Therapeutic nutrition in diseases of the cardiovascular system. Diseases of the cardiovascular system in pregnant women
It depends on the so-called physiological plethora of pregnant women, when the total blood mass rises to 21% of the presence of additional uteroplacental circulation, high diaphragm standing in the last months of pregnancy and the resulting restriction of lung excursions, heart displacement. The cardiovascular system during childbirth is in a state of great tension, especially in the period of exile. Increased demands are placed on her in the afterbirth period and soon after the end of childbirth (early postpartum period), when, due to the relatively rapid emptying of the uterus, the pressure in the abdominal cavity drops sharply.
With a well-pronounced regulatory ability of the organism, observed in a healthy pregnant woman, all this does not have a noticeable negative effect on the course of pregnancy, childbirth, unless there are other complicating circumstances.
The situation is different if the regulatory capacity of the pregnant woman's body is insufficient, and especially if this deficiency is combined with organic changes in the cardiovascular system. The most dangerous of the complications is circulatory failure. It can occur in the first months of pregnancy, but is more often observed in the second half of it. This complication occurs especially easily in the period of exile with instability of cardiac compensation, if this period lasts more than an hour or, conversely, if it is very short (several minutes), but too energetic. Overstrain of the nervous and muscular systems, which in such cases reaches high degrees, in combination with a sudden violation of hemodynamics, adversely affects the work of the heart. Patients with myoendocarditis of rheumatic etiology are most prone to decompensation for the indicated reasons.
Compensation of the cardiovascular system can also be disturbed due to bleeding, which relatively often complicates childbirth, especially in the afterbirth and early postpartum period. In case of failure of the cardiovascular system and, which is especially important, when the body's strength is exhausted (painfulness of the birth process, fatigue of the woman in labor during prolonged labor, etc.), even a small blood loss, for example, 300 ml, can cause an acute violation of cardiovascular compensation .
Of the various forms of diseases of the cardiovascular system, the least dangerous during pregnancy is steadfastly compensated mitral valve insufficiency. With this pathology, there is rarely a violation of cardiovascular compensation during childbirth and in the postpartum period, unless during the entire pregnancy the compensation was not violated and childbirth was not complicated by a narrow pelvis, nephropathy, placenta previa, polyhydramnios, multiple pregnancy, incorrect position of the fetus, incorrect insertion of the head in the pelvis, hypertension, etc. In the presence of at least one of these complications, circulatory failure may occur with all the ensuing consequences.
Pregnant women with mitral disease, with a predominance of mitral valve stenosis, require special attention. In such cases, long-term and dangerous circulatory disorders are observed in almost half of pregnant women.
In case of detection of a disease of the cardiovascular system, active medical supervision should be established for the pregnant woman. In the presence of one of the diseases of the cardiovascular system dangerous to health, it is necessary to establish the presence of indications for artificial termination of pregnancy already in the early stages of pregnancy. These indications include: endocarditis, anatomical lesions of the heart valves, damage to the muscles of the heart and pericardium with initial symptoms of circulatory failure, mitral stenosis (decompensated, subcompensated, compensated), syphilitic mesaortitis. An induced miscarriage is also indicated if a pregnant woman has hypertension and persistent hypertension of pregnant women (toxicosis) that cannot be treated in a hospital.
Termination of pregnancy in terms of more than 12 weeks is permissible only in case of circulatory failure, which is not eliminated in a hospital.
If a woman persistently wants to keep her pregnancy, despite her indications for an induced miscarriage, she should be admitted to a hospital for a comprehensive examination of the functional state of the cardiovascular system and a final decision regarding the possibility of further continuation of the pregnancy. In this case, all diagnostic methods should be used whenever possible, including fluoroscopy, radiography, roentgenogram, electrocardiography, etc.
Pregnant women with signs of circulatory failure should be immediately admitted to the hospital. Here they are examined in detail, a course of treatment is carried out according to the principles set forth in the course of therapy. They can be discharged from the hospital only after the restoration of stable compensation. In case of repeated occurrence of circulatory failure, pregnant women should remain in the hospital until delivery.
Conducting childbirth in patients with cardiovascular diseases is a very responsible matter. They must be carried out with anesthesia; during childbirth, the doctor must constantly monitor the condition of the woman in labor and widely use cardiac agents, glucose, and oxygen.
Following the birth of a child, in order to prevent collapse, which can occur due to a sharp decrease in intra-abdominal pressure and hemodynamic disturbances, a sandbag should be placed on the mother's stomach.
In parturient women with a predominance of stenosis of the left atrioventricular opening, in whom decompensation of cardiac activity occurred during the previous birth, the opening period is carried out expectantly, using cardiac agents, while in the period of exile, operative delivery is indicated (usually forceps are applied).
In case of a very severe condition of the patient at the end of pregnancy or at the beginning of childbirth with symptoms of acute circulatory failure or insufficiency that could not be eliminated, despite treatment in a hospital, in exceptional cases, a caesarean section can be performed under local anesthesia "as a delivery operation. It should not be forgotten that delivery by caesarean section is a dangerous intervention in case of heart disease, which can worsen the already serious condition of the patient.
In the subsequent and early postpartum period, it is necessary to strictly monitor the amount of blood lost and the general condition of the woman, since in such patients blood loss even up to 300 ml can lead to circulatory disorders. The follow-up period must be carried out strictly expectantly. With a blood loss of more than 300 ml, it is advisable to transfuse 200 ml of single-group blood by the drip method, prescribe oxygen, glucose under the skin (500 ml of a 5% solution) and heart funds. In the postpartum period, especially in the case of surgery, preventive measures should be taken to prevent postpartum infections (penicillin, sulfa drugs, etc.).
All pregnant women, women in childbirth and puerperas who have diseases of the cardiovascular system, due to the weakening of the body, are extremely susceptible to various kinds of infections. Diseases such as influenza, tonsillitis and postpartum septic infection often complicate the course of pregnancy, childbirth, and the postpartum period. Often, the causative agents of a general infection are microbes that grow on the heart valves with various kinds of endocarditis of septic or rheumatic origin. Therefore, pregnant women with heart lesions should be taken into special account even in the antenatal clinic. Here, they are placed under special supervision and, through sanitary and educational propaganda, they are taught the correct scientifically based behavior in order to prevent possible complications.
Among the most serious complications, depending on the state of the cardiovascular system, one should also include the sudden death of a woman in labor or puerperium, in particular from an embolism.
Cardiovascular disease in pregnant women occupy the first place among all pathology. The frequency of detection of heart disease in them ranges from 0.4 to 4.7%. Recently, there has been an increase in the number of pregnant women and women in labor suffering from cardiovascular diseases, which is explained by a number of reasons: early diagnosis of heart diseases, an increase in indications for maintaining pregnancy, an increase in the group of women undergoing heart surgery, and the number of seriously ill women who are either themselves, or with the permission of doctors decide to keep the pregnancy, being confident in the success of medical science.
During pregnancy, the cardiovascular system of healthy women undergoes significant changes.. The minute volume of the heart increases (up to 80%), especially at 26-28 weeks, with a gradual decrease towards childbirth. The volume of circulating blood increases by 30-50%, reaching a maximum by the 30-36th week. The volume of extracellular fluid increases by 5-6 liters. An additional load is created on the cardiovascular system, and, as a result, in 30% of healthy pregnant women, a systolic murmur is heard over the pulmonary artery and the apex of the heart, the 2nd tone over the pulmonary artery intensifies, the excitability and conduction of the heart muscle are disturbed, and arrhythmias occur.
Among the heart diseases that complicate pregnancy, the most common are:
- acquired and congenital heart defects;
- anomalies in the development of the main vessels;
- myocardial disease;
- operated heart;
Developing pregnancy worsens the course of cardiovascular diseases and can lead to the development of extreme conditions that require urgent measures not only from the obstetrician, but also from the therapist, cardiologist, and surgeon.
Every pregnant woman suffering from a disease of the cardiovascular system must be hospitalized at least 3 times during pregnancy.
The first hospitalization is desirable before the period of 12 weeks (in a specialized hospital for a thorough cardiological and rheumatological examination). In some cases, termination of pregnancy after cardiac and antirheumatic therapy may be indicated.
The second hospitalization should be carried out during the period of greatest hemodynamic stress on the heart (weeks 28-32).
The third mandatory hospitalization should be 2 weeks before delivery for examination and preparation for childbirth, development of a birth plan.
Delivery at term is acceptable in cases where prenatal preparation has significantly improved hemodynamic parameters with a favorable condition of the fetus. In connection with the deterioration of the pregnant woman, the question often arises of early delivery.. The best result is given by labor induction at 37-38 weeks. The delivery plan is drawn up consultatively with the participation of an obstetrician, cardiologist and resuscitator. The choice of method is strictly individual for each patient, depending on the obstetric situation, but the period of exile for all women in labor must be shortened. Indications for caesarean section are strictly limited.
After the birth of the fetus and the discharge of the placenta, in order to prevent deterioration of the condition, it is necessary to administer cardiotonic agents immediately after the birth of the child. Women in childbirth with heart disease can be discharged from the maternity home no earlier than 2 weeks after birth in a satisfactory condition under the supervision of a cardiologist at the place of residence.
PREGNANCY AND CARDIOVASCULAR DISEASES.
Cardiovascular diseases in pregnant women are
take the first place among all extragenital pathology.
The frequency of detection of heart disease in them ranges from 0.4
up to 4.7%. Recently, there has been an increase in the number of
pregnant and parturient women suffering from CVD, which is explained next
reasons: early diagnosis of heart disease, expansion
indications for maintaining pregnancy, an increase in the group of women
women operated on the heart, and the number of seriously ill women
chins who either themselves or with the permission of doctors decide to save
hurt pregnancy, being confident in the success of medical
science and practice.
During pregnancy, the cardiovascular system is healthy
women is undergoing significant changes. Increases-
sya (up to 80%) minute volume of the heart, especially at 26-28 weeks
delah, with a gradual decline to childbirth. At 30-50% of age -
no BCC due to BCP, reaching a maximum by 30-36 weeks. At 5-6
liters increases the volume of extracellular fluid. Created
additional load on the CCC, and, as a result,
30% of healthy pregnant women have a systolic murmur over
pulmonary artery and the apex of the heart, the 2nd tone increases
above the pulmonary artery, excitability and conduction are disturbed
bridge of the heart muscle, arrhythmias occur.
