Extragenital and concomitant diseases during pregnancy. Kidney anomalies and pregnancy
Currently, the number of women suffering from chronic somatic diseases and wishing to have a child is steadily increasing. Extragenital pathology is an unfavorable background for the development of pregnancy, which exacerbates all the complications that occur during pregnancy, childbirth and the postpartum period. The therapist observes pregnant women with a wide variety of extragenital pathologies (EGP), and it is much easier for him than for an obstetrician-gynecologist to assess the degree of risk to the health and life of the patient with a particular disease, against which the pregnancy developed or was complicated.
The EGP frequency is quite high. According to various authors, heart defects are observed in 2-5% of pregnant women, