Forms of heart and pregnancy, clinical recommendations. Features of the future mothers in women's consultation. Methods for monitoring the state of the mother and fetus during pregnancy

The content of the article

Assessing the state pregnant women with heart defects, as well as solving questions about the possibility of pregnaning pregnancy, conducting and treating such a woman, choosing the method of roostening, should be taken into account: the activity of the rheumatic process, the nature of the heart damage (the form of heart defect, its localization, degree of structural changes and their severity), deficiency stage Circulatory, the functional state of the cardiovascular system and primarily myocardial, the state of other organs and systems related to diseases and obstetric situation.

Activity of the rheumatic process

The situation is currently the provision that pregnancy and childbirth is very adversely affecting the active rheumatic process and therefore the presence of it threatens with severe consequences for women's health. Most women with heart defects died in childbirth or after childbirth, the current endomiocarditis is revealed to the section. It leads to acute cardiovascular insufficiency (emana) or chronic progressive, often irreversible decompensation, the development of heavy thromboembolic complications with multiple lung infarction, liver, spleen, brain. With the active phase of rheumatism, the frequency of complications of pregnancy and childbirth increases, fruit and newborn suffer significantly.
For rheumatic carditis, shortness of breath, heartbeat, cardialigia, temperature increase, increasing the size of the heart, the presence of pericarditis, rhythm disruption, the muffling of the tops, systolic noise increasing in the dynamics, appearance or increasing circulatory failure, accelerated EE, neutrophilic leukocytosis, hypochromic anemia , decrease in blood pressure.
The diagnosis of rheumatic carditis in pregnant women is associated with certain difficulties, which is caused by two reasons:
1) in the overwhelming majority of pregnant women, the aggravation of the rheumatic process proceeds as a sluggish current endomyocarditis, acquiring the character of erase and atypical forms;
2) Subfebrile temperature, tachycardia, cardialigia, shortness of breath, a change in auscultivation and percussion data and other signs that are based on the diagnosis of endomyocarditis and the therapeutic clinic are often noted in healthy pregnant women. These changes are caused by those shifts and complex neurohumoral, hormonal, allergic and mechanical factors that take place at normal pregnancy.
It is also necessary to consider that the interpretation of the resulting auscultative data from the heart is complex due to the fact that they change significantly during pregnancy. On the one hand, the typical melody of the valve heart rate of the heart often disappears and the typical melody, which had a pregnancy and again appearing after some time after the reason. On the other hand, during pregnancy, many women, as mentioned above, additional sound phenomena appear (first of all noise and changing the nature of the tops), which, simulating various heart disease, can cause serious errors.
In the clarification of the diagnosis, it is greatly important with the correct anamnesis, taking into account all the diseases transferred in the past in the past, mainly angina, and various manifestations of rheumatism.
Certain diagnostic importance acquires "rheumatic" anamnesis - reducing the present disease with a previous streptococcal nasophal infection, instructions for family rheumatism. Leukocytes, exceeding 12,000, shift of the leukocyte formula to the left, progressive anemia, EE 35-40 mm in 1 hour, along with other signs, indicate the exacerbation of rheumatism. Waldman's jammed sample (determining the content of the number of monocytes in the blood, taken from the finger, until the treatment bank is made after it) facilitates the recognition of rheumatic endocardits. In the presence of endotheliosis, the number of monocytes in the blood after the removal of the jar increases more than 2 times. The diagnosis of the active phase of rheumatism in pregnant women facilitate auxiliary research methods.
Methods of non-specific immunobacteric and biochemical diagnosis of the rheumatic process are especially important in the diagnosis of the active rheumatic process.
Electrocardiography Also greatly facilitates the assessment of the lesion of the muscles of the heart in the active phase of rheumatism in pregnant women. The most important, often the first sign of rheumatic carditis is a violation of atreservantic conductivity. The elongation of the PQ interval (0.22-0.25 C against 0.12-0.18 C in healthy) is an important differential diagnostic symptom indicating an active rheumatic process.
Extrasystolia is also one of the characteristic signs of rheumatic carditis. However, it should be remembered for the possibility of the emergence of extrasystole and in healthy pregnant women as a result of complex neuro-humoral and hormonal shifts in the body.
None of the methods of research (laboratory or instrumental) separately does not give absolute, strictly specific to the diagnosis of the active rheumatic data process. Therefore, a comprehensive survey, taking into account the data of the clinic and a complex of laboratory, biochemical, immunological methods, is of particular importance. By setting the presence of the active phase of the disease, the degree of activity and the nature of the flow of rheumatism should be determined. According to the classification proposed by A. I. Nesterov, there are three degrees of activity of the process: I - minimal activity, II - moderately pronounced, III - maximum, explicitly or pronounced activity. There are also 5 options for rheumatism: rational, prime, protracted or sluggish, continuously recurrent, latent. If, on the basis of these comprehensive surveys, it can be assumed to exist an exacerbation of endomyocarditis or a sluggish current process, pregnancy should be interrupted in early terms (up to 12 weeks). Moreover, given that after the disappearance of clinical manifestations, the rheumatic process in the heart lasts another 7-8 months, it should be assumed that pregnancy is contraindicated and in cases where active endomiocarditis took place in about a year before the start of real pregnancy. If the active rheumatic process has been identified in a later date (after 12 pregnancy pedigree), it is necessary to urgently proceed to treat such a pregnant woman, embrying the entire arsenal of the means of complex antipers.

Character valve heart rate

Akuster-gynecologist In his practical activity, most often you have to observe the following valve flaps of the heart.
Acquired heart defects (rheumatic etiology):
1) deficiency of the mitral valve;
2) the narrowing of the left venous opening (mitral stenosis);
3) combined (combined) mitral heart rate: stenosis of the left atrio-ventricular opening and deficiency of the mitral valve (mitral disease);
4) Aortic heart defects: Aortic valve deficiency, aortic stenosis or combination thereof;
5) Different complex and combined vices. The isolated deficiency of the trilateral valve is extremely rare, as a complication of the damages of the left heart. Accession it significantly changes hemodynamics and worsens the forecast.
Congenital heart defects and abnormalities of heart development and large vessels:
1) the incoming of the Botallian duct;
2) insulated stenosis of the pulmonary artery;
3) the defect of the interprisened partition;
4) the interventricular septum defect (Tolochinov's disease - Roger);
5) Stenosis The Aorta isthmus (coarctation of aorta).
Single cases of pregnancy and childbirth are described with the Eisenmenger complex and tetrade Fallo other congenital heart defects and especially vices with primary cyanosis in pregnant women are practically found.
Obstechem increasingly have to observe pregnant women who have experienced the heart surgery, most often - mitral commissurotomy, aortal or tricuspid valvulotomy (operation on 2 or 3 valves) and recently - valve prosthetics.
In terms of the frequency among heart defects, the first place occupies the lack of a mitral valve, the second - combined (combined) mitral defects of the heart. Congenital heart defects are much less common. If there is only insufficiency of the mitral valve, decompensation occurs relatively rarely, pregnancy and childbirth, as a rule, proceed without complications and do not worsen the state of the patient. On the contrary, the narrowing of the left atri-ventricular hole, that is, mitral stenosis in the "pure" form or in combination with mitral insufficiency, more often than other vices are complicated during pregnancy circulatory disorders. This is due to the fact that compensation for this vice, as is known, is carried out by the weak muscles of the left atrium, which very quickly leads to an increase in pressure in a small circle of blood circulation, followed by a stagnation in it. Often develops pulmonary swelling. Frequent complications are hemoptal, flickering arrhythmia, embolism in various vessels with the formation of heart attacks (kidneys, spleen, lungs), blockage of the brain arteries with the development of hemiplegia, etc. This heart disease in pregnant women is the most common cause of death.
With aortic vices, compensation is carried out due to the powerful muscles of the left ventricle. Therefore, most pregnant women are not violated and decompensation, as a rule, does not develop. The latter takes place in cases where a pronounced diastolic expansion of the left ventricle is poured. With a combination of aortic and mitral heart defects, the forecast is very unfavorable.
The effect of pregnancy on the condition of women with congenital heart defects is primarily determined primarily by the character of the vice, the mechanism of compensation with it, the functional abilities of the muscles of the heart and weathered endocarditis.
If the lumen (diameter) and the length of the open arterial duct are small, as with a small narrowing of the pulmonary artery, in cases of lack of pulmonary hypertension and endocarditis, pregnancy and childbirth proceed favorably. With an isolated small defect of the interpresentrial or interventricular partition, when there are no symptoms of reverse discharge of venous blood, destroying failure and pulmonary hypertension, most patients have a safe tolerance of pregnancy. With severe congenital defects, pregnancy interruption or surgical correction of vice is shown.
In patients with coarctation of aortic (II-III degrees, accompanied by high arterial hypertension) during pregnancy and especially in childbirth, serious complications may sometimes be observed (the aorta breaks over the location, hemorrhage in the brain).
Due to the fact that the maintenance of pregnancy and childbirth in women with heart disease is largely determined by the character of heart damage, it is necessary to determine in each case to determine the form of heart defect and its severity.

Basic diagnostic signs of acquired vices

Mitral valve failure. The heart push is shifted to the left, spilled, the boundaries of cardiac stupidity are increased to the left, and to a lesser extent upward, later right. I ton on the top weakened; Systolic noise at the top, carried out up and left, distinguished by consistency, emphasis II top on the pulmonary artery. X-ray heart increased due to the left atrium and the left (and later and right) ventricle (talnium smoothed). The maximum blood pressure is normal or slightly increased, the minimum is increased. Electrocardiographically - at the beginning of the left, with the further development of the disease - the legal line.
The narrowing of the left atrio-ventricular hole.
Cardiac push is weakened. Presysteming jitter over the top of the heart ("Cat purring"), an increase in the boundaries of cardiac dullness up, and later to the right. It is characterized by auscultative pattern - I tone clapping, diastolic noise with presetolytic amp (or two noise - protodiastolic and presets), splitting of the second tone on the top, accent and split 11 tones on the pulmonary artery. The pulse of small filling, on the left hand is often weaker than on the right. X-ray - mitral heart configuration, that is, as a result of a sharp increase in the left atrium and the right ventricle, the smoothness of the waist of the heart shadow and the narrowing of the repalarding space is noted. Electrocardiographically - increasing and splitting of teeth P (P-Mitrale), Program (Low R and Deep S Deep I Decomposition and High R and Minor S in III Decommission). Dyspnea, cyanosis, stagnant wheezing in the lungs, often hemoptia, congestive enlarged painful liver, etc. appear very early.
Combined (combined) mitral heart disease.
The clinical picture depends on the severity of one or another form of damage to the bivalve valve, that is, the predominance of the lack of mitral valve or the stenosis of the left atrioventricular hole. Cleaning arrhythmia, cyanosis, a significant shortness of breath speak of a predominance in the clinical picture of the sensore-ventricular hole over the valve deficiency.
Insufficiency of the aortic valves.
Pallor of skin, pulsation Carotid, subclavian artery. A strengthened "domed" top push. Fast and high pulse (Pulsus Celer et altus). Maximum blood pressure is increased, minimal - lower (often almost to zero). The heart bounds are shifted to the left and inspe. Auxual-diastolic noise on aorta, weakened I and II tops on Aorta. Peculiar sound phenomena over peripheral vessels (double tone of the traube, double noise Drozier). X-ray - aortic heart configuration. Electrocardiographically - a pronounced leveogram (high Ri and deep ZS with low RM).
Stenosis of aortic.
The top push is shifted to the left and sharply strengthened. Systolic jitter in the ascending aorta area. Pulse - Small and slow (Pulsus Parvus et Tardus). Complete discrepancy between the enhanced topshaft and small pulse. Blood pressure is somewhat low. Increasing the boundaries of cardiac dullness to the left and down. Auscultative - systolic noise on the aorta, which is well carried out by blood flow. Weakening I and almost complete absence of second tones on aorta. The ECG is expressed leftogram.
Due to the large variability of the auscultative data, pregnant women are quite often difficult to solve the question of the nature of the defect of the heart and fraud. Facilitates this problem method of phonocardiography. Phonocardiography allows you to explore the length and location of the tones and noise, their relationship and place in the heart cycle, as well as to identify the sound phenomena poorly determined by the ear. This method acquires particular importance to the differentiation of individual valve defects, in particular the stenosis of the mitral opening and valve deficiency.
Phonocardiography not only helps to distinguish organic noises from functional, due to pregnancy, identify the nature of the vice, and allows you to determine the severity of it. For example, according to most authors at the R (q) interval of ECG - I Top FKG more than 0.08 with the area of \u200b\u200bthe mitral hole does not exceed 1 cm. Great features are phonocardiography in the diagnosis of congenital heart defects in pregnant women. Auscultatively in pregnant women with congenital heart disease is difficult to differentiate noise, and they can only decipher the character with phonocardiography. Consequently, phonocardiography in the obstetric clinic belongs to an important role: it allows you to clarify the diagnosis, correctly interpret the auscultative data, which is extremely important in solving a number of issues of diagnosis and treatment of heart disease in pregnant women; She is harmless and easy.