Among the heart diseases that complicate pregnancy, more often
all there are rheumatism, acquired and congenital
heart defects, anomalies in the development of the main vessels,
myocardial lesions, operated heart, cardiac disorders
rhythm. Developing pregnancy worsens the course of CVD and may
can lead to the development of extreme conditions requiring
carrying out urgent measures not only from the obstetrician, but also
from the therapist, cardiologist, surgeon. Fairly high lethality
ness of pregnant women, women in childbirth, puerperas suffering from
heart defects, pulmonary hypertension, complex congenital
malformations, acute and chronic CHF.
Rheumatism is a systemic connective tissue disease with
predominant lesion of the cardiac system, more common
occurs in young women; caused by β-hemolytic
group A streptococcus. In the pathogenesis of the disease,
chenie allergic and immunological factors. Taking into account
clinical manifestations and laboratory data distinguish between acute
active and inactive phases and 3 degrees of process activity:
1 is the minimum, 2 is the average and 3 is the maximum degree. by locale-
zations of an active rheumatic process allocate carditis without
valvular disease, recurrent carditis with valvular disease, kar-
children without cardiac manifestations, arthritis, vasculitis, nephritis and
etc. In pregnant women, rheumatism occurs in 2.3 - 6.3%, and
its exacerbation occurs in 2.5 - 25% of cases, most often in
the first 3 and in the last 2 months of pregnancy, as well as during those
the first year after childbirth.
Acquired rheumatic heart disease is
75-90% of all heart lesions in pregnant women. Of all the forms
rheumatic origin is most often observed
mitral defects in the form of a combination of insufficiency and stenosis
left atrioventricular orifice, i.e. in the form of a combination
mitral valve disease or mitral disease. However
the clinical picture of the disease is usually dominated by signs
ki or mitral stenosis, or insufficiency of bicuspid-
chat valve. Therefore, the terms "mitral stenosis" or
"mitral insufficiency" refers not only to pure
forms of defects, but also those forms of combined lesion of the
pans, in which there is a dominance of the sign of
ka. Clinical symptoms of mitral stenosis and mitral
insufficiency depend on the stage of the disease according to the class
sifications of A.N.Bakulev and E.A.Damir 1st grade - full compensation,
2nd grade - relative circulatory failure. 3st.-
the initial stage of severe circulatory failure.
4th grade - severe circulatory failure, 5th grade - distant
rheic period of circulatory insufficiency. Generally accepted
that bicuspid valve insufficiency is small
degree or combined mitral valve disease with a predominance
insufficiency usually has a favorable prognosis. Aortal-
nye defects are much less common than mitral and
predominantly combined with other vices. More often
the predominance of aortic valve insufficiency is found
pan and less often stenosis. The prognosis for aortic stenosis is more
favorable than in aortic valve insufficiency.
Congenital heart defects and anomalies of the main vessels
At present, more than 50 forms have been described. Frequency vrozh-
congenital heart defects in pregnant women ranges from 0.5 - 10%
from all heart diseases. Most often in pregnant women,
there is an atrial septal defect, non-closure of the arte-
rial duct and ventricular septal defect. Blah
Thanks to the improvement of diagnostic technology, many
roki are detected even before the onset of pregnancy, which gives
the ability to resolve issues of saving or interrupting
changes. Women with an atrial septal defect
(9-17%), non-closure of the arterial duct and an inter-
ventricular septum (15-29%) are quite well tolerated
pregnancy and childbirth. With classic "blue" vices: tet-
Rade of Fallot, Eisenmeiger's syndrome, aortic coarctation, stenosis
the mouth of the pulmonary artery develop very formidable complications,
which leads to death in 40-70% of pregnant women.
In addition to these defects, the course of pregnancy and childbirth can be
false myocarditis, myocardial dystrophy, myocarditis
cardiosclerosis, cardiac arrhythmias. In the village
during the winter, more and more pregnant women are
who underwent heart surgery before pregnancy and even during
pregnancy. Therefore, the concept of the so-called operation
rirovanny heart in general and during pregnancy in particular.
It should be remembered that not always corrective
heart surgery leads to the elimination of organic changes
nenies in the valvular apparatus or the elimination of congenital anoma-
ley development. Often, after surgical treatment,
there is a recurrence of the underlying disease, for example, in the form of resteno-
for commissurotomy. Therefore, the question of the possibility of saving
of pregnancy and the admissibility of childbirth should be decided in-
individually before pregnancy, depending on the general condition
patient.
Every pregnant woman suffering from CVD should
be hospitalized at least 3 times during pregnancy.
First up to 12 weeks. preferably a specialized hospital
for a thorough cardiological and rheumatological examination
research and resolve the issue of the possibility of prolonging the
precariousness. If 3 and 4 risk levels are detected, an interruption is shown
pregnancy after cardiac and antirheumatic therapy
FDI. The second hospitalization should be carried out during the period of
large hemodynamic loads on the heart 28-32 weeks. For
surveys and prof. treatment. Interruption during this period is
laterally. The third mandatory hospitalization must be
2 weeks before childbirth for examination and preparation for childbirth, expressing
childbirth plan boots.
