Pregnancy and cardiovascular diseases. Cardiovascular pathology and pregnancy

General provisions

Note 1

Cardiovascular diseases - a group of diseases extragenital pathology most common in pregnant women.

Among other diseases, it ranks first in maternal and perinatal morbidity and mortality.

Increased performance requirements cordially- vascular system are required even during normal, physiologically occurring pregnancies and childbirths, due to:

• development and growth of the fetus;
• the appearance of the placental circulation;
• an increase in the pregnant woman’s body weight and other changes occurring in the woman’s body.

All diseases of the cardiovascular system can be divided into groups:

• congenital heart defects;
• diseases of the myocardium, pericardium, endocardium;
• rheumatic heart defects and rheumatism;
• “operated heart” condition;
• hypotension;
• hypertonic disease;
• systemic lupus erythematosus.

Rheumatism and rheumatic heart defects

Streptococcal infection plays a major role in the occurrence of rheumatism.

The prognosis of birth outcomes for rheumatic heart defects largely depends on

• nosological form of the disease;
• the nature of gynecological disorders;
• condition of the myocardium and other organ systems;
• features of pregnancy;
• some external factors.

Mitral valve insufficiency

Mitral valve insufficiency can develop with:

• rheumatism;
• septic endocarditis;
• systemic lupus erythematosus;
• scleroderma;
• cardiosclerosis;
• myocarditis.

Forecast of the course and outcomes of pregnancy, labor activity, as a rule, favorable.

Possible complications:

• pulmonary edema;
• atrial fibrillation;
• hemoptysis;
• paroxysmal atrial tachycardia.

Diseases of the myocardium, endocardium, pericardium

Myocardial diseases are represented by inflammatory and non-inflammatory etiology and are presented

• myocarditis;
• cardiosclerosis;
• myocardial dystrophies;
• myocardiopathies.

Endocardial diseases are divided into subacute, acute and protracted septic endocarditis. The disease is caused by streptococci or staphylococci. A characteristic feature is the growth of formations on the valve leaflets, parietal endocarditis, chordae tendineae various shapes and sizes, consisting of platelets, fibrin, polymorphic leukocytes.

Most often, the aortic, mitral valve, or both valves are affected.

At bacterial endocarditis It is recommended to terminate the pregnancy. Termination of pregnancy may be accompanied by heart failure and thromboembolic complications.

• for allergic conditions;
• for collagenosis;
• as an accompaniment of metabolic disorders;
• after heart surgery;
• with radiation damage.

Systemic lupus erythematosus

Definition 2

Systemic lupus erythematosus is a collagen disease accompanied by impaired immune processes.

Most often occurs in women aged 18 to 25 years.

The disease is detected during pregnancy, after abortion and childbirth, stressful situations(mental trauma, surgery, etc.), after taking certain medicines(individual intolerance to antibiotics, sulfonamides).

Diagnostic criterion: the presence of specific antibodies and lupus cells in the blood.

Clinical manifestations – with slow or rapid progression.

Forms of lupus erythematosus:

• endocardial;
• visceral;
• polyarthritic;
• anemic;
• renal;
• neuropsychic.

Kidney damage, accompanied by pronounced changes, indicates progression of the process and can quickly lead to death.

Often the symptoms are polymorphic:

• skin manifestations;
• lung damage;
• cardiac changes;
• defeat lymphatic vessels and spleen;
• thromboembolic complications;
• vasculitis.

Pregnancy aggravates the general painful condition and is contraindicated in most cases.

Operated heart

The admissibility of pregnancy in women who have undergone surgery is taken into account:

• activity of the rheumatic process;
• the effectiveness of the operation;
• pulmonary hypertension;
• possible relapse of the disease;
• heart failure, etc.

During a physiologically proceeding pregnancy and especially during childbirth, circulatory conditions arise under which the load on the cardiovascular system significantly increases.

Pregnancy and childbirth place significant demands on the function of the heart due to an increase in blood mass 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, 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 position of the diaphragm, which reaches its greatest extent by the 36th week of pregnancy. The high position of the diaphragm, according to V.V. Saikova, reduces its function as an additional engine of blood circulation, reduces the vital capacity of the lungs, complicates pulmonary circulation and entails a displacement of the heart; in this case, the heart does not so much rise as approach the chest and at the same time rotate somewhat around its axis. A change in the position of the heart is accompanied by a relative “twisting” of the vessels that bring and carry away blood, which also causes difficulty in pulmonary circulation.