Insufficiency of blood circulation in pregnant women with heart disease

In accordance with the classification proposed by N. D. Strazhestko and V. X. Vasilenko, distinguish three stages of blood circulation.
In the first stage, blood circulation deficiency is manifested only with light fatigue, shortness of breath, heartbeat during or after work, with any intoxication or infectious disease. Usually, these disorders are quickly passing, although, for example, the pulse is leveled slower than usual.
In the second stage, the circulatory disorder occurs with the easiest job and even at rest, and it is often durable. In this stage, the functions of many organs, hemodynamics and metabolism can be installed. Heart expansion due to miogenic dilatation, congestive phenomena in the lungs, an increased stagnant liver, swelling, an increase in venous pressure and other objective data that can be expressed to varying degrees characterize this stage of blood circulation deficiency. Patients with this stage of cardiovascular failure are divided into two groups: II A and II B.
Group II A treats patients who have tachycardia and moderate shortness of breath expressed even at rest. There are edema extremities, small cyanosis, moderate increase in the liver, but there are still no phenomena of deep hemodynamic disruption in the entire vascular system.
In patients with insufficiency of blood circulation II B all listed phenomena are expressed more dramatically: significant shortness of breath and cyanosis, tachycardia, stagnant phenomena in the internal organs - lungs (cough, shortness of breath, hemoptal, the presence of wheezes), liver (increase and pain), gastrointestinal tract (Dispotic phenomena), nights (proteinuria), accumulation of fluid in serous cavities (ascites, hydrotorax), general anasarka. Eknesses in heart patients arise as a result of the difficulties of blood outflow and lymph, stagnant phenomena, sodium chloride delays in tissues.
It should, however, remember that both healthy women in the second half of pregnancy may have swelling. On the other hand, it should be borne in mind that the delay of even significant amounts of liquid in the body (up to 5 l) due to the blood circulation board, a relatively long time can remain unnoticed. Therefore, the systematic weighing and measuring daily diurea in pregnant women with diseases of the cardiovascular system is of great importance.
Finally, the third, the final stage of blood circulation deficiency is characterized by all the described phenomena are expressed to the maximum extent and indicate sharp irreversible changes and the development of dystrophic processes not only in the heart, but also in other organs and tissues. Deeply broken metabolism, function and morphological structure of all organs. This stage of circulatory disorders N. D. Strazhessko calls terminal, dystrophic, or cached.
Blood impairment may occur with any form of damage to the valve apparatus of the heart, endocardium or myocardium. Most often it develops in the presence of a stenosis of the left venous hole ("clean" or in combination with deficiency of the mitral valve).
In the light of modern ideas, the main cause of heart failure is rheumatic endomiocarditis. Decompensation in pregnant women with a heart disease is developing most often in the second half of pregnancy between the 28th and 32nd weeks, when the hemodynamic conditions are greater severe. Insufficiency of blood circulation in most cases during pregnancy develops gradually and for a long time. It is extremely important not to view the signs of the starting disorder of blood circulation. Of course, the previously detected symptoms of circulatory disorders, the easier and more successful to the fight against it.

Functional state of myocardium

The outcome of pregnancy and childbirth in women with heart disease is largely determined by the state of the heart muscle. It is therefore important, therefore, but only evaluate the functional state of myocardials at the nerve of pregnant, but also to determine what it will be by the end of pregnancy, to childbirth.
The definition of the functional state of myocardium in pregnant women suffering from rheumatism represents well-known difficulties. The appearance of "heart" complaints and signs of circulatory disorder (shortness of breath, heartbeat, swelling, the expansion of the dishes of the heart, etc.) is in some cases not an expression of the weakness of myocardium or its functional inferiority, but by the manifestation of those complex neuro-humoral, hormonal and mechanical factors (high Standing diaphragms), which take place during pregnancy and in healthy women. Therefore, to identify early signs of cardiovascular insufficiency, the functional inferiority of myocardials in pregnant women, as well as to assess the reserve and adaptive capabilities of the mother and the fetus, it is necessary to conduct a number of additional studies.
Hemodynamic indicators.
The most common tests characterizing the state of hemodynamics are the speed of blood flow, arterial and venous pressure, the pulse rate, systolic and minute volumes, the number of circulating blood. With developing heart failure, the mass of circulating blood increases, the rate of blood flow changes, the pulse is raised, the venous pressure and a minute volume increases. However, each of these indicators in itself has relative importance and only the set of them in comparison with the data of careful clinical observation allows us to make the correct assessment of the patient's condition and serves as a basis for choosing the right treatment. Of particular importance in pregnant women with diseases of the cardiovascular system are acquired by the widely used in the cardiology clinic instrumental methods of study - electrocardiography, balleriography, vector vigorography, phonocardiography, polycardiography. The nature of electrocardiographic, as well as ballisto-vector-phonocardiographic data is determined, as already indicated, on the one hand, the presence of the pathology of the cardiovascular system, and on the other - the pregnancy itself, that is, due to hemodynamic shifts.
The most frequent electrocardiographic signs of rheumatic myocarditis are: Changing the sinus rhythm (sinus arrhythmia, tachycardia or bradycardia), impairment of the atrocadic conductivity from a small lengthening of the PQ interval to the full blockade, the blockade of the GISE beam legs, a change in the ventricular complex QRS, an increase in the systolic indicator, signs of violation Coronary blood circulation (ST offset from isoline, changing T, etc.. Often, extrasystolia and flickering arrhythmia (with mitral stenosis and rheumatic cardiosclerosis) are often observed.
Ballistocardiography - a method of registration of body movements caused by the activities of the heart and blood flow through vessels, it allows you to judge the mechanical work of the heart, the strength of the reduction, the rate of expulsion, the systolic volume of the heart. BKG reflects the main passive contractile strength of myocardium. The balleridiographic signs of myocardial lesions are: a decrease in the maximum body velocity (MST), the elongation of the PC distance, an increase in the relation JK / IJ, the appearance of pronounced degrees changes in Brown. Changes in BKG respond to the degree of myocardial damage and often appear before the clinical manifestations of cardiovascular failure. This is a large diagnostic and prognostic value of this method in obstetric practice.
Large importance in the assessment of the state of the heart muscle has vector-digger - a study method that allows you to study the spatial dynamics of the electric field of the heart. When involving the myocardial process, the basic properties of it - excitability, conductivity and contractile function, as well as bioelectric processes (depolarization and repolarization), which is also reflected on BKG: The loop shape changes, additional loops appear, the hinge route changes, the loop deformation changes. The angle is increasing between the maximum loop vector QRS and T (up to 40-45 ° instead of 10-30 ° normally).
The phonocardiographic signs of the myocardial lesion is the change in the shape of the i tone (it becomes more stretched and low-frequency), the appearance of III tones, etc.
Pregnant women with cardiovascular insufficiency have distinct signs of hypoxia. The pulmonary respiration varies, the respiratory properties of blood and tissue oxygen mode. With decompensated heart defects in pregnant women decrease, the maximum lung ventilation decreases, the frequency, depth and minute respiratory volume change, deteriorates the use of inhaled air oxygen, the content of carbon dioxide in the alveolar air and in the blood decreases, decreases the saturation of arterial blood oxygen, increases the oxygen utilization percentage of tissues And the arterio-venous difference in oxygen, the content of unsophisticated metabolic products increases, the elimination time of oxygen debt and the recovery coefficient increases.
The study of the functional state of the cardiovascular system allows to determine the ability of the body of a pregnant woman with heart disease, to put a forecast and helps in solving the main issues of the conduct and treatment of such patients.

State of various organs and systems

Of particular importance is a comprehensive examination of pregnant women. At the same time, it is extremely important not only to diagnose the presence in a patient of a disease of the heart, to determine the phase and activity of the process, its flow, and in each individual case, estimate the functional state of various organon and systems, their backup and adaptation capabilities. In this regard, it is of great importance to the integrated use of modern methods for determining cardio- and hemodynamics (ECG, FKG, BKG, VKG, PKG, the study of hemodynamics "the colorful method", etc.), the gas composition of arterial and venous blood, acid-alkaline equilibrium, physical performance, oxygen supply of tissues, functional state of the pulmonary respiratory machine, as well as various organs (liver, kidneys, adrenal cortex), electrolyte, enzyme, vitamin and hormonal balance; Immunological, biochemical and genetic studies. Modern methods of studying the functional state of the body of pregnant women should be widely used in the clinic to address the issue of continuing pregnancy, developing tactics of pregnancy and childbirth in women with diseases of the cardiovascular system.

Related diseases and obstetrics

For pregnant with heart disease, the presence of tuberculosis, hypertension, kidney disease, blood, is unfavorable.
A different kind of complications of pregnancy and childbirth can also exacerbate the disease of the heart and contribute to the occurrence of decompensation. Therefore, women with diseases of the cardiovascular system require exceptional attention, in which pregnancy and childbirth are complicated by nephropathy, hypertension, preservation of kindergarten, bleeding, women with a narrow pelvis, multipleness, multi-way, improper position of the fetus, etc.

Maintaining pregnancy and childbirth at heart defects

Women's consultation should take each pregnant under strict dispensary observation, which has a disease of the cardiovascular system. To clarify the diagnosis, estimates of the functional state of the cardiovascular system, it is necessary (up to hospitalization) to dively examine each pregnant, using modern research methods and attracting the doctors of related specialties.
Pregnant women with heart disease should be observed by a female consultation doctor at least 1 time per month in the first half of pregnancy and 1 time in 2 weeks in the second half, and from the 32-34th week of pregnancy - weekly. In exacerbation or deterioration of the state, the inspection is carried out significantly more often, according to the indications.
All women suffering from the diseases of the cardiovascular system are advisable during pregnancy to hospitalize 3 times: 1. in early pregnancy terms (7-8 weeks) to clarify the diagnosis, functional characteristics, clarifying the degree of activity of the rheumatic process and solving the issue of the possibility of continuing pregnancy or the need for its interrupt. 2. In 25-32 weeks of pregnancy during the period of the most adverse hemodynamic conditions and the maximum load on the cardiovascular system for carrying out appropriate cardiac therapy. 3. 2-3 weeks before delivery - to prepare pregnant women, making a plan for conducting birth, carrying out appropriate cardiac and anti-revochetic therapy.
Any aggravation of the rheumatic process, the appearance of the slightest signs of cardiovascular insufficiency, the addition of toxicosis, an increase in blood pressure over 140 mm Hg. Art., The deterioration of the general condition, the emergence of other complications are indications for hospitalization in the ward or separation of pathology of pregnancy. The hospitalization of pregnant women with blood circulation should be carried out immediately in the order of emergency assistance.
Long-term inpatient treatment is especially shown pregnant with current endomyocarditis.
Indications for interrupting pregnancy at heart defects. The question of the possibility of preservation of pregnancy or the need for its interruption in women with heart defects, as already mentioned, should be resolved, taking into account the nature of the vice, its severity, the functional state of the myocardium, the stages of the circulation of blood circulation and the degree of activity of the rheumatic process. When solving the issue of admissibility after commissioning, it is necessary to evaluate the effectiveness of the operation, orient the magnitude of the extended opening and take into account the functional ability of myocardium. It should be especially recorded on the recurrences of rheumatism and circulatory disorders that took place after surgery. We should not forget about the possibility of restenosis after surgery and repeated rheumatic attacks.
Pregnancy is contraindicated:
1. When activating the rheumatic process (exacerbation of endomyocarditis) or in cases where the active process occurred during the year before the start of this pregnancy. The presence of the slightest signs of exacerbation of endocarditis over the past year is an indication for interrupting pregnancy, regardless of the form of heart defect and its severity. This, as indicated, is explained by the fact that pregnancy provokes an outcardite outbreak, has a very unfavorable effect on its timber, it often leads to a fatal outcome. Endocarditis is the most common cause of death of pregnant women with heart defects.
2. With any form of anatomical damage of valves, if it is accompanied by the functional inferiority of myocardium or there is a phenomenon of blood circulation. It is also necessary to take into account the presence of compensation disorder in the past (including for the previous pregnancies).
3. With combined mitral heart defects with a stenosis predominance (or under "pure" stenosis), a pregnancy is contraindicated with a combination of mitral stenosis with other vices, especially with aorto-mitral vice, since the impaired function of the cardiovascular system is enhanced, summed up and expressed in more degree than with each of these defects separately.
In the presence of mitral stenosis, its stoine has great importance, to determine which the classification of Bakulev-Damir is used to determine the breast surgery. If, with the I degree of stenosis for this classification, pregnancy can be resolved, with II - only conditionally under thorough observation and control, then the III, IV and V, the degree of stenosis are direct contraindication.
4. When coercilement aorta.
5. With congenital defects, if there are cyanosis, signs of pupils of blood circulation or pulmonary hypertension.
6. After the Mitral Commissionwood in the case of the small efficiency of the operation, the presence of a density, an active rheumatic process, signs of unstable compensation or functional inferiority of myocardium.
7. With acute myocarditis, coronory, coronary insufficiency with frequent attacks of angina and myocardial infarction.
8. If there is a patient at the same time, other diseases (blood, liver, kidneys, chronic infections), as well as a narrowed basin.
Pregnancy is not contraindicated in the presence of lack of mitral valve or aortic vices in the inactive phase of the rheumatic process without any phenomena of circulatory disorders. In all complex, dubious and obscure cases, the possibility of continuing pregnancy can be resolved only after a thorough examination in the hospital.
In the case of a categorical failure of a woman from interruption of pregnancy or when applying it to a doctor in a later date, it is necessary to provide systematic medical observation and highly qualified help of specialists.
What position should occupy an obstetrician and therapist if patients with diseases of the cardiovascular system of pregnancy of large deadlines? It is possible to solve this difficult and complex question only with a strict individual approach.
In patients with heart disease, the abortion of pregnancy in any way in the later dates is not less, and sometimes greater danger than spontaneous childbirth or childbirth with the help of a careful obstetric intervention. Therefore, it is necessary for all possible ways to try to bring a patient from a difficult state without resorting to an artificial interruption of pregnancy. Only if the integrated treatment does not give effect and restore compensation is impossible, and the phenomena of circulatory disorder, despite the treatment, increase, it is necessary to interrupt pregnancy regardless of the term. If the patient enters the obstetric hospital for the first time with acute phenomena of blood circulation deficiency (or with a sharp deterioration in the state of the cardiovascular system and the threat of pulmonary edema), it is necessary to carry out active therapy, to derive a patient from a difficult state and then only proceed to the most gentle reproduction in optimal conditions.
With any activation of the rheumatic process, strict bed regime is mandatory. Similarly, the appearance of signs of circulatory disorder serves as an indication for the translation of the pregnant on bed mode, preferably in the hospital.
In the treatment of pregnant women with diseases of heart, rational nutrition is of great importance, which should be prescribed, taking into account the diverse disorders of metabolism in such patients and features caused by directly pregnancies. Common calirage should not exceed 2600-2800 kcal. It is necessary to ensure sufficient administration of vitamins both with food (vegetables, fruits, juices, fish oil), and in the form of therapeutic drugs - ascorbic acid, group vitamins in (thiamine, riboflavin, pyridoxine, cyappkobalamin, calcium pangamate, folic acid), Nicotinic Acid et al.
For the treatment of rheumatism, the pregnant women are currently widely used amidopin (pyramidone) 0.5 g 3 times a day, butadion - 0.12-0.15 g 3 times a day, analgin - 0.5 g 3 times a day, acetylsalicyl Acid (aspirin) - 0.5 g 4 times a day. The appointment of antibiotics in rheumatism in pregnant women is advisable mainly if they have foci of infection.
With an acute rheumatic process and its pronounced activity that are not amenable to conventional antiperships, complex therapy is used, including steroid hormones - prednisone or prednisone. The prednisone and prednisone have a more pronounced and effective action than cortisone, and significantly raise side effects and complications. Treatment starts with 20 mg of prednisolone per day (5 mg 4 times a day), followed by a decrease in the dose to 5 mg per day. The course of treatment is designed for 1 month (200-300 mg). The experience of the department of extragenital diseases of the Kiev Research Institute of Pediatrics, Obstetrics and Gynecology suggests that steroid hormones in seriously ill with exacerbation of endomyocarditis and pericarditis, expressed by generalized rheumatic vasculitis and cardiovascular insufficiency gives a good effect and allow you to bring pregnancy to a prosperous outcome. Steroid hormones can be prescribed only in hospital conditions, under the strict control of clinical and laboratory research and data on the functional state of adrenal cortex. It is not recommended to prescribe these drugs in the first trimester of pregnancy, given the possibility of a negative impact of hormones, antibiotics and salicylates on the fetus during organogenesis.
It is extremely important individually for each patient to choose the most effectively active heart glycosides. The latter are used in combination with potassium chloride under the control of the state of patients and electrocardiographic data.
In the Kiev Research Institute of Pediatrics, Obstetrics and Gynecology, the schemes of differentiated treatment of pregnant women suffering from diseases of the cardiovascular system were developed and implemented, taking into account the main disease, the term and complications of pregnancy, the effects of medicines on the fruit. Not only antierematical, cardiac electro hypotensive drugs are included in the complex therapy, but also funds aimed at normalizing the violated functional state of various organs and systems, metabolic processes, the fight against hypoxia and acidosis, increasing the non-specific reactivity and the stability of the mother and the fetus to harmful effects, prevention intrauterine asphyxia of the fetus. These include, in particular, glucose (40% -40-50 ml), sodium bicarbonate (under the control of acid-alkaline equilibrium indicators), complex of vitamins C and B (BI, B2, VZ, WB, B15), folic and nicotinic Acids, vitamin E, amino acids (glutamic acid 0.25 g 3 times a day, methionine 0.5 g 3 times a day), ATP (1 ml), caocarboxylase (100 mg) and "adaptogens" (26 oxyl 0.2 g 3 times a day). Our experience shows the great efficiency of such therapy, a favorable effect of it on the course of the main disease, pregnancy and childbirth, the state of the fetus and the newborn.
During pregnancy and after childbirth, the rheumatic process occurs quite often. In order to prevent prevention, it follows during pregnancy to sanitize all local infectious foci (chronic tonsillitis, caries teeth, inflammatory processes of the liver and biliary tract, etc.).
Preventive contiguous treatment of all pregnant women suffering from heart defects, regardless of the form and stage of the process. It is most advisable, as our experience showed, to designate for all pregnant women 2-3 courses for 2-3 weeks each: after the first trimester of pregnancy, at the end of it and from the first days of the postpartum period: amidopin (Pyramidon) - 0.5 g 3 times On the day and Bicyllin-3-600 000 U intramuscularly 1 time per week for 5-6 weeks.
Preparation for childbirth.
Huge importance for the favorable outcome of pregnancy in women with heart disease has thorough preparation for childbirth. Such patients, even with the normal course of pregnancy and a satisfactory condition, should be hospitalized to the obstetric hospital (separation or chamber of pathology of pregnancy) 2-3 weeks before delivery for the relevant cardiac and antipership.
An extremely useful event in the disease of the heart in pregnant and feminine is a systematic enrichment of the organism with oxygen, glucose, ascorbic acid. For both mother and the fruit in the presence of a cardiovascular disease, especially with blood circulation disorder, suffer from hypoxemia. This chronic state in itself is extremely harmful in the state of the central nervous system of the mother and the fetus. During the birth, hypoxemia is significantly enhanced, and the fetal is often developing intrauterine asphyxia, which dictates the need for appropriate prevention and therapy for intrauterine asphyxia.
A great positive value is psychoprophylactic preparation for childbirth. Pregnant women should have a positive emotional background: the lack of fear, the wonderful expectation of the unknownness, insecurity in their forces, in the functional abilities of his heart, fear for themselves and for their child.
The choice of the method of root separation and maintenance of labor. When the patient arrives in the hospital, an obstetrician and therapist jointly outlays the planning plan. It should take into account not only the state of the cardiovascular system, but also an obstetric status, especially those moments that can complicate or lengthen the generic act. With the onset of active generic activity, when the reaction of the cardiovascular system on the contractions is clear, the management plan is revised. With the appearance of changes in the state of women in labor, appropriate adjustments to the planning plan are made. If after each fight, the number of heart abbreviations increases more than 20 strikes, the respiratory number exceeds 22-24, cyanosis appear, shortness of breath, cough, wheezing in the lungs, this indicates increasing Cardiac weakness and indicates the need to take urgent measures in therapeutic and obstetric terms.
In the Hozard with diseases of the cardiovascular system, the most responsible and dangerous is the end of the second and the beginning of the third birth period. In the second period, conditions are created for excessive heart alignment, but the main point is a significant and sudden increase in blood pressure during the dyghog and a sharp drop in it in pauses. Frequently observed tachycardia may worsen and without that tense heart activity.
Immediately after the birth of a child, a new danger arises: in the abdominal cavity, pressure and blood vessels are sharply, almost suddenly overwhelmed with blood, which leads to a sharp change in the hemodynamic state of the body. The need for rapid adaptability to new blood supply conditions requires a large voltage of the cardiovascular system and, above all, the activity of nervous machines regulating it. The sick heart is not always able to cope with these requirements. As a result of a sharp change in hemodynamics and violations of the activities of nervous mechanisms of regulation and blood circulation correlation, an acute circulatory disorder may occur.
In pregnant women with deficiency of the mitral valve or with a combined mitral defect, where the predominance of valve deficiency over the weakly pronounced stenosis of the left venous hole, with full compensation and good functional state of myocardium, is usually carried out conservatively through natural generic paths. In the stenosis of the left venous hole ("pure" or with a combined mitral vice with a predominance of stenosis) and, even more so, when blood circulation is disturbed, at least weakly pronounced, the turning off of the expulsion period by imposing forceps is shown. In the presence of cardiovascular failure, regardless of the shape of the damage of the valves of the heart or myocardium, it is certainly shown to turn off the second period. This is also fully also for those women who, with preceding birth or in the postpartum period, there were phenomena of circulatory disorders.
In general, turning off the wave period, which is the most dangerous for the feminine, should be considered shown:
1) in the presence of a mitral disease with the predominance of stenosis,
2) with blood circulation deficiency, regardless of the shape of the defect,
3) with congenital heart defects,
4) at endocardits,
5) after the mitral commissurotomy.
In cases where, for some reason, the forceps were not superimposed, produce perineotomy to accelerate the cutting and teething of the prerequisite part of the fetus.
To Cesarean section in women with diseases of the cardiovascular system should be resorted almost exclusively at the corresponding obstetric testimony (narrow pelvis, the presence of the placenta, etc.), that is, when an obstetric pathology is also joined to the disease of the heart, which does not allow Fast ending of childbirth through natural generic paths. The exception is the coarcation of the Aorta II-III degree (if it is presented, a cesarean section should be carried out).
Frequent and formidable complication in childbirth in pregnant women with mitral heart disease is the swelling of the lungs. It is observed mainly at the beginning of the generic activity (due to the fact that with each fighting increases the number of circulating blood coming from the cutting uterus) or during a dyg, when the cardiovascular system accounts for maximum load. Swells of the lungs can develop in the third period of delivery, when due to the rapid change in intra-abdominal pressure and emptying of the uterus, a sharp change in hemodynamics, to which the patient heart cannot adapt is occurred. A certain meaning in the occurrence of pulmonary edema in such patients, in addition to acute myocardial weakness, there are factors as pronounced anemia due to large blood loss, an increase in the permeability of pulmonary vessels, as a result of rheumatic vasculitis, an increase in pressure in the pulmonary artery and deep dispensenemia. The signs of eighties of the lungs in pregnant women are shortness of breath, turning into the chopping, cough, abundant wet wheezing, often hearing in the distance, pallor and cyanosis of the lips, a frequent small pulse, the appearance of frothy pink (painted blood) sputum.
It is very important that all the staff of the obstetric branch be well familiar with the early signs of this terrible complication, and the maternity hall is equipped with everything necessary to provide urgent assistance. The obstetric tactics should be different depending on when (in which period of childbirth) the edema of the lungs developed.
If the swelling of the lungs began in the first period of birth (at the first fights), the childbirth should not be forced. It is advisable, on the contrary, try to suspend childbirth, apply the entire arsenal of means of dealing with acute cardiovascular failure, to bring a patient from the state of edema of the lungs and only after that to be the question of the most careful delivery depending on the obstetric situation. If the swelling of the lungs is developing in the second period of childbirth, the obstetric tactics should be different: it is necessary to raise the woman as quickly as possible, the best of all (nry the presence of conditions) by imposing forceps and at the same time carry out intensive measures to eliminate the patient from this state. In the third period of birth, all therapeutic measures to combat pulmonary edema are carried out.
Pregnant women's edema treatment is carried out in accordance with the general rules: the position of the woman in labor sitting, harnesses on the limbs, banks, mustard pieces, camphor, cozool or cordamine, intravenous infusion of stanfantine (0.05% solution of 0.5-0.7 ml by 40% Glucose solution) or Corgal Golon (0.06%) - 0.5-0.7 ml). In the absence of stanfantine in ampoules, an alcohol tincture of strange can be used: 3 drops of the tincture of the stanfant are added to 20 ml of 40% of glucose and the mixture is slowly injected into the vein. However, it should be remembered that if the patient for a long time before the birth was obtained by Digitalis preparations, it is impossible to enter stroofitin. In the development of acute cardiovascular failure, in such cases, 1 ml of digal-neo or digiporate should be intimulated. It is advisable to introduce intravenously euffillain or diaphyline (2.4% -5-10 ml) simultaneously with strangectin. These drugs contribute to a reduction in pressure in a small circulation circle, expand the coronary vessels, improve the renal blood flow. Required abundant inhalation of oxygen with ethyl alcohol vapor via the nasal catheter. Intravenously together with glucose, cardiac glycosides and diaphiline are injected with caocarboxylase (100-200 mg), vitamins (Bi and C). In solving the question of bloodstand, it should always be remembered about the possibility of a large blood loss in the last and postpartum period. However, if, despite the therapy, the phenomena of the pulmonary edema are rapidly developing, the phenomena of the lungs should be carried out (300-400 ml). In recent years, ganglipalocators, which have the ability to interrupt the stream of threading pulses at the level of vegetative ganglia, are used to combat pulmonary edema.
In cases of non-efficiency of drug therapy, an urgent surgery for the heart is a mitral commissurotomy on life indications.
Big blood loss worsens the state of the pants, contributes to the emergence of decompensation, the exacerbation of the rheumatic process and the deterioration of the overall state. Therefore, when blood loss in the postpartum period in an amount of over 400 ml, the blood transfusion of the same name (better drip) or plasma is recommended. At the same time, a 5% glucose solution (500 ml) is introduced subcutaneously. Postpartum period.
With the end of the generic act, the danger of complications cannot be considered liquidated. As you know, sometimes the patient, safely undergoing pregnancy and childbirth, dies in the postpartum period. Death occurs most often due to the exacerbation of the endomyocarditis, easily emerging on the basis of any intercurrent infection, against the background of the reduced resistance to the body. Inflammatory and degenerative changes in myocardial, as well as a sharp overworking of it during pregnancy and childbirth, they often lead to severe persistent decompensation that is not amenable to the most intensive therapy. Very often arise during this period thromboembolic complications due to pronounced vasculitis and blood circulation deficiency. That is why the mission of the postpartum period of the pupil with diseases of the cardiovascular system should be given a special piming.
Strict and long-term bed medical and security regime are needed, careful care, full of peace, long sleep, strict control over the functions of the kidneys, intestines, liver, lungs, the condition of the skin, prophylactic measures to prevent infection. Mandatory in this period is to conduct a full course of antipership therapy and the purpose of cardiac means.
Due to the high frequency of thromboembolic complications, especially in mitral stenosis complicated by fliccious arrhythmia, vasculitis, stress phenomena, it is necessary to prophylactic applications from the first days of the postpartum period, under the control of prothrombin time, small doses of anticoagulants (Peltenan 0.15-0, 3 g 1-2-3 times a day, phenilina 0.03 g 1-2 times a day, syncumar - 1 tablet - 2 mg 1-2-3 times a day).
It was noted that after the operation of the cesarean section, the sluggish healing of the operating wound is often observed, sometimes the discrepancy between the seams. Therefore, the seams should be removed 2-3 days later than it is usually accepted. Prescribe the pupils with diseases of the cardiovascular system not earlier than 2 weeks. After childbirth, even with the very favorable course of the postpartum period.

The vices of the heart are the structural changes, as a result of which the heart function suffers, the efficiency of the heart muscle is reduced, the risk of developing complications increases. Often, at heart defects arise arrhythmias, symptoms of heart failure - shortness of breath, lack of air, swelling.

In the process of tooling the fetus, the load on the heart increases even in healthy women, which is talking about future mothers with vices. However, this diagnosis is not a sentence. With a reasonable approach, it is possible to avoid complications and give birth to a healthy baby.

Possibility of pregnancy at heart defects

Pregnancy at any vice heart is possible, but with severe heart lesions there is a very big risk not only to lose the fetus, but also to get serious complications for the mother. In some cases, the abortion may be recommended, from which the woman has the right to refuse, but must be aware of possible dangers.

Features of pregnancy planning during heart pattern

To reduce the risk of possible complications to pregnancy, you need to prepare in advance. It is advisable for operational treatment if it is shown. With pronounced valve changes due to vices (including rheumatic), the replacement of the valve or its plastic is recommended. After the operational treatment of the vice, the likelihood of normal pregnancy is much higher.

If the valve is replaced with artificial, this design serves a long time, is reliable, but requires a lifelong reception of drugs - anticoagulants. It is important to know that these are necessary, but somewhat risky for the fetus medicines that have teratogenic action.

In the case of replacing the valve with bioprostheses, such drugs are not recommended, but the service life of the prosthesis is small - 5-15 years, then a re-operation will be necessary.

If the vice is accompanied by a rhythm violation, the treatment of arrhythmia is best to start not during pregnancy, but before its offensive.

With accompanying arterial, it is also impossible to allow pressure to increase - the daily receptions are shown.

The pregnancy is better planning in the range of 20 to 30 years - so it, according to statistics, proceeds the most prosperous.

Features of pregnant women with heart defects

All flavors are divided according to the degree of danger to pregnant and fetus, and depending on which group, this vice belongs, doctors decide whether pregnancy is possible, what are the chances of carrying out fruit and what measures should be taken. Moreover, such decisions are accepted only by collegially - immediately by a group of highly qualified specialists.

The least dangerous vices of the heart:

moderately pronounced stenosis of the pulmonary artery and open arterial duct;

defects of interventricular or interpresenting partitions, which were operated on to pregnancy (DMWP, DMPP).

With these pathologies, the monitoring of the cardiologist is mandatory. Without identifying other complications, it is obligatory to inspect 2 times for pregnancy.

Somewhat worse situation With the vices of the second group:

Tetrad Fallo, after surgical treatment;

defects of interventricular and interpresenting partitions, not operated on;

vices accompanied by heart rhythm disorders.

The observation of the cardiologist with these diseases is carried out every trimester.

Third group of congenital heart defects:

the extension of the aorta is more than 40 cm in diameter (found at various anomalies, such as marfan syndrome);

hypertrophic cardiomyopathy;

status after a fountain surgery or operation about the coarctation of aorta.

In this case, the risk of pregnancy complications is high, every month a woman is examined by a cardiologist and a doctor who is pregnant, treatment is prescribed. Often, with such vices, the pregnancy is independently interrupted or children with low weights are born due to hypoxia.

Fourth group:

all defects flowing with heart failure - a decrease in the emission fraction to 30% (the indicator is estimated at the ultrasound of the heart);

valve vices - stenosis of aortic or mitral valves of high degree;

coarctation of aorta;

aorta dilatation is more than 45 cm;

other, more rare states, significantly complicating pregnancy.

Such states are contraindicated to pregnancy, as they are conjugate with the huge risk of death for the mother and the baby. Even the manipulation of the interruption of pregnancy in such women is unsafe.

With many defects, labor is possible in a natural way:

DMWP low, needs only in the observation of the cardiologist, DMWP is high in easy cases;

DMPP, flowing without complications;

the operated valve flaps (in some cases, the genus is natural, but the exclusion of the wave period is required).

Many are detected. Find out the opinion of the doctor's cardiologist about making pregnancy with this pathology!

Anastasia Myshov, Cardiologist, especially forwebsite

Useful video

The inability to have children is a tragedy for a woman. However, there are such situations where pregnancy is possible, but conjugate with the risk for the health of the fetus, and sometimes - and for the life of the mother. It is so often happening in women with diseases of the cardiovascular system. Recently, there is an increase in the number of pregnant and feminines suffering from heart defects, which is explained by a number of reasons: early diagnosis of such diseases; the possibility of preserving pregnancy in cases in which it was previously impossible; An increase in the number of women undergoing the operation on the heart, and the number of seriously ill women who, either with the permission of doctors, or decide to preserve pregnancy, being confident in the success of medical science and practice.

Maintaining pregnancy and childbirth in women with heart defects - real art, requiring joint and coordinated efforts of an obstetrician-gynecologist and a cardiologist or therapist, since this state places increased requirements for the cardiovascular system of the future mother. This is caused by changes that are due to the coexistence of two organisms - mother and fetus.

Speaking about the combination of heart disease and pregnancy vessels, it is necessary to note that pregnancy and determination of changes in blood circulation, metabolism, body weight (its increase by 10-12 kg by the end of pregnancy), water and salt metabolism (during pregnancy, the total water content in The body increases by 5-6 liters, and sodium content in the body increases by 2 times) requires from the heart of reinforced work and often aggregate the course of cardiovascular disease. All these changes are associated with the fact that a pregnant woman has additional blood circulation - uterine-placental blood flow. And accordingly change the load on the heart. These enlarged loads depend on the type of vice and on how the heart copes with the task assigned to it.

Congenital heart defects

There are three groups among congenital heart defects:

• Vices with blood discharge on the right left. These include the defects of the interpresentrial and interventricular partition - their incoming (through the holes at the same time, and the wrong blood reset occurs), as well as open arterial duct *.
• Vices with blood discharge from left to right - Transposition (relocation) of trunk (basic) vessels.
• Vices under which there is an obstacle to blood flow (narrowing large vessels).

* Arterial duct is a short thin-walled vessel connecting the pulmonary artery and aorta. It provides normal blood circulation of the fetus in the intrauterine period - bypassing the lungs, since oxygen goes through the placenta, and in the normal doc.

As you know, the heart is a hollow muscle body responsible for pumping blood in the body. It consists of four departments. This is the right atrium and the right ventricle, which make up the right heart, and the left atrium and the left ventricles that make up the left heart. Oxygen rich in oxygen coming from the lungs, the pulmonary veins falls into the left atrium, from it - in the left ventricle and further in the aorta. The venous blood in the upper and lower hollow veins falls into the right atrium, from there to the right ventricle and further on the pulmonary artery in the lungs, where it is enriched with oxygen and goes back to the left atrium.

Cleaning the heart is called a persistent pathological change in the structure of the heart, which violates its function. The vices of the heart can be congenital and acquired. Congenital heart defects are much less commonly acquired. They arise as a result of violation of the normal development of the heart and mainstream vessels in intrauterine development and amount to 1-2% of all diseases of the heart.

Most often in pregnant women there are vices of the first group. If the disease is accompanied by insufficiency of blood circulation, i.e. The heart, and so working at the limit, ceases to cope with the load, then the abortion is necessary. Insufficiency of blood circulation is manifested by fatigue, heartbeat, in more severe cases, shortness of breath appears, gravity in the chest. The lack of medical care for the rapid development of heart failure can lead to serious consequences - the lungs (i.e., in fact turn off their breathing), thromboembolism (clogs of blood clots) of the pulmonary artery or thrombosis of other large vessels. But usually women with this disease are well transferred pregnancy and childbirth.

Often, after the timely operational correction of heart disease (if the hole was narrow, it is expanding, and vice versa) future mothers cope with the load and the pregnancy ends safely. Recently, women who have experienced a heart surgery and even during pregnancy are becoming increasingly.

The vices of the second group are the most severe, and usually pregnancy have to be interrupted, because with these vices of the circulatory disorder, the heart of a pregnant woman often does not cope with the emerging load.

The obstacle blood flow in patients with the third group in the absence of insufficiency of blood circulation usually does not provide an indication for the interruption of pregnancy, however, it is often bodies ending with a cesarean section, which is due to a significant increase in the heart load during childbirth.

Acquired heart defects

Acquired heart defects are associated with inflammation of endocardium (inner heart sheath) and myocardium - heart muscle. These inflammations may occur in rheumatism - heart disease and connective tissue, sepsis - generalized infectious damage, atherosclerosis, syphilis. Under the influence of the inflammatory process in the valve, a scar tissue is developing, which causes deformation and shortening of valve flaps or narrowing the hole. As a result, the valve cannot completely close the hole and the valve failure arises. In case of deficiency of the valves during systole (reduction of ventricles), there is a reverse anti-test blood flow from ventricles in the atrium. With stenosis (narrowing) of the left atrioventricular hole during the diastole (relaxation of ventricles), the blood does not have time to move from the atrium into the ventricle. There is a pathological overflow of the left atrium, and the load on it increases. Thus, heart defects lead to blood circulation disorders.

Most often (in 75-90% of cases) the acquired heart defects are developing against rheumatism. (This disease is caused by streptococco - the same microbe, which is usually the causative agent of angina and often strikes women of young age.) The lesions of the heart valves are prevailing - the mitral, located between the left atrium and the left ventricle, and the aortic, located between the left ventricle of the heart and the aorta. These lesions lead to a violation of the normal operation of the valves, the overload of the heart muscle and insufficiency of blood circulation.

Often, stenosis and insufficiency are developing on one valve (the so-called combination vice). In addition, there are cases when the defects affect two or more valves - it is customary to be called a combined heart defect.

How will pregnancy pass?

Pregnancy The pregnancy depends on the degree and combination of defeat, as well as from the activity of the rheumatic process (in other words, whether its exacerbation is at the moment) and from the severity of circulatory disorders.

The question of preservation or interruption of pregnancy is solved by a collegial cardiologist and an obstetrician-gynecologist in each case individually. If pregnancy has come after the heart surgery, you need a cardiac surgeon consultation. It should be known that far from always corrective heart surgery lead to the elimination of organic changes in the valve apparatus or eliminate congenital developmental abnormalities. Often, after surgery treatment, there is a relapse of the underlying disease, for example, in the form of a restenosis (repeated narrowing) after some operations.

It is extremely difficult to solve the question of the admissibility of pregnancy in women with prosthetized heart valves. They have a high risk of blood cloves, so pregnant women with mechanical valves are constantly obtaining anticoagulant (antosvertible) therapy.

Of course, the question of preservation of pregnancy in women with cardiovascular diseases is better to solve in advance, before its offensive. The basis of the right leading and treatment of such pregnant women is the exact diagnosis that takes into account the cause of the disease.

Blood discharge vices right serve as a contraindication to pregnancy, as well as any type of decompensation defects, during which blood circulation failure has already been formed.

Features of pregnancy at heart defects

Maintaining pregnancy in women with heart defects, as already mentioned above, is carried out with the participation of several specialists. It requires not only the coordinated activities of the female consultation specialists, but also the disciplined behavior of the woman itself: early registering in women's consultation, timely visits to doctors and surrender analyzes, full examination, timely comprehensive treatment.

If there is an opportunity, then, of course, better entrust your health to a large medical center specializing in this problem. This may be a branch for women with cardiovascular pathology at the institute or a specialized branch based on a large maternity hospital, where competent specialists who have experience in conducting patients with such pathology will be able to effectively help.

Pregnancy during women with heart defects has its own characteristics. Often there are complications such as gestosis (complications of pregnancy, manifested by the appearance of edema, protein in the urine, an increase in blood pressure), which are characterized by hidden current and are poorly treatable. Pregnancy in such patients is often complicated by the threat of interrupt - the number of spontaneous abortions and premature genera significantly exceeds the average indicators. In addition, the course of pregnancy may be complicated by a violation of the uterine-placental blood flow, which leads to hypoxia (oxygen starvation) or the delay in the intrauterine development of the fetus. High also the risk of detachment placenta. The accumulation of thrombus in the placenta leads to the shutdown of the placenta of the placenta from the blood flow and enhancing the oxygen starvation of the fetus.

According to all the reasons for the reasons for women with heart defects and, another pathology of the cardiovascular system, during pregnancy, should be hospitalized in the hospital at least three times:

First hospitalization - on to clarify the diagnosis and solving the issue of preservation of pregnancy. The question of the interruption of pregnancy up to 12 weeks is solved depending on the severity of the vice, the functional state of the circulatory system and the degree of activity of the rheumatic process.

Second hospitalization - on to monitor the condition of the cardiovascular system and, if necessary, to maintain the heart function during the period of maximum physiological loads. This is due to the fact that it was during this period that the load on the heart is significantly increasing (one of the periods of maximum physiological load) - almost a third increases the so-called cardiac output, mainly due to an increase in heart rate.

Third hospitalization - on to prepare for childbirth and the choice of the method of root separation, drawing up a planning plan.

When signs of insufficiency of blood circulation, the exacerbation of rheumatism, the occurrence of fliccity arrhythmia (frequent non-medical reduction of the heart), gestosis or pronounced anemia (reduction of the amount of hemoglobin) and other complications are necessary hospitalization regardless of the period of pregnancy.

The question of the interruption of pregnancy at the later deadlines is quite complicated. Often, doctors have to decide that less dangerous for the patient: to interrupt pregnancy or allow it to develop further. In any cases, when signs of insufficiency of blood circulation or any concomitant diseases, the patient must be hospitalized, subjected to a thorough examination, treatment.

If the situation does not require such cardinal measures, pregnant must observe maximum caution. First of all, it is necessary to take care of a sufficient holiday and long-term, 10-12-hour sleep. Useful daily 1-2-hour sleep. Pulk effective treatment and prevention are therapeutic physical culture, morning gymnastics, outdoor walks. The complex of morning exercises should be the easiest, not leading to excessive overvoltages, fatigue.

Power must be made as much as possible, full, with a high content of protein products (up to 1.5 g / kg body weight). Reception of polyvitamins is required. In addition, the doctor may assign sessions of hyperbaric oxygenation (sessions in the barocamera, where air with an increased oxygen content is supplied), general ultraviolet irradiation.

Conducting birth at heart pattern

The question of medical tactics in childbirth is of particular importance. The best choice is early hospitalization. The plan of delivery is drawn up consultatively with the participation of obstetric, cardiologist or therapist and anesthesiologist. The choice of the method is strictly individual for each patient, depending on the situation.

Modern medicine has sufficient arsenal of diagnostic tools in order to prevent complications of pregnancy in women with heart defects. The following techniques are usually applied:

• Electrocardiography - Registration of electrical phenomena arising in the heart muscle when it is excited. This study allows you to register changes in the heart muscle to change the electrical impulse.
• Phonocardiography - The method of registration of sounds (tones and noises) arising from the heart of the heart. It is used to evaluate the work of the heart and recognition of disorders, including valve vices.
• Echocardiography (heart ultrasound). It is used to study blood circulation and cardiodeynamics (heart work), determining the size and volume of heart cavities, assessing the functional state of the heart muscle. The method is harmless to mother and fetus.
• Samples with load Used to estimate the functional state of the heart muscle. Samples with a load on the cyergometer are used in examination of pregnant women - during this sample, the patient remove the ECG with different intensity of physical exertion.
• Study of the function of external respiration and acid alkaline blood state It assumes the study of the tank of lungs and blood saturation with oxygen alone and under load. The study makes it possible to determine how adequate blood saturation with oxygen, i.e. As far as the heart is coping with the load at the moment.
• Blood research - Usually enough standard analysis, which is carried out during the examination of all pregnant women. However, in this case, the doctor pays special attention to the state of the blood coagulation system.
• Ultrasound of the fetus, cardiotocographywhich are regularly held after to assess the state of the placenta and the fetus. These studies help to find out if the fetus suffers from lack of oxygen and nutrients. In addition, the ultrasound of the fetus allows you to identify possible defects of the child's development before it is born and take appropriate measures - from an urgent surgery after the delivery to the interruption of pregnancy.

The advantage remains behind the natural method of delivery. With compensated pounding of the heart, therapy is carried out aimed at preventing heart failure and heart support, the prevention of pulmonary edema, with the possibility of arrhythmia - ECG control. An adequate anesthesia is carried out, since fear and pain lead to an additional load on the heart.

As a rule, the most difficult period of childbirth - sweat (the period of expulsion of the fetus) - try to shorten with episiotomy - dissection of the crotch. Turning off the dyg (the impulse of obstetric forceps) is carried out with circulatory disorders.

Many doctors believe that the delivery of the cesarean section reduces the load on the cardiovascular system and reduces mortality among pregnant women suffering from heart defects.

Caesarean section in the vice of the heart is carried out in the following cases:

• with an active rheumatic process (increase in temperature, the appearance of pain in the relevant organs, characteristic changes in analyzes);
• with severely pronounced pounding of the heart with a pronounced deficiency of the left ventricle and the absence of the effect of medical therapy;
• with a combination of heart defect with obstetric pathology, requiring surgical delivery.

Successful delivery of patients suffering from severe congenital and acquired heart defects can be facilitated by hyperbaric oxygenation.

After the birth of the fetus and the death of the lapse, there is a tide of blood to the internal organs (and first of all to the abdominal organs) and a decrease in blood circulation in the brain vessels and vessels that feed the heart muscle. Therefore, to prevent the deterioration of the state immediately after the birth of a child, women introduce funds to provide normal heart performance.

Postpartum period

The danger of the occurrence of thrombosis, bleeding and heart failure is preserved up to 5 days after childbirth, so in this period a woman is assigned to bed rest. From the 7-11 days of the day with the rheumatic nature of the vice, a study on the activity of rheumatism is appointed; The activity of rheumatism is monitored and within a year after delivery.

Pedaries with heart disease can be discharged from the hospital no earlier than 2 weeks after childbirth in a satisfactory condition under the supervision of the cardiologist at the place of residence.

If decompensation after childbirth did not occur and the reception of drugs is not required, preferably breastfeeding.

After the birth of the child, experts necessarily examine it for the presence of heart defects, as in children whose mother had such problems, the risk of their presence increases many times.

Thus, timely diagnosis and proper treatment allow many women who used to be inaccessible to the birth of a child, to feel this joy. And experts are always ready to help them in this.

Alexander Ivanov
doctor obstetrician gynecologist
Cell. gynecological division of n5 polyclinics,
Ulyanovsk

Discussion

I have a corrected heart disease. Now PMK, problems with valves. 39 years. First pregnancy. We have 90 kg - with hormones scored. Not that I didn't lie three times in the hospital - not a single hospital before the decree took. I go like a locomotive puff. Hemoglobin - anemia 1 step. All in the same Ulyanovsk ... What are you talking about, doctor, here write? I thought I had a good gynecologist in a clinic ...

03/25/2018 19:17:30, Ninel1

I do not agree with the author. Pokoka Pokoka Maine is true, but why well-operated defects (correspondingly fully compensated) vices equal to something terrible, I do not understand: (not always the operation on the heart is made to save your life, very often - just to improve the quality of life ! I made an operation - and the heart works as you need, you can not be afraid of the loads, as in vice (even compensated), but, apparently, the cardiologists from the hospitals have their theories. Because of the operation (15 years ago, in childhood) I am now refused now Take an ordinary hospital, sent to the cardiological. Fortunately, at least with hospitalization 3 times for pregnancy, we do not suffer from us, but Cesarean threatens very visible. This is at least very offensive - pregnancy I move fine (Tt-T), About the problems with the heart, what were in childhood, I have already managed to forget - and here it turns out that I am a terribly sick person who has had to ask the doctor at all, to give me a child (

Thank you for the article. I, honestly, at one time, was afraid to go under the supervision of state clinics. After prolonged thought, I went to the "Mother and Child", immediately warning doctors about your problem. Although. I think even if I did not warn it - it was discovered by it. In general, the whole pregnancy was under control, people really know their work, the approach of them is correct and the level is very high. I can tell them only thanks for that, my health and my child (TTT) grows without problems.

Thank you very much for the article, I have a congenital heart disease, now I am waiting for a child and was very worried about how the heart disease was not reflected on the baby, but thanks to the article I learned a lot (what doctors do not say) and now do not worry about for the baby and for himself.

09/24/2008 22:14:59, Alena

I am a student of medical university, the article helped in preparing for practical classes. Thank you!

04.05.2007 16:13:36, Sufle

I absolutely did not like the article.
I have a congenital heart rate (DMWP) in a state of correction (operation to pregnancy). Four years ago, gave birth to the first child (natural childbirth in the usual maternity hospital) is now pregnant with the second. The part of the article, which is devoted to pregnancy and childbirth, to put it mildly, is not true - everything is not as scary, as it is written here. And about the fact that parents with heart defects are more often born children with the same pathology - generally complete nonsense.
It would be correct that articles on such topics would not see the doctor an obstetrician-ginegologist, and a cardiologist who had experience in one of the specialized maternity homes, the benefit of such. This article considers it harmful for pregnant women. Girls, look for and refer to specialists!

05/23/2006 10:51:21, Natalia

Thanks for the information, otherwise doctors usually achieve clarification impossible!

Excellent article! Very detailed and available written. Unfortunately, in the LCD neither gynecologists neither therapists in the problems and features of such patients do not want and fear them panic.

Comment Article "Pregnancy in women with heart defects. Minimum risk strategy"

Baby with heart disease. Medicine / Children. Adoption. Discussion of adoption issues, forms of children's children in families, upbringing Has anyone took a newborn with a vice heart requiring operation? I heard the opinion that it is for young children in principle ...

Discussion

specify the diagnosis. Consult, at least in absentia. I am in Bakulevka Con-A. Everything is perfect for now.

If the child is in MO or in Moscow, do without any problems by quota in Bakulevka. But the prospects can only say the doctor and only after the operation. I have a big boy who did not do this operation on time. We already did when it was with us, very hard. But the kids do really and close. And mostly everything is fine.
By the way, my also received a second group of health this year, there are almost no restrictions on the load.

Is it possible on an early pregnancy with the help of ultrasound and echo to identify the coarse malformations of the health of the fetus? I want to exactly 12-13 weeks. The first guy has a congenital heart disease (Tetrad Fallo) operated at an early age now everything is fine.

Discussion

i traveled for a period of 10 weeks per st. AK. Oparin, 4 (Scientific Center of Gynecology, Obstetrics and Perinatology), Department of Functional and Ultrasound Diagnostics Professor Zatigyan Evgenia Pavlovna
tel. 438-25-29

Try contacting the Perinatal Center in Bakulevka (by reference). It is up to 12-13 weeks that something is unlikely to find out if only a completely coarse vice, when not all heart cameras laid, etc., too, everything is fine.

Problems of tooling twins. Ailment, disease, toxicosis. Pregnancy and childbirth. If you are pregnant and if blessings are so blessing the Lord IMHO! So someone here to think is risky or not, it is worthwhile to come to the point with the mind.

Discussion

But about the question "Is it worth a risk" I didn't understand ... If you are seriously sick with your heart, then you will simply be observed as a pregnant high risk, and will make sure Cesarean. I had a friend with a heart disease gave birth to anything (not a bunk) of a baby and lives a spock further. Everyone was also very afraid as it would be trimmed "with her problems. If you are pregnant and if blessings are so blessing, the Lord IMHO! So what do you think it's risky here or not, it is worthwhile to come to business. In this life everything costs If with the mind! IMHO!

Not very clear - are you pregnant twins ?? Do you have reasonable (confirmed ECG and analyzes) problems with the SCC ??
What does it mean "Is it worth risking" ?? ; ((

Pregnancy and childbirth: conception, tests, ultrasound, toxicosis, childbirth, caesarean section, giving. And this "vice" discovered during pregnancy or was it before? My friend gave birth to 67th p / d and was very dissatisfied with it, she just was detected in childhood, so in ...

Discussion

Where did the vice diagnosed? If the exchanging has already been written that only 67 will not take it for money anywhere, in Euromed at 67, too, just as already wrote with the fights, I asked me at consultation, I asked me there, where you would give birth and wrote a hospital when 7gkb, where she wanted, i.e. Violation is not so terrible recognized

where did you get a conclusion? If in Bakulevka, then there can be no more other than the 67th not to take.
If not there, let them come and get there the conclusion that it can give birth anywhere. With their conclusion, most likely take everywhere

IMHO of course

I had a heart disease, my mother in the period of pregnancy was silent by inflammation of the lungs. My older brother is healthy. Other children. I have born a boy from the UPU, more precisely left-sided hypoplasia, the pregnancy proceeded perfectly, I did not hurt anything, nor I smoke.

Discussion

If your husband has no problems with the heart of special, and there is no problem of such defects, too, there is no probability of the birth of a second child with a vice heart no more than any other healthy pair. Consult for complacency can be in genetics. But sometimes "trouble to the gate" comes unknown from where and re-under other names. This is your own experience: My husband in the first marriage has a second daughter died in a year from oncology, unexpectedly. I am his second wife. Our first son has a heart disease. Heredity is not burdened by both cases ... and genetic when I was pregnant for the second time, I told me that it is random, ecology, etc. All by the will of God ... Maybe our sins, free and unwitting? ..

I suffered such an operation, even more difficult. I had a defect of the interventricular partition (the hole is narrow and long), and it is deeper in the heart and more difficult. I found it at me for 6 months and up to 11 years old my mother was not solved for an operation, which finally took place in 1973. Imagine how much progress went ahead? Even then, the defect of the interdestrian partition corrected without the use of aics (artificial circulation apparatus). And with me with aics and with the disconnection of the heart. And everything went well! Grown, married, gave birth to two children (herself, by the way, without any cesarean). True, when I gave birth to the first, I went to the district hospital, and they shouted on me, they say, I had to give birth in a specialized heart, and in general, it is possible to give birth to me. But it was too late to yell. The second child has already gave birth in a specialized hospital, but also herself. So, do not worry, the vice is not complicated, but it is necessary to operate. After that, a person becomes absolutely healthy. Well, we observed me 5 years after surgery and that's it. By the age of 16 and skating and skiing, the truth was never at the lessons of physical education :)
If anything else interests, ask, I know what it is, and I know how you worry. By the way, after its operation at 11 years old, I read the book Amosov "Thoughts and Heart" and began to understand what was. Recommend.

Recently, the number of pregnant women with congenital heart defects has increased significantly. Thanks to modern methods of treatment, these patients who previously died in childhood are waiting until a childbearing age.

1. Defect of the Interpidential Partition - The most common congenital heart disease in pregnant women.

but. Hemodynamics. The disease often proceeds asymptomatic. In physical research, systolic noise is listened. As a result of discharge of blood from left to right, pulmonary blood flow increases. However, severe pulmonary hypertension is rare.

b. The course of pregnancy. The tactics of pregnancy and childbirth in women with a defect between the interpresentation partition depends on the severity of pulmonary hypertension. In the absence of pulmonary hypertension, pregnancy is moved well and does not affect the course of the disease. In contrast, pulmonary hypertension increases the risk of Eisenmenger's syndrome, in which maternal mortality reaches 50%. Approach Ehoche and catheterization of the right heads of the heart.

in. Influence on the fruit. The risk of congenital heart disease in a child reaches 15%.

g. Pregnancy. With pulmonary hypertension, the tactics of keeping the same as in the Eisenmenger syndrome. In other cases, the usual observation is shown.

2. Defect of the interventricular partition

but. Hemodynamics.The severity of heart failure depends on the magnitude of the defect. With a small defect, the disease occurs favorably, pulmonary blood flow increases slightly, with a large - discharge of blood from left to right leads to the left ventricular hypertrophy due to its volumetric overload. A significant increase in pulmonary blood flow leads to pulmonary hypertension and hypertrophy of the right ventricle. As pulmonary hypertension is raised, the direction of blood relief is changing (right to left).

b. The course of pregnancy. In the absence of pulmonary hypertension, pregnancy favorably affects the course of the disease by reducing the OPS and an increase in cardiac output. In the case of long-standing hypertrophy of the left ventricle, an increase in the BCC characteristic of pregnancy increases the risk of heart failure. With pulmonary hypertension, the risk of Eisenmenger's syndrome is increasing. Women who previously conducted a surgical correction of vice, pregnancy proceeds without complications.

in. Influence on the fruit. The risk of a congenital heart disease in a child reaches 22%.

g. Pregnancy.

3. Open arterial duct. - One of the most common heart defects in pregnant women in the past. It is rarely found rarely due to timely surgical correction.

but. Hemodynamicschanges the same way as the defect of the interventricular partition.

b. The course of pregnancy. With a small diameter of open arterial duct, pregnancy is favorable. The development of pulmonary hypertension increases the risk of Eisenmenger's syndrome and its complications.

in. Influence on the fruit. The risk of congenital heart disease in a child is 10-15%.

g. Pregnancy. With pulmonary hypertension, pregnancy leads as an Eisenmenger syndrome. In other cases, the usual observation and prevention of infectious endocarditis is shown.

4. Capacation of Aortait is often combined with such vices as a double aortic valve and bag-shaped aneurysms of cerebral arteries.

but. Hemodynamics. Due to the obstacle blood flow, as a rule, systolic blood pressure sharply increases and hypertrophy of the left ventricle develops. The blood circulation is reduced in the lower half of the body.

b. The course of pregnancy. When coaching aorta, pregnancy usually proceeds favorably. In rare cases (with a long existing left ventricular hypertrophy), heart failure develops. In addition, pregnant women change the structure of the vascular wall, which increases the risk of aortic separation.

in. Influence on the fruit. Due to the reduction of placental blood circulation, a intrauterine delay in development is possible. The risk of a congenital heart disease in a child is about 20%.

g. Pregnancy. To prevent the separation and rupture of the aorta, hypotensive means are prescribed. Conduct the prevention of infectious endocarditis.

5. Tetrad Fallo - heart disease, including the stenosis of the mouth of the pulmonary trunk, hypertrophy of the right ventricle, a large defect of the interventricular partition and the dextroposition of aorta. This is the most common heart rate among congenital cyanotic vices in pregnant women.

but. Hemodynamics. Due to the obstruction of the ending path of the right ventricle, there is a discharge of blood on the right to left and the blood with low oxygen in the large circle comes into a large circle. The right ventricular hypertrophy develops.

b. The course of pregnancy. Pregnant women who have complete surgical correction are not included in the risk group. Without surgical correction of damage, patients rarely live up to a childbearing age. The decrease in the OPS (characteristic of pregnancy) aggravates blood discharge on the right left. SO 2 decreases. In hematocrit below 60%, the saturation of the hemoglobin of arterial blood oxygen is less than 80%, fainting in history and a significant increase in pressure in the right heart deposits The forecast is extremely unfavorable. During pregnancy after incomplete surgical correction, for example, the operation of the Blinder-Taussig (the imposition of the anastomosis between the right plug-in and pulmonary arteries), Potts (the imposition of the anastomosis between the downward aorta and the left pulmonary artery) or Waterstone in the modification of the Kuli (the imposition of anastomosis between the ascending aorta and the right lung Artery), high risk of aggravation of heart failure, even if the condition was satisfactory before pregnancy. To clarify the forecast, a thorough collection of anamnesis is carried out, hematocrites, SO 2 are determined and the pressure in the right hearts of the heart is measured.

in. Influence on the fruit. Due to low SO 2, the risk of intrauterine development delay is great. The risk of congenital heart disease in a child reaches 15-20%.

g. Pregnancy. The aggravation of the obstruction of the right ventricular removal path and an increase in blood relief to the right to the left is very dangerous. In this regard, it is important to avoid hypovolemia. Inhalation of oxygen is prescribed for the prevention of hypoxia.

6. Aortic Stenosisit happens congenital and acquired. Congenital aortic stenosis most often occurs on the background of a bivalve aortic valve. In childhood, the disease is usually not manifested, but with age, as the size of the heart increases, the symptoms of the aortic stenosis increase.

but. Hemodynamics. If the area of \u200b\u200bthe aortic valve opening is less than 1 cm 2, the obstruction of the left ventricular ending path is developing with subsequent hypertrophy. Restriction of cardiac emissions entails a decrease in coronary blood flow and myocardial ischemia. In this case, any additional load can cause the attack of the angina or the development of acute left-selling deficiency.

b. The course of pregnancy.Since pregnancy significantly increases the load on the heart, with severe aortic stenosis, the forecast is unfavorable. Due to the obstruction of the left ventricle, the increase in cardiac emission is achieved only by increasing the heart rate. Tachycardia shocked diastole. This, respectively, reduces the coronary blood flow and the time of filling the left ventricle. Reducing the OPS due to pregnancies, in combination with limited cardiac emission leads to arterial hypotension and fainting. With severe aortal stenosis, a pregnancy interruption is shown, since maternal mortality reaches 15%.

in. Influence on the fruit. Because of the complications of the mother, the aortic stenosis is accompanied by a high perinatal mortality. The risk of a congenital heart disease in a child is about 20%.

g. Pregnancy. With severe aortic stenosis, a strict bed mode is shown. To maintain venous return, hypovolemia is carried out and we recommend that elastic stocking. Conduct heart failure. With a valve mechanical prosthesis, anticoagulant therapy is shown. Since in I and in II trimesters of pregnancy, warfarin is contraindicated, the patient is prescribed heparin. In all cases of aortic stenosis, the prevention of infectious endocarditis is carried out.

7. Stenosis of the pulmonary artery valve. Unlike aortic stenosis, the disease usually does not progress with age.

but. Hemodynamics. Easy stenosis usually proceeds asymptomatic, heavy - causes the obstruction of the right ventricle's ending path and its hypertrophy. In addition, with heavy stenosis, the pressure of the filling of the left ventricle and the heart rate is reduced. Clinical manifestations of heavy stenosis include shortness of breath during exercise and fast fatigue.

b. The course of pregnancy. In case of easy stenosis, pregnancy proceeds favorably, with severe - fixed cardiac emission and an increase in the BCC (characteristic of pregnancy) increase the risk of heart failure.

in. Influence on the fruit. The risk of a congenital heart disease in a child is about 20%.

g. Pregnancy. The prevention of infectious endocarditis, hyper and hypovolemia is carried out. It is treated by the right-hand deficiency. If drug treatment is inefficient, the balloon holvoplasty or holvulotomy is shown.

8. Martan Syndrome - It is hereditary disease of the connective tissue. The damage to the cardiovascular system is manifested by the mixture degeneration of the valves of the heart (more often by mitral) and cystic medion chosen of the aorta leading to the development of aneurysm.

but. Hemodynamics. In most cases, a mitral valve prolapse is observed. At the same time, due to the regurgitation, the left-willed atrogation and compensatory hypertrophy of the left ventricle arise. Over time, left ventricular failure is developing. The dilatation of the left atrium increases the risk of flickering arrhythmias and thromboembolic complications. With damage to the aorta develops the dilatation of its root. This leads to aortic regurgitation, chronic overload and dilatation of the left ventricle. With a significant dilatation of the root of the aorta, its gap is possible.

b. The course of pregnancy. Since, due to the decline in the OPS, the cardiac emission is raised, when the mitral valve is prolapse with regurgitation proceeds favorably. However, due to the increase in the BCC during pregnancy, the risk of left ventricular failure increases with pronounced regurgitation. In addition, pregnant women change the structure of the aorta wall, the risk of its rupture is significantly increased. The aortic break is the main cause of the death of pregnant women with Martan syndrome. Earlier it was believed that maternal mortality in marfan syndrome is about 50%, but these data turned out to be strongly overestimated. With the diameter of the aorta root less than 4 cm, the forecast is usually favorable.

in. Influence on the fruit. The disease is inherited by autosomal dominant type with high penetrate and various expressiveness. The risk of birth of a child with Martan syndrome reaches 50%.

g. Pregnancy. Beta-blockers are prescribed to reduce the load on the wall of the aorta. Conduct the prevention of infectious endocarditis.

9. Eisenmengeneger syndromeit is characterized by the development of irreversible pulmonary hypertension due to blood relief from left to right. Causes: Large defects of interventricular and interpresentation partitions, large diameter of open aortic duct, tetrad Fallo and a number of other congenital cyanotic heart defects.

but. Hemodynamics. At an early stage, pulmonary blood flow increases, as a result of blood discharge, the pulmonary hypertension is developing. Later, the pressure in both halves of the heart is aligned, the discharge of blood becomes cross. When the pressure in the pulmonary artery exceeds the system, the direction of resetting blood changes (right to left) and in a large circle begins to flow the blood oxygen. The subsequent development of compensatory erythrocytosis increases the risk of thromboembolic complications.

b. The course of pregnancy. In the Eisenmenger syndrome, the forecast is extremely unfavorable. Pregnancy is accompanied by a decrease in OPS (which is exacerbated in the case of bleeding) and an increase in blood coagulation (risk of thromboembolism of pulmonary artery branches with a subsequent increase in pulmonary vascular resistance). All this contributes to the change in the direction (right to left) and the increase in blood discharge. Due to significant oscillations of the BCC, childbirth and the postpartum period are of the greatest danger. Due to the development of hypoxemia resistant, maternal mortality reaches 50%. The risk of death in Eisenmengeneger syndrome is especially high with progressive pulmonary hypertension, when the inhalation of oxygen is ineffective.

in. Influence on the fruit. Characterized intrauterine delay in development. High perinatal mortality (28%) is usually due to prematurity.

g. Pregnancy. In Eisenmenger syndrome, pregnancy is recommended to interrupt. If the woman insists on its preservation, careful observation is required. In order to prevent the increase in blood discharge and the change in its direction, as well as reduce the need for oxygen, prescribe a long bed mode, conduct hypovolemia prevention. Since hypoxia, acidosis and hypercupnia increase the pulmonary vascular resistance, it is important to monitor the acid-alkaline equilibrium. The appointment of heparin for the prevention of thromboembolic complications, according to some data, is inefficient, and sometimes dangerous, as the risk of bleeding increases. Since after the cesarean section, maternal mortality reaches 75%, rowed through natural labor paths. A high mortality rate for cesarean section is probably due to a sharp decrease in intra-abdominal pressure due to the rapid extraction of the fetus, as well as the oscillations of the BCC due to blood loss. To monitor hemodynamics during childbirth, the peripheral and pulmonary artery is catheteris. Control the cdd in the right ventricle and hell. When or increasing blood discharge on the right left is required urgent treatment. In the case of arterial hypotension, vasopressor means are prescribed. The inhalation of oxygen and the shortening of the second period of labor by imposing obstetric tongs are shown by imposing obstetric forceps.

Speaking about the combination of heart disease and pregnancy vessels, it should be noted that pregnancy and changes determined by it require from the heart of reinforced work and often aggregate the course of cardiovascular disease. For example, the mass of the telecon by the end of pregnancy increases by 10-12 kg., The total water content in the body increases by 5-6 liters, and the content of sodium increases by the 10th week of pregnancy, the circulatory and metabolic system changes. This is due to the fact that a pregnant woman appears additional blood circulation - uterine-placental blood flow. And accordingly change the load on the heart. These enlarged loads depend on the type of vice and on how the heart copes with the task assigned to it.

Arterial duct is a short thin-walled vessel connecting the pulmonary artery and aorta. It provides a normal blood circulation of the fetus in the intrauterine period - bypassing the lungs, as the oxygen placenta, and in the norm, this duct oversight after birth.

The inability to have children is a tragedy for a woman. However, there are such situations where pregnancy is possible, but conjugate with the risk for the health of the fetus, and sometimes - and for the life of the mother. It is so often happening in women with diseases of the cardiovascular system. Recently, there is an increase in the number of pregnant and feminines suffering from heart defects, which is explained by a number of reasons: early diagnosis of such diseases; the possibility of preserving pregnancy in cases in which it was previously impossible; An increase in the number of women undergoing the operation on the heart, and the number of seriously ill women who, either with the permission of doctors, or decide to preserve pregnancy, being confident in the success of medical science and practice.

Congenital heart defects

There are three groups among congenital heart defects:

1.polds with blood discharge on the right left. These include the defects of the interpresentrial and interventricular partition - their incoming (through the holes at the same time and there is a wrong blood reset), as well as open arterial duct.

2. Positions with blood discharge from left to right - transposition (movement) of trunk (basic) vessels.

3. Positions under which there is an obstacle to blood flow (narrowing large vessels).

Most often in pregnant women there are vices of the first group. If the disease is accompanied by insufficiency of blood circulation, i.e. The heart, and so working at the limit, ceases to cope with the load, then the abortion is necessary. Insufficiency of blood circulationProducts and heartbeat, in more severe cases, shortness of breath appears, gravity in the chest. The lack of medical care for the rapid development of heart failure can lead to serious consequences - the lungs (i.e., in fact turn off their breathing), thromboembolism (clogs of blood clots) of the pulmonary artery or thrombosis of other large vessels. But usually women with this disease are well transferred pregnancy and childbirth.

