Pregnancy and childbirth in women with diseases of the cardiovascular system. Pregnancy and the cardiovascular system. How to be

Is pregnancy possible with diseases of the cardiovascular system. It is possible, but before that it is necessary to consult a doctor, especially if you suffer from rheumatic heart disease, he must give you permission to plan a pregnancy. In cases where you feel good and you get tired, while shortness of breath and palpitations rarely occur only during physical exertion, you will not have problems with bearing and giving birth to a healthy child.

If you constantly, even when calm, have shortness of breath and it begins to increase when you quickly begin to move, do light work. It is better not to take risks with pregnancy, it is very dangerous for both you and the baby. Even termination of pregnancy in this case is a dangerous procedure.

With the development of pregnancy, a lot of stress goes on the cardiovascular system of a woman, because all systems work doubly, because a woman must provide the fetus with a full life. A pregnant woman increases her body weight, the blood also increases in volume, and the growing uterus begins to push up the diaphragm, which causes changes in the position of the heart. In the body, changes in the hormonal background begin to occur. Such changes in a woman's body greatly load the cardiovascular system, when the period begins to increase, the loads become even greater.

During labor, the cardiovascular system is very much overstrained, especially when the second period of attempts begins. Also, after childbirth, the cardiovascular system will have to endure the load. Because with the rapid emptying of the uterus, blood begins to redistribute, because of this, changes in hormones occur again.

What is the risk of cardiovascular disease for pregnant women?

Women begin to experience complications of a different nature during pregnancy, in labor and the postpartum period, here both the life of the woman and the child are endangered. It is very dangerous that the fetus lacks blood circulation for the first time of the month, especially this problem occurs in the second half and during childbirth.

Is pregnancy possible in women with rheumatism

Rheumatism is an immune-toxic disease that affects the joints and heart valves. Rheumatism appears due to B-hemolytic streptococcus, most often affects women at a young age.

During pregnancy, the rheumatic process begins to worsen. Especially for the first month then during childbirth. What complications occur in pregnant women with rheumatic fever?

1. Pregnancy is often terminated prematurely.

2. Toxicosis continues in the later lines.

3. The fetus lacks oxygen (hypoxia).

4. Uteroplacental blood flow is disturbed.

Pregnancy with heart disease

Women who have heart disease require urgent hospitalization, according to indications, be sure to three times during pregnancy:

1. At 12 weeks, a pregnant woman should undergo a complete cardiological examination in the hospital, and here the question will already be raised of leaving the child or it would be better to terminate the pregnancy.

2. At 32 weeks, a woman should undergo a heart check, if necessary, then heart therapy, because it is during this period that the greatest stress on the heart occurs.

3. The last heart check should be two weeks before the actual
childbirth in order to prepare well for them.

A pregnant woman with cardiovascular problems should remember that the whole outcome depends on her behavior, especially on her lifestyle. If a woman receives the necessary drugs that support and facilitate the work of the heart, follows the regime, listens to the recommendations of the doctor, the pregnancy will end safely and the woman will be able to give birth without problems.

What to do if pregnancy is contraindicated for a woman?

First you need to cure the defect, possibly with the help of a surgical method, often it helps a woman return to a full life. But still, such a woman is at risk, so she will need to be observed by a cardiac surgeon throughout her pregnancy.

Is pregnancy possible with hypertension

Up to 15% of pregnant women suffer from hypertension, high blood pressure. Often women do not know that they have high blood pressure. For the first months, most often it is reduced or normalized, this will complicate the task.

Hypertension is dangerous because up to 70% is complicated by toxicosis in the later lines. During childbirth, hypertensive encephalopathy may appear, with this disease a headache appears and vision is very impaired. Retinal detachment and cerebral hemorrhage are considered very dangerous complications.

How to prevent hypertension in pregnant women? Constantly and carefully observed by a doctor, weekly. If the pressure is high, urgently go to the hospital in the maternity ward.

Also, hypertension can have its own stages of development, it depends on this whether it is possible to maintain a pregnancy:

Stage 1 - pregnancy is possible, gestation and childbirth are successful.

Stage 2 - pregnancy is allowed only if the woman has not experienced hypertension crises before and both her liver and kidneys are fully functional.

2 B and 3 stage pregnancy is completely prohibited.

Pregnant women who suffer from hypertension are sent to the maternity hospital three weeks in advance, where they should be provided with both physical and emotional peace.

So, pregnancy with cardiovascular disease is possible, but here you need to be very careful. Before planning, he was definitely examined by a cardiac surgeon, if you need to undergo the necessary course of treatment. If you suddenly have a serious illness and in no case should you carry and give birth to a child, because this threatens both your health and the child, it is best to think about other ways. It's not worth the risk. It is very important for pregnant women who suffer from cardiovascular diseases to constantly control their state of health, undergo the necessary course of treatment and not forget about preventive methods.

One of the most severe extragenital pathologies in pregnant women are diseases of the cardiovascular system, and heart defects occupy the main place among them. Pregnant women with heart defects are at high risk of maternal and perinatal mortality and morbidity. This is explained by the fact that pregnancy imposes an additional burden on the cardiovascular system of women.

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

These are the complex, but in the vast majority of cases, still solvable problems that arise before the doctor, who decides whether a woman suffering from any cardiovascular disease 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 the volume of circulating blood and cardiac output can be unfavorable and even dangerous in pregnant women with diseases of the cardiovascular system, due to their layering on the already existing ones, caused by the disease.

A change in hemodynamics in the mother has a negative effect on the uteroplacental circulation, which in some cases can cause fetal malformations, including 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. The doctor needs to know the changes in hemodynamics characteristic of these periods in order to distinguish physiological from pathological changes, to provide the necessary effect on the cardiovascular system when it is necessary and not to intervene when it is not necessary.

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 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 increased blood flow to the heart, a decrease in the size of the uterus, an increase in blood viscosity the work of the heart intensifies again on the 3-4th day after childbirth. 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 sudden shutdown uteroplacental circulation, elimination of compression of the inferior vena cava immediately after the birth of the fetus, there is a rapid increase in BCC, which a diseased heart cannot always compensate for by an increase in cardiac output.

The body's oxygen consumption increases during pregnancy 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, as well as 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 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 liters, the sodium content in the body increases by 500-60 by the 10th week of pregnancy mmol, and potassium by 170 mmol, before childbirth, up to 870 mmol of sodium accumulates in the body) require increased work from the heart and often aggravate the course of cardiovascular disease.

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

With some heart defects, the risk of bacterial endocarditis increases, especially in the prenatal and postnatal periods. Changes in hemodynamics can adversely affect the course of kidney disease. In addition, cardiovascular diseases often complicate the course of pregnancy (late gestosis, premature detachment of a normally located placenta, premature birth) and childbirth (rapid delivery, discoordination of labor, increased blood loss, etc.). In severe cardiovascular diseases, perinatal infant mortality is high.

For the correct management of pregnant women with diseases of the cardiovascular system, it is necessary to assess the so-called cardiac reserve, which depends on the age of the woman, the duration of the heart disease and the functionality of the heart muscle. It is advisable to establish a cardiac reserve even before pregnancy, and then regularly evaluate it during the dynamic observation of the patient. Modern diagnostics and adequate treatment now make it possible in many cases to transfer pregnancy and childbirth to women with cardiovascular diseases.

ACQUIRED HEART DEFECTS

Acquired rheumatic heart disease accounts for 75% to 90% of cardiac lesions in pregnant women.

The most common form of rheumatic heart disease is mitral stenosis"pure" or predominant, when combined with mitral valve insufficiency. This defect is found in 75-90% of pregnant women suffering from acquired heart defects.

The second most common defect (6-7%) is mitral valve insufficiency. As a rule, with this defect, in the absence of severe regurgitation, cardiac arrhythmias and circulatory failure, pregnancy does not noticeably worsen the course of heart disease.

Aortic valve insufficiency . These defects (aortic) are less common (0.75-5%), but the risk of developing acute heart failure in pregnant women is quite high. Quite often, aortic defects are combined with lesions of other valves (mitral).

aortic stenosis . Aortic stenosis can be valvular (due to fusion of the valve leaflets), subvalvular (due to fibrous narrowing below the valve or severe left ventricular outflow tract hypertrophy) and supravalvular.