Term delivery (spontaneous or with labor induction) is acceptable
in cases admissible in those cases when prenatal
preparation managed to significantly improve hemodynamic
indicators for a healthy fetus. Due to the deterioration
solving the condition of a pregnant woman often raises the question of early
nominal delivery. The best result is given by labor induction
at 37-38 weeks. The delivery plan is drawn up consultatively
with the participation of an obstetrician, cardiologist and resuscitator. Choice of method
strictly individual for each patient, depending on
obstetric and somatic situation. Indications for caesarean section
sections are strictly limited. The period of exile for all women in labor
need to be shortened. In women with mitral stenosis AND NOT-
SUFFICIENCY of blood circulation of any degree, with endocardi-
volume with decompensation phenomena in previous births - overlay
weekend obstetrical forceps. And the rest have no production
rhineotomy.
After the birth of the fetus and the discharge of the placenta, there is
a rush of blood to the internal organs (and primarily to the or-
ganam of the abdominal cavity) and a decrease in BCC in the vessels of the brain
brain and coronary. In order to prevent deterioration of the
it is necessary immediately after the birth of the child to introduce cardio-
tonic agents. Parents with heart disease may
be discharged from the rod.home no earlier than 2 weeks later. after
delivery in a satisfactory condition under the supervision of cardio-
log at the place of residence.
BENIGN TUMORS OF THE UTERINE.
In the process of practical activity, each obstetrician-gi-
a non-cologist has to meet patients with uterine fibroids - one
of the most common tumors of the genital organs of women
tires. Among gynecological patients, uterine fibroids are observed
in 10-27%. Myoma of the uterus is a benign tumor developing
yasya in the muscular membrane of the uterus - myometrium. The term "myoma"
atki" is the most accepted because it gives an idea
leniye about development of a tumor from a myometrium. uterine fibroids are
from myomatous nodes of various sizes, located
in all layers of the myometrium.
The etiology of this disease is currently represented
lyatsya as dishormonal disease. In experiments, she
develops with prolonged and continuous administration of estrogen-
nyh hormones. "Growth zones" when activated by estrogen pre-
suffer several successive stages of development: 1st.
the formation of an active growth germ 2st. rapid tumor growth
whether without signs of differentiation. 3st. expansive growth
tumors with their differentiation and maturation. As a rule, ak-
active zones are located next to the vessels and are characterized by
high level of metabolism. Specific receptor proteins, enter-
solder in connection with hormones forming an estrogen-receptor complex.
Each uterine fibroid is multiple. located
myomatous nodes mainly in the body of the uterus (95%) and much
to less often in the neck (5%). In relation to the muscular wall of the body
uterus, there are three forms of myomatous nodes: subperitoneal,
intermuscular and submucosal. The growth of myomatous nodes occurs
dit towards the abdominal cavity or uterine cavity. Myomatous
nodes located closer to the internal os of the uterus, can
grow in the direction of the side wall of the small pelvis, located
between the sheets of the broad ligament of the uterus (intraligamentary).
The fastest growing are intermuscular and submucosal
nodes. According to morphological features, simple myoma is distinguished
uterus, developing as a benign muscular gi-
perplasia, proliferative myoma, true benign
The clinical picture of uterine fibroids largely depends on
age of the patient, duration of the disease, localization of fibroids
pelvic nodes, concomitant genital and extragenital
pathology and other factors.
The premorbid background in patients with uterine myoma is often aggravated
gynecological and extragenital diseases. Among
transferred gynecological diseases are dominated by inflammatory
litelnye diseases of the genital organs, dysfunctional ma-
precise bleeding, endometriosis. Uterine fibroids are often combined
lurks with cystic changes in the ovaries and hyperplastic
mi changes in the endometrium.
In the initial stages of tumor development, which, as a rule,
coincides with the reproductive period of a woman's life, appear
prolonged and profuse menstruation. At an older age,
acyclic bleeding may be observed, which is characteristic
thorns for submucosal localization of the node, intermuscular fibroids
uterus with DMK. Menorrhagia in patients with uterine myoma may be
due to the increase in the inner surface, with which
desquamation of the endometrium occurs during menstruation. Not-
the usefulness of the myometrium and vessels located in the muscle
layer, endometrial hyperplasia and an increase in its fibrinolytic
chesky activity. Increased blood loss during menstruation
tions, as well as joining acyclic bleeding with
lead to iron deficiency anemia.
Often, patients with uterine fibroids complain of
whether. Pain has a different origin. Constant aching
pain in the lower abdomen, lower back is most often associated with
stretching of the peritoneum with the growth of subperitoneally located nodes
fishing, pressure of myomatous nodes on the nerve plexuses of the small
pelvis. Sometimes pains are caused by dystrophic, necrotic
some changes in the myomatous uterus. Contraction
various pains during menstruation are characteristic of the submucosa
localization of the tumor, the birth of a submucosal node. Location-
myoma nodes in the lower third of the uterus, on its anterior
or rear surfaces may be accompanied by a violation
functions of the bladder or rectum. The most frequent
a complication of uterine fibroids is node necrosis due to
disruption of his diet. Another complication is torsion
legs of the subperitoneal node.
Diagnosis in most patients is not difficult.
ness, because in a routine gynecological examination, determine
the enlarged uterus with a nodular surface is divided
ness. When a node is being born or when a node is born, examination with
the power of mirrors allows you to make a diagnosis. With more complex
cases, the diagnosis of uterine fibroids allows you to put probing
curettage of the endometrium, ultrasound, hysterography or hysterography
roscopy.
Treatment of uterine fibroids currently occurs in 2
directions: 1 conservative methods. 2 operational methods.
When deciding on the method of treatment, age is taken into account
patient, premorbid background, concomitant extragenital and
gynecological diseases, hormonal disorders, characteristic
tumor growth rate and its localization.
Indications for starting conservative treatment are:
small tumor size, stable size, moderate menopause
ragia. Conservative therapy is also subject to patients with myo-
my uterus with the presence of severe forms of extragenital diseases
vaniya, which is contraindicated in surgery. To conservative
methods include hormone therapy, vitamin therapy.
Contraindications to conservative treatment are the following:
blowing conditions: submucosal uterine fibroids, intermuscular lo-
node localization with centripetal growth and sharp deformation
uterine cavity, necrosis of the myomatous node, suspicion of malignancy
qualitative degeneration of uterine fibroids, a combination of uterine fibroids
kis tumors of the genital organs of another localization. Testimony
to radical surgical treatment of patients with uterine myoma
are the rapid growth and large size of the tumor, expressed
anemization of the patient in the absence of the effect of hemostatic
therapy, submucosal uterine fibroids, cervical fibroids, necrosis
node, dysfunction of the bladder and rectum. Hee-
surgical intervention, especially in young women,
capabilities should be conservative. With concomitant
pathology of the cervix and the elderly, the volume of the operation should be
The spectrum of cardiovascular diseases is quite wide. Among them are acquired and congenital malformations of the heart and large vessels, rheumatism, myocarditis, cardiomyopathy and other myocardial diseases, rhythm and conduction disturbances, and hypertension. The most common pathology of these are heart defects.
What is dangerous heart disease?
Heart disease aggravates the course of pregnancy, causing an increase in the frequency of premature birth, lagging intrauterine development of the fetus. At the same time, in a significant part of patients with an increase in the duration of pregnancy, symptoms of cardiovascular insufficiency increase, which sometimes becomes life-threatening for a woman.
At the heart of numerous forms of the disease is a violation of blood circulation. As a result, the flow of oxygen-rich arterial blood to organs and tissues decreases, which leads to oxygen deficiency in the body of the pregnant woman and the woman in labor, as well as in the body of the fetus.
In the process of pregnancy, the load on the cardiovascular system increases, and in severe forms of the defect, complications can occur - pulmonary edema, congestion in the liver, and multiple tissue edema.
Management of pregnancy in women with heart defects
Over the past decades, thanks to the advances in cardiology and especially cardiac surgery, as well as the possibility of early diagnosis of the disease, including intrauterine ultrasound diagnosis, it has become possible to treat an exacerbation of the rheumatic process, and most importantly, to surgically correct heart disease during pregnancy and the postpartum period. Considering the complexity of the problem, specialized maternity hospitals for pregnant women with cardiovascular diseases have been created in Moscow and a number of large Russian cities. In Moscow, since 1965, such an institution has been the maternity hospital at the city clinical hospital No. 67, where most of the pregnant women suffering from one or another disease of the cardiovascular system are observed.
The presence of a consultative and diagnostic center often makes it possible to detect a heart defect in a patient or to clarify the form of the defect and the stage of its development. In the departments of pathology, pregnant women receive the necessary treatment, including surgical care in leading cardiosurgical institutions in Moscow. Timely surgical treatment makes it possible to correct the existing cardiac pathology, significantly reduce the risk of future childbirth and successfully complete the postpartum period.
Regardless of the severity of the pathology of the heart, patients with such diseases are hospitalized three times during pregnancy. The first time a woman enters the hospital at 8-10 weeks to clarify the diagnosis and decide whether the pregnancy can be continued (the need to terminate the pregnancy occurs if there are signs of heart failure, exacerbation of rheumatism at the beginning of pregnancy; if the pregnancy has not been terminated, then after 12 weeks, an appropriate treatment). The second time a pregnant woman is hospitalized at 28-30 weeks - during the period of the greatest load on the heart, and the third - 3 weeks before childbirth - to prepare for them.
In the process of observation and treatment in the pregnancy pathology department, a woman and her relatives are informed in detail about the nature of the disease, the prognosis for the health of the mother and fetus, and the method of delivery. In especially severe cases of the disease, a woman is offered termination of pregnancy in the interests of her health.
Childbirth in women with heart defects
The nature of delivery in patients with cardiovascular diseases depends on the form of heart disease, on the stage of development of the disease, as well as on the obstetric situation - the size of the pelvis, the size of the fetus, fetal presentation and placenta. For most women with heart defects, vaginal delivery is preferable, given the simultaneous large release of blood from the uterus into the bloodstream during cesarean section and the increased load on the cardiovascular system of the woman in labor. In moderate heart diseases, interventions are used that exclude attempts during the third stage of labor (obstetrical forceps, vacuum extraction). Indications for operative delivery are severe forms of heart failure and valve prostheses in the heart.