The main changes in hemodynamics during pregnancy are reduced to an increase in circulating blood mass (volume of plasma and red blood cells), minute and stroke volumes, number of heartbeats, and blood flow speed.

The increase in circulating blood mass occurs gradually. At the same time, the volume of circulating blood in 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 liquid (plasma), which causes a decrease specific gravity blood and the occurrence of “plethora of pregnancy”. While the amount of circulating blood during pregnancy increases by 30%, the hemoglobin content increases only by 15%; the hematocrit decreases.

As the duration of pregnancy increases, 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 blood volume is caused mainly by an increase in stroke volume and, to a lesser extent, by an increase in heart rate. In this case, the systolic volume increases by 25-50%, reaching 70-80 ml versus 60-65 ml in non-pregnant women. The speed of blood flow in pregnant women, equal to 10 s in the “hand-ear” section at the beginning of pregnancy, increases slightly towards the end of it (11-13 s). The heart rate of healthy pregnant women increases even at rest. In this case, tachycardia is observed in more than 50% of pregnant women.

When talking 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. 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, a major role is played by the functional state of the body, its nervous system, caused by both exogenous and endogenous factors;
• in the absence of pathological changes in the state of the cardiovascular system, blood pressure changes relatively little during pregnancy and even during childbirth.

In the first half of pregnancy, systolic, diastolic and pulse pressure decreases slightly, and from 6-7 months there is a tendency to increase (especially diastolic). Many authors talk about a wave-like rise in maximum blood pressure, starting from about the 6th month of pregnancy, but it remains within the physiological norm.

However, it must be emphasized that if in women with a normal initial blood pressure value of 110-120/70-80 mm Hg. Art. it rises in the second half of pregnancy above 130-135/80-90 mm Hg. Art., this should be regarded as a signal of a possible onset pathological condition vascular system on soil.

It must be remembered that during childbirth there are often sharp fluctuations in hemodynamics, which is also reflected in changes in blood pressure levels.

After opening amniotic sac blood pressure usually decreases, sometimes quite sharply. Therefore, V.V. Stroganov recommends early opening of the membranes as a preventive method of treating eclampsia.

During the second and third stages of labor, rapid and sharp 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 pregnancy, while in the femoral veins it increases markedly.

When assessing the state of the cardiovascular system in pregnant women, gas exchange rates should also be taken into account. As pregnancy progresses, vital capacity of the lungs (VC) decreases, maximum ventilation of the lungs and oxygen saturation of arterial blood decreases, and the amount of under-oxidized metabolic products increases (the content of lactic acid increases). At the same time, the minute volume of breathing (MVR) increases and the efficiency of using oxygen in the inhaled air increases. In the body of pregnant women, the oxygen reserve is significantly reduced and regulatory capabilities are extremely strained. Particularly significant circulatory and respiratory changes occur during childbirth. An increase in heart rate, an increase in stroke and minute volumes, blood pressure, tissue oxygen consumption, an increase in the concentration of lactic and pyruvic acids, etc. are detected.

Studies by Adams and Alexander showed an increase in heart function during contractions by 20%, and after the passage of the placenta by 18%. During labor, 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. Their degree of expression depends on general condition the body of a pregnant woman, its ability to quickly and fully adapt to new, unusual conditions of the external and internal environment, from diseases suffered in the past. In determining these abilities of the pregnant woman’s body big 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 bordering on significant impairment of the functions of the cardiovascular system.

The most common 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 expulsion of the fetus. Immediately after the end of labor, most often in the first hours of the postpartum period, if there was no significant blood loss during childbirth, bradycardia is observed with a slowdown in heart rate to 60-70 beats/min.

Tachycardia in pregnant women - 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 during labor can reach a significant degree, especially during the period of fetal expulsion. The reasons are as follows:

• great physical stress;
• pronounced negative emotions (pain, fear);
• relative oxygen starvation increasing towards the end of childbirth.

Relative hypoxemia , along with mechanical factors that complicate the normal functioning of the cardiovascular system and reduce vital capacity, causes the occurrence of 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 the second half of pregnancy there is also a mechanical factor, shortness of breath in pregnant women should be attributed to mixed look. During contractions and especially pushing, the oxygen saturation of the blood is significantly reduced, because the process of childbirth combines holding the breath, intense muscle work and a significant depletion of the oxygen reserve. All this is one of the prerequisites for the appearance of shortness of breath in pregnant women and women in labor.

However, the body's adaptive mechanisms 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 enlargement of 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 blood mass, b) some difficulty in moving the gradually increasing blood mass. However, minor 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 performance of the heart increases, which, according to the literature, increases by an average of 50% compared to the period before pregnancy.

Significant increase during pregnancy in the absence of valvular disease or inflammatory process in the myocardium indicates a decrease in the contractility of the heart.

Auscultation, as many authors indicate, in some pregnant women (about 30%), especially in the second half of pregnancy, a soft blowing systolic murmur is detected at the apex of the heart and on the pulmonary artery. These noises can be heard in a completely healthy cardiovascular system and are purely functional in nature. Thus, the systolic murmur in the pulmonary artery depends on its temporary relative narrowing due to some inflection caused by the high position of the diaphragm, which changes normal location heart and great vessels. A systolic murmur at the apex of the heart indicates slight functional insufficiency of the mitral valve. These noises disappear soon after birth, which confirms 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, causing diagnostic difficulties (displacement of the borders of the heart, the appearance of murmur, emphasis of the second tone on the pulmonary artery, extrasystole). It is often difficult to decide whether they are a manifestation of organic heart disease or caused by physiological changes caused by pregnancy.

To assess the functional state of the cardiovascular system in pregnant women, electrocardiography (ECG), vectorcardiography (VCG), ballisto- and phonocardiography (BCG and FCG) 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 indicator, an increase in the QRST segment and T wave in leads I and III. With increasing gestational age, certain changes in FCG are observed, due to difficulty in pulmonary circulation and increased pressure in the pulmonary circulation. They boil down to an increase in the distance Q(R) of the ECG to the 1st FCG tone (from 0.035 to 0.05 s), a change in the 2nd tone due to an increase in the amplitude of its second component, an increase in the distance T ECG - the 2nd FCG tone (from 0.03 to 0.05 s), the appearance of additional sound phenomena - systolic murmur, an increase in the amplitude of the second sound 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 very 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, greater blood filling of the vessels of the pelvis and abdominal cavity, an increase in pressure in them, and, consequently, a corresponding increase in peripheral resistance.

With increasing gestational age, the amplitude of respiratory oscillations IJ increases, the ballistocardiographic index (BI) decreases, the respiratory index (RI) increases, Brown's grade I changes and disturbances in the ratios of ballistocardiogram waves - JK/IJ, KL/IJ, KL/JK are noted.

BCG changes in healthy women are the result of blood overflow in the pelvic vessels, an increase in venous inflow to the right heart, and changes in the anatomical axis of the heart due to its horizontal position.

At physiological course During pregnancy, there are noticeable changes in vascular permeability associated with disruption of the functional state of vascular membranes and changes in capillary circulation.

Capillaroscopic studies reveal an increase in the number of capillary loops, their expansion, mainly of the venous part, the presence of a more turbid background, pericapillary edema, and a slowdown in blood flow.

IN last years it has been proven that an increase in cardiac output (and changes in other hemodynamic parameters) occurs from the beginning of pregnancy, increasing only until the 28-32nd week, after which it gradually decreases.

As is known, the main load on the cardiovascular system is observed immediately after the expulsion of the fetus against a background of relative rest. Due to a sudden decrease in intra-abdominal pressure, an immediate restructuring of the entire blood circulation should occur. At this moment, the vessels of the abdominal cavity quickly fill with blood. There is a sort of bleeding into the vessels of the abdominal cavity. 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 during the period of expulsion, especially towards the end of it, the woman in labor necessarily experiences a state of relative hypoxia; To eliminate it, the heart must work hard, with tension.