Tricuspid valve insufficiency usually has a rheumatic 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 very rare clinically. Most often combined with lesions of other heart valves.

Multivalvular rheumatic heart disease occur quite frequently. 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 AND MAJOR VASCULAR DEFECTS IN PREGNANT WOMEN

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.

Let's consider the main ones:

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 tetrad, pregnancy poses both a risk to the mother and to the 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" vices. 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.

METHODS FOR STUDYING THE CARDIOVASCULAR SYSTEM IN PREGNANT WOMEN

Anamnesis - may contain important information about the time of occurrence of rheumatism, the duration of the existence of a heart defect, the number of rheumatic attacks suffered, circulatory disorders, etc.

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

Vectorcardiography - Identification of signs of hypertrophy of the heart.

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

Radionuclide research methods - should not be used during pregnancy.

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

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

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

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

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

Blood studies.

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

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

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

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

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

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

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

Aortic valve insufficiency is a direct contraindication.

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

Patients after heart surgery are treated differently.

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

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

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

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

If there are signs of circulatory failure, exacerbation of rheumatism, the occurrence of atrial fibrillation, late gestosis of pregnant women or severe anemia, the patient must be hospitalized regardless of the duration of pregnancy.

The issue of terminating a pregnancy at a later date is quite complicated. Not infrequently, a problem arises, which is less dangerous for the patient: to terminate the pregnancy or to develop it further. In any case, if signs of circulatory failure or any intercurrent diseases appear, the patient should be hospitalized, subjected to a thorough examination, treatment. With the ineffectiveness of treatment, the presence of contraindications to surgical intervention on the heart, a decision is made to terminate the pregnancy. Pregnancies beyond 26 weeks should be terminated by abdominal caesarean section.

Until now, many physicians believed that delivery at term by caesarean section reduces the burden on the cardiovascular system and reduces the mortality of pregnant women suffering from heart defects. However, many authors recommend that, in severe degrees of heart defects, delivery by caesarean section should be performed, but not as a last resort for protracted births through the natural birth canal, complicated by cardiac decompensation, but as a timely preventive measure.

Recently expanded somewhat indications for caesarean section in patients with cardiovascular diseases. These include the following:

circulatory failure II-B - III stage;

Rheumocarditis 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.

VASCULAR DYSTONIA IN PREGNANT WOMEN

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

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

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

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

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

PREGNANCY AND CHILD IN HYPOTENSION

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

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

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

PREGNANCY AND BIRTH WITH HYPERTENSION

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

According to A.L. Myasnikov (1965) distinguish three stages of the disease with an additional division of them into phases A and B.

Stage I

A - characterized by an increase in blood pressure during psychological stress.

B - transient hypertension: blood pressure rises for a while and under certain conditions.

Stage II

A - characterized by persistent, but not stable hypertension.

B - characterized by a significant and persistent increase in blood pressure. There are hypertensive crises. Note signs of angina pectoris. Detect changes in the fundus.

Stage III - sclerotic, along with a persistent and significant increase in blood pressure, sclerotic changes in organs and tissues are observed.

A is compensated.

B - decompensated, noted violations of the functions of organs, the development of heart and kidney failure, cerebrovascular accident, hypertensive retinopathy.

The clinical picture of hypertension during pregnancy is not much different from hypertension in non-pregnant women and depends on the stage of the disease. The complexity of diagnosis lies in the fact that many pregnant women, especially young ones, are unaware of changes in blood pressure. It can be very difficult to assess the degree of depressor effect of pregnancy on the initial forms of hypertension. In addition, often developing preeclampsia in the second half of pregnancy makes it difficult to diagnose hypertension.

Properly collected anamnesis, including family history, helps in the diagnosis of hypertension. You should pay attention to the data of medical examinations at school, at work. If a pregnant woman has repeated births, find out the course of the previous ones. When analyzing patient complaints, attention should be paid to headaches, nosebleeds, pain in the heart area, etc.

An objective examination includes a mandatory measurement of blood pressure in both arms, an ECG, and an examination of the fundus.

At I stage hypertensive patients note recurrent headaches, tinnitus, sleep disturbance, rare nosebleeds. The ECG usually shows signs of hyperfunction of the left ventricle, the fundus is not changed.