Childbirth in women with cardiovascular disease is usually carried out in a semi-sitting position or lying on its side. This reduces the flow of venous blood to the heart, and the pregnant uterus squeezes less one of the large venous collectors - the inferior vena cava.
In pregnant women with heart disease, the following complications occur:
- premature birth. It should be noted that it is quite difficult for patients suffering from heart disease to choose drugs that help maintain pregnancy, since most of these drugs affect the smooth muscles of not only the uterus, but also the heart and blood vessels, worsening the work of the heart.
- bleeding complicating the postpartum period, since with heart failure the liver suffers, which normally produces substances involved in the process of blood clotting.
Heart disease can be complicated by the occurrence of acute heart failure during childbirth.
Doctors closely monitor the condition of the woman in labor: they determine the pulse rate, respiratory rate, and regularly measure blood pressure. For patients at risk of arrhythmias, childbirth is carried out under cardiac monitoring. They also monitor the amount of urine excreted, since its decrease indicates congestion.
Since altered valves are more susceptible to infection, antibiotics are usually used during childbirth. Since women with pathology of the cardiovascular system are at risk for bleeding, immediately after childbirth, this complication is prevented by intravenous administration. METHYLERGOMETRIN, which improves not only uterine contractions, but also the blood supply to the lungs.
After childbirth, depending on the type of heart disease, it is recommended for part of the women in labor, and for some it is contraindicated to put weight on the stomach - the doctor who observes the woman during childbirth knows this in advance.
Childbirth and caesarean section are carried out with careful anesthesia to avoid the progression of heart failure and pulmonary edema. For anesthesia, both relatively new methods are used - epidural anesthesia, and endotracheal anesthesia, which has been used for many decades.
Pregnancy with hypertension
Quite often, a woman suffering from hypertension finds out about her disease only at the antenatal clinic during the first measurement of blood pressure. A feature of this disease is the addition of gestosis 1 , more often developing by the 28-30th week of pregnancy. This complication is manifested by edema, increased blood pressure, the appearance of protein in the urine. The first manifestations of preeclampsia in women with hypertension require urgent hospitalization in the department of pregnancy pathology for appropriate treatment. The progression of gestosis adversely affects the intrauterine development of the fetus, leads to a delay in its growth, and in severe cases, to its intrauterine death. The neglected course of preeclampsia in the second half of pregnancy threatens the woman's health and can lead to a serious complication in the form of a convulsive seizure - eclampsia, which is unsafe for a woman's life. To prevent such a serious complication, it is necessary to regularly attend a antenatal clinic from early pregnancy and undergo timely treatment in a maternity hospital.
With a physiologically proceeding pregnancy and especially in childbirth, such conditions of blood circulation arise under which the load on the cardiovascular system increases significantly.
Pregnancy and childbirth impose significant demands on the function of the heart due to an increase in the mass of blood and the total weight of the pregnant woman, the emergence of a new link in the systemic circulation (uteroplacental circulation), changes in all types of metabolism, the functions of the endocrine apparatus, and the central nervous system.
In the second half and especially towards the end of pregnancy, mechanical factors also become of considerable importance, to a certain extent complicating the normal functioning of the cardiovascular system, mainly the high standing of the diaphragm, which reaches its greatest degree by the 36th week of pregnancy. The high standing of the diaphragm, according to VV Saykova, reduces its work. at the same time, the heart does not so much rise as it approaches the chest and at the same time rotates somewhat around its axis. A change in the position of the heart is accompanied by a relative "twisting" of the vessels that bring and take away blood, which also causes difficulty in pulmonary circulation.
The main changes in hemodynamics during pregnancy are reduced to an increase in the mass of circulating blood (volume of plasma and erythrocytes), minute and stroke volumes, the number of heartbeats, and blood flow velocity.
The increase in the mass of circulating blood occurs gradually. At the same time, the volume of circulating blood at 28-32 weeks of pregnancy increases by approximately 30-40%, amounting to 5-5.3 liters in the first trimester of pregnancy, and 6.0-6.5 liters in the third. The amount of circulating blood increases mainly due to the liquid (plasma), which leads to a decrease in the specific gravity of the blood and the appearance of "pregnant plethora". While the amount of circulating blood during pregnancy increases by 30%, the hemoglobin content increases by only 15%; hematocrit is reduced.
With an increase in the duration of pregnancy, the minute volume of blood also increases - from 5.5 liters at the beginning of pregnancy to 6.4-7 liters at 28-32 weeks of pregnancy.
The increase in minute volume of blood is mainly due to an increase in stroke volume and, to a lesser extent, an increase in heart rate. At the same time, the systolic volume increases by 25-50%, reaching 70-80 ml versus 60-65 ml in non-pregnant women. The blood flow velocity in pregnant women, equal to 10 s in the “hand-ear” section at the beginning of pregnancy, slightly increases towards the end of it (11-13 s). The pulse rate in healthy pregnant women increases even at rest. At the same time, tachycardia is observed in more than 50% of pregnant women.