Often, after the timely operational correction of heart disease (if the hole was narrow, it is expanding, and vice versa) future mothers cope with the load and the pregnancy ends safely. Recently, women who have experienced a heart surgery and even during pregnancy are becoming increasingly.

The vices of the second group are the most severe, and usually pregnancy have to be interrupted, because with these vices of the circulatory disorder, the heart of a pregnant woman often does not cope with the emerging load.

The obstacle blood flow in patients with the third group in the absence of insufficiency of blood circulation usually does not provide an indication for the interruption of pregnancy, however, it is often bodies ending with a cesarean section, which is due to a significant increase in the heart load during childbirth.

Acquired heart defects

Acquired heart defects are associated with inflammation of endocardium (inner heart sheath) and myocardium - heart muscle. These inflammations may occur in rheumatism - heart disease and connective tissue, sepsis - generalized infectious damage, atherosclerosis, syphilis. Under the influence of the inflammatory process in the valve, a scar tissue is developing, which causes deformation and shortening of valve flaps or narrowing the hole. As a result, the valve cannot completely close the hole and the valve failure arises. In case of deficiency of the valves during systole (reduction of ventricles), there is a reverse anti-test blood flow from ventricles in the atrium. With stenosis (narrowing) of the left atrioventricular hole during the diastole (relaxation of ventricles), the blood does not have time to move from the atrium into the ventricle. There is a pathological overflow of the left atrium, and the load on it increases. Thus, heart defects lead to blood circulation disorders.

Most often (in 75-90% of cases) the acquired heart defects are developing against rheumatism. (This disease is caused by streptococco - the same microbe, which is usually the causative agent of angina and often strikes women of young age.) The lesions of the heart valves are prevailing - the mitral, located between the left atrium and the left ventricle, and the aortic, located between the left ventricle of the heart and the aorta. These lesions lead to a violation of the normal operation of the valves, the overload of the heart muscle and insufficiency of blood circulation.

Often, stenosis and insufficiency are developing on one valve (the so-called combination vice). In addition, there are cases when the defects affect two or more valves - it is customary to be called a combined heart defect.

As you know, the heart is a hollow muscle body responsible for pumping blood in the body. It consists of four departments. This is the right atrium and the right ventricle, which make up the right heart, and the left atrium and the left ventricles that make up the left heart. Oxygen-rich blood coming from the lungs, in the lung veins falls into the left atrium, from it, in the left ventricle and further in the aorta. The venous blood in the upper and lower hollow veins falls into the right atrium, from there to the right ventricle and further on the pulmonary artery in the lungs, where it is enriched with oxygen and goes back to the left atrium.

Cleaning the heart is called a persistent pathological change in the structure of the heart, which violates its function. The vices of the heart can be congenital and acquired. Congenital heart defects are much less commonly acquired. They arise as a result of violation of the normal development of the heart and mainstream vessels in intrauterine development and amount to 1-2% of all diseases of the heart.

How will pregnancy pass?

Pregnancy The pregnancy depends on the degree and combination of defeat, as well as from the activity of the rheumatic process (in other words, whether its exacerbation is at the moment) and from the severity of circulatory disorders.

The question of preservation or interruption of pregnancy is solved by a collegial cardiologist and an obstetrician-gynecologist in each case individually. If pregnancy has come after the heart surgery, you need a cardiac surgeon consultation. It should be known that far from always corrective heart surgery lead to the elimination of organic changes in the valve apparatus or eliminate congenital developmental abnormalities. Often, after surgery treatment, there is a relapse of the underlying disease, for example, in the form of a restenosis (repeated narrowing) after some operations.

It is extremely difficult to solve the question of the admissibility of pregnancy in women with prosthetized heart valves. They have a high risk of blood cloves, so pregnant women with mechanical valves are constantly obtaining anticoagulant (antoslude) therapy.

Of course, the question of preservation of pregnancy in women with cardiovascular diseases is better to solve in advance, before its offensive. The basis of the right leading and treatment of such pregnant women is the exact diagnosis that takes into account the cause of the disease.

Blood discharge vices right serve as a contraindication to pregnancy, as well as any type of decompensation defects, during which blood circulation failure has already been formed.

Features of pregnancy

Maintaining pregnancy in women with heart defects, as already mentioned above, is carried out with the participation of several specialists. It requires not only the coordinated activities of experts of women's consultation, but also the disciplined behavior of the woman itself: early registering in women's consultation, timely visits to doctors and surrender analyzes, full examination, timely complex treatment.

If there is an opportunity, then, of course, better entrust your health to a large medical center specializing in this problem. This may be a branch for women with cardiovascular pathology at the institute or a specialized branch based on a large maternity hospital, where competent specialists who have experience in conducting patients with such pathology will be able to effectively help.

Pregnancy during women with heart defects has its own characteristics. Often there are complications such as gestosis (complications of pregnancy, manifested by the appearance of edema, protein in the urine, increased blood pressure), which are characterized by a hidden flow and are poorly treatable. Pregnancy in such patients is often complicated by the threat of interrupt - the number of spontaneous abortions and premature genera significantly exceeds the average indicators. In addition, the course of pregnancy may be complicated by the impaired uterine-placental blood flow, which leads to hypoxia (oxygen starvation) or the delay of the intrauterine development. The accumulation of thrombus in the placenta leads to the shutdown of the placenta of the placenta from the blood flow and enhancing the oxygen starvation of the fetus.

For all the above reasons for women with heart defects and other pathology, pregnancy time must be hospitalized in the hospital at least three times:

First hospitalization - on the 8-10th week of pregnancy to clarify the diagnosis and solving the issue of preservation of pregnancy. The question of the interruption of pregnancy up to 12 weeks is solved depending on the severity of the vice, the functional state of the circulatory system and the degree of activity of the rheumatic process.

The second hospitalization is on the 28-29th week of pregnancy to monitor the condition of the cardiovascular system and, if necessary, to maintain a function during the period of maximum physiological loads. This is due to the fact that it was during the period in the norm that the load on the heart increases significantly (one of the periods of maximum physiological load) - almost a third increases the so-called cardiac output, mainly due to the estimation of heart rate.

The third hospitalization - at the 37th - 38th week to prepare for childbirth and the choice of the method of root separation, the preparation of the planning plan.

When signs of insufficiency of blood circulation, the exacerbation of rheumatism, the occurrence of fliccity arrhythmia (frequent non-medical reduction of the heart), gestosis or pronounced anemia (reduction of the amount of hemoglobin) and other complications are necessary hospitalization regardless of the period of pregnancy.

The question of the interruption of pregnancy at the later deadlines is quite complicated. Often, doctors have to decide. What is less dangerous for the patient: interrupt pregnancy or allow it to develop further. In any cases, when signs of insufficiency of blood circulation or any concomitant diseases, the patient must be hospitalized, subjected to a thorough examination, treatment.

If the situation does not require such cardinal measures, pregnant must observe maximum caution. First of all, it is necessary to take care of sufficient holidays and long-term, 10-12 hours sleep. Useful day 1-2 hours. Fully effective means of treatment and prevention are therapeutic physical culture, morning gymnastics, outdoor walks. The complex of morning exercises should be the easiest, not leading to excessive overvoltages, fatigue.

Power must be made as much as possible, full, with a high content of protein products (up to 1.5 g / kg body weight). Reception of polyvitamins is required. In addition, the doctor may assign sessions of hyperbaric oxygenation (sessions in the barocamera, where air with an increased oxygen content is supplied), general ultraviolet irradiation.

Knowledge of birth

The question of medical tactics in childbirth is of particular importance. The best choice is early hospitalization in 36-37 weeks of pregnancy. The plan of delivery is drawn up consultatively with the participation of obstetric, cardiologist or therapist and anesthesiologist. The choice of the method is strictly individual for each patient, depending on the situation.

The advantage remains behind the natural method of delivery. With compensated pounding of the heart, therapy is carried out aimed at preventing heart failure and heart support, the prevention of pulmonary edema, with the possibility of arrhythmia - ECG control. An adequate anesthesia is carried out, since fear and pain lead to an additional load on the heart.

As a rule, the most difficult period of childbirth - sweat (the period of expulsion of the fetus) - try to shorten with episiotomy - dissection of the crotch. Turning off the dyg (the impulse of obstetric forceps) is carried out with circulatory disorders.

Many doctors believe that the delivery of the cesarean section reduces the load on the cardiovascular system and reduces mortality among pregnant women suffering from heart defects.

Cesarean section is carried out in the following cases:

• with an active rheumatic process (increase in temperature, the appearance of pain in the relevant organs, characteristic changes in analyzes);
• with severely pronounced pounding of the heart with a pronounced deficiency of the left ventricle and the absence of the effect of medical therapy;
• with a combination of heart defect with obstetric pathology, requiring surgical delivery.

Successful delivery of patients suffering from severe congenital and acquired heart defects can be facilitated by hyperbaric oxygenation.

After the birth of the severity of the lapse, there is a tide of blood to the internal organs (and primarily to the abdominal organs) and a decrease in blood circulation in the brain vessels and vessels that feed the heart muscle. Therefore, to prevent the deterioration of the state immediately after the birth of a child, women introduce funds to provide normal heart performance.

Modern medicine has sufficient arsenal of diagnostic tools in order to prevent complications of pregnancy in women with heart defects. The following techniques are usually applied:

• Electrocardiography - Registration of electrical phenomena arising in the heart muscle when exciting it. This study allows you to register changes in the heart muscle to change the electrical impulse.
• Phonocardiography - method of registration of sounds (tones and noises) arising from the heart of the heart. It is used to evaluate the work of the heart and recognition of disorders, including valve vices.
• Echocardiography (heart ultrasound). It is used to study blood circulation and cardiodeynamics (heart work), determining the size and volume of heart cavities, assessing the functional state of the heart muscle. The method is harmless to mother and fetus.
• Samples with load are used to estimate the functional state of the heart muscle. Samples with a load on the cyergometer are used in examination of pregnant women - during this sample, the patient remove the ECG with different intensity of physical exertion.
• The study of the function of the external respiration and the acid-alkali state of the blood involves the study of the tank of lungs and the saturation of the blood oxygen alone and under load. The study makes it possible to determine how adequate blood saturation with oxygen, i.e. As far as the heart is coping with the load at the moment.
• Blood studies - usually enough standard analysis, which is carried out during the examination of all pregnant women. However, in this case, the doctor pays special attention to the state of the blood coagulation system.
• Ultrasound of the fetus, cardiotocography, which are regularly held after 28 weeks to estimate the state of the placenta and the fetus. These studies help to find out if the fetus suffers from lack of oxygen and nutrients. In addition, the ultrasound of the fetus allows you to identify possible defects of the child's development before it is born and take appropriate measures - from an urgent surgery after the delivery to the interruption of pregnancy.

Postpartum period

The danger of the occurrence of thrombosis, bleeding and heart failure is preserved up to 5 days after childbirth, so in this period a woman is assigned to bed rest. From the 7th and 11th day with the rheumatic nature of the vice, a study is assigned a study on the activity of rheumatism; The activity of rheumatism is monitored and within a year after delivery.

Pedaries with heart disease can be discharged from the hospital no earlier than 2 weeks after childbirth in a satisfactory condition under the supervision of the cardiologist at the place of residence.

If decompensation after childbirth did not occur and the reception of drugs is not required, preferably breastfeeding.

After the birth of the child, experts necessarily examine it for the presence of heart defects, as in children whose mother had such problems, the risk of their presence increases many times.

Thus, timely diagnosis and proper treatment allow many women who used to be inaccessible to the birth of a child, to feel this joy. And experts are always ready to help them in this.