A healthy body and a healthy cardiovascular system have the ability to easily and quickly adapt to the often significant and sudden changes hemodynamics , and therefore, in a healthy woman in labor, as a rule, the necessary coordination in the circulatory system quickly occurs. However, with certain defects in the functioning of the heart, most often it is in the third stage of labor that its functional insufficiency can 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 to know what pathological changes in this system lead to dangerous disturbances during childbirth.

In cases of unclear diagnosis, the pregnant woman should definitely be sent to a hospital (at the beginning of pregnancy - to a therapeutic hospital, in the third trimester - to a hospital) for in-depth clinical examination, observation and treatment.

Cardiovascular diseases occupy one of the leading places in the structure of extragenital pathology. Maternal mortality with this pathology comes in 3rd-4th place, behind bleeding and preeclampsia.

The generally accepted point of view is that with an active rheumatic process, pregnancy is unacceptable. It is also contraindicated in severe valve defects (mitral valve stenosis of III-IV degree and others), decompensated heart failure, high pulmonary hypertension, multivalve defects, especially in the stage of decompensation. However, pregnant women with such heart lesions are admitted to the hospital, in some cases categorically refusing to terminate the pregnancy. In such situations, it is necessary to choose the right treatment methods and tactics, taking into account not only the danger of progression of the pathology for the mother, but also the negative effect of many drugs on the fetus.

To select the optimal tactics for managing a pregnant woman and the method of delivery, it is necessary to establish an accurate diagnosis (clarification of the heart defect), determine the nature and severity of hemodynamic disorders, the activity of the rheumatic process (with rheumatic defects), the presence of arrhythmia, and the condition of other vital organs - liver, kidneys, lungs; and, of course, the peculiarities of the obstetric situation must be taken into account.

Preoperative clinical and laboratory examination of such patients must necessarily include echocardiography with determination of the contractility of the left ventricular myocardium, ECG and CVP indicators over time; clinical and biochemical tests, coagulogram, electrolytes, acid-base status and blood gases, tests for the activity of the rheumatic process; Chest radiography and spirometry are additionally performed as prescribed by specialists. Consultation with a cardiologist or cardiac surgeon is necessary.

Pathophysiology of heart failure

The consequence of cardiovascular pathology, as a rule, is heart failure: with valvular lesions of the heart, hypertension, cardiomyopathy - this is chronic heart failure, with myocardial infarction - acute.

The main clinical signs of heart failure are tachycardia, decreased exercise tolerance and shortness of breath, peripheral edema, congestion in the pulmonary circulation and cardiomegaly. The consequence of decreased cardiac output is an inadequate response to physical activity with rapid onset of muscle weakness.

External neurohumoral reflex compensation for decreased cardiac output includes two main mechanisms: sympathetic nervous system, increasing peripheral vascular resistance, heart rate and strength, and venous tone, as well as the renin-angiotensin-aldosterone hormonal response. The latter, through the retention of sodium and water ions, leads to an increase in blood volume and, as a result, to edema. On the other hand, increased sympathetic activity and increased arterial tone cause an increase in afterload, reduce the ejection fraction, cardiac output and renal perfusion.

The internal compensatory mechanism of chronic heart failure is myocardial hypertrophy, which can maintain cardiac activity under conditions of pressure or volume load or decreased cardiac contractility. However, subsequently, against the background of hypertrophy, ischemia and impaired diastolic filling may develop.

In practice, to determine the severity of hemodynamic disorders, they use the classification of heart failure according to N. D. Strazhesko - V. X. Vasilenko (1953) or the classification of the New York Association of Cardiologists, which identifies the following functional classes(FC).

The spectrum of cardiovascular diseases is quite wide. Among them are acquired and birth defects heart and large vessels, rheumatism, myocarditis, cardiomyopathies and other myocardial diseases, rhythm and conduction disorders, hypertension. The most common pathology listed is heart defects.

Why is heart disease dangerous?

Heart disease aggravates the course of pregnancy, causing an increase in the frequency premature birth, lag intrauterine development fetus At the same time, in a significant proportion of patients, as pregnancy progresses, symptoms of cardiovascular failure increase, which sometimes becomes life-threatening for the woman.