Speaking about the level of blood pressure during pregnancy and childbirth in women with a healthy cardiovascular system, it is necessary to remember two circumstances:
- you need to know the dynamics of blood pressure before pregnancy and from the very beginning of it. The degree of excitability of the vasomotor apparatus in different women is different, and in changes in blood pressure, and in the state of vascular tone, the functional state of the body, its nervous system, due to both exogenous and endogenous factors, plays an important role;
- in the absence of pathological changes in the state of the cardiovascular system, blood pressure during pregnancy and even during childbirth changes relatively slightly.
In the first half of pregnancy, systolic, diastolic and pulse pressure decreases slightly, and from 6-7 months there is a tendency to increase it (especially diastolic). Many authors speak of a wave-like rise in maximum blood pressure, starting from about the 6th month of pregnancy, but it remains within the physiological norm.
Nevertheless, it must be emphasized that if women with a normal initial blood pressure value of 110-120 / 70-80 mm Hg. Art. there is a rise in the second half of pregnancy over 130-135 / 80-90 mm Hg. Art., this should be regarded as a signal of the possible onset of a pathological state of the vascular system on the soil.
At the same time, it must be remembered that in childbirth, sharp fluctuations in hemodynamics are often observed, which is also reflected in changes in the level of blood pressure.
After the opening of the fetal bladder, blood pressure usually decreases, sometimes quite dramatically. Therefore, V.V. Stroganov recommends early opening of the fetal bladder as a preventive method of treating eclampsia.
In the second and third stages of labor, rapid and abrupt changes in the rise and fall of blood pressure are observed. Venous pressure in the upper extremities (in the vein of the elbow) does not change significantly with increasing gestational age, while in the femoral veins it increases markedly.
When assessing the state of the cardiovascular system in pregnant women, gas exchange indicators should also be taken into account. As pregnancy develops, the vital capacity of the lungs (VC) decreases, the maximum ventilation of the lungs and oxygen saturation of arterial blood decrease, the amount of under-oxidized metabolic products increases (the content of lactic acid increases). At the same time, the minute volume of breathing (MOD) increases, and the efficiency of the use of oxygen in the inhaled air increases. In the body of pregnant women, the oxygen reserve is significantly reduced and the regulatory capabilities are extremely stressed. Particularly significant circulatory and respiratory changes occur during childbirth. An increase in heart rate, an increase in stroke and minute volumes, blood pressure, oxygen consumption by tissues, an increase in the concentration of lactic and pyruvic acids, etc. are detected.
Studies by Adams and Alexander showed an increase in the work of the heart during contractions by 20%, and after the discharge of the placenta - by 18%. During the birth act, the work of the heart increases by 5%! and more compared to the state of rest (V. X. Vasilenko). All of the above factors cause the emergence and development of that symptom complex of complaints and clinical manifestations, which undoubtedly indicates some changes and known tension in the functions of the cardiovascular system in pregnant women. However, these changes in the body of a healthy pregnant woman are physiological. The degree of their severity depends on the general condition of the pregnant woman's body, its ability to quickly and fully adapt to new, unusual conditions of the external and internal environment, from past diseases. In determining these abilities of the body of a pregnant woman, a large role belongs to the central nervous system. The symptom complex of functional changes that occur in most pregnant women can be different, from barely noticeable phenomena that almost do not cause any complaints, to those that are on the verge of significant impairment of the functions of the cardiovascular system.
The most frequent complaints, especially in the second half of pregnancy, often presented by healthy pregnant women, are shortness of breath, palpitations, general weakness, and sometimes dizziness. The pulse rate reaches 90-100 beats / min, increasing even more during childbirth, especially during the period of fetal expulsion. Immediately after the end of childbirth, most often in the first hours of the postpartum period, if there was no significant blood loss during childbirth, bradycardia is observed with a slowing of the pulse to 60-70 beats / min.
Tachycardia in pregnancy - one of the usual reactions of the heart. In the vast majority of cases, tachycardia in pregnant women with a healthy cardiovascular system is a temporary phenomenon. It weakens and disappears as the woman's body adapts to new external and internal stimuli.
Tachycardia in childbirth can reach a significant degree, especially during the period of expulsion of the fetus. Its reasons are as follows:
- great physical stress;
- pronounced negative emotions (pain, fear);
- increasing relative oxygen starvation towards the end of labor.
Relative hypoxemia , along with mechanical factors that impede the normal functioning of the cardiovascular apparatus and reduce VC, causes shortness of breath, which many women complain to a greater or lesser extent in the second half of pregnancy. Shortness of breath in healthy pregnant women may be due to metabolic disorders with a pronounced shift towards acidosis and relative hypoxemia. Since, in addition, a mechanical factor acts in the second half of pregnancy, dyspnea of pregnant women should be classified as a mixed type. During contractions and especially attempts, oxygen saturation of the blood is significantly reduced, because in the process of childbirth, breath holding, intense muscular work and a significant depletion of the oxygen reserve are combined. All this is one of the prerequisites for the appearance of shortness of breath in pregnant women and women in childbirth.
However, the adaptive mechanisms of the body allow the vast majority of women to adapt well to the inevitable functional changes that occur during pregnancy, and serious disturbances in the activity of the cardiovascular system usually do not occur.
