessary 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 resulting changes in hemodynamics, metabolism, body weight (increase by 10-12 kg by the end of pregnancy), water-salt metabolism (during pregnancy, the total water content in the body increases by 5-6 l, the sodium content in the body increases already by the 10th week of pregnancy by 500-600 mmol, and potassium by 170 mmol, up to 870 mmol of sodium accumulates in the body before childbirth) require increased work from the heart and often aggravate the course cardiovascular disease.

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

Pregnancy is a very dynamic process, and changes in hemodynamics, hormonal status and many other physiological factors in the body of a pregnant woman occur constantly and gradually, and sometimes suddenly. In this regard, it is important not only to make a correct diagnosis, to determine the nosological form of heart or vascular disease, but to assess the etiology of this disease and the functional state of the cardiovascular system.

In addition, it is important to assess the degree of activity of the primary pathological process (rheumatism, rheumatoid arthritis, thyrotoxicosis, etc.), which led to damage to the cardiovascular system, as well as 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. AT

resolving this issue, the doctor who carries out dispensary observation of patients, as well as the attending physician who constantly monitors the patient (district doctor, family doctor, cardiologist) has certain advantages. In the future, in the event of pregnancy, childbirth and the postpartum period, this issue should be resolved jointly by a cardiologist with an obstetrician-gynecologist, and, if necessary, with the involvement of doctors of other specialties.

During pregnancy, an increased load on the cardiovascular system causes physiologically reversible, but quite pronounced changes in hemodynamics and heart function. Without knowing about the changes in hemodynamics in healthy pregnant women, it is impossible to adequately assess it in cardiovascular diseases.

The increase in load is associated with an increase in metabolism aimed at meeting the needs of the fetus, an increase in the volume of circulating blood, the appearance of an additional placental circulatory system, with a constantly increasing body weight of the pregnant woman.

With an increase in size, the uterus limits the mobility of the diaphragm, increases intra-abdominal pressure, changes the position of the heart in the chest, which ultimately leads to changes in the working conditions of the heart. Such hemodynamic changes as an increase in circulating blood volume and cardiac output can be unfavorable and even dangerous in pregnant women with diseases of the cardiovascular system, due to their layering on the already existing ones, caused by the disease.

A change in hemodynamics in the mother has a negative effect on the uteroplacental circulation, which in some cases can cause fetal malformations, including congenital heart defects.

A long period of pregnancy is replaced by a short, but extremely significant period of childbirth in terms of physical and mental stress. Following the period of childbirth, the postpartum period begins, which is no less important in terms of hemodynamic and other physiological changes.

Among the heart diseases that complicate pregnancy, the most common are rheumatism, acquired and congenital heart defects, anomalies in the development of the main vessels, myocardial disease, an operated heart, and cardiac arrhythmias.

Developing pregnancy worsens the course of CVD and can lead to the development of extreme conditions that require urgent measures not only from the obstetrician, but also from the therapist, cardiologist, and surgeon. The mortality of pregnant women, parturient women, puerperas suffering from acquired heart defects, pulmonary hypertension, complex congenital malformations, acute and chronic cardiovascular insufficiency (CVS) is quite high.

Critical periods of pregnancy for exacerbation of CVD.

Start of pregnancy - 16 weeks.

During these terms, the most common exacerbation of rheumatic heart disease.

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

35 weeks - the beginning of labor. Weight gain, difficulty in pulmonary circulation due to the high standing of the uterine fundus, decreased diaphragm function.

The beginning of childbirth - birth fetus. Increase in blood pressure (BP),systolic and cardiac output.

Early postpartum period.

Postpartum collapses are possible due to a sharp change in intra-abdominal and intrauterine pressure.

Methods for studying CCC in pregnant women.

History - maybe contain important information about the time of occurrence of rheumatic disease,the duration of the existence of heart disease, the number of transferred rheumaticattacks, circulatory disorders, etc.

Electrocardiography - registration of electrical phenomena that occur in the heart muscle when it is excited.

Vectorcardiography - detection of signs of hypertrophy of the heart.

X-ray examination - without sufficient grounds, it should not be carried out during pregnancy.

Radionuclide research methods - should not be carried out during pregnancy.

Phonocardiography is 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 is used to study hemodynamics and cardiodynamics, determine the size and volume of the heart cavities, and 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.

Tests with a load - to assess the functional state of the myocardium. Tests with a load on a bicycle ergometer up to a heart rate of 150 per minute are also used in pregnant women.

Studies of the function of external respiration and acid-base status.

Blood studies.

General information 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 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-st 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-nd 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 signs of circulatory failure, exacerbation of rheumatism, atrial fibrillation, late preeclampsia of pregnant women or severe anemia appear, 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, the indications for caesarean section in patients with cardiovascular diseases have been somewhat expanded. 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 for caesarean section is severe pulmonary hypertension.

Self-delivery through the natural birth canal is allowed with compensation of blood circulation in patients with mitral valve insufficiency, combined mitral heart disease with a predominance of stenosis of the left antriventricular orifice, aortic heart defects, congenital heart defects of the “pale type”, with mandatory anesthesia for childbirth, to prevent the onset or aggravation heart failure (should start with the / m injection of 2 ml of a 0.5% solution of diazepam and 1 ml of 2% promedol already from the moment the first contractions appear).

Successful delivery of patients suffering from severe congenital and acquired heart defects can be facilitated by conducting labor under hyperbaric oxygen therapy, taking into account possible complications of HBOT in the postpartum period.

After the birth of the fetus and the discharge of the placenta, there is a rush of blood to the internal organs (and primarily to the abdominal organs) and a decrease in BCC in the vessels of the brain and coronary.

In order to prevent deterioration of the condition, it is necessary to administer cardiotonic agents immediately after the birth of the child. Women in childbirth with heart disease can be discharged from the maternity hospital no earlier than 2 weeks after delivery in a satisfactory condition under the supervision of a cardiologist at the place of residence.

Rheumatism and Acquired Heart Disease (ACD)

Rheumatism is a systemic connective tissue disease with a predominant lesion of the cardiac system, more common in young women; caused by b-hemolytic group A streptococcus.

In the pathogenesis of the disease, allergic andimmunological factors. Taking into account clinical manifestations and laboratory datadistinguish between active and inactive phases and 3 degrees of process activity: 1 -minimum, 2 - average and 3 - maximum - degrees.

By localization of activerheumatic process allocate carditis without valvular disease, recurrent carditis withvalvular disease, carditis without cardiac manifestations, arthritis, vasculitis, nephritis andetc. In pregnant women, rheumatism occurs in 2.3-6.3%, and its exacerbationoccurs in 2.5-25% of cases, most often in the first 3 and last 2 monthspregnancy, as well as during the first year after childbirth.

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

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

During pregnancy and in the postpartum period, the rheumatic process proceeds in waves. Critical periods of exacerbation of rheumatism correspond to the early stages of pregnancy - up to 14 weeks, then from 20 to 32 weeks and the postpartum period. The course of rheumatism during pregnancy can be associated with fluctuations in the excretion of corticosteroid hormones.

Until the 14th week, corticosteroid excretion is usually at a low level. From the 14th to the 28th week, it increases by about 10 times, and on the 38th-40th week it increases by about 20 times and returns to its original level on the 5th-6th day of the postpartum period. Therefore, preventive anti-relapse treatment should be timed to critical periods.

Of particular note is the cerebral form of rheumatism, which occurs with a predominant lesion of the central nervous system. Pregnancy can provoke relapses of chorea, the development of psychosis, hemiplegia due to rheumatic vasculitis of the brain. With this form of rheumatism, a high mortality rate is observed, reaching 20-25%.

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

Hemodynamic shifts naturally developing during physiological pregnancy can lead to heart failure.

Pregnant women with heart defects are at high risk of maternal and perinatal mortality and morbidity. This is explained by the fact that pregnancy imposes an additional burden on the cardiovascular system of women.

PPS account for 75-90% of all cardiac lesions in pregnant women. Of all the forms of defects of rheumatic origin, mitral defects are most often observed in the form of a combination of insufficiency and stenosis of the left atrioventricular orifice, i.e. in the form of combined mitral defect or mitral disease. However, the clinical picture of the disease is usually dominated by signs of either mitral stenosis or bicuspid valve insufficiency.

Therefore, the terms "mitral stenosis" or "mitral insufficiency" denote not only pure forms of malformations, but also those forms of combined valvular damage in which the defect sign dominates.

The clinical symptoms of mitral stenosis and mitral insufficiency depend on the stage of the disease, according to the classification of A.N. Bakuleva and E.A. Damir: 1st. - full compensation, 2st. - relative circulatory failure, 3st. - the initial stage of severe circulatory failure, 4st. - severe circulatory failure, stage 5 - dystrophic period of circulatory failure.

It is generally accepted that mild bicuspid valve insufficiency or combined mitral valve disease with a predominance of insufficiency usually has a favorable prognosis. Aortic defects are much less common than mitral and are predominantly combined with other defects. Most often, the predominance of aortic valve insufficiency and less often stenosis is found. The prognosis for aortic stenosis is more favorable than for aortic valve insufficiency.

PPS occur in 7-8% of pregnant women. To predict the outcomes of pregnancy and childbirth, the activity of the rheumatic process is important. The form and stage of development of the defect, compensation or decompensation of blood circulation, the degree of pulmonary hypertension, rhythm disturbance, as well as the addition of obstetric pathology.

All these data determine the choice of obstetric tactics during pregnancy, childbirth and in the postpartum period. Rheumatologists note that obliterated forms of the rheumatic process currently prevail, and therefore their diagnosis on the basis of clinical, hematological, and immunobiological studies is very difficult.

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 from the 12-20th week of pregnancy. Restoration of hemodynamics begins in puerperas only 2 weeks after birth. In patients with mitral stenosis during pregnancy, due to physiological hypervolemia, which increases pulmonary hypertension, the risk of pulmonary edema increases.

At the same time, no method of delivery (with the help of obstetric forceps, by caesarean section) helps to stop pulmonary edema. The most reliable way to ensure a favorable outcome in such cases is mitral commissurotomy. This operation, depending on the situation, can be recommended in 3 options.

The first option: an artificial abortion is performed and then a mitral commissurotomy (after the first menstruation); after 5-6 months. after successful heart surgery, re-pregnancy can be allowed.

The second option is mitral commissurotomy during this pregnancy at any time (with intractable drug-induced pulmonary edema), but better at 24-32 weeks, when the risk of spontaneous abortion as a reaction to surgical trauma is 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 maturity of the fetus) and one-stage (after delivery) - mitral commissurotomy. The operation of mitral commissurotomy during pregnancy appears to be more radical due to decalcification of the valve leaflets and greater amenability to separation of subvalvular adhesions.

Mitral insufficiency

Pregnancy with this pathology is much easier. Usually ends in spontaneous delivery. With pronounced mitral insufficiency with significant regurgitation and a sharp increase in the left ventricle, pregnancy is difficult and may be complicated by the development of acute left ventricular failure.

In such women, signs of heart failure appear or increase from early pregnancy, which, as a rule, is accompanied by severe nephropathy with a torpid course. Drug therapy for heart failure in these cases is ineffective, therefore, either early termination of pregnancy (induced abortion, small cesarean section) or early delivery in a planned manner by the abdominal route is used. Subsequently, the patient is recommended surgical treatment of heart disease.

In the Russian Federation, there is experience in the implantation of a ball prosthesis and allograft in patients with decompensated mitral insufficiency during pregnancy. Even for such patients, after abortion by the vaginal route, the use of an intrauterine device is recommended, and sterilization is performed with the abdominal method.

aortic stenosis

Among the acquired heart defects in pregnant women, this disease deserves attention. Pregnancy and childbirth can be allowed only in the absence of pronounced signs of left ventricular hypertrophy and symptoms of circulatory failure, since the defect is compensated for by concentric hypertrophy of the left ventricular muscle, thickening of its wall.

In cases of severe aortic stenosis, when surgical correction of the defect is necessary - replacement of the affected valve with a prosthesis, the possibility of carrying a pregnancy is decided after the operation. Aortic insufficiency compared to aortic stenosis is a less severe defect, since it maintains circulatory compensation for a long time.

However, due to changes in hemodynamics due to pregnancy and the frequent addition of late toxicosis, the course of aortic insufficiency may be more severe. In patients with aortic heart disease, pregnancy and childbirth through the natural birth canal are allowed only in the stage of circulatory compensation.

In the second stage of labor, in order to reduce the stimulating effect of childbirth on the development of the defect, it is shown to turn off attempts by applying obstetric forceps. With symptoms of heart failure, pregnancy should be considered unacceptable. The resulting pregnancy is subject to termination. If the pregnancy has reached a long term, the most rational is early delivery by abdominal route with sterilization.

Tricuspid valve insufficiency is usually rheumatic in nature. Most often, this defect occurs in pulmonary hypertension.

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

Acquired valvular disease of the pulmonary artery - clinically detected very rarely. Most often combined with lesions of other heart valves.

Multivalvular rheumatic heart disease is quite common. Their diagnosis is difficult, because. hemodynamic shifts characteristic of certain types of defects, and their symptoms, prevent the manifestation of some hemodynamic shifts and clinical signs characteristic of each type of defect.

However, the identification of concomitant malformations in pregnant women may be of decisive importance for making a decision on the possibility of maintaining the pregnancy and on the advisability of surgical correction of the defect or malformations. congenital heart defects (CHD).

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

Atrial septal defect

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

Ventricular septal defect

Less common than atrial septal defect. Often associated with aortic valve insufficiency. Pregnant women with a minor ventricular septal defect can tolerate pregnancy well, but as the defect increases, the risk of developing heart failure, sometimes fatal, increases. Postpartum paradoxical systemic embolism may occur.

Open ductus arteriosus

When a duct is blocked, blood flows from the aorta into the pulmonary artery. With a significant discharge of blood, dilatation of the pulmonary artery, left atrium and left ventricle occurs. In terms of tactics of managing a pregnant woman with this defect, the diagnosis of the diameter of the duct is of primary importance. This disease, with an unfavorable course, can complicate the development of pulmonary hypertension, subacute bacterial endocarditis, and heart failure. During pregnancy, 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 pulmonary stenosis

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

Tetralogy of Fallot

Fallot's tetrad is classified as a classic "blue" heart disease. Consists of right ventricular outflow tract stenosis, large ventricular septal defect, displacement of the aortic root to the right, and right ventricular hypertrophy. In women with Fallot's tetralogy, pregnancy poses a risk to both mother and fetus. Especially dangerous is the early postpartum period, when severe syncopal attacks can occur.

With Fallot's tetrad, the percentage of complications such as the development of heart failure is high, and the lethal outcome for the mother and fetus is quite high. Women who have undergone radical surgery for this defect are more likely to have a favorable course of pregnancy and childbirth.

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

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

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

operated heart

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

It should be remembered that not always corrective operations on the heart lead to the elimination of organic changes in the valvular apparatus or the elimination of congenital 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 disorders

This pathology is also important in the prognosis of pregnancy and childbirth, it should be borne in mind that pregnancy itself can cause arrhythmias. So, extrasystole, paroxysmal tachycardia in pregnant women can be observed without any organic changes in the myocardium. They occur in 18.3% of pregnant women. The addition of late toxicosis further contributes to the appearance or intensification of arrhythmias. There is no significant effect on the outcome of pregnancy.

Atrial fibrillation in combination with organic pathology of the heart, in particular with mitral stenosis, is a contraindication to carrying a pregnancy, and the method of terminating it matters. Caesarean section for these patients is more dangerous than delivery through the natural birth canal, because of the possible thromboembolism in the pulmonary artery system.

On the contrary, violations of atrioventricular conduction (incomplete and complete heart block) in themselves do not pose a danger to the pregnant woman. Moreover, in these patients, pregnancy, as a rule, causes an increase in the ventricular rate, thereby preventing the risk of Adams-Stokes-Morgagni attacks.

Only with a very rare pulse - 35 or less per 1 minute - in the second stage of labor, in order to speed up labor, attempts are turned off by applying 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 is the flexion of the leaflets of the mitral valve into the left atrium during ventricular systole. A mild degree of prolapse is established using echocardiography. Severe mitral valve prolapse syndrome is diagnosed on the basis of clinical data and phonocardiography.

Depending on the degree of prolapse of the leaflets, one or another degree of insufficiency of the closing function of the mitral valve develops with blood regurgitation into the cavity of the left atrium. The clinical manifestations of this pathology are very diverse - from an asymptomatic course to a pronounced clinical picture. The most pronounced symptoms are observed in patients with prolapse of both leaflets of the mitral valve.

At present, for the first time, the course of this syndrome in combination with pregnancy has been studied, and it has been established that mildly pronounced deflection of the posterior wall of the mitral valve, and therefore, mildly pronounced regurgitation, decreases with increasing gestational age and returns to its original state 4 weeks after birth. This can be explained by the physiological increase in the cavity of the left ventricle during pregnancy, which changes the size, length and degree of tension of the chords.

The tactics of conducting labor is the same as in physiological pregnancy. A pronounced prolapse of the valves with a large amplitude of deflection during pregnancy proceeds without significant dynamics.

In these patients, due to the severity of cardiac symptoms, attempts during childbirth must be turned off by applying obstetric forceps. With a combination of obstetric pathology (weakness of labor and prolonged, large fetus, a sharp strain during attempts, etc.), they resort to delivery by caesarean section.

Myocarditis and cardiomyopathy

Myocarditis of various etiologies in pregnant women is relatively rare. Among them, post-infectious myocarditis is more common, which proceed relatively easily and in pregnant women sometimes take a 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.

Post-infectious myocarditis in some cases can be treated, and pregnancy can end in childbirth (often premature). If myocarditis is complicated by atrial fibrillation, then there is a risk of thromboembolic complications. In severe myocarditis in the early stages of pregnancy, an artificial abortion is performed (up to 12 weeks) in the later stages - a caesarean section (small or early).

Of particular danger during pregnancy are cardiomyopathies. 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, a sharp deterioration in the condition can occur, even death after childbirth is possible. But, despite this, with a slight and moderate obstruction, with proper management of patients, pregnancy is possible.

Long-term prognosis in patients with cardiomyopathy is unfavorable, so re-pregnancy should not be allowed. In cases of severe cardiomyopathy, termination of pregnancy is recommended, regardless of its timing.

Hypertonic disease

Pregnancy in combination with hypertension occurs in 1-3% of cases. Only with a mild form of hypertension, when hypertension is not pronounced and unstable, in the absence of organic changes in the heart, i.e., at stage 1 of the development of the disease, pregnancy and childbirth can proceed normally.

With persistent hypertension and a significant increase in blood pressure (IIA stage), pregnancy worsens the clinical course of hypertension. In patients with stage III of the disease, the ability to conceive is sharply reduced, and if pregnancy does occur, it usually ends in spontaneous abortion or fetal death.

The course of hypertension during pregnancy has its own characteristics. So, in many patients with stage I-IIA of the disease, at the 15-16th week of pregnancy, blood pressure decreases (often to normal levels), which is explained by the depressant effect of the formed placenta. In patients with stage IIB, such a decrease in pressure is not observed. After 24 weeks, the pressure rises in all patients - both in I and IIA, and IIB stages. Against this background, late toxicosis often (in 50%) joins.

In connection with the spasm of the uteroplacental vessels, the delivery of essential nutrients and oxygen to the fetus worsens, which creates a delay in the development of the fetus. Every 4-5th patient has fetal hypotrophy. The frequency of intrauterine fetal death reaches 4.1%. These patients also have a high risk of premature detachment of normally placental attachments. Premature termination of pregnancy (spontaneous and operative) is 23%.

During childbirth, a hypertensive crisis may develop with hemorrhage in various organs and in the brain.

Nephropathy often turns into eclampsia. Therefore, timely diagnosis of hypertension in pregnant women is the best prevention of these diseases. This can be done under the following conditions: early access to the antenatal clinic, examination of the patient by a therapist with attention to all the details of the disease history (beginning, course, complications, etc.); measurement of blood pressure, performing fluoroscopy (to determine the degree of enlargement of the left ventricle and aorta), as well as an ECG.

Obstetric tactics for hypertension: in seriously ill patients suffering from persistent forms of the disease (IIB, stage III), abortion is performed at an early stage (artificial abortion followed by the introduction of a contraceptive coil into the uterus) - when applying in late pregnancy and an insistent desire to have a child, it is indicated hospitalization.

Therapy of hypertension includes the creation of psycho-emotional peace for the patient, strict adherence to the daily regimen, diet, drug therapy and physiotherapy.

Drug treatment is carried out using a complex of drugs that act 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 b-adrenergic receptors (anaprilin, clonidine, methyldopa); vasodilators and calcium antagonists (apressin, verapamil, fenitidine); antispasmodics (dibazole, papaverine, no-shpa, eufillin).

Physiotherapeutic 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 agents that improve microcirculation (pentoxifylline, eufillin), protein biosynthesis and bioenergetics (Essentiale), microcirculation and protein biosynthesis (alupent).

During childbirth, it is necessary to conduct anesthesia with the use of ataractics (tazepam), antispasmodics (papaverine) and narcotic drugs (promedol). If childbirth is carried out without controlled hypotension, then the patient continues to receive antihypertensive therapy (dibazole and papaverine intramuscularly). In the second stage of labor, the attempts are turned off with the help of obstetric forceps under inhalation anesthesia (halothane).

Caesarean section is used in patients with cerebrovascular accident or obstetric pathology (breech presentation in primiparous aged 30 years and older, weakness of labor, etc.). Long-term results indicate that after childbirth, especially in cases of nephropathy, the disease often progresses.

Preventive measures for complications of pregnancy and childbirth with hypertension are 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 if she feels well, and effective outpatient antihypertensive therapy.

Arterial hypotension

Arterial hypotension is a disease characterized by a decrease in blood pressure below 100/60 mm Hg. Art. (millimeters of mercury), caused by a violation of vascular tone. A similar condition occurs in young women quite often, but not all people with reduced blood pressure are considered sick. Many do not respond at all to a decrease in blood pressure, maintain good health and ability to work.

This is the so-called physiological or constitutional hypotension. Hypotension can be both an independent suffering and a symptom of another disease (for example, infectious), so doctors distinguish between primary and symptomatic (resulting from another disease) hypotension.

Primary arterial hypotension can be considered as vascular neurosis or neurocirculatory dystonia, accompanied by low blood pressure. In a conversation with a patient, it is often possible to find out that the onset of the disease is associated with neuropsychic trauma, overwork, and emotional overstrain.

Complaints of headache, dizziness, general weakness, palpitations, pain and other unpleasant sensations in the heart area, sweating, memory loss, decreased ability to work, insomnia are characteristic. Some women develop dizziness, darkening of the eyes, up to fainting when moving from a horizontal to a vertical position (getting out of bed). Often irritability appears or intensifies, a tendency to a minor mood.

If arterial hypotension is manifested only by a decrease in blood pressure, then it is referred to as a stable (compensated) stage of the disease. In the unstable (decompensated) stage, easily occurring syncope appears as a result of hypotonic crises, which can develop against the background of good health, without any precursors.

There is a sharp weakness, dizziness, a feeling of stupor, accompanied by pallor of the skin and visible mucous membranes, cold sweat, vomiting may join. BP drops to 80-70/50-40 mm Hg. and below. The hypotonic crisis lasts from a few seconds to minutes.

However, not in all cases with arterial hypotension, the pressure is steadily lowered. With excitement, it can reach normal and even elevated numbers (although it quickly decreases). It has long been noticed that women of asthenic physique with pale skin, cold to the touch hands are susceptible to the disease.

These women often find varicose veins of the legs. When examining the heart, doctors rarely detect any abnormalities, and there are no characteristic changes on the ECG. The only thing that can be paid attention to is bradycardia or rare heartbeats.

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

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

The frequency of arterial hypotension in pregnant women is from 4.2-12.2% to 32.4% according to different authors. Arterial hypotension is the result of general disturbances 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 on the Apgar scale was statistically significantly reduced.

First of all, you need to take care of sufficient rest and a long, 10-12 hour sleep. Useful daily 1-2 hour sleep. Sufficiently effective means of treatment and prevention are physiotherapy exercises, morning exercises, walks in the fresh air. A set of morning exercises should be the simplest, not leading to excessive overstrain, fatigue.

Nutrition must be made as varied as possible, certainly complete with a high content of protein products (up to 1.5 g / kg of body weight). Strong tea and coffee (with milk, cream) can be drunk in the morning or afternoon, but not in the evening, so as not to disturb sleep. It is useful to take vitamin B1 (thiamine bromide) 0.05 g 3 times a day, as well as multivitamins (undevit, gendevit).

In addition, the doctor may prescribe sessions of hyperbaric oxygenation, general ultraviolet irradiation, electrophoresis of drugs that increase vascular tone in the neck or intranasally. A good restorative, tonic effect is exerted by pantocrine, prescribed in 2-4 tables.

Or 30-40 drops inside 2-3 times a day. Tinctures of aralia, zamaniha, leuzea, Chinese magnolia vine, eleutherococcus are effective, which are taken 20-30 (up to 40) drops 2-3 times a day for 30 minutes. before meals.

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

Cardiovascular disease (CVD) in pregnant women

Groshev S.
The student of 6 course to lay down. otd. honey. Faculty of Osh State University, Kyrgyz Republic
Israilova Z.A.
Assistant of the Department of Obstetrics and Gynecology

Introduction and justification of the problem.

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

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 suffering from CVD, which is explained by a number of reasons:

early diagnosis of heart disease,

extension

indications for maintaining pregnancy,

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

science and practice.

The most important hemodynamic shift during pregnancy is the increase cardiac output

. At rest, its maximum increase is 30-45% of the cardiac output before pregnancy. The increase in this indicator occurs already in the early stages of pregnancy: on the 4-8th week 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 magnitude of cardiac output is significantly affected by changes in the position of the body of a 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 time 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 the gestation period. 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 on 3-4 days after birth. All this can threaten a woman with cardiovascular diseases with the development of circulatory decompensation before childbirth, during childbirth and after them.

Volume of circulating blood

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

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

also with an increase in the load on the maternal heart. In addition, a direct relationship was found between fetal body weight and the degree of increase in maternal oxygen consumption. At the very beginning of labor, there is an increase in oxygen consumption 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 elevated by 25% compared to prenatal levels. A sharp increase in oxygen consumption during labor is a significant risk factor for parturient women 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 due to an increase in uterine pressure and a decrease in venous return of blood to the heart, resulting in a decrease in blood pressure (with a sharp decrease, fainting occurs), and with a fall in systolic blood pressure - loss of consciousness. The syndrome of compression of the inferior vena cava can be manifested by anxiety, a feeling of lack of air, increased respiration, dizziness, darkening of the eyes, blanching of the skin, sweating, tachycardia. These signs can be in other shock states. But unlike from the latter, a sharp increase in venous pressure in the legs is noted with an altered venous pressure in the arms. Most often, the syndrome occurs with polyhydramnios, pregnancy with a large fetus, with arterial and venous hypotension, with multiple pregnancy, in pregnant women of small stature. Special treatment is usually not required. If a syndrome of compression of the inferior vena cava occurs, it is enough to immediately turn the woman on her side. The first signs of the disorder usually appear in women lying on their backs. Of particular danger is the appearance of collapse (shock) due to compression of the inferior vena cava during operative delivery. It is necessary 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 resulting changes in hemodynamics, metabolism, body weight (increase by 10-12 kg by the end of pregnancy), water-salt metabolism (during pregnancy, the total water content in the body increases by 5-6 l, the sodium content in the body increases already by the 10th week of pregnancy by 500-600 mmol, and potassium by 170 mmol, up to 870 mmol of sodium accumulates in the body before childbirth) require increased work from the heart and often aggravate the course cardiovascular disease.

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

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

During pregnancy, an increased load on the cardiovascular system causes physiologically reversible, but quite pronounced changes in hemodynamics and heart function. Without knowing about the changes in hemodynamics in healthy pregnant women, it is impossible to adequately assess it in cardiovascular diseases. The increase in load is associated with an increase in metabolism aimed at meeting the needs of the fetus, an increase in the volume of circulating blood, the appearance of an additional placental circulatory system, with a constantly increasing body weight of the pregnant woman. With an increase in size, the uterus limits the mobility of the diaphragm, increases intra-abdominal pressure, changes the position of the heart in the chest, which ultimately leads to changes in the working conditions of the heart. Such hemodynamic changes as an increase in circulating blood volume and cardiac output can be unfavorable and even dangerous in pregnant women with diseases of the cardiovascular system, due to their layering on the already existing ones, caused by the disease.

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

Among the heart diseases that complicate pregnancy, more often

rheumatism is common, acquired and congenital heart defects, anomalies in the development of the main vessels, myocardial diseases, 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 the therapist, cardiologist, surgeon. The mortality of pregnant women, parturient women, puerperas suffering from acquired heart defects, pulmonary hypertension, complex congenital malformations, acute and chronic cardiovascular insufficiency(SSN).