At stage II headaches are permanent, shortness of breath on exertion. There are hypertensive crises. On the ECG, there are pronounced signs of left ventricular hypertrophy, changes in the fundus.

III stage hypertension is extremely rare, as women in this group have a reduced ability to conceive.

In differential diagnosis with preeclampsia of the second half of pregnancy, it should be remembered that in stages I and II of hypertension, as a rule, there are no changes in the urine, there are no edema, a decrease in daily diuresis, and hypoproteinemia.

MANAGEMENT OF PREGNANCY AND DELIVERY

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

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

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

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

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

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

TREATMENT

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 a and b -adrenergic receptors (anaprilin, clonidine, methyldopa); vasodilators and calcium antagonists (apressin, verapamil, fenitidine); antispasmodics (dibazole, papaverine, no-shpa, eufillin).

Physiotherapy procedures include electrosleep, inductothermy of the feet and legs, diathermy of the perirenal region. Hyperbaric oxygen therapy has a great effect.

Micromorphometric studies of the placenta revealed changes in the ratio of the structural elements of the placenta. The area of ​​the intervillous space, stroma, capillaries, vascular index decrease, the area of ​​the epithelium increases.

Histological examination noted focal angiomatosis, widespread dystrophic process in syncytium and trophoblast, focal plethora of the microvasculature; in most cases, a lot of "glued" sclerotic villi, fibrosis and edema of the stroma of the villi.

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

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

PREVENTION

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

ANEMIA IN PREGNANT WOMEN

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

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

ETIOLOGY AND PATHOGENESIS

Anemia in pregnant women is the result of many reasons, including those caused by pregnancy: high levels of estrogen, early toxicosis, which prevent the absorption of iron, magnesium, and phosphorus elements in the gastrointestinal tract, which are necessary for hematopoiesis.

For the development of anemic conditions during pregnancy, frequent childbirth with a long lactation period, which depletes the reserves of iron and other anti-anemic substances in the body of women, is of particular importance. Anemia has been noted in rheumatism, diabetes mellitus, gastritis, kidney disease and infectious diseases. The daily iron requirement is 800 mg (300 mg per fetus). With insufficient intake of iron in the body or insufficient absorption due to protein deficiency, a pregnant woman develops iron deficiency anemia, Hb is below 110 g / l. Megaloblastic anemia is associated with a lack of folate. One of the reasons for the development of anemia in pregnant women is considered to be a progressive iron deficiency, which is associated with the utilization of iron for the needs of the fetoplacental complex, to increase the mass of circulating red blood cells. Most women of childbearing age have an insufficient supply of iron, and this supply decreases with each subsequent birth, especially complicated by bleeding and the development of posthemorrhagic (iron deficiency) anemia. The lack of iron in a woman's body may be due to its insufficient content in a normal diet, with the way food is processed and the loss of vitamins necessary for its absorption (folic acid, vitamins B 12, B 6 , FROM); with the lack in the diet of a sufficient amount of raw vegetables and fruits, animal proteins. All of these factors can be combined with each other and lead to the development of true iron deficiency anemia in pregnant women. As you know, anemia in pregnant women is often combined with both obstetric and extragenital pathology.

DIAGNOSTICS

Assessment of disease severity, hematocrit level, plasma iron concentration, iron-binding capacity of transferrin and transferrin iron saturation index. As the disease develops, the concentration of iron in the blood plasma decreases, and the iron-binding ability increases, as a result, the percentage of transferrin saturation with iron decreases to 15% or less (normally 35-50%). The hematocrit index decreases to 0.3 or less.

Iron reserves are judged by the level of ferritin in the blood serum using the radioimmune method. In addition, they conduct other biochemical studies of blood parameters, examine the function of the liver, kidneys, and gastrointestinal tract. It is necessary to exclude the presence of specific infectious diseases, tumors of various localization.

COURSE AND MANAGEMENT OF PREGNANCY AND CHILD IN ANEMIA

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

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

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

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

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

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

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

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

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

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

Ascorbic acid 0.5 g 3 times a day;

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

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

Methylxanthines - pentoxifylline 7 mg/kg;

Bioantioxidant - Essentiale at 0.5 mg / kg.