The basis of numerous forms of the disease is circulatory disorders. As a result, the supply of oxygen-rich arterial blood to organs and tissues is reduced, which leads to oxygen deficiency in the body of the pregnant woman and woman in labor, as well as in the fetus.

As pregnancy progresses, the load on the cardiovascular system increases, and in severe forms of the defect complications may arise - pulmonary edema, congestion in the liver, multiple tissue edema.

Management of pregnancy in women with heart defects

Over the past decades, thanks to the successes of cardiology and especially cardiac surgery, as well as the possibility early diagnosis diseases, including intrauterine ultrasound diagnostics, the possibility arose of treating exacerbation of the rheumatic process, and most importantly - surgical correction of heart disease during pregnancy and in postpartum period. Given the complexity of the problem, specialized maternity for pregnant women with cardiovascular diseases. In Moscow, such an institution since 1965 is maternity hospital at the city clinical hospital No. 67, where the majority of 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 pathology departments, pregnant women receive the necessary treatment, including surgical care in leading cardiac surgery institutions in Moscow. Timely surgical treatment allows you to correct existing cardiac pathology and significantly reduce the risk upcoming birth and successfully complete the postpartum period.

Regardless of the severity of heart pathology, patients with such diseases are hospitalized three times during pregnancy. The first time a woman is admitted to the hospital at 8-10 weeks to clarify the diagnosis and decide on the possibility of continuing the pregnancy (the need to terminate the pregnancy arises if there are signs of heart failure, exacerbation of rheumatism at the beginning of pregnancy; if the pregnancy was not terminated, then after 12 weeks an appropriate treatment). The second time a pregnant woman is hospitalized at 28-30 weeks - during the period of greatest stress on the heart, and the third time - 3 weeks before childbirth - to prepare for it.

During the process of observation and treatment in the pregnancy pathology department, the 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 illness, 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 the heart defect, the stage of development of the disease, as well as on the obstetric situation - the size of the pelvis, the size of the fetus, presentation of the fetus and placenta. For most women with heart defects, vaginal delivery is preferable, given the immediate large release of blood from the uterus into the bloodstream during cesarean section and the increased load on the maternal cardiovascular system. For moderate heart disease, interventions are used that eliminate pushing during the third stage of labor (obstetric forceps, vacuum extraction). Indications for surgical delivery are severe forms of heart failure and valve prostheses in the heart.

Childbirth in women with cardiovascular diseases is usually carried out in a semi-sitting position or in a side lying position. This makes it possible to reduce the flow of venous blood to the heart, and the pregnant uterus puts less pressure on one of the large venous collectors - the inferior vena cava.

The following complications occur in pregnant women with heart disease:

• Premature birth. It should be noted that for patients suffering from heart disease, it is quite difficult 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 functioning of the heart.
• Bleeding complicating the postpartum period, since in case of 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, breathing 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, antibacterial drugs are usually used during childbirth. Since women with pathologies of the cardiovascular system are at risk for bleeding, immediately after childbirth this complication is prevented by intravenous administration METHYLERGOMETRINE, which improves not only uterine contractions, but also blood supply to the lungs.

After childbirth, depending on the type of heart defect, some women in labor are recommended, but some are contraindicated, to place a weight on their stomach - the doctor monitoring the woman during childbirth knows this in advance.

Childbirth and caesarean section are carried out under careful anesthesia to avoid progression of heart failure and pulmonary edema. For pain relief, both relatively new methods are used - epidural anesthesia, and endotracheal anesthesia, which has been used for many decades.

Pregnancy with hypertension

Often a woman suffering hypertension, finds out about her disease only in the antenatal clinic when her blood pressure is measured for the first time. A feature of this disease is the addition of gestosis 1 , most often developing by the 28th -30th week of pregnancy. This complication manifests itself as edema, increased blood pressure, and the appearance of protein in the urine. The first manifestations of gestosis in women with hypertension require urgent hospitalization in the pregnancy pathology department 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 advanced course of gestosis in the second half of pregnancy threatens the woman’s health and can lead to serious complications in the form of seizure- eclampsia, unsafe for a woman’s life. To prevent such a serious complication, it is necessary to visit regularly antenatal clinic from the early stages of pregnancy and undergo timely treatment in a maternity hospital.