Critical periods of pregnancy for exacerbation of CVD

.

Start of pregnancy - 16 weeks

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

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

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

Start of labor

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

Early postpartum period

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

Methods for studying CCC in pregnant women.

- may contain important information about the time of occurrence of rheumatism, the duration of the existence of 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

- detection of signs of hypertrophy of the heart.

X-ray examination

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

Radionuclide research methods

- should not be used during pregnancy.

Phonocardiography

- a method of recording sounds (tones and noises) resulting from the activity of the heart, and is used to evaluate its work and recognize disorders, including valve defects.

echocardiography

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

Rheography

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

Loaded samples

- to assess the functional state of the myocardium. Tests with a load on a bicycle ergometer up to a heart rate of 150 per minute are also used in pregnant women.

Studies of the function of external respiration and acid-base status.

Blood studies.

General information

for the management of pregnant women with CVD.

Speaking about the tactics of pregnancy and childbirth in women with diseases of the cardiovascular system, it must be said that the issue of maintaining pregnancy and its safety for the mother and unborn child should be decided not only before pregnancy, but also better before the patient's marriage. The basis for the correct management and treatment of pregnant women suffering from cardiovascular diseases is an accurate diagnosis that takes into account the etiology of the disease.

Large loads on the cardiovascular system during pregnancy occur at the 7-8th obstetric month of pregnancy and during childbirth. Therefore, pregnant women should be hospitalized at least three times:

I- hospitalization - at the 8-10th week of pregnancy to clarify the diagnosis and resolve the issue of the possibility of maintaining pregnancy.

With mitral stenosis I st. Pregnancy can be continued in the absence of exacerbation of the rheumatic process.

Mitral valve insufficiency is a contraindication to pregnancy only in the presence of cardiac weakness or activation of the rheumatic process, as well as when it is combined with heart rhythm disturbance and circulatory failure.

Aortic valve stenosis - pregnancy is contraindicated in case of signs of myocardial insufficiency, with a significant increase in the size of the pregnant woman's heart.

Aortic valve insufficiency is a direct contraindication.

Congenital malformations of the pale type are compatible with pregnancy unless accompanied by pulmonary hypertension.

Patients after heart surgery are treated differently.

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

Summarizing the above, we can say that the issue of termination of pregnancy up to 12 weeks is decided depending on the severity of the defect, the functional state of the circulatory system and the degree of activity of the rheumatic process.

II- hospitalization - at the 28-29th week of pregnancy to monitor the state of the cardiovascular system and, if necessary, to maintain heart function during the period of maximum physiological stress.

III- i hospitalization - at 37-38 weeks to prepare for childbirth and choose the method of delivery.

If signs of circulatory failure, exacerbation of rheumatism, atrial fibrillation, late preeclampsia of pregnant women or severe anemia appear, 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.

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

Rheumatism and Acquired Heart Disease (ACD)

).

Rheumatism

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

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

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

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

to critical times.

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

form of rheumatism, there is a high mortality rate, reaching 20-25%.

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

Hemodynamic shifts naturally developing during physiological pregnancy can lead to heart failure.

Pregnant women with heart defects are at high risk of maternal and perinatal mortality and morbidity. This is explained by the fact that pregnancy imposes an additional burden on the cardiovascular system of women.

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

mitral stenosis.

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

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

12-20-th week of pregnancy. Hemodynamic recovery begins at puerperas only after 2 weeks after childbirth. In patients with mitral stenosis, during pregnancy due to physiological hypervolemia, which exacerbates pulmonary hypertension, increased risk of pulmonary edema. At In this case, no method of delivery (with the help of obstetric forceps, by caesarean section) helps to stop pulmonary edema. The most reliable way to ensure a favorable outcome in such cases is a mitral commissurotomy. This operation, depending on the situation, can be recommended in 3 options.

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

re-pregnancy is possible. Second option- produced mitral commissurotomy during real pregnancy in any of its terms (with intractable drug-induced pulmonary edema), but better on 24-32-th week, when the risk of spontaneous abortion like reactions for surgical trauma, less (due to sufficient relaxation of the uterus). Third option: a caesarean section is performed at the 30-40th week of pregnancy with sufficient maturity of the fetus) and one-stage (after delivery)- mitral commissurotomy. The operation of mitral commissurotomy during pregnancy is more radical due to decalcification of the valve leaflets and greater susceptibility to separation of subvalvular adhesions.

mitral insufficiency. Pregnancy with this pathology is much easier. Usually ends in spontaneous delivery. At

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

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

allow only in the absence of pronounced signs of hypertrophy of the left ventricle and symptoms of circulatory failure, since compensation for the defect occurs due to concentric muscle hypertrophy left ventricle, thickening of its wall. In cases of severe aortic stenosis, when surgical correction of the defect is necessary- replacement affected valve with a prosthesis, the possibility of carrying a pregnancy is decided after surgery. Aortic insufficiency is less severe than aortic stenosis because it for a long time the compensation of blood circulation remains. However due to changes in hemodynamics due to pregnancy and frequent the addition of late toxicosis during aortic insufficiency may be heavier. At patients with aortic heart disease, pregnancy and births through the natural birth canal are allowed only in stages of circulatory compensation. In the second stage of labor in order to reduction of the stimulating effect of childbirth on the development of the defect is shown turning off attempts by applying obstetric forceps. For symptoms heart failure pregnancy should be considered unacceptable. The resulting pregnancy is to be terminated. If the pregnancy has reached a long term, the most rational is early delivery by abdominal route with sterilization.

Tricuspid valve insufficiency

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

Tricuspid valve stenosis

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

Acquired valvular disease of the pulmonary artery

- are rarely seen clinically. Most often combined with lesions of other heart valves.

Multivalvular rheumatic heart disease is quite common. Their diagnosis is difficult, because. hemodynamic shifts characteristic of certain types of defects, and their symptoms, prevent the manifestation of some hemodynamic shifts and clinical signs characteristic of each type of defect. However, the identification of concomitant malformations in pregnant women may be of decisive importance for making a decision on the possibility of maintaining the pregnancy and on the advisability of surgical correction of the defect or malformations.

congenital heart defects (CHDs)

).

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

Atrial septal defect.

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

Ventricular septal defect.

Less common than atrial septal defect. Often associated with aortic valve insufficiency. Pregnant women with a minor ventricular septal defect can tolerate pregnancy well, but as the defect increases, the risk of developing heart failure, sometimes fatal, increases. Postpartum paradoxical systemic embolism may occur.

Open ductus arteriosus.

When a duct is blocked, blood flows from the aorta into the pulmonary artery. With a significant discharge of blood, dilatation of the pulmonary artery, left atrium and left ventricle occurs. In terms of tactics of managing a pregnant woman with this defect, the diagnosis of the diameter of the duct is of primary importance. This disease, with an unfavorable course, can complicate the development of pulmonary hypertension, subacute bacterial endocarditis, and heart failure. During pregnancy, 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.

The isolated stenosis of a pulmonary artery.

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

Tetralogy of Fallot.

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

Eisenmeiger syndrome

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

congenital aortic stenosis

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

Coarctation of the aorta

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

operated heart.

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

It should be remembered that not always corrective operations on the heart lead to the elimination of organic changes in the valvular apparatus or the elimination of congenital 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 prognosis of pregnancy and childbirth, it should be borne in mind that in itself pregnancy can cause arrhythmias. So, extrasystole, paroxysmal tachycardia in pregnant women can be observed without any organic changes in the myocardium. They occur in 18.3% of pregnant women. The addition of late toxicosis further contributes to the appearance or intensification of arrhythmias. There is no significant effect on the outcome of pregnancy.

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

meaning how to interrupt it. Caesarean section for these patients is a great danger, than delivery through the natural birth canal, due to the possible thromboembolism in the pulmonary artery system.

On the contrary, disturbances of atrioventricular conduction (incomplete and

complete heart block) by themselves do not pose a danger to a pregnant woman. Furthermore, in these patients pregnancy is usually, causes an increase in the ventricular rate, thereby preventing the danger occurrence of attacks of Adams - Stokes - Morgagni. Only with very rare pulse - 35 or less in 1 min - during second stage of labor for acceleration of labor activity turn off attempts with the help of imposition obstetric forceps. When choosing antiarrhythmic drugs for pregnant women, it is also necessary to take into account the negative effect of some of them. (quinidine, novocainamide, atropine sulfate, etc.) on uterine excitability 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. A mild degree of prolapse is established using echocardiography. Severe mitral valve prolapse syndrome diagnosed on the basis of clinical findings and phonocardiography. AT Depending on the degree of prolapse of the valves, one or another the degree of insufficiency of the closing function of the mitral valve with regurgitation of blood into the cavity of the left atrium. The clinical manifestations of this pathology are very diverse.- from asymptomatic to pronounced clinical picture. The most pronounced symptoms are observed in patients with prolapse of both leaflets of the mitral valve.

At present, for the first time, the course of this syndrome in combination with pregnancy has been studied; it has been established that mildly pronounced deflection

posterior wall of the mitral valve, and hence mild regurgitation decreases with increasing gestational age and return to baseline after 4 weeks after childbirth. This can be explained by the physiological increase in the cavity of the left ventricle with pregnancy, which changes the size, length and degree of tension of the chords.

The tactics of conducting labor is the same as in physiological pregnancy.

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

myocarditis

and cardiomyopathy.

Myocarditis

of various etiology in pregnant women are observed relatively rarely. Among them, post-infectious myocarditis is more common, which proceed relatively easily and in pregnant women are sometimes taken long course, may be accompanied by persistent extrasystole. Myocarditis itself, in the absence of valvular heart disease, rarely leads to development of heart failure. Post-infectious myocarditis in some cases can be treated, and pregnancy can end in childbirth. (more premature). If myocarditis is complicated by atrial fibrillation arrhythmia, there is a risk of thromboembolic complications. In severe myocarditis in early pregnancy perform an induced abortion(up to 12 weeks) in the later stages - caesarean section (small or early).

Of particular danger during pregnancy are cardiomyopathies. AT

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, it may a sharp deterioration, even death after childbirth is possible. But despite this, with mild to moderate obstruction, with proper management of patients, pregnancy is possible.

Long-term prognosis in patients with cardiomyopathy is unfavorable,

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

Hypertonic disease.

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

, when hypertension is mild and unstable, in the absence of organic changes in the heart, i.e. at stage 1 development of the disease, pregnancy and childbirth can proceed normally. At persistent hypertension and a significant increase in blood pressure(II Stage A) pregnancy worsens the clinical course of hypertension. In patients with III the stage of the disease, the ability to conceive is sharply reduced, and if pregnancy does occur, then, how 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 15-16-1st week of pregnancy, blood pressure drops (often to normal values), which is explained by the depressor effect of the formed placenta. In sick people II In stage B, no such decrease in pressure is observed. After 24 weeks pressure rises in all patients - and at I and IIA, and IIB stages. Against this background, late toxicosis often (in 50%) joins.

In connection with the spasm of the uteroplacental vessels, the delivery of necessary nutrients and oxygen to the fetus worsens,

which creates a delay in fetal development. At each 4 -5- The patient has fetal hypotrophy. The frequency of intrauterine fetal death reaches 4.1%. At these patients also have a greater risk of premature detachment of normal placental attachments. Premature termination of pregnancy (spontaneous and operative) is 23%.

During childbirth, a hypertensive crisis may develop with hemorrhage in

various organs and brain. Nephropathy often turns into eclampsia. Therefore, timely diagnosis of hypertension in pregnant women is the best prevention of these diseases. it possible under the following conditions: early negotiability in antenatal consultation, examination of the patient by a general practitioner paying attention to all the details of the disease history (beginning, course, complications and etc.); measurement of blood pressure, performing fluoroscopy (to determine degree of enlargement of the left ventricle and aorta), as well as an ECG.

Obstetric tactics in hypertension: in seriously ill patients,

suffering from persistent forms of the disease ( IIB, III stage), abortion is performed at an early stage (artificial abortion followed by the introduction of a contraceptive spiral into the uterus)- upon contact in the late stages of pregnancy and the persistent desire to have a child, hospitalization is indicated.

Therapy of hypertension includes the creation of psycho-emotional peace for the patient, strict adherence to the daily regimen, diet, drug therapy and physiotherapy.

Medical treatment

carried out using a complex of drugs acting on various links in the pathogenesis of the disease. Apply the following antihypertensive drugs: diuretics (furosemide, brinaldix, dichlothiazide); drugs that act on various levels of the sympathetic system, including b-adrenoreceptors (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 agents that improve microcirculation (pentoxifylline, eufillin), protein biosynthesis and bioenergetics (Essentiale), microcirculation and protein biosynthesis (alupent).

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

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

Preventive measures for complications of pregnancy and childbirth with hypertension - regular monitoring of a pregnant woman in a women's consultation by an obstetrician-gynecologist and a general practitioner, mandatory three-time hospitalization of a pregnant woman even with good health and effective outpatient antihypertensive therapy.

Arterial hypotension.

Arterial hypotension

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

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

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

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

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

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

The frequency of arterial hypotension in pregnant women is from 4.2-12.2% to 32.4% according to different authors. Arterial hypotension is the result of general disturbances 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 on the Apgar scale was statistically significantly reduced.

Primarily

, it is necessary to take care of sufficient rest and a long, 10-12 hour sleep. Useful daily 1-2 hour sleep. Sufficiently effective means of treatment and prevention are physiotherapy exercises, morning exercises, walks in the fresh air. A set of morning exercises should be the simplest, not leading to excessive overstrain, fatigue.

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

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

varicose veins.

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

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

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

the growing uterus compresses the veins of the small pelvis.

All this leads to difficulty in the outflow of blood through the veins of the legs, and the crowded veins have no choice but to expand. Further:

progesterone secreted in abundance during pregnancy 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 that the load on the veins ...

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

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

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

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

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

Today, the most common and most effective way to prevent varicose veins is to wear compression stockings. Most importantly, it does not violate the usual way of life. We are talking about special tights, stockings and stockings that squeeze the legs, preventing the veins from expanding. Compression knitwear is comfortable, it does not interfere with movement, the legs “breathe” freely in it.

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

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

Main sources of information.

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

M. Sara Rosenthal

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

Until the thunder strikes ... Varicose veins during pregnancy

. FROM . Tatkov. Deputy Director of the Phlebology Center, phlebologist surgeon, Ph.D.