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

Congenital megaloblastic anemias are dangerous because they have high maternal and child perinatal morbidity and mortality.
selection of women according to the risk of developing this pathology, classes on FPPP before childbirth, prenatal hospitalization.

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"

the city of Krasnoturinsk

Zabolotskaya Natalya Alexandrovna

Supervisor:

MD Anatoly Ivanovich Koryakov

Ekaterinburg

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 the atypical clinical picture, difficulties in determining biochemical markers, using other diagnostic methods, and also due to 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 cesarean 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. In 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 whom 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.

A 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 heart area 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 the recognition of 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 increase during normal pregnancy, as well as in 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 drug 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 restriction of 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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Unfortunately, heart disease occupies one of the first places among all diseases that are observed in women during pregnancy. Therefore, physicians of such a pathology have long paid increased attention, this is due to the fact that the state of pregnancy very often significantly worsens the health of the expectant mother. Often, all this leads to very serious complications that are extremely dangerous for both the expectant mother and the unborn child. Therefore, pregnancy in women and cardiovascular diseases are very often nearby. Therefore, if there are signs of cardiovascular insufficiency in women, you should not panic, but medical attention is urgently needed.

Today, situations are not uncommon when the issue of maintaining pregnancy is resolved with both a cardiologist and a gynecologist not at an early stage of pregnancy, but even during its planning. And this is absolutely the right approach, since you can’t joke with it. No wonder the year of the fight against cardiovascular diseases in Russia was announced. It is very important how competently diagnostics of diseases of the cardiovascular system is carried out in women.

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

1. Gestosis, which pass in a severe course.
2. Fetoplacental insufficiency.
3. Chronic fetal hypoxia.
4. The death of the fetus inside the womb.
5. The pregnancy is terminated prematurely.

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

During pregnancy, the most common diseases are:

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

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

• various means against arrhythmia. Each remedy must be selected individually;
• cardiac glycosides;
• drugs that have a diuretic effect;
• antiplatelet agents.

The doctor can also prescribe a diet, diet therapy in this condition is very important, you should say this more than once! However, not all diets are the same.

Management of pregnancy in women with heart disease

One of the most important factors in a pregnant woman with heart disease is that, whenever possible, the child should be kept. However, circumstances are not uncommon when the state of pregnancy has to be interrupted. Here are the main ones:

• Development of the aortic valve is insufficient.
• The heart is greatly enlarged, there is marked myocardial insufficiency and aortic valve stenosis.
• The rheumatic process functions with rhythm disturbances, blood circulation is insufficient.
• Heart after surgery
• Chronic processes in an acute form or a rheumatic process (also in an acute form).
• The presence of cardiomyopathy (if there is a severe form of the course).
• The presence of myocarditis (if there is a severe form of the course).
• Heart defects, if they are present together with atrial fibrillation.
• The interventricular septum has pronounced defects.

To summarize all of the above, the decision to terminate the pregnancy or abandon the child should be decided on the basis of how the existing defects are expressed, how the blood circulation is disturbed and how active the rheumatic process is. Timely laboratory diagnosis of a person who suffers from cardiovascular disease is very important.

Principles of pregnancy management (how everything should be carried out)

• the entire treatment process should be carried out jointly by a gynecologist, a cardiac surgeon and a therapist. All these specialists should be mandatory, as various urgent conditions may arise in diseases of the cardiovascular system;
• the heart should be examined on a regular basis, since there is a risk of various cardiovascular diseases, even if there were no signs of the disease very recently. Signs of various cardiovascular diseases may not always be obvious;
• depending on the type of disease, appropriate medications are prescribed, which should be taken strictly according to the instructions;
• it is imperative to do an ultrasound scan of the unborn child on a regular basis, cardiotography is also necessary;
• while the question of whether to leave the child or not is being decided, planned hospitalization is shown, which usually lasts 3 months. If we are talking about preventive treatment, then hospitalization should last up to 8 months! If the issue of the method of childbirth is resolved, the hospitalization process must last more than 8 months. The following is very important: the methods of delivery should always be purely individual, everything is directly dependent on what disease the woman suffers from, what her state of health is, how severe the treatment of the disease is (when collecting the consultation, there must be an anesthesiologist-resuscitator).