Heart transplant

In accordance with modern recommendations, pregnancy after heart transplantation should be planned taking into account individual characteristics women. These include the risk of graft rejection and the development of infectious complications, the full functioning of the graft, as well as the need to take potentially toxic and teratogenic drugs. In the absence of signs of graft rejection and preserved ventricular function, pregnancy is usually successful.

A woman's examination aimed at detecting transplant rejection should be carried out both before and during pregnancy. During this period, you can reduce the dose of immunosuppressants by increasing the frequency of monitoring. Depending on the indication for transplantation (eg, mitochondrial myopathy or familial dilated cardiomyopathy), prior genetic counseling may be required. During pregnancy in such women, LV function should be constantly monitored to prevent complications such as hypertension, infection, premature birth, intrauterine growth restriction and preeclampsia.

In patients regularly taking cyclosporine and tacrolimus, dose adjustment is required during pregnancy. When drugs are used in recommended doses, no teratogenic or mutagenic effect has been registered, and the prevalence of developmental anomalies in newborn children does not exceed that in the population. It should be noted that both cyclosporine and tacrolimus can cause intrauterine growth restriction, low birth weight births, and fetal size discrepancy gestational age. The choice of delivery method is determined by obstetric indications.

Hypertension and preeclampsia

Arterial hypertension is the most common complication of pregnancy, occurring in 10% of women and having a significant impact on the risk of complications and mortality in newborns. Arterial hypertension and its complications are one of the leading causes of maternal mortality, accounting for 15% of deaths in pregnant women. Normally, in the first half of pregnancy, blood pressure decreases, and from the 30th week it returns to the level that existed before pregnancy, or increases moderately. Hypertension that occurs during pregnancy (arterial hypertension of pregnant women) should be differentiated from pre-existing or chronic arterial hypertension. The development of these diseases is based on various factors, and their treatment tactics also differ. Both forms of arterial hypertension can cause the development of proteinuria and preeclampsia.

Preeclampsia causes half of all induced preterm births and is one of the main problems of the antenatal period, so early diagnosis is of particular importance.

During pregnancy, blood pressure may change when the woman's body position changes, which is explained by physiological characteristics. It should be measured while sitting (optimally) or lying on your left side. A rise in systolic blood pressure to 140-159 mm Hg, and diastolic blood pressure to 90-109 mm Hg. should be regarded as moderate arterial hypertension. An increase in these indicators is more than 160 and 110 mmHg. accordingly, it is considered severe arterial hypertension. When examining patients with this syndrome, for the early diagnosis of preeclampsia, it is recommended to monitor the concentration of hemoglobin, creatinine, uric acid, albumin, hematocrit, platelet count, transaminase activity, lactate dehydrogenase, blood coagulation parameters and the volume of protein excretion.

Chronic hypertension is considered to be an increase in systolic blood pressure of more than 140 mm Hg. or diastolic pressure above 90 mm Hg. before the onset or 20th week of pregnancy.

If an increase in blood pressure above the specified values ​​(systolic - more than 140 mm Hg, diastolic - above 90 mm Hg) is not accompanied by proteinuria and was first registered in the second half of pregnancy (after the 20th week), then hypertension is called gestational . If left untreated, arterial hypertension in pregnant women can cause the development of preeclampsia, which is manifested by an increase in blood pressure by later pregnancy and concomitant proteinuria (1+ with qualitative definition and protein concentration in urine more than 0.3 g/l). Hypertension is only one symptom of preeclampsia, the severity of which varies widely. In some cases, in patients with severe preeclampsia, blood pressure remains normal.

In women with arterial hypertension, abdominal pain, neurological disorders, thrombocytopenia and small in size Preeclampsia can be suspected in the fetus even in the absence of proteinuria. Preeclampsia develops in 3-8% of pregnant women. It is believed that its occurrence is based on damage to the mother’s blood vessels involved in the blood supply to the placenta. Preeclampsia is accompanied by multiple organ dysfunction and endothelial damage blood vessels, manifesting vascular spasm, activation of the blood coagulation system, dysfunction of hormones and biologically active substances that control blood pressure and circulating blood volume.