Table of contents of the topic "The fetus in certain periods of development. The fetus as an object of childbirth. Changes in the body of a woman during pregnancy.":
1. The fetus in certain periods of development. Two (II) month fetus. The level of development of two (II) monthly fetus.
2. The level of development of a three-six-month-old fetus. Signs of a three to six month fetus.
3. The level of development of a seven-eight month fetus. Maturity of the newborn. Signs of maturity of the newborn.
4. The fetus as an object of childbirth. Fetal skull. Sutures of the fetal skull. Fontanelles of the fetal skull.
5. Dimensions of the fetal head. Small oblique size. Medium oblique size. Straight size. Large oblique size. Vertical size.
6. Changes in a woman's body during pregnancy. Mother-fetus system.
7. The endocrine system of a woman during pregnancy.
8. The nervous system of a woman during pregnancy. gestational dominance.

10. The respiratory system of a woman during pregnancy. Respiratory volume of pregnant women.
11. The digestive system of a woman during pregnancy. Liver in pregnancy.

During pregnancy there are significant changes in activities maternal cardiovascular system. These changes make it possible to provide the necessary intensity for the fetus to deliver oxygen and a variety of nutrients and remove metabolic products.

The cardiovascular system functions during pregnancy with increased load. This increase in load is due to an increase in metabolism, an increase in the mass of circulating blood, the development uteroplacental circulation, a progressive increase in the body weight of a pregnant woman and a number of other factors. As the size of the uterus increases, the mobility of the diaphragm is limited, intra-abdominal pressure rises, the position of the heart in the chest changes (it is located more horizontally), at the apex of the heart, some women experience an unsharply pronounced functional systolic murmur.

Among the many changes of cardio-vascular system inherent in a physiologically proceeding pregnancy, first of all, an increase in the volume of circulating blood (BCC) should be noted. An increase in this indicator is already noted in the first trimester of pregnancy and in the future it increases all the time, reaching a maximum by the 36th week. The increase in BCC is 30-50% of the initial level (before pregnancy).

Hypervolemia occurs mainly due to an increase in the volume of blood plasma (by 35-47%), although the volume of circulating red blood cells also increases (by 11-30%). Since the percentage increase in plasma volume exceeds the increase in erythrocyte volume, the so-called physiological anemia of pregnancy. It is characterized by a decrease in hematocrit (up to 30%) and hemoglobin concentration from 135-140 to 100-120 g/l. Since during pregnancy there is a decrease in hematocrit, a decrease in blood viscosity also occurs. All these changes, which have a pronounced adaptive character, ensure the maintenance of optimal conditions for microcirculation (oxygen transport) in the placenta and in such vital organs of the mother as the central nervous system, heart, and kidneys during pregnancy and childbirth.

In a normal pregnancy, systolic and diastolic blood pressure decreases in the II trimester by 5-15 mm Hg. Peripheral vascular resistance is also usually reduced. This is mainly due to the formation of the uterine circulation, which has low vascular resistance, as well as the effect on the vascular wall of estrogens and progesterone of the placenta. A decrease in peripheral vascular resistance, together with a decrease in blood viscosity, greatly facilitates the processes of hemocirculation.

Venous pressure measured on the hands healthy pregnant women, does not change significantly.

During pregnancy there is physiological tachycardia. The heart rate reaches a maximum in the III trimester of pregnancy, when this figure is 15-20 per minute higher than the initial data (before pregnancy). Thus, the normal heart rate in women in late pregnancy is 80-95 per minute.

The most significant hemodynamic shift during pregnancy is an increase in cardiac output. The maximum increase in this indicator at rest is 30-40% of its value before pregnancy. Cardiac output begins to increase from the earliest stages of pregnancy, with its maximum change observed at 20-24 weeks. In the first half of pregnancy, an increase in cardiac output is mainly due to an increase in the stroke volume of the heart, later - a slight increase in heart rate. The minute volume of the heart increases partly due to the effect on the myocardium of placental hormones (estrogens and progesterone), partly as a result of the formation of the uteroplacental circulation.

Electrocardiography, carried out in the dynamics of pregnancy, allows you to detect a persistent deviation of the electrical axis of the heart to the left, which reflects the displacement of the heart in this direction. According to echocardiography, there is an increase in the mass of the myocardium and the size of individual parts of the heart. An X-ray examination reveals changes in the contours of the heart, resembling a mitral configuration.

The processes of hemodynamics during pregnancy are greatly influenced, as already noted, provides a new uteroplacental circulation. Although the blood of the mother and fetus does not mix with each other, changes in hemodynamics in the uterus are immediately reflected in the blood circulation in the placenta and in the body of the fetus and vice versa. Unlike the kidneys, CNS, myocardium, and skeletal muscles, the uterus and placenta are not able to maintain their blood flow at a constant level during changes in systemic blood pressure. The vessels of the uterus and placenta have low resistance and the blood flow in them is passively regulated mainly due to fluctuations in systemic arterial pressure. In late pregnancy, the vessels of the uterus are maximally dilated. The mechanism of neurogenic regulation of uterine blood flow is mainly associated with adrenergic influences. Stimulation of alpha-adrenergic receptors causes vasoconstriction and a decrease in uterine blood flow. Reducing the volume of the uterine cavity (prenatal rupture of amniotic fluid, the appearance of contractions) is accompanied by a decrease in uterine blood flow.

Despite the existence separate circles of blood circulation in the uterus and placenta(there is a placental membrane in the way of two blood flows), the hemodynamics of the uterus is closely connected with the circulatory system of the fetus and placenta. The participation of the capillary bed of the placenta in the fetal circulation consists in the rhythmic active pulsation of the chorionic capillaries, which are in constant peristaltic motion. These vessels with varying blood volume cause alternate elongation and contraction of the villi and their branches. Such movement of the villi has a significant impact not only on the blood circulation of the fetus, but also on the circulation of maternal blood through the intervillous space. Therefore, the capillary bed of the placenta can rightly be considered as the "peripheral heart" of the fetus. All these features of the hemodynamics of the uterus and placenta are usually combined under the name "uteroplacental circulation".

SEI HPE "Ural State Medical Academy of the Federal Agency for Health and Social Development"

Department of Therapy FPC and PP

The cycle of thematic improvement "New technologies for the diagnosis and treatment of therapeutic patients"

abstract

on the topic

"Cardiovascular Diseases and Pregnancy"

Executor:

therapist GBUZ SO "KGB No. 1"

city ​​of Krasnoturinsk

Zabolotskaya Natalya Alexandrovna

Supervisor:

MD Anatoly Ivanovich Koryakov

Yekaterinburg

Introduction

Most doctors consider cardiovascular accidents in pregnant women to be casuistry. Atherosclerosis of the coronary arteries, which is the main cause of myocardial infarction, is rare in young women. That is why doctors are not wary of the possible occurrence of cardiovascular complications during pregnancy. Currently, pregnancy is increasingly occurring in women aged 30-40 years, and with the use of modern reproductive technologies (in vitro fertilization - IVF, with intracytoplasmic sperm injection, the use of a donor egg) - in women already at the age of 40-50 years. Women of the older age group often suffer from somatic pathology. In recent years, the incidence of myocardial infarction in pregnant women has increased by more than 6 times, since there has been a significant increase in the prevalence of risk factors for the development of cardiovascular diseases in pregnant women, such as arterial hypertension, obesity, lipid metabolism disorders, diabetes mellitus, and smoking. Diagnosis and treatment of myocardial infarctions and strokes during pregnancy present certain difficulties due to an atypical clinical picture, difficulties in determining biochemical markers, using other diagnostic methods, and also because of contraindications to the use of a number of drugs commonly used to treat myocardial infarction and stroke.

In recent decades, worldwide, an increase in the frequency of abdominal delivery was combined with a real decrease in perinatal mortality, while in Russia the frequency of caesarean section increased on average 3 times and amounted to about 18.4%. The increase in operative delivery is largely due to an increase in the number of pregnant women with extragenital pathology, including heart defects, and a significant proportion are patients who have undergone heart surgery, including those with complex heart defects.

However, an increase in the growth of operative delivery in women with heart defects should not be steadily progressive, and the presence of heart disease is by no means synonymous with caesarean section. A number of cardiological societies (the Royal Societies of Cardiology of Great Britain, Spain, the American and Canadian Society of Cardiology, etc.), leading domestic cardiologists have developed and assessed the risks for pregnant women with heart defects / focused primarily on specific hemodynamic disorders and the likelihood of developing clinical signs of heart failure (SN). In accordance with Order No. 736 dated 05.12.07 of the Ministry of Health and Social Development of the Russian Federation, a contraindication to pregnancy in women with heart defects is the development of HF of functional class III (FC), at the same time, it is equally important for a practitioner to understand the likelihood of developing severe HF in those or other heart defects, which determines the tactics of pregnancy and delivery.

Risk factors for cardiovascular complications in pregnant women

The prevalence of cardiovascular disease among pregnant women is the subject of study in many countries. The presence of these diseases is one of the most common problems that complicate pregnancy.

In pregnant women, the combination of various risk factors for the development of cardiovascular diseases and somatic pathology is of great importance.

Risk factors for development myocardial infarction in pregnant women differ little from those in the population. However, their influence may be exacerbated by the hypercoagulable state that is characteristic of pregnancy. During pregnancy, the most significant risk factors are age, chronic arterial hypertension, smoking, obesity, and carbohydrate metabolism disorders. At the same time, gestational diabetes mellitus is less of a risk factor than pre-pregnancy diabetes.

Known and specific "female" risk factors for the development of cardiovascular disease. In women with a homozygous mutation of the Leiden factor, taking oral (hormonal) contraceptives, the risk of developing myocardial infarction is 30-40 times higher than in women who do not take and do not have hereditary thrombophilia for the Leiden factor. In recent years, the risk of myocardial infarction when using oral contraceptives has been widely discussed in the literature. An increase in the risk of myocardial infarction in women of reproductive age by 3-4 times was found when taking oral contraceptives compared with the risk in women not taking estrogens. However, these data refer to high-dose estrogens, which are currently practically not used for contraception in women of reproductive age. Atherosclerosis of the coronary arteries, which is the main cause of myocardial infarction, is often found in young women. Age is one of the leading risk factors for myocardial infarction during pregnancy, according to an analysis of more than 12 million births from 2000 to 2002 in the United States. In patients aged 20-25 years, the risk of developing myocardial infarction is 30 times lower than in women over 40 years old, and is 1 versus 30 cases per 100,000 births, respectively.

A rather high risk of myocardial infarction was noted in pregnant women with antiphospholipid syndrome (APS), hereditary thrombophilias. It is known that these conditions are characterized by impaired hemostasis, an increased tendency to develop thrombosis. The most common clinical manifestations of thrombophilia and APS are deep vein thrombosis of the lower extremities and pulmonary embolism, less often myocardial infarction and stroke. Hypercoagulability observed during normal pregnancy, combined with a genetic predisposition to thrombosis, more often leads to such severe thrombotic complications as myocardial infarction.

We should not forget about young primiparas, in which the cause of myocardial infarction can be both rare genetic anomalies and severe somatic diseases: Marfan's syndrome, Kawasaki disease, Takayasu's aortoarteritis, anomalies in the development of coronary arteries, familial hypercholesterolemia.

Risk factors for development stroke during pregnancy are diverse: age over 35 years, hypertension, history of CVD, hereditary thrombophilia, multiple pregnancy, postpartum infection, diabetes mellitus, blood transfusion, migraine, systemic lupus erythematosus, sickle cell anemia, smoking, alcoholism, drug addiction, etc. Factors risk of developing cerebral vein thrombosis are hematological diseases (polycythemia, leukemia, sickle cell anemia, thrombocytopenia), APS, vasculitis, malignant neoplasms. Ischemic stroke is most often caused by paradoxical embolism from the pelvic veins, deep veins of the lower extremities, from the right atrium. Movement of emboli may be due to non-closure of the foramen ovale or a ventricular septal defect. In addition, there is a rather rare type of dilated cardiomyopathy - peripartum cardiomyopathy, which manifests itself in the last months of pregnancy and up to 5 months of the postpartum period. Stroke develops in 5% of patients with peripartum cardiomyopathy due to cardiac thromboembolism. In patients with hereditary connective tissue diseases (Marfan syndrome, Ehlers-Danlos syndrome, etc.), the development of a stroke during pregnancy can also be caused by rupture of intracranial arterial aneurysms.

The relationship between hemorrhagic stroke and severe complications of pregnancy, such as preeclampsia, eclampsia, was discovered a long time ago. It is possible that there are common hereditary factors in the development of arterial hypertension, cardiovascular diseases, stroke and preeclampsia in pregnant women. Stroke is the leading cause of death in patients with HELLP syndrome. Eclampsia has been associated with both hemorrhagic and ischemic stroke in pregnant women. The proportion of patients with preeclampsia and eclampsia who had a stroke during and after pregnancy ranges from 25 to 45%. The risk of ischemic stroke associated with preeclampsia appears to persist even after pregnancy in the late postpartum period. Data from the Prevention of Stroke in Young Women study suggests that women with a history of preeclampsia have a 60% higher risk of ischemic stroke. It seems unlikely that high blood pressure alone is responsible for the increased risk of stroke, since cerebral hemorrhages are relatively rare in women with preeclampsia, even in combination with severe chronic hypertension. 80% of patients with stroke associated with preeclampsia did not notice an increase in diastolic blood pressure to more than 105 mm Hg before the stroke. Art. These data suggest that endothelial dysfunction is apparently the main cause of stroke in pregnant women with preeclampsia and eclampsia.

There are also risk factors for cardiovascular events associated with pregnancy itself. These are formidable complications of pregnancy: preeclampsia, eclampsia and HELLP syndrome.

Place preeclampsia among the main risk factors for obstetric and perinatal pathology determines the continued relevance and attention of researchers to this problem. Thanks to the paradigms of the development of perinatal medicine in recent decades, the curtain has been lifted over the molecular genetic determinants of the early stages of fetal development, various complications of the gestational process and the long-term consequences of preeclampsia.

Preeclampsia is a condition characterized by increased vascular tone, coagulopathy, ischemia of the vessels of the brain, liver, kidneys, and placenta. A direct relationship was found between the risk of developing CVD and the severity of preeclampsia and an inverse relationship with the gestational age at which preeclampsia developed. The reason for this relationship needs to be further investigated. Probably, the development of severe transient dysfunction of the vascular endothelium, which is one of the stages in the development of atherosclerosis, matters. Damage to the vascular endothelium is detected in preeclampsia from the second half of pregnancy and for at least 3 months after delivery.