How to conduct childbirth with heart disease

You need to have a caesarean section if:

• heart diseases are observed jointly with various obstetric pathologies, their manifestations may be different;
• there are aortic valve defects, this symptom is very common;
• circulatory rhythms are disturbed;
• there is atrial fibrillation (if it is observed in severe form) /

If no of the above contraindications are observed in the expectant mother, then we can talk about self-permission of childbirth using the natural birth canal. The risk of cardiovascular diseases in women in childbirth is not so great if you carefully monitor your health from an early age, a common truth, but it should be mentioned. You should also pay attention to medical nutrition, this is also very important. So nutrition for heart diseases should not include very salty and spicy foods, this is very important not only for the health of the expectant mother, but also for the normal development of the fetus.

How to conduct natural childbirth (features of the process)

• a woman must necessarily be on her left side. In no case should you be on your back, it is extremely dangerous and can lead to the most negative consequences;
• during childbirth, it is imperative to carry out an anesthetic process (anesthesia should be prescribed taking into account the state of health of the woman in labor);
• the second stage of labor should be reduced, and this is done through the so-called "off labor". In this case, a dissection of the perineum is carried out (this is done so that the child is born faster). If we are talking about severe cases, then there is the use of special obstetric forceps;
• a cardiologist and an anesthesiologist-resuscitator should monitor the woman in labor at the same time;
• the cardiovascular system of the woman in labor must necessarily be under the close supervision of specialists, the condition of the fetus must also be constantly monitored;
• hyperbaric oxygen therapy is a very favorable area for childbirth in such conditions.

Conclusion

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

Pregnancy at all stages of its development has the peculiarity of worsening the course of cc, this is fraught with the most extreme conditions. Nobody wants to scare anyone, but deaths among the fair sex, who are preparing to become a mother with heart disease, unfortunately, are far from rare. The risk of cardiovascular diseases in women does not always depend on age, problems with blood vessels can occur for a variety of reasons. For example, failure of the cardiac outlet is common.

It depends on the so-called physiological plethora of pregnant women, when the total blood mass rises to 21% of the presence of additional uteroplacental circulation, high diaphragm standing in the last months of pregnancy and the resulting restriction of lung excursions, heart displacement. The cardiovascular system during childbirth is in a state of great tension, especially in the period of exile. Increased demands are placed on her in the afterbirth period and soon after the end of childbirth (early postpartum period), when, due to the relatively rapid emptying of the uterus, the pressure in the abdominal cavity drops sharply.

With a well-pronounced regulatory ability of the body, observed in a healthy pregnant woman, all this does not have a noticeable negative effect on the course of pregnancy, childbirth, unless there are other complicating circumstances.

The situation is different if the regulatory ability of the pregnant woman's body is insufficient, and especially if this deficiency is combined with organic changes in the cardiovascular system. The most dangerous of the complications is circulatory failure. It can occur in the first months of pregnancy, but is more often observed in the second half of it. This complication occurs especially easily in the period of exile with instability of cardiac compensation, if this period lasts more than an hour or, conversely, if it is very short (several minutes), but too energetic. Overstrain of the nervous and muscular systems, which in such cases reaches high degrees, in combination with a sudden violation of hemodynamics, adversely affects the work of the heart. Patients with myoendocarditis of rheumatic etiology are most prone to decompensation for the indicated reasons.

Compensation of the cardiovascular system can also be disturbed due to bleeding, which relatively often complicates childbirth, especially in the afterbirth and early postpartum period. In case of failure of the cardiovascular system and, which is especially important, when the body's forces are exhausted (painfulness of the birth process, fatigue of the woman in labor during prolonged labor, etc.), even a small blood loss, for example, 300 ml, can cause an acute violation of cardiovascular compensation .

Of the various forms of diseases of the cardiovascular system, the least dangerous during pregnancy is steadfastly compensated mitral valve insufficiency. With this pathology, there is rarely a violation of cardiovascular compensation during childbirth and in the postpartum period, unless during the entire pregnancy the compensation was not violated and childbirth was not complicated by a narrow pelvis, nephropathy, placenta previa, polyhydramnios, multiple pregnancy, incorrect position of the fetus, incorrect insertion of the head in the pelvis, hypertension, etc. In the presence of at least one of these complications, circulatory failure may occur with all the ensuing consequences.

