Pregnancy and Cardiovascular disease

Cardiovascular diseases at pregnant women win first place among all extragenital pathology. Frequency of detection of illnesses of heart at them fluctuates from 0,4 to 4,7 %. Recently the augmentation of number of pregnant women and the parturient women, suffering is observed by cardiovascular diseases that speaks a number of the causes: early diagnostics of diseases of heart, dilating of indications to pregnancy conservation, augmentation of bunch of the women operated on heart, and numbers of seriously sick women which or, or with the permission of doctors decide to keep pregnancy, being assured of success of a medical science and practice.

During pregnancy the cardiovascular system of healthy women undergoes appreciable changes. It is enlarged (to 80 %) minute volume of heart, especially on 26-28 weeks, with gradual depression to sorts. On 30-50 % increases CBV for account CPV, reaching a maximum to 30-36 weeks. The volume of extracellular fluid is enlarged by 5-6 litres. The additional load on cardiovascular system, and, as consequence of it is framed, at 30 % of healthy pregnant women the systolic pulmonic murmur and a heart apex is auscultated, 2nd tint over a pulmonary artery strengthens, excitability and conductivity of a cardiac muscle is broken, there are arrhythmias.

Among the diseases of heart complicating pregnancy, there is a rheumatic disease, the got and congenital heart diseases, anomalies of development of the main pots, illnesses of the myocardium, the operated heart, disturbances of a warm rhythm more often. Educing pregnancy worsens flow of cardiovascular diseases and can lead to development of the extreme conditions demanding carrying out of urgent actions not only from the accoucheur, but also from the therapist, the cardiologist, the surgeon. The lethality of pregnant women, parturient women, the women in childbirth, suffering the got heart diseases, a pulmonary hypertensia, complex congenital faults, acute and chronic cardiovascular insufficiency is high enough.

Rheumatic disease - a general disease of a copulative tissue with a primary lesion of warm system, meets at women of young age is more often; causes b-gemoliticheskim a streptococcus of bunch A. In a disease pathogenesis allergic and immunologic factors matter. With the account of clinical implications and datas of laboratory distinguish active and inactive phases and 3 degrees of activity of process:

1. minimum degree
2. average degree
3. maximum degree

On localisation of active rheumatic process excrete a carditis without fault of valves, a carditis returnable with fault of valves, a carditis without warm implications, arthritises, vasculites, a nephritis etc. At pregnant women the rheumatic disease meets in 2,3 - 6,3 % and its exacerbation arises in 2,5 - 25 % of cases, more often in the first 3 and last 2 months of pregnancy, and also within the first year after sorts.

The got rheumatic heart diseases compound 75-90 % of all lesions of heart at pregnant women. From all forms of faults of a rheumatic parentage mitral faults in the form of a combination of insufficiency and a stenosis of the left atrioventricular foramen, i.e. in the form of the combined mitral fault or mitral illness more often are observed. However in a clinical picture of disease signs either a mitral stenosis, or insufficiency of the two-cuspidate valve usually prevail. Therefore "the mitral stenosis" or "mitral insufficiency" are designated by terms not only pure forms of faults, but also those forms of the combined lesion of valves at which domination of a sign of fault takes place. Clinical symptoms of a mitral stenosis and mitral insufficiency depend on a disease stage.

1. 1 stage - full indemnification
2. 2 stage - a relative circulatory unefficiency
3. 3 stage - an initial stage of the expressed circulatory unefficiency
4. 4 stage - an expressed circulatory unefficiency
5. 5 stage - the dystrophic season of a circulatory unefficiency

It is standard, that insufficiency of the two-cuspidate valve of small degree or the combined mitral fault with prevalence of insufficiency usually has the congenial forecast. Aortal faults meet much less often, than mitral and are mainly combined with other faults. More often prevalence of insufficiency of the aortal valve is found and the stenosis is rarer. The forecast at an aortal stenosis more congenial, than at insufficiency of the aortal valve.

Congenital heart diseases and anomalies of the main pots now it is described more than 50 forms. Frequency of congenital heart diseases at pregnant women fluctuates from 0,5 - 10 % from all diseases of heart. More often defect of an interatrial septum, a patent ductus arteriosus and defect of an interventricular septum is found in pregnant women. Thanks to perfection of diagnostic technics many faults are taped before pregnancy that gives possibility to solve questions on conservation or an abortion. Women with defect of an interatrial septum (9-17 %), a patent ductus arteriosus and defect of an interventricular septum (15-29 %) well enough tolerate pregnancy and labours. At classical "dark blue" faults: a Fallot's tetrad, an Eisenmenger's syndrome, an aorta coarctation, a stenosis of an ostium of a pulmonary artery complications that leads to a lethal outcome 40 - 70 % of pregnant women educe very terrible.

Except these faults flow of pregnancy and sorts can complicate myocardites, myocardial dystrophies, a cardiosclerosis, disturbance of a rhythm of warm reductions. Recently even more often there are pregnant women tolerated operation on heart to pregnancy and even during pregnancy. Therefore the concept about the so-called operated heart in general is introduced and at pregnancy in particular. It is necessary to remember that is far not always resolve operation on heart liquidations of organic changes in the valval apparatus or to elimination of congenital anomalies of development lead. Quite often after surgical treatment basic disease relapse, for example in the form of a restenosis is observed at a commissurotomy. Therefore the question on possibility of conservation of pregnancy and an admissibility of sorts should be solved individual to pregnancy depending on the general condition of the patient.

Each pregnant woman, suffering disease of cardiovascular system should be hospitalised not less than 3 times for pregnancy. The first till 12 weeks it is desirable specialised hospital for careful cardiologic and rheumatological inspection and decision of a question on possibility to prolong pregnancy. At detection 3 and 4 items of risk are shown an abortion after cardial and antirheumatic therapy. The second hospitalisation should is spent to the season of the greatest hemodynamic loads on heart of 28-32 weeks. For inspection and the prof. of treatment. Discontinuing in this season is undesirable. The third obligatory hospitalisation should be for 2 weeks prior to sorts for inspection and preparation for sorts, development of the plan of sorts.

Labours in time (it is spontaneous or with a labour induction) are admissible in those cases, are admissible when by antenatal preparation it was possible to enrich considerably hemodynamic indicators at a safe condition of a foetus. In connection with an aggravation of symptoms of the pregnant woman quite often there is a question on a preschedule delivery. The best result gives a labour induction in 37-38 weeks. The delivery plan is compounded is advisory with participation of the accoucheur, the cardiologist and the resuscitator. A method choice strictly individual for each patient depending on an obstetric and somatic situation. Indications for cesarean sections are strictly circumscribed. The expulsion season to all parturient women is necessary for shortening. At women with a mitral stenosis And the CIRCULATORY UNEFFICIENCY of any degree, with an endocarditis, with the decompensation phenomena in the previous sorts - applying of target obstetric forcepses. And at the others perineotomy effecting.

After a birth of a foetus and an afterbirth discharge the rush of blood to an internals (and first of all to organs of an abdominal lumen) and reduction CBV in pots of a brain and coronary is observed. For the purpose of the prevention of an aggravation of symptoms it is necessary to introduce right after births of the child cardiotonic agents. Women in childbirth with heart diseases can be written out from a maternity home not earlier than in 2 weeks after sorts in a satisfactory condition under observation of the cardiologist on a residence.

Benign Tumors of the Uterus

In the course of practical activities each accoucheur-gynecologist should meet sick of a hysteromyoma - one of the most widespread tumours of generative organs of women. Among gynecologic patients the hysteromyoma is observed at 10-27 %. The Hysteromyoma - a benign tumour educing in a uterus muscular coat - myometriums. The term "hysteromyoma" is the most accepted because gives representation about development of a tumour from a myometrium. The hysteromyoma consists from various on the dimensions of the myomatous knots which are settling down in all layers of a myometrium.

The aetiology of this disease for today is represented as dishormonal disease. In experiments it educes at long and continuous introduction of estrogenic hormones. "Regions of growth" at activation by their estrogens undergo some consecutive stages of development:

1. Formation of an active germ of growth
2. A tachyauxesis of a tumour without differentiation signs
3. An expansive growth of a tumour with its differentiation and maturing

As a rule active regions settle down near to pots and are characterised by high level of an exchange. Specific squirrels-receptors, taking up with hormones forming a complex an estrogen - a receptor.