Until recent decades, the prevailing view was that preeclampsia and related clinical symptom complexes do not cause significant negative consequences. The view on this problem has changed dramatically after the appearance of reports of an increased risk of developing cardiovascular complications, including those with fatal outcomes, in the long term of the life cycle in women who have previously had preeclampsia (especially during the first birth). Based on a number of publications, based on an analysis of the outcomes of about 800,000 pregnancies, an average two-fold increase in the risk of death from cardiovascular diseases in women who had preeclampsia, especially in the first preterm birth, was revealed.

The modern concept of preeclampsia is based on the two-stage nature of its development, within which, at the first, preclinical stage, changes occur mainly at the level of the uterus in the form of defects in implantation and placentation with impaired cytotrophoblast differentiation, transformation of spiral arteries, development of ischemia/hypoxia of the placenta and placental free radical oxidation. Against the background of these disorders, various factors rush into the maternal bloodstream, which at the second, clinical, stage initiate a cascade of cellular and molecular phenomena that cause a systemic inflammatory response and the development of endothelial and vascular dysfunction and a clinical symptom complex pathognomonic for preeclampsia in the form of arterial hypertension, proteinuria, thrombocytopenia, liver dysfunction, etc. The development of arterial hypertension under these conditions is due to a number of endothelial-mediated (angiogenic) and non-endothelial factors. The complexity of considering this range of issues is due to the fact that functional disorders, to a certain extent similar to the early stages of a systemic inflammatory reaction in the circulatory system in atherosclerosis, also accompany physiological pregnancy. With a tendency to develop the metabolic syndrome, especially in women predisposed to a similar phenotype, these changes occur at the level of an elusive line between physiological and pathological conditions with the development of gestational arterial hypertension, preeclampsia and / or type 2 diabetes mellitus. This necessitates exceptional accuracy in the use of diagnostic evaluation criteria due to the not always easy diagnosis of preeclampsia. Difficulties are also associated with the lack of a unified classification and diversity in terminology. In this regard, in order to unify the data presented in the preparation of this publication, we used homogeneous materials based on the most common classification of hypertensive disorders during pregnancy, prepared by the working group of the American College of Obstetricians and Gynecologists. Accordingly, for the diagnosis of preeclampsia, the appearance of the following symptoms after 20 weeks of pregnancy and the subsequent normalization of blood pressure within the first 8 weeks of puerperia are pathognomonic.

· moderate preeclampsia- increase in systolic or diastolic blood pressure up to 140/90 mm Hg. Art. with a double measurement within 6 hours and proteinuria> 0.3 g / day;

· hes tational hypertension - increased blood pressure without proteinuria;

· severe preeclampsia - progression of the severity of the disease with the inclusion of two or more symptoms: BP> 160/110 mm. rt. Art. with a double measurement within 6 hours; proteinuria > 5.0 g/day, oliguria, cerebral or visual symptoms, pulmonary edema, cyanosis, epigastric pain, abnormal liver function, thrombocytopenia, fetal growth retardation (< 5 центили соот­ветственно гестационному возрасту);

· early hypertension - development of a symptom complex earlier than 34 weeks of pregnancy.

· HELLP -syndrome- hematolysis, increased activity of liver enzymes and thrombocytopenia.

· Eclampsia- occurrence of convulsions.

Cardiovascular risk markers

Influenced by the results of these studies, in recent years data have begun to accumulate on the content of pathophysiological markers of cardiovascular risk (systemic inflammatory response, free radical oxidation and endothelial dysfunction) in women who have had preeclampsia. These data cover the period from several months to decades after childbirth. Although the number of women examined in this regard in individual studies is relatively small, the identity of the results obtained gives reason to consider them quite convincing.

Among them, among the prognostic factors of adverse outcomes of cardiovascular risk, as well as the early development of atherosclerosis, can be attributed the results of non-invasive screening using computed tomography of the thickness of the intima-media complex of the coronary vessels of the heart and determining the degree of calcification of the latter, including in patients without symptoms. During a re-examination with a ten-year interval of 491 healthy women aged 49-70 years with an obstetric history aggravated by preeclampsia - residents of Utrecht
(Netherlands), along with an extended study
lipid profile and measurement of blood pressure, with multicomponent CT of the coronary arteries of the heart in 62% of cases, their calcification was noted. A significant relationship was found between the development of hypertensive disorders
during pregnancy in history and the presence of arterial hypertension with an increase in systolic and diastolic blood pressure and a high body mass index in the process of re-examination, as well as an association between the phenotype of metabolic disorders and the detection of endothelial dysfunction in women 3-12 months after suffering preeclampsia as evidence of increased risk of developing atherosclerosis.

These data confirmed the need to develop a special strategy for the management of women after they have suffered preeclampsia with appropriate measures to reduce the degree of cardiovascular risk in the years following pregnancy.

The greatest attention was paid to markers of free radical oxidation and endothelial dysfunction. Among them, there was a decrease in the vasodilatory response to acetylcholine (against a background of a higher level of blood pressure than in the control group), a more significant decrease in vasodilation in those who had preeclampsia again, as well as severe preeclampsia and repeated reproductive losses in women. The development of preeclampsia in young women is considered as a predictive stress test in relation to future cardiovascular risk.

Detection of activated autoantibodies to the angiotensin II receptor in 17.2% of women who had preeclampsia during their first pregnancy, when they were detected in 2.9% in the control group, also served as evidence of endothelial dysfunction remaining after childbirth complicated by preeclampsia. A marker of cardiovascular risk after childbirth is also C-reactive protein, the content of which is above 3 mg/l indicates the presence of a systemic inflammatory response. Similar deviations have been noted in blood serum in postmenopausal women - residents of Iceland (up to 8.97-40.6 mg / l) against the background of a significant increase in systolic blood pressure, low levels of high-density lipoprotein cholesterol, high levels of apolipoprotein B and insulin against the background of starvation and insulin resistance according to compared with control.

Data on the incidence of acute myocardial infarction in pregnant women were obtained in an American population study for 2000-2002. AMI was diagnosed in 859 out of 13,801,499 women who gave birth during this period, in 626 (73%) a heart attack developed during pregnancy, in 233 (27%) in the postpartum period; 44
(5.1%) of these women died, the death rate was
0.35 per 100,000 births. The overall risk of MI during pregnancy was 6.2 per 100,000 births. The odds ratio (OR) of developing AMI during pregnancy in women aged 40 years and older was 30 times higher than that for women younger than 20 years. In a univariate analysis
it was found that the OR for the development of AMI during pregnancy with thrombophilia is 22.3, with diabetes - 3.2, with hypertension - 11.7, with smoking - 8.4, with blood transfusions - 5.1, with postpartum infection - 3 ,2. The age of 30 years and older was also among the significant risk factors for the development of AMI during pregnancy. In women who have had preeclampsia, compared with women with an uncomplicated reproductive history, there is
a two-fold increase in cardiovascular risk in the long-term postpartum period.

Evidence of the risk of earlier development of cardiovascular diseases are observations regarding the tendency to earlier development of ischemic brain lesions in young women after preeclampsia. A paired case study conducted in the Greater Washington Region compared the history of 261 women aged 15-44 years with ischemic stroke and 421 randomized control women. After appropriate adjustment of the data obtained, taking into account age, parity, education and other indicators, it turned out that the OR for the development of ischemic cerebral stroke in women who had preeclampsia in childbirth is 60% higher than the OR for its development in women who did not have it.

Preeclampsia is also a significant risk factor for kidney failure. This was confirmed by the results of another study by the same group of authors, based on the use of data from the medical birth registry in Norway, which has existed since 1967 and includes data on the birth of all fetuses at a gestational age of 16 weeks and a register of all cases of kidney biopsy in a country with 1988 (according to the Norwegian regulation, all persons with proteinuria > 1 g/day and/or serum creatinine > 150 µmol/l undergo a kidney biopsy). This study used data from a cohort of 756,420 women who had their first single pregnancy in 1967-1968, about 16 years after the reference pregnancy, of whom 477 underwent kidney biopsy. In women who were pregnant 3 or more times and had preeclampsia in one pregnancy, the RR for developing end-stage renal disease was 6.3 (95% CI from 4.1 to 9.9), with 2-3 pregnancies - 15.5 (95% CI 7.8 to 30.8). The authors concluded that although the overall absolute risk of developing end-stage renal disease in preeclamptic women is relatively low, preeclampsia is an increased risk factor for developing renal disease. This study confirmed the association between preeclampsia and a high risk of having offspring with low body weight and, accordingly, a rather high risk of indications for a kidney biopsy in the long-term postpartum period for their mothers.

Unlike such acute complications of preeclampsia as myocardial infarction and ischemic cerebral strokes, renal failure develops at a later date after pregnancy complicated by preeclampsia.

The above complications of preeclampsia transferred during pregnancy could be considered in the light of the early development of atherosclerosis. A similar conclusion is drawn by the results of the analysis of intravital ultrasound in this contingent of women with the detection of greater thickness of the intima-media complex of the coronary vessels of the heart and femoral artery than in women after normal pregnancy. These data were obtained 3 months after delivery and 6 weeks after cessation of lactation. When compared according to commonly studied clinical criteria, in addition to the detection of a slight increase in blood pressure, as well as the levels of triglycerides and homocysteine ​​in the blood serum of women who had preeclampsia, there were no other differences between the groups of the examined, while the thickness of the studied vessel wall was more significant in women who had had preeclampsia . These studies are additional evidence of the diversity of the paths of development of atherosclerotic lesions of the vascular system, on the one hand, and the asymptomatic development of atherosclerosis, on the other.

The risk of developing cardiovascular disease in in vitro fertilization currently understudied. A powerful hormonal effect on a woman's body, carried out during the implementation of the in vitro fertilization program, creates a threat of a number of complications, which include, first of all, ovarian hyperstimulation syndrome, which manifests itself in a wide range of clinical symptoms: from mild biochemical changes to hypercoagulability, with the formation of thrombosis main and peripheral vessels. In the literature, there is information about the formation of both venous and arterial thrombosis, in rare cases, the occurrence of strokes and myocardial infarction during in vitro fertilization.

In Europe, according to various sources, arterial hypertension occurs in 5-15% of pregnant women, while the frequency of its detection in economically developed countries over the past 10-15 years has increased by almost 1/3.

obese suffer from 10 to 30% of pregnant women.

Prevalence of all forms diabetes in pregnant women reaches 3.5%, while type 1 and type 2 diabetes mellitus occurs in 0.5% of pregnant women, and the prevalence of gestational diabetes mellitus is 1-3%.

Smoking during pregnancy- a risk factor for the development of various complications not only in the mother, but also in the fetus. In recent years, the number of women who smoke has increased in many countries of the world. In the US, about 30% of women over the age of 15 smoke, of whom at least 16 continue to smoke during pregnancy.

The most common forms of cardiovascular pathologies during pregnancy and methods of their treatment

Cardiovascular accidents (myocardial infarction and stroke) during pregnancy are relatively rare, but they are serious complications, often leading to death.

myocardial infarction

Myocardial infarction in a pregnant woman was first described in 1922.

The incidence of myocardial infarction during pregnancy ranges from 1 to 10 cases per 100,000 births. However, recently, with the advent of new, more sensitive diagnostic criteria for myocardial infarction, and an increase in the age of pregnant women, a greater number of cases of myocardial infarction have been recorded. In addition, myocardial infarction significantly worsens perinatal outcomes.

According to a retrospective study (published in 1997) case-control, in the group of women from 15 to 45 years of age, myocardial infarction in non-pregnant women is recorded much less frequently than in pregnant women.

According to angiography, atherosclerosis of the coronary vessels in pregnant women with myocardial infarction was detected in 43% of cases, coronary thrombosis of various etiologies - in 21%. An extremely rare complication of myocardial infarction in the general population - rupture of the coronary arteries - was reported in 16% of cases. However, in 21% of patients with myocardial infarction, no changes in coronary vessels were detected.

Myocardial infarction during pregnancy has a number of features (see Table 1). Diagnosis and differential diagnosis of myocardial infarction during pregnancy is extremely difficult. In pregnant women, heart attacks often occur without pain. Symptoms such as shortness of breath, tachycardia, discomfort in the region of the heart can be observed during the normal course of pregnancy, as a result of the appointment of tocolytic therapy (3-adrenamimetics and magnesium sulfate).

ECG registration is a necessary and often decisive element in recognizing acute myocardial infarction, as well as in determining its stage, localization, extent and depth. With a single ECG recording, the diagnosis of acute myocardial infarction is established only in 51-65% of cases. At the same time, 37% of patients who had
a caesarean section was performed, the ECG recorded changes similar to ischemic ones.

In the diagnosis of myocardial infarction, usually, in addition to the clinical picture, an important role is played by the determination of such sensitive and specific biomarkers as cardiospecific troponins I and T and the creatine phosphokinase MB fraction (CPK MB). They have both high sensitivity and high specificity for myocardial injury, even in microscopic areas of myocardial necrosis. However, in pregnant women, the determination of CPK MB cannot be used in the diagnosis of myocardial infarction, since an increase in its activity can also be observed during normal pregnancy, as well as during childbirth and the early postpartum period. Only the determination of cardiospecific troponins is the gold standard for diagnosing myocardial infarction, including during pregnancy.

The use of additional diagnostic methods, such as coronary angiography and myocardial scintigraphy, is limited during pregnancy. Currently, pregnant women can undergo echocardiography to determine areas of myocardial hypo- and akinesia.

Differential diagnosis of myocardial infarction in pregnant women is carried out with the same diseases as in the general population (pulmonary embolism, dissecting aortic aneurysm, acute pericarditis, intercostal neuralgia). Nevertheless, during pregnancy, myocardial infarction has its own characteristics (see Table 1). Heart attacks during pregnancy can be complicated by pulmonary edema - one of the main causes of death. However, during pregnancy, there are many specific risk factors for the development of this edema: preeclampsia, the use of tocolytic therapy, amniotic fluid embolism, septic shock, massive infusion therapy.