Pregnant women with mitral disease, with a predominance of mitral valve stenosis, require special attention. In such cases, long-term and dangerous circulatory disorders are observed in almost half of pregnant women.

In case of detection of a disease of the cardiovascular system, active medical supervision should be established for the pregnant woman. In the presence of one of the diseases of the cardiovascular system dangerous to health, it is necessary to establish the presence of indications for artificial termination of pregnancy already in the early stages of pregnancy. These indications include: endocarditis, anatomical lesions of the heart valves, damage to the muscles of the heart and pericardium with initial symptoms of circulatory failure, mitral stenosis (decompensated, subcompensated, compensated), syphilitic mesaortitis. An artificial miscarriage is also indicated if a pregnant woman has hypertension and persistent hypertension of pregnant women (toxicosis) that cannot be treated in a hospital.

Termination of pregnancy in terms of more than 12 weeks is permissible only in case of circulatory failure, which is not eliminated in a hospital.

If a woman persistently wants to keep her pregnancy, despite her indications for an induced miscarriage, she should be admitted to a hospital for a comprehensive examination of the functional state of the cardiovascular system and a final decision regarding the possibility of further continuation of the pregnancy. In this case, all diagnostic methods should be used, if possible, including fluoroscopy, radiography, X-ray kymography, electrocardiography, etc.

Pregnant women with signs of circulatory failure should be immediately admitted to the hospital. Here they are examined in detail, a course of treatment is carried out according to the principles set forth in the course of therapy. They can be discharged from the hospital only after the restoration of stable compensation. In case of repeated occurrence of circulatory failure, pregnant women should remain in the hospital until delivery.

Conducting childbirth in patients with cardiovascular diseases is a very responsible business. They must be carried out with anesthesia; during childbirth, the doctor must constantly monitor the condition of the woman in labor and widely use cardiac agents, glucose, and oxygen.

Following the birth of a child, in order to prevent collapse, which can occur due to a sharp decrease in intra-abdominal pressure and hemodynamic disturbances, a sandbag should be placed on the mother's stomach.

In parturient women with a predominance of stenosis of the left atrioventricular orifice, who had decompensated cardiac activity during the previous birth, the opening period is expected, using cardiac agents, while in the period of exile, operative delivery is indicated (usually forceps are applied).

In case of a very severe condition of the patient at the end of pregnancy or at the beginning of childbirth with symptoms of acute circulatory failure or insufficiency that could not be eliminated, despite treatment in a hospital, in exceptional cases, a caesarean section can be performed under local anesthesia "as a delivery operation. It should not be forgotten that delivery by caesarean section is a dangerous intervention in case of heart disease, which can worsen the already serious condition of the patient.

In the subsequent and early postpartum period, it is necessary to strictly monitor the amount of blood lost and the general condition of the woman, since in such patients blood loss even up to 300 ml can lead to circulatory disorders. The follow-up period must be carried out strictly expectantly. With a blood loss of more than 300 ml, it is advisable to transfuse 200 ml of one-group blood by the drip method, prescribe oxygen, glucose under the skin (500 ml of a 5% solution) and heart funds .. In the postpartum period, especially in the case of surgery, preventive measures should be taken to prevent postpartum infections (penicillin, sulfa drugs, etc.).

All pregnant women, women in childbirth and puerperas who have diseases of the cardiovascular system, due to the weakening of the body, are extremely susceptible to various kinds of infections. Diseases such as influenza, tonsillitis and postpartum septic infection often complicate the course of pregnancy, childbirth, and the postpartum period. Often, the causative agents of a general infection are microbes that grow on the heart valves with various kinds of endocarditis of septic or rheumatic origin. Therefore, pregnant women with heart lesions should be taken into special account even in the antenatal clinic. Here, they are placed under special supervision and, through sanitary and educational propaganda, they are taught the correct scientifically based behavior in order to prevent possible complications.

Among the most serious complications, depending on the state of the cardiovascular system, one should also include the sudden death of a woman in labor or puerperium, in particular from an embolism.