In pregnant women, there is a slight increase in the heart due to some hypertrophy and expansion of the left ventricle. This depends on a number of interrelated reasons: a) an increase in the total mass of blood, b) some difficulty in moving a gradually increasing mass of blood. However, slight hypertrophy and expansion of the heart develop slowly and gradually, and the heart has time to adapt to the increased demands placed on the cardiovascular system.
During pregnancy, the working capacity of the heart increases, which, according to the literature, increases by an average of 50% compared with the period before pregnancy.
A significant increase during pregnancy in the absence of valvular disease or inflammation in the myocardium indicates a decrease in cardiac contractility.
Auscultatory, as many authors point out, in some pregnant women (approximately 30%), especially in the second half of pregnancy, a soft blowing systolic murmur is determined at the apex of the heart and on the pulmonary artery. These noises can be heard in a perfectly healthy cardiovascular system and are purely functional in nature. So, the systolic murmur in the pulmonary artery depends on its temporary relative narrowing due to some inflection due to the high standing of the diaphragm, which changes the normal arrangement of the heart and large vessels. Systolic murmur at the apex of the heart indicates a slight functional insufficiency of the mitral valve. These murmurs disappear shortly after delivery, confirming their functional origin.
Features of blood circulation during pregnancy, mainly in the second half of it, cause the appearance of a number of clinical symptoms that cause diagnostic difficulties (displacement of the borders of the heart, the appearance of noise, accent II tone on the pulmonary artery, extrasystole). It is often difficult to decide whether they are a manifestation of organic heart disease or are caused by physiological changes due to pregnancy.
To assess the functional state of the cardiovascular system in pregnant women, electrocardiography (ECG), vectorcardiography (VCG), ballisto- and phonocardiography (BCG and PCG) are of particular importance. ECG changes in pregnant women are reduced to the appearance of the left type, a negative T wave in lead III, an increase in the systolic index, an increase in the QRST segment and a T wave in leads I and III. With an increase in the duration of pregnancy, certain changes in PCG are noted, due to the difficulty of pulmonary circulation and an increase in pressure in the pulmonary circulation. They come down to an increase in the distance Q (R) of the ECG to the I tone of the FCG (from 0.035 to 0.05 s), a change in the II tone due to an increase in the amplitude of its second component, an increase in the distance T ECG - the II tone of the FCG (from 0.03 to 0.05 s), the appearance of additional sound phenomena - systolic murmur, an increase in the amplitude of the second tone in the pulmonary artery, its splitting and bifurcation.
During pregnancy, the vectorcardiogram also changes - the area of the QRS loop increases by more than 40% by the end of pregnancy.
The ballistocardiogram also changes quite significantly during pregnancy. In the second half of pregnancy, the K wave increases and deepens, which is associated with an increase in blood flow in the descending aorta, a large blood supply to the vessels of the small pelvis and abdominal cavity, an increase in pressure in them, and, consequently, a corresponding increase in peripheral resistance.
With an increase in the gestational age, the amplitude of respiratory oscillations IJ increases, the ballistocardiographic index (BI) decreases, the respiratory index (RI) increases, changes in the first degree according to Brown and violations of the ratios of the ballistocardiogram waves - JK / IJ, KL / IJ, KL / JK.
Changes in BCG in healthy women are the result of overfilling of the pelvic vessels with blood, an increase in venous flow to the right heart, and changes in the anatomical axis of the heart due to its horizontal position.
During the physiological course of pregnancy, there are noticeable changes in vascular permeability associated with a violation of the functional state of vascular membranes and a change in capillary circulation.
Capillaroscopic studies reveal an increase in the number of capillary loops, their expansion, mainly in the venous part, the presence of a more turbid background, pericapillary edema, and slowing of blood flow.
In recent years, it has been proven that an increase in minute volume (and a change in other hemodynamic parameters) occurs from the beginning of pregnancy, increasing only up to the 28-32nd week, after which it gradually decreases.
As you know, the main load on the cardiovascular system is observed immediately after the expulsion of the fetus against the background of relative rest. Due to the sudden decrease in intra-abdominal pressure, an immediate restructuring of the entire circulation must occur. At this point, the vessels of the abdominal cavity quickly overflow with blood. There is a kind of bleeding into the vessels of the abdominal cavity. The blood flow to the heart decreases, and the heart works faster, but with a significant decrease in systolic volume - “half empty” (G. M. Salgannik and others). Meanwhile, increased work of the heart at this moment is also required because in the period of exile, especially towards the end of it, a state of relative hypoxia necessarily occurs in the woman in labor; to eliminate her heart must work hard, with tension.
A healthy body, a healthy cardiovascular system have the ability to easily and quickly adapt to often significant and sudden changes in hemodynamics , in connection with which, in a healthy woman in labor, as a rule, the necessary coordination in the circulatory system occurs quickly. However, with certain defects in the work of the heart, most often it is in the third stage of labor that its functional insufficiency may be revealed. It is possible and necessary to foresee and prevent the occurrence of circulatory failure, for which it is necessary to study in advance the state of the cardiovascular system of each pregnant woman and know what pathological changes in this system cause dangerous violations in childbirth.
In cases of an unclear diagnosis, a pregnant woman should definitely be sent to a hospital (at the beginning of pregnancy - to a therapeutic one, in the third trimester - to) for an in-depth clinical examination, observation and treatment.