Table 1

Features of the course and diagnosis of MI during pregnancy

	Feature characteristic
Localization	The anterior and anterolateral wall of the left ventricle is most commonly affected.
Etiology	Atherosclerotic lesions of the coronary vessels are detected less frequently than in the general population.
Prevalence	1 to 10 cases per 100,000 births
Mortality	0.35 per 100,000 births
Complications of pregnancy and risk of myocardial infarction	Most often, the risk of MI is associated with massive fluid therapy, blood transfusion, preeclampsia, eclampsia, gestational hypertension, infection in the postpartum period
Perinatal outcomes in pregnant women	Premature births were observed in 43% of cases and premature babies were born in 40% of cases.
	Can detect ischemic-like changes in 37% of patients who have a caesarean section
Biochemical markers	In pregnant women, the measurement of CPK MB is not used in the diagnosis of MI, since it may also increase during normal pregnancy, as well as during childbirth and the early postpartum period

There are 2 approaches to the choice of tactics for the treatment of myocardial infarction: a conservative method and invasive tactics. During pregnancy, the issue of the safety of coronary thrombolysis has been debated to date. In animal experiments, streptokinase, a tissue plasminogen activator, did not cross the placenta. However, conducting clinical trials in humans is, for obvious reasons, difficult. During pregnancy, complications of thrombolytic therapy are especially dangerous: spontaneous abortions, vaginal, uterine bleeding, premature detachment of a normally located placenta, so pregnancy and the 1st week after birth are a relative contraindication to thrombolysis. It must also be remembered that during pregnancy, angiotensin-converting enzyme inhibitors, statins are contraindicated, non-selective b-blockers should be used carefully. Otherwise, drug therapy for myocardial infarction in pregnant women does not differ from the standard one.

Invasive tactics include coronary angiography followed by myocardial revascularization (coronary angioplasty, coronary artery bypass grafting - CABG). According to an American population study, coronary balloon angioplasty was performed in 23% of cases of myocardial infarction in pregnant women, stenting was required in 15% of cases, and CABG was required in 6% of cases.

Stroke

Stroke during pregnancy is one of the most potentially life-threatening situations. Maternal mortality reaches 26%, and neurological disorders persist in surviving patients. At the same time, perinatal mortality is also quite high. Stroke in the structure of causes of maternal mortality is 12%. According to epidemiological studies, in the age group from 15 to 35 years, women are more likely to suffer from a stroke than men; the prevalence of stroke in women of reproductive age is 10.7 per 100,000. This may be due to specific female risk factors for developing cardiovascular diseases, such as pregnancy, oral contraceptives, hormone therapy, etc.

The prevalence of stroke in pregnant women, according to different authors, ranges from 11 to 200 cases per 100,000 births. According to A. James (data analysis of more than 3,000 strokes during pregnancy), the prevalence of strokes is 34.2 per 100,000 births, and the mortality rate is 1.4 per 100,000 births. The risk of stroke during pregnancy is 3 times higher than in women in the general population. Most cases of stroke during pregnancy occur in the third trimester and in the postpartum period. 76-89% of all strokes occur in the postpartum period. The risk of ischemic stroke in the postpartum period is 9.5 times higher than during pregnancy, and 23 times higher than in the general female population. According to the largest Swedish study, which includes an analysis of about 1,000,000 births over an 8-year period, the highest risk of developing both ischemic and hemorrhagic stroke during pregnancy occurs between 2 days before delivery and 1 day after them. In the general population, usually about 60% of strokes are due to thrombosis, 20% - to embolic causes, 15% - to hemorrhagic strokes, 5% are due to rare causes, such as hereditary diseases, connective tissue pathology, arterial dissection, metabolic disorders. However, during pregnancy, ischemic and hemorrhagic strokes occur in approximately equal proportions. In 23% of cases, their cause could not be reliably established. Many different causes are suggested: infection, tumor, hereditary thrombophilia, trauma, somatic pathology (rheumatic heart disease, systemic lupus erythematosus, etc.). Atherosclerosis as a cause of stroke during pregnancy ranges from 15 to 25%.

Currently, most neurologists believe that a pregnant woman with suspected stroke should be examined according to the standard algorithm. The diagnosis is based on a thorough history, identification of risk factors and analysis of clinical data, namely neurological symptoms. It is necessary to establish the cause of the stroke (ischemia or hemorrhage) as soon as possible. For ischemic stroke, the presence of motor, speech or other focal neurological disorders is more characteristic. Disorders of consciousness, vomiting, intense headache in most cases are observed in hemorrhagic stroke. However, there are no pathognomonic clinical signs for hemorrhagic and ischemic strokes. Methods such as computed tomography (CT) and magnetic resonance imaging are indispensable for the differential diagnosis between hemorrhagic and ischemic stroke.

Pregnancy is a relative contraindication to CT, x-ray angiography, but in certain cases, the study can be performed with careful protection of the abdomen. A negative CT scan does not rule out a diagnosis of stroke. In some cases, the results of subsequent magnetic resonance imaging with angiography confirmed this diagnosis.

Postpartum strokes usually occur between 5 days and 2 weeks after delivery. Clinical symptoms of stroke in pregnancy such as headache, vision changes, epigastric pain, nausea and vomiting, and focal neurological defects are often mistaken for symptoms of preeclampsia and eclampsia. Differential diagnosis of stroke during pregnancy is carried out with the same conditions as in the general population: meningoencephalitis, traumatic brain injury, brain tumors, hypoglycemia, uremia, liver failure.

Currently, a differentiated approach to the choice of therapy for stroke is being carried out. Treatment of ischemic stroke in the verification of the diagnosis due to obstruction of the artery (atherothrombotic stroke, including due to arterio-arterial embolism) includes the possibility of medical thrombolysis. There are strict restrictions for thrombolysis: admission of the patient in the first 3-6 hours from the onset of the disease, with stable blood pressure not higher than 185/100 mm. rt. Art. and no change on CT. There are few reports of thrombolytic therapy in pregnant women with stroke. According to A. Murugappan et al., 7 out of 8 women survived, one patient died (the cause of death was arterial dissection during angiography). Of the 7 surviving patients, 3 had an abortion, 2 had a miscarriage, and 2 had a safe delivery. After strokes, approximately 50% of women have residual neurological deficits. Stroke prevention should be carried out in high-risk groups. Pregnant patients with a history of rheumatic fever should be given antibiotic prophylaxis because of the high risk of recurrence during pregnancy. Patients with artificial heart valves need special observation due to the high risk of developing thromboembolic complications. Women who have had a previous stroke should receive preventive treatment throughout their pregnancy. Aspirin and low molecular weight heparin are considered the treatment of choice.

Heart defects

It should be noted that an increase in the volume of circulating blood characteristic of pregnancy (up to 30-50% of the initial and maximum by 20-24 weeks of gestation) creates conditions for volume overload of the myocardium, and pregnancy itself represents a certain model of HF development, which imposes increased requirements on the functional reserve. myocardium. In most cases, in pregnant women with heart defects (excluding stenosis of the left atrioventricular orifice), the development of HF proceeds rather slowly, with clinical symptoms depending on the overload of certain chambers of the heart (left and right ventricular HF), which makes it possible to carry out the necessary therapeutic measures in time, to determine indications for further prolongation of pregnancy. It should be noted that only careful monitoring of the patient by a cardiologist allows us to determine the earliest (and non-specific!) clinical signs of heart failure.

The risk of adverse maternal outcomes (pulmonary edema, bradycardia or tachycardia, stroke or death) is about 4% in the absence of the following symptoms: a decrease in ejection fraction of less than 40%, aortic stenosis with a valve area of ​​less than 1.5 cm 2, mitral stenosis with valve area less than 1.2 cm 2 , a history of cardiovascular complications (HF, transient cerebrovascular accident or stroke) or HF II and higher FC. In the presence of one of the above signs, the risk of complications is 27%, two or more - 62%. The table shows the level of risk in relation to the mother with various heart defects.

Shunting of blood from left to right. This hemodynamic disorder is accompanied by the most common congenital heart defects: atrial and ventricular septal defects (VSD and VSD), patent ductus arteriosus. Peripheral vasodilatation, commonly seen during pregnancy, greatly alleviates the course of these heart defects. Moderate pulmonary hypertension accompanying them is hypervolemic in nature and usually does not exceed 30-40 mm Hg. Art. Pregnancy and childbirth in women with ASD even of large sizes through the natural birth canal are well tolerated. Perhaps the development of arrhythmias (extrasystole, paroxysmal supraventricular tachycardia) and paradoxical embolism. An increase in the risk of complications can only be with VSD of the membranous part of more than 1 cm in diameter.

Obstruction of the outflow tract of the left ventricle. Left ventricular outflow tract obstruction syndrome occurs with aortic valve stenosis (congenital or acquired), aortic coarctation and/or ascending aortic aortopathy, and hypertrophic cardiomyopathy. It is not recommended to prolong pregnancy with aortic valve stenosis, accompanied by clinical symptoms (shortness of breath, suffocation, angina pectoris). However, the absence of these symptoms does not exclude their occurrence during pregnancy. With severe aortic stenosis, left ventricular hypertrophy limits the growth of systolic pressure and filling pressure of this chamber of the heart during attempts, in this case, operative delivery is performed, with a slight or moderate defect - spontaneous delivery without or with limited attempts. Maternal mortality in uncorrected aortic coarctation is up to 3% and is associated with the likelihood of aortic dissection in the third trimester and postpartum period. Operative correction of the defect significantly reduces, but does not completely eliminate the risk of developing this complication.

Hypertrophic cardiomyopathy usually does not affect the course of pregnancy, however, with a high pressure gradient (more than 40 mm Hg), 24-hour Holter ECG monitoring is recommended to exclude life-threatening arrhythmias. With the development of arrhythmias, sotalol therapy is carried out under monitor control. With a high pressure gradient, ventricular extrasystole of high grades or mitral valve insufficiency of the III degree, delivery is carried out with the exception of attempts.

Stenosis of the pulmonary artery of moderate and moderate degree does not affect the course of pregnancy and childbirth, and with severe stenosis, arrhythmias and right ventricular failure can be observed, therefore, in the latter case, operative delivery is recommended.

Operated and non-operated defects of the "blue" type. Heart defects accompanied by cyanosis (tetrad and triad of Fallot, Eisenmenger's syndrome), in 27-32% are complicated by heart failure, thromboembolism, life-enhancing arrhythmias, infective endocarditis. Carrying a pregnancy with them is contraindicated.

Patients who underwent radical surgery for Fallot's tetrad have a good prognosis, and the 25-year survival rate among them is 94%, which allows most girls to reach reproductive age. Patients with incomplete correction of the tetrad of Fallot or significant residual stenosis or shunt have a relatively high risk of developing HF, and the possibility of prolonging pregnancy and the mode of delivery are decided individually. An increase in hematocrit of more than 60%, a decrease in arterial blood saturation of less than 80%, a significant increase in pressure in the right ventricle are indicators of a poor prognosis. In these cases, fatal complications in relation to the mother are noted in 3-17%.

If after surgical treatment there is no residual septal defect, the pregnancy is well tolerated and childbirth is carried out through the natural birth canal.

Transposition of the great vessels is a rare heart disease, in which the anatomically right ventricle releases into the systemic circulation and is accompanied by HF and arrhythmias in 7-14% of pregnant women.

Rheumatic heart disease. Mitral stenosis (MS) is the most common rheumatic heart disease in pregnant women. Pregnant women with MS are characterized by a high risk of life-threatening complications. This is primarily due to an increase in transmitral blood flow, an increase in left atrial pressure, and a decrease in diastolic relaxation time, which are based on an increase in cardiac output and heart rate characteristic of pregnancy. An increase in pressure in the left atrium creates conditions for the development of atrial arrhythmias, which can further increase the number of ventricular contractions.

Thus, literature data indicate the possibility of delivery through the birth canal in most women with mitral valve disease. It is recommended to shorten the second stage of labor by applying obstetric forceps or a vacuum extractor, performing epidural anesthesia to reduce pain, fluctuations in cardiac output, and also to reduce pressure in the left atrium and pulmonary artery. An increase in venous return in the early postpartum period can lead to a significant increase in pressure in the left atrium and pulmonary artery with the development of pulmonary edema.

When determining the indications for prolongation of pregnancy, it should be taken into account that with the development of endovascular surgery, it became possible to correct heart defects in pregnant women (mitral valve stenosis, ASD and VSD) and further delivery through the natural birth canal. Thus, with most congenital and acquired heart defects, there are real prospects not only for carrying a pregnancy, but also for spontaneous childbirth. It should be borne in mind that the assessment of the prognosis of pregnancy and childbirth should be carried out taking into account other extragenital and obstetric pathologies. The addition of preeclampsia, arterial hypertension, diabetes mellitus and other diseases can worsen metabolic processes in the myocardium, lead to an increase in myocardial oxygen consumption with the development of heart failure of high functional classes. The doctor's tactics should be based solely on internationally developed recommendations with dynamic clinical and echocardiographic observations, and, if necessary, 24-hour Holter ECG monitoring.

Conclusion

According to the data presented, the problem of prevention, diagnosis, treatment and management of pregnancy and childbirth in women with an obstetric history of aggravated cardiovascular disorders and the presence of risk factors for their development is of interdisciplinary importance, which necessitates the formation of an appropriate strategy for their management. At the same time, the commonality of individual components of the pathobiology of cardiovascular disorders during pregnancy with the pathogenesis of atherosclerosis and other factors creates opportunities for early detection of women in the high cardiovascular risk group at the preclinical stage of complications. This entails a reduction in maternal and infant mortality and, as a result, optimizes the demographic situation as a whole.

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24. Leiserowitz G., Evans A., Samuels S. Creatine kinase and its MB isoenzyme in the third trimester and the peripartum period. J. Reprod. Med. 1992; 37:910-916.

25. Shivers S., Wians S., Keffer H, Ramin S. Maternal cardiac troponin I levels during normal labor and delivery. Am. J. Obstetr. Gynecol. 1999; 180:122-127.

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The main place among the somatic pathology in pregnant women is occupied by diseases of the cardiovascular system. They account for aboutof all diseases of the internal organs. Most often there arecongenital and congenital heart defects, operated heart, hypertensive disease.