Risk factors for the development of this pathological condition include dyslipidemia, diabetes mellitus or insulin resistance, as well as multiple pregnancy accompanied by hypercoagulation. One epidemiological study suggested that women with a history of preeclampsia had an increased risk of developing CVD, but this assumption was not confirmed by the results of prospective studies. Based on the knowledge accumulated to date, active treatment aimed at correcting risk factors for the development of CVD is recommended for women with arterial hypertension (including preeclampsia) during pregnancy.

The diagnosis of preeclampsia is established when a pregnant woman with arterial hypertension suddenly develops proteinuria, which was absent at baseline. early stages pregnancy, or after the 20th week, pre-existing hypertension and proteinuria begin to increase. Delivery is considered a radical treatment for hypertension in pregnant women. Since this syndrome predominantly develops in late pregnancy, preference is given to delivery through caesarean section. If severe arterial hypertension occurs in the early stages, it is recommended to terminate pregnancy, since against this background the incidence of preeclampsia and eclampsia can reach 100%.

The goal of treating arterial hypertension is to reduce the risk of complications in a woman. The drugs used must be sufficiently effective and safe for the fetus. IN clinical studies The benefits of antihypertensive therapy for chronic or moderate arterial hypertension arising during pregnancy have not been proven. If clinical indications exist (development of renal failure), such patients are prescribed antihypertensive drugs. First choice drugs for hypertension medium degree severity - methyldopa and labetalol. Second-line agents include nifedipine. Taking into account the pathophysiology of preeclampsia (hypoperfusion of internal organs), the use of diuretics is not recommended.

It is generally accepted that severe arterial hypertension in pregnant women requires treatment aimed at reducing the risk of developing hemorrhagic stroke and, accordingly, maternal mortality. The drugs of first choice are labetalol (start with an IV bolus at a dose of 20 mg, and if there is no effect, the dose is repeated every 10 minutes until a maximum dose of 220 mg is reached) and hydralazine (start with an IV bolus at a dose of 5 mg with repeated administration in the same dose every 20 minutes until the pressure stabilizes). If parenteral administration of drugs is not possible, preference is given to nifedipine.

Complete regression of arterial hypertension and clinical signs Preeclampsia usually occurs within 6 weeks after birth. If symptoms persist, a re-examination is recommended after another 6 weeks. In some cases, when risk factors exist, hypertension in pregnant women transforms into chronic arterial hypertension.

The incidence of preeclampsia during subsequent pregnancies is determined by the severity of the process during the first pregnancy. If preeclampsia first developed in the very late stages of pregnancy and was of moderate severity, then the risk of recurrence in a subsequent pregnancy is 10%. At early development and severe preeclampsia it reaches 40%.

Arrhythmogenic right ventricular cardiomyopathy

Arrhythmogenic cardiomyopathy of the pancreas is characterized by progressive fibrosis of the pancreas myocardium or its replacement by fibrofatty tissue. This disease also includes the occurrence of asymptomatic PVCs, VT and SCD. The literature describes many cases where, after installing a defibrillator in women with this syndrome, pregnancy proceeded without complications. If a woman has such cardiomyopathy, constant monitoring is recommended heart rate during pregnancy. Delivery tactics are determined based on obstetric indications.

Long QT syndrome

According to studies conducted among women suffering from long term syndrome QT interval, within 9 months after delivery, the risk of developing an adverse cardiac event (mainly fainting) increases by 2.7 times, and a life-threatening condition (cardiac arrest or sudden death against the background of the syndrome) - 4.1 times compared to the state before pregnancy. This statement is especially true for women with type II syndrome. After this period, the risk indicator returns to its previous values. During pregnancy, the risk of developing cardiac complications in this group of patients remains low.

It has been proven that the use of β-blockers can significantly reduce the incidence of complications in patients with congenital long QT interval syndrome, and therefore this treatment should be resumed in the postpartum period. In type II syndrome in the postpartum period, dynamic ECG monitoring is recommended every 1-2 weeks, which will detect a prolongation of the Q-T interval of more than 500 ms compared to the state before pregnancy.

Patrizia Presbitero, Giacomo G. Boccuzzi, Christianne J.M. Groot and Jolien W. Roos-Hesselink

Pregnancy and cardiovascular diseases