Each hysteromyoma is plural. Myomatous knots mainly in a body of the womb (95 %) settle down and is much rarer in a neck (5 %). In relation to a muscular wall of a body of the womb distinguish three forms of myomatous knots: subperitoneal, intermuscular and submucosal. Growth of myomatous knots descends towards an abdominal lumen or a cavity of the uterus. The myomatous knots which are settling down more close to intrinsic fauces of a uterus, can grow on a direction of a lateral side of a small basin, settling down between leaves of wide ligament of a uterus (is intraligamentous). Most a tachyauxesis intermuscular and submucosal knots possess. On morphological characters distinguish the simple hysteromyoma educing as benign muscular hyperplasias, a proliferative myoma, the true benign.

Clinical picture of a hysteromyoma in many respects depends on age of the patient, prescription of disease, the localisation of myomatous knots concomitant a genital and extragenital pathology and other factors.

The premorbidal background at sick of a hysteromyoma is often burdened by gynecologic and extragenital diseases. Among the tolerated gynecologic diseases inflammatory diseases of generative organs, dysfunctional uterine bleedings, an endometriosis prevail. The hysteromyoma is quite often combined with cystic changes of ovaries and hyperplastic changes in endometriums.

In initial stages of development of a tumour, that, as a rule, coincides with the genesial season of life of the woman, there is long and abundant menses. In more advanced age, acyclic bleedings which are characteristic for submucosal localisation of knot, intermuscular hysteromyoma with, dysfunctional uterine bleedings can be observed. Menorrhagias at patients with a hysteromyoma can be caused augmentation of an intrinsic surface to which there is a desquamation of an endometrium during a menses. Inferiority of a myometrium and the pots located in a muscular layer, a hyperplasia of an endometrium and rising of its fibrinolitic activity. Rising of a blood loss during a menses, and also joining acyclic bleedings lead to an iron deficiency anaemia.

Quite often sick with a hysteromyoma show complaints to pains. The pain has a various parentage. Constant aching pains in the inferior parts of a gaste, a loin are bound to a peritoneum distention at growth subperitoneal the located knots, pressure of myomatous knots upon neuroplexes of a small basin more often. Sometimes pains happen are caused by dystrophic, necrotic changes in myomatous to the variated uterus. Colicy pains during a menses are characteristic for submucosal localisation of a tumour, a birth of submucosal knot. The locating of myomatous knots in the inferior third of uterus, on its forward or back surfaces can be accompanied by disturbance of function of a bladder or a rectum. The most frequent complication of a hysteromyoma is the necrosis of knot caused by disturbance of its food. Other complication is the torsion of a leg of subperitoneal knot.

Diagnostics at the majority of patients does not represent complexity since at usual gynecologic research the uterus enlarged in the dimensions with a nodulose surface is defined. At born or at the born knot survey by means of mirrors allows to diagnose. At more complex cases the hysteromyoma diagnosis allows to put sounding, an endometrium currettage, ultrasonic, a hysterography or a hysteroscopy.

Hysteromyoma treatment descends now in 2 directions: 1 conservative methods. 2 operative methods. At the decision of a question on a treatment method the age the sick, premorbidal background, concomitant extragenital and gynecologic diseases, hormonal disturbances, character of growth of a tumour and its localisation is considered.

Indications to start conservative treatment are: the small dimension of a tumour the stable dimensions, a moderate menorrhagia. Patients with a hysteromyoma with presence of serious forms of extragenital diseases to which operation is contraindicative also are subject to conservative therapy. Hormonal therapy, a vitamin therapy concern conservative methods.

Contraindication to conservative treatment are following conditions: a submucosal hysteromyoma, intermuscular localisation of knot with centripetal growth and sharp deformation of a cavity of the uterus, a necrosis of myomatous knot, suspicion on a malignant degeneration of a hysteromyoma, a combination of a hysteromyoma to tumours of generative organs of other localisation. As indications to radical surgical treatment of patients with a hysteromyoma the tachyauxesis and the big dimensions of the tumour, the expressed anaemia of the patient in the absence of effect from haemostatic therapy, a submucosal hysteromyoma, a myoma of a neck of a uterus, a knot necrosis, disturbance of function of a bladder and a rectum serve. The surgical intervention, especially at young women, whenever possible should be conservative. At a concomitant pathology of a neck of a uterus and advanced age the operation volume should be maximum.