Pregnancy places increased demands on the cardiovascularwoman's system. Adaptive changes are due to the coexistence of twoorganisms - mother and fetus. Pregnant women experience physiologicaltachycardia, more pronounced in III trimester. Simultaneously increasesstroke and minute volume of the heart. By the 28-30th week of pregnancy, cardiacoutput increases by almost 30%, mainly due to increased heart ratecontractions and increase in stroke volume of the heart. At the same time beginsmarked increase in circulating blood volume. Decreased peripheralvascular resistance and blood viscosity facilitate the process of hemocirculation.These changes provide a progressive increase in blood flow to the uterus, placenta, mammary glands, and kidneys. As pregnancy progressesthe need of the organism of the mother and fetus for oxygen increases, which in many respectsgom is provided by hyperfunction of cardiac activity. Compensation-torny opportunities in women suffering from diseases of the cardiovascular system are limited, so their pregnancy is often complicated and can lead to decompensation of cardiac activity.
A new chain of changes in the cardiovascular system is caused by childbirth andice age. With each contraction, blood is pushed out of the uterusto the heart, which increases cardiac output by 15-20%, increasesblood pressure and reflexively reduces the heart rate.In women who are in pain or fear, there is an even more pronouncedincrease in cardiac output. Such a load on the heart can become critical for women with cardiac pathology.
Immediately after the birth of the fetus, due to a sharp shutdown of the uteroplacentalblood flow and elimination of compression of the inferior vena cava, there is a rapida slight increase in the volume of circulating blood, which increases the load onheart, and in sick women can contribute to the occurrence of cardiac insufficiency.
Acquired heart defects. Acquired heart defects meet-in 6-8% of pregnant women. Most often they are of rheumatic origin.Rheumatism refers to toxic-immune diseases. The causative agent isβ-hemolytic streptococcus group A. Rheumatism is systemicconnective tissue disease with predominant localization of the processsa in the circulatory organs. Girls and women are most often affected young age. Most often, rheumatism affects the mitral valve, less often - the aortic valve, and even more rarely - the tricuspid valve.
Stenosis of the atrioventricular orifice ranks first among thekov of rheumatic etiology. With severe obstruction of blood flow fromleft atrium into the left ventricle, there is an increase in pressure in the leftatria, pulmonary veins and capillaries. Changes in the functions of the cardiovascularvascular system during pregnancy, expressed in an increase in the volume of circulating blood, heart rate and cardiac selectiondew, contribute to the development of pulmonary edema. The risk of hypertension, pulmonary edema, pulmonary embolism, atrial fibrillation withstenosis of the atrioventricular valve increases with increasing physical, emotional and hemodynamic load during childbirth.
Mitral valve insufficiency occurs in isolated formrarely, more often it is combined with atrioventricular stenosis andwith aortic valve disease. Due to blood regurgitation with insufficientaccuracy of the mitral valve, filling of the left atrium is observed, and then overflow and expansion of the left ventricle. Excessive dilationof the left ventricle leads to a decrease in systolic volume and to impaired circulation (left ventricular failure). A similar circulatory disorder develops with severe mitral insufficiency.valve. A small degree of insufficiency or combinedmitral valve disease with a predominance of insufficiency usually have favorableclear forecast. Mitral valve prolapse is relatively rare.Hemodynamic shifts in this case are mainly due to insufficiency mitral valve.
Aortic stenosis - stenosis of the aortic mouth in its pure form is rare. It is usually associated with aortic insufficiency or mitral stenosis.zom. The narrowing of the mouth of the aorta twice does not affect the patient's condition. Atmore pronounced aortic stenosis develops dilatation of the cavity of the leftventricle, pressure rises, cardiac output decreases. First-la there is left ventricular, and then right ventricular failure circulation.
Effect of pregnancy on rheumatic heart disease. During pregnancy, and then during childbirth and in the postpartum periodIn some cases, complications may develop in the form of an exacerbation of the rheumatic process, an increase in circulatory failure and the development of acute heart failure. sufficiency.
Exacerbation of the rheumatic process, due to the characteristics of the immunologicalcal status and hormonal background in pregnant women, there is quiterarely. Critical periods of exacerbation of rheumatism correspond to the first14 weeks and then 20-32 weeks of pregnancy. Slightly more often exacerbation of rev-matism occurs in the postpartum period. At present, all rheumaticlogs indicate the predominance of erased forms of the rheumatic process,
Circulatory failure in women with acquired heart disease may complicate the course of pregnancy at the end II trimester, during childbirth and in the first 2 weeks. postpartum period. These periods are considered critical. However, the possibility of developing cardiac decompensation persists during the first year of life after childbirth. Developmentcirculatory failure is associated not only with the nature of heart diseasetsa, but also with the duration of its existence and the age of the woman. Factorsleading to decompensation of cardiac activity are the following: 1) irrational lifestyle of a woman; 2) development of late preeclampsia; 3) activation of the rheumatic process; 4) the presence and exacerbation of chronicfoci of infection; 5) acute infectious (especially viral) diseases;6) the lack of regular monitoring during pregnancy by an obstetrician and tera-peutom-cardiologist; 7) lack of sufficient anesthesia and incorrect childbirth management.
Acute heart failure in pregnant women most often developstype of left ventricular and manifests itself in the form of cardiac asthma or pulmonary edemato their. This pathology is characteristic of mitral stenosis due to inappropriate effects of blood flow from the lungs to the heart and its outflow.
Features of the course of pregnancy and childbirth in rheumatic heart disease. Among obstetric complications in patients withOPG-preeclampsia often occurs in patients with heart defects. Especially often gestosisexacerbates aortic valve insufficiency. Gestoses develop early, during II trimester of pregnancy, are characterized by a latent course and poor amenable to treatment. Changes in central and peripheral hemodynamics,activation of the procoagulant and platelet components of hemostasis, deterioration of the rheological properties of blood observed in preeclampsia, on the one hand, increase the risk of developing thrombotic complications in the pulmonary circulationon the other hand, they increase the risk of premature detachment of normal located placenta.

In women with diseases of the cardiovascular system, pregnancy isThis is complicated by the threat of interruption. The number of spontaneous miscarriages andpreterm birth is significantly higher than the average. During the ro-the percentage of anomalies in the contractile activity of the uterus increases: the number of fast and rapid births increases. Excessive birth de-activity can cause destabilization of hemodynamics. Features of the contractile activity of the uterus in women with heart defects are associated with an increase their content of prostaglandins.

Some pregnant women with acquired heart disease develophypochromic iron deficiency anemia, which adversely affects the fetal development.

The course of pregnancy with heart defects can be complicated by a violationuteroplacental blood flow, leading to hypoxia or delayed development of the intrauterine fetus. The frequency and severity of these complications depend onthe presence and severity of cardiac decompensation.

Due to stagnation in the uteroplacental circulation in women withheart defects blood loss in the afterbirth and early postpartum periods often exceeds the physiological norm.

Diagnosis of acquired heart defects. Clinical medical observation and all diagnostic measures in pregnant women with heart defects are carried out jointly by a cardiologist-therapist and an obstetrician, in some cases teas attracting a cardiologist-surgeon.

More than 75% of women have heart defects diagnosed beforepregnancy, which greatly simplifies the actions of the obstetrician and cardiologistologist. Diagnosis of acquired heart defects during pregnancyvyvaetsya on the same signs as outside it. This topic is covered in detail intextbooks on internal medicine. Diagnostic difficulties that arisein some cases, due to changes in the cardiovascular systemwomen due to pregnancy: the appearance of murmurs at the apex of the heart, II tone, "lying" heart with a high standing of the diaphragm. Therefore, in addition topercussion and auscultation, be sure to use electrocardiography, phono-cardiography, ultrasound scanning, spirometry, speed detection blood flow and venous pressure.

Clinical diagnosis, in addition to the characteristics of the defect, should containindications of the presence or absence of activity of the rheumatic process, on degree of circulatory failure.

Determination of the activity of the rheumatic process during pregnancypresents certain difficulties, since some clinical signski active form of rheumatism (low-grade fever, moderate tachycardia, increasedESR, leukocytosis, shift of the neutrophil formula to the left) are also observed inhealthy pregnant women. Only a set of clinical and laboratory datahelps to diagnose the activation of the rheumatic process. to clinicalsigns include weakness, fatigue, shortness of breath, subfebrile condition, tachycardiadia, arrhythmias. Laboratory signs of rheumatism are leukocytosismore than 11.0x10 9 /l, ESR more than 35 mm / h, a pronounced shift of neutrophilsto the left, a decrease in reticulocytes, the titer of antibodies to streptolysin-0 is above 1:800 andto hyaluronidase above 1:1000, Cardiovascular insufficiency and hypochromic anemia, which are not amenable totreatment. Clinical variants of the course of rheumatism have three degrees process activity:

I degree - minimal, characterized by a weak severity of cli-nic symptoms and minimal changes in laboratory parameters;

II degree - moderate, which is characterized by moderate clinicalmanifestations of a rheumatic attack with low fever, without pronouncedexudative component of inflammation in the affected organs; small off- cloning of laboratory parameters;

III degree - maximum, characterized by bright general and local
mi clinical manifestations and severe deviations in the laboratory
ny indicators.

Chronic heart failure in our country is usually assessed,using the classification of N. D. Strazhesko and V. x. Vasilenko:

/ stage - symptoms of circulatory disorders (shortness of breath, palpitations,fatigue) appear only after physical exertion;

PA stage- shortness of breath and palpitations become almost constant orappear at very light load; symptoms of myogenicdilatation of the heart and congestion in the pulmonary circulation withleft ventricular insufficiency, in the liver - with insufficiency of the right departments of the heart;

PB stage -stagnation is expressed both in small and large circle of blood circulation;

III stage -irreversible changes in internal organs.

Diagnosis of rhythm and conduction disorders of the heart is vitalvalue. If extra asystole and paroxysmal tachycardia canappear in healthy pregnant women, then the registration of atrial tachycardia inwomen with heart disease can be a harbinger of atrial fibrillation, leading to a rapid increase in heart failure.

Treatment of rheumatic heart disease in pregnant women n s. Both diagnostic and therapeutic measures require jointefforts of cardiologists and obstetricians. Rational assistance to a pregnant woman with a defectheart consists of the following components: regimen, diet, psychoprophylactic preparation for childbirth, oxygen therapy, drug treatment. In modepatients should be provided with sufficient night sleep (8-9 hours) and daytimerest in bed (1-2 hours). The diet should be easily digestible, contain vitaminsmines and potassium salts. Psychoprophylactic preparation for childbirth should begin from the early stages of pregnancy and be aimed at eliminating the countryha before childbirth. Saturation of the body of a pregnant woman with oxygen shouldcarried out by any available means: from oxygen cocktails to oxybarotherapy.

Drug therapy has many goals: prevention or treatmentrecurrence of rheumatism, prevention of cardiac decompensationsti, treatment of chronic and acute cardiovascular insufficiency.

Most clinicians believe it is necessary to carry out prophylaxisrelapses of rheumatism during critical periods of a possible exacerbation of the processsa: up to 14 weeks, from 20 to 32 weeks. pregnancy and postpartum period. For this purpose, bicillin-1 or bicillin-5 is used in combination withacetylsalicylic acid. The latter should not be administered in the first 8 weeks.(teratogenic effect) and in the last 2 weeks. pregnancy (the possibility of pro-prolongation of pregnancy due to the antiprostaglandin effect). For the treatment of recurrence of rheumatism, penicillin or its semi-synthetic is usually used.cal analogues. For severe forms of rheumatism, corticosteroids are added(prednisolone or dexamethasone).

Cardiac therapy for heart defects largely depends on the degree of circulatory disorders. For compensated defects, it is recommendedperiodically for 2-3 weeks. apply an infusion of herb adonis, vita- mines of groups B and C, rutin.

The main drugs in the treatment of heart failurefeatures are cardiac glycosides: strophanthin, corglicon, digoxin, whole-nid, digitoxin. Along with glycosides, diuretics are widely used, whichreduce the amount of fluid in the body, reduce venous pressure andreduce venous stasis in organs. Furo is used as a diuretic.semid, hypothiazide, spironolactone, aminofillin. To improve the function of myofib-it is recommended to prescribe vitamins of groups B, E, C for a long time, potassium orotate, riboxin.

Emergency therapeutic care is required for pregnant women, women in labor andpuerperas with pulmonary edema, which can occur with mitral ste-nose and aortic valve insufficiency. Treatment starts immediatelyintravenous administration 2-4 ml of 0.25% solution of pipolfen, 2 ml of 0.5% solutionseduxen and 1 ml of a 2% solution of promedol. Simultaneously administered intravenously1 ml of 0.05% strophanthin solution per 10 ml of 20% glucose solution. At highblood pressure, ganglionic blockers such as imekhin, benzohexo-nia, pentamin. You can put a nitroglycerin tablet under your tongue.

Emergency care may be required if the heart rhythm is disturbed. To suppress paroxysms of atrial tachycardia, slowintravenous administration of 2 ml of a 0.25% solution of verapamil, dissolving it in 8 mlisotonic sodium chloride solution or 5-10 ml of 10% novocaine-amide solution with 10 ml of isotonic sodium chloride solution. Ventricular tachykar- dia are stopped by lidocaine.

Thromboembolism of the pulmonary artery and its branches, which occurred in pregnant women with valvular heart disease, requires emergency therapeutic measures, whichwhich should be aimed at eliminating bronchospasm and spasm of the vessels of the pulmonary circulation, improving the rheological properties of blood, sub-maintaining effective treatment of gas exchange and blood circulation. Treatment startsis administered with intravenous injection of 2 ml of a 0.25% solution of droperidol, 1-2 ml0.005% solution of fentanyl and 1-2 ml of 1% solution of diphenhydramine; then intravenousbut 400 ml of rheopolyglucin is dripped in, with an increase in blood pressure, adding 10 ml of a 2.4% solution of aminophylline to it. Later on,thrombolytic therapy with streptokinase, urokinase, or fibri-nolysin. At the time of intensive care, cardiac glycosides are administered intravenously. Simultaneously with drug therapy is carried outoxygen inhalation through a mask or nasal catheters, with an increase in respiratory insufficiency are switched to mechanical ventilation.

Patients with heart defects induring pregnancy, it is necessary to be placed in a hospital at least 3 times. Per-Vuyu hospitalization is carried out in a period of 8-12 weeks. to the antenatal department of a specialized maternity hospital or to the therapeutic department of a multidisciplinaryphilanthropic hospital. The second time a pregnant woman is hospitalized in the antenatal wardtreatment within 28-32 weeks, the third hospitalization is carried out in 3 weeks. before childbirth.

In the first hospitalization, the issue of maintaining or interruptingpregnancy, To this end, involving all the necessary diagnostic methods, determine the degree of risk of an adverse outcome of pregnancy. L. V. Wa- Nina (1961) proposed to distinguish 4 degrees of risk:

I degree - pregnancy with heart disease without signs of cardiac insufficiency and exacerbation of the rheumatic process;

II degree - pregnancy with heart disease with initial symptomsheart failure (shortness of breath, cyanosis), in the presence of minimal symptomssigns of exacerbation of the rheumatic process ( IA degree according to Nesterov);

III degree - pregnancy with decompensated heart disease withsigns of predominance of right ventricular failure, in the presence ofmoderate signs of activation of rheumatism (PA), with the appearance of flicker- Noah arrhythmia or pulmonary hypertension;

IV degree - pregnancy with decompensated heart diseasewith signs of left ventricular or total insufficiency, withchii maximum signs of exacerbation of the rheumatic process (ShA), mer-cationic arrhythmias and thromboembolic manifestations of pulmonary hyper- tension.

Continuation of pregnancy is allowed only if I and II degrees of risk.
The second mandatory hospitalization is carried out during the period of greatesthemodynamic stress on the heart. At this time, pregnant women needconducting cardiac therapy and other therapeutic and prophylactic measures riyatiya.

The third compulsory hospitalization is necessary for the preparation of the pregnancy.for childbirth, conducting cardiac therapy and developing a management plan childbirth.

In modern obstetrics, indications for a caesarean sectionThe effects in women with acquired heart disease are well defined. Caesareansection is carried out in the following cases: 1) with active rheumatic pro-cess; 2) with a pronounced heart disease with severe insufficiencyleft ventricle and the absence of the effect of active drug therapy;3) with a combination of heart disease with obstetric pathology requiring surgical cal delivery.

Conducting childbirth through the birth canal requires compliance with the followingrules. It is necessary to periodically use cardiac agents andoxygen inhalation; provide adequate anesthesia; if necessary-to carry out the regulation of labor activity, avoiding protracted, quick or rapid labor; to make an early opening of the fetal bladder; shorten the period of exile; prevent bleeding in the futurein the first and early postpartum periods. The imposition of obstetric forcepstreat the period of exile in women with mitral stenosis, with insufficiencycirculation, with endocarditis, with symptoms of decompensation during previouschildbirth. In other cases II period is shortened as a result of perineotomy.

Postpartum women with heart disease do not tolerate hemodynamic changesafter turning off the uteroplacental circulation, so theyimmediately after the end of childbirth, cardiotonic drugs are administered, and with mitral and aortic insufficiency put a burden on the stomach.

The principles of postpartum management are the same as during pregnancy.sti. Breastfeeding is contraindicated in the active form of rheumatic fever. tizma and with an increase in the phenomena of decompensation.

Pregnancy and congenital heart defects. There are about 50 timespersonal forms of anomalies in the development of the cardiovascular system, of which about15 forms refer to the variants of vices with which sick women liveup to reproductive age. During pregnancy, congenital heart defectstsa meet much less often acquired. In recent years, their number has nothow much has increased, but their frequency does not exceed 5% of all defects hearts in pregnant women.

Among the most common congenital malformations, there are 3 groups py:

1) defects, accompanied by a discharge of blood from left to right (defect of inter-atrial septum, open ductus arteriosus, interventricular defect kovy partition);

2) defects in which there is a shunt of blood from right to left (tetrad Fallot, transposition of the great vessels);

3) malformations in which there is an obstruction to blood flow (stenosis of the pulmonary arteries, aortic stenosis, coarctation of the aorta).

Due to the wide variety of forms of congenital malformations, there are noThere is no point of view on the possibility of predicting the effect of pregnancy onthe functioning of the cardiovascular system and, therefore, on healthwomen. For each case of pregnancy in such patients, it is necessary to strictlyindividual approach after a thorough examination in a specializedlocal hospital and joint care by therapists, cardiac surgeons andobstetricians. The prognosis is determined not only by the form of the defect, but also by the presence orthe absence of circulatory failure, the presence or absence of increased pressure in the pulmonary artery, the presence or absence of hypoxemia.These factors contribute to the unsatisfactory course of pregnancy and adverse outcomes for mother and fetus.

Most common in pregnant women bleeding malformations from left to right.Pregnancy well tolerated by patients with a defect in musclesection of the interventricular septum, with a small atrial defectpartitions and with partial obliteration of the open ductus arteriosus.If the disease is accompanied by circulatory failure of anyseverity, pulmonary hypertension, or shunting of blood to the right If so, the pregnancy must be terminated.

Pregnant women after timely surgical correction of congenital defects of this group cope well with the load and give birth safely healthy children.

Congenital malformations with shunting of blood from right to left("blue") are the mostheavier. Tetralogy of Fallot and transposition of large vessels are an indication for termination of pregnancy.

Congenital malformations with obstruction of blood flow in the absence of insufficientsti cardiac activity and blood circulation do not serve as an obstacle to the pro-due to pregnancy. If pulmonary stenosis is isolated, then, as a rule, the pregnancy ends safely for the mother andfetus. With coarctation of the aorta, pregnancy is permissible only with its moderateconstriction and blood pressure not exceeding 160/90 mm Hg. Art. However, in this case, due to the danger of rupture of the altered aortic wall, childbirth ends with a caesarean section.

Follow-up and management of pregnant women with congenital heart diseasechildbirth are carried out according to the principles developed for patients with shadow heart defects.

Pregnancy and operated heart. In recent decades, thanks toAlong with the successes of cardiac surgery, a group of women appeared in obstetric practice,who underwent surgical correction of heart defects. The most frequent operationsmitral commissurotomy and replacement of defective cardiacvalves with artificial prostheses or biological transplants.Surgical treatment of malformations improves the health status of manyth number of women that it becomes possible to carry a pregnancy. One-However, pregnancy and childbirth in such patients pose a high risk, not always justified.

For patients who have had a successful commissurotomy,pregnancy not earlier than one year after the operation after the disappearance of allsigns of heart failure. You can't drag out the timingpregnancy due to the threat of restenosis. Pregnancy is contraindicatedin women of this group in the following cases: bacterial endocarditis,activation of the rheumatic process, restenosis, traumatic mitral valve insufficiency, excessive expansion of the atrioventricular orifice. If there are no contraindications, then the management of pregnancy and childbirth is carried outstvlyatsya on the principles common to all cardiac patients.

It is extremely difficult to decide on the permissibility of pregnancy in womenwith prosthetic heart valves. Despite the fact that patients with mechanicalcal prostheses constantly receive anticoagulants, they retainthe risk of developing thromboembolic complications, including thrombosisvalve. This danger increases during pregnancy due to physiological hypervolemia and hypercoagulability. Pregnancy may be permittedone year after the operation with full adaptation of the body to new conditionshemodynamics. Patients need to be closely monitored by a cardiac surgeon forthroughout pregnancy, so all 3 hospitalizationsaccording to the plan, should be carried out in a specialized obstetric hospital.Like all cardiac patients, they are given complex therapy, including anti-rheumatic, desensitizing agents, cardiac glycosy-dy, oxygen therapy, vitamins. In addition, pregnant women with mechanicalvalvular prostheses receive anticoagulant therapy. As an-ticoagulant used phenylin. AT I trimester due to a possible teratogenphenylin is replaced by heparin. For the prevention of hemorrhagicfetal complications in the fetus, phenylin is canceled for 3 weeks. before expected birthagain replacing it with heparin. Childbirth is carried out carefully, through natural childbirth.vye ways without the imposition of obstetric forceps and perineal incision. Caesarean section is performed only when heart failure occurs or according to strict obstetric indications. In the postpartum period, cardio- al and anticoagulant therapy.

Once again, it should be emphasized that the prevention of complications in the mother andyes during pregnancy and childbirth with all types of heart defects isthe following: early and accurate diagnosis of the defect, timely solution ofmillet about the possibility of maintaining pregnancy, careful observation of the therapist, cardiologist and obstetrician with planned hospitalization in a hospital during critical periods.

Pregnancy with hypertension. Among the most common forms of diseases of the cardiovascular system is hypertension, essential arterial hypertension. Arterial hypertension is observed in 5-15% of pregnant women. Of this number, late preeclampsia is detected in 70% of cases, hypertension in 15-25%, secondary hypertension associated with kidney diseases, endocrine pathology, diseases of the heart and large vessels, etc., in 2-5%.
Classification. To date, there is no single classification indications of hypertension. In our country, a classification has been adopted, according to which 3 stages of the disease are distinguished (Table 16).
According to the WHO classification, refined in recent years, it is customary to distinguish between the following degrees of arterial hypertension (Table 17).

Table 1

Classification of hypertension used in Russia

There is an increase in blood pressure, but no changes in heart rate.but-vascular system caused by arterial hypertension(no left ventricular hypertrophy according to ECG, changes ocular vessels).
There is an increase in blood pressure, combined with changescardiovascular system, due to both arterialhypertension (left ventricular hypertrophy according to ECG, angio-retinal pathology) and coronary heart disease (angina pectoris)or brain (dynamic cerebrovascular accident), but the function of the internal organs is not disturbed.

Previously elevated blood pressure may decrease due todevelopment of a heart attack or stroke. There is a significant breachheart function (heart failure), and/or brain function (stroke),and/or kidneys (chronic renal failure).

Table 17

Classification of the degree of arterial hypertension (WHO, 1999)

Clinical picture and diagnosis. Clinical manifestationshypertension during pregnancy are of the same nature as in non-pregnant women. They depend on the stage of the disease. However, it shouldimagine some decrease in blood pressure in the first half of pregnancy, characteristicfor hemodynamics of healthy pregnant women. This ability extends to in pregnant women with hypertension.

The main diagnostic difficulties that a doctor may encounter are determined by the following circumstances. Many pregnant women (especiallyyoung) are unaware of changes in blood pressure. The specialist who examines thevariable, it is difficult to assess the degree of the depressor effect of pregnancy oninitial forms of hypertension. Often developing in the third trimesterPregnancy OPG-preeclampsia makes it difficult to diagnose hypertension.

Diagnosis is helped by a carefully collected anamnesis, including family history.ny. It is necessary to establish the presence of an increase in blood pressure in the next of kin. It is necessary to establish whether there was an increase in blood pressure before pregnancy, for exampleduring medical examinations at school and at work. Information may be important

0 during previous pregnancies and childbirth. Finding out the complaints of the patient, following
attention should be paid to headaches, nosebleeds, pain in the
sti heart, etc.

Conducting an objective examination, it is necessary to measure blood pressure on both hands, repeating the measurements 5 minutes after the decrease in emotional stress in women. ECG recording, fundus examination are mandatory for this categories of pregnant women.

At I stages of hypertension, most patients do not experienceThere are significant physical limitations. They have a history ofindications of recurrent headaches, tinnitus, sleep disturbances, episodic nosebleeds. ECG shows signs of hyper-left ventricular function. There are no changes in the fundus. Functions by the check is not violated.

With hypertension II stages are marked by constant headpain, shortness of breath on exertion. This stage of the disease is characterized byare hypertensive crises. The signs of hypertrophy of thestomach. In the fundus, narrowing of the lumen of the arteries can be determinedand arterioles, moderate thickening of their walls, compression of the veins by compacted arterioles riolami. Urinalysis unchanged.

Clinical observations indicate that pregnancy with hypertension III stage practically does not occur due to the decrease female ability of women of this group to conceive.

Differential diagnosis of the initial stages of hypertensionand OPG-gestosis, as a rule, does not cause serious difficulties, since with

1 and II stages of the disease, there are no changes in the urine, there are no edema,
hypoproteinemia is not detected, there is no decrease in daily diuresis.

Treatment. Therapy of hypertension should begin with the creation ofthe patient is in a state of psycho-emotional peace and confidence in the effectiveness of the therapy and the successful outcome of the pregnancy. It is necessary topay attention to the strict implementation of the daily regimen (work, rest, sleep) and nutritionniya. Food should be easily digestible, rich in proteins and vitamins.

Drug treatment is carried out using a complex of preparationscommodities acting on various links in the pathogenesis of the disease. Applythe following antihypertensive drugs: diuretics (dichlorthiazide, spironolactone,furosemide, brinaldix); drugs that act on different levels of the symp-tic system, including a- and p-adrenergic receptors (anaprilin, clonidine, me-tildofa); vasodilators and calcium antagonists (apressin, verapamil, phenitidine); antispasmodics (dibazole, papaverine, no-shpa, eufillin).

Along with drug therapy, physiotherapy is prescribed.procedures: electrosleep sessions, inductothermy of the feet and legs, diathermymiyu perirenal region. The beneficial effect is exerted by hyperbaric sky oxygenation.

Management of pregnancy and childbirth. Hypertensive disease canmay adversely affect the course and outcome of pregnancy. The most common complication is the development of OPG-gestosis. Preeclampsia manifests itselfearly, from the 28th-32nd week, is difficult, poorly amenable to therapy, often recurs in subsequent pregnancies.

When the mother suffers from hypertension, the fetus suffers. An increase in peripheral vascular resistance against the background of vasoconstriction, sodium retention, followed byconsequently, and fluids in the interstitial spaces, increased permeability of theprecise membranes lead to dysfunction of the placenta. With hypertensivedisease, uteroplacental blood flow is significantly reduced. These changeslead to hypoxia, malnutrition and even death of the fetus. Antenatal deathfetus can also occur as a result of detachment of a normally located placentayou, which is a frequent complication of hypertension.

Childbirth with hypertension often acquires a rapid, rapidnoe course or protracted, which equally adversely affects the fetus.

To determine the management tactics of a pregnant woman suffering from hypertensiondisease, the most important are the assessment of the severity of the disease and the identificationpossible complications. For this purpose, the first hospitalization is necessary.the patient in the early stages, pregnancy (up to 12 weeks). At I stages of hypertensiondisease, pregnancy continues with regular monitoring of the therapeuticvolume and obstetrician. If installed II stage of the disease, then pregnancy cancan be maintained in the absence of concomitant disruption of activitiescardiovascular system, kidneys, etc.; III stage is indicative of termination of pregnancy.

The second hospitalization is necessary during the period of the greatest load on the heart.dechno-vascular system, i.e. at 28-32 weeks. In the antenatal departmentcareful examination of the patient and correction of the therapy. Thirdplanned hospitalization should be carried out in 2-3 weeks. to presumablychildbirth to prepare a woman for delivery.

As a rule, childbirth occurs through the natural birth canal. Wherein I the period of childbirth is carried out with adequate anesthesia with ongoingantihypertensive therapy and early amniotomy. During the period of exile, hypertensivenaya therapy is enhanced with the help of ganglionic blockers up to controllablemy hypo-, or rather, normotonia. Depending on the condition of the mother and fetus II the period is shortened by perineotomy or obstetric forceps. AT III during childbirth, preventive measures are taken toreduction of blood loss; with the last push, 1 ml of methylergometrine is injected.Throughout the birth act, preventive measures are periodically carried out. fetal hypoxia.

Prevention of complications of pregnancy and childbirth. Pro- preventive measures are reduced to regular and more frequent monitoringpregnant woman in the antenatal clinic. The patient should be managedjoint obstetrician and therapist. You should strictly adhere to the rule of threeemergency hospitalization of a pregnant woman, even with good health and effectiveeffectiveness of outpatient antihypertensive therapy. Absolutely shown hospitallysis in case of accession of late gestosis, even occurring in the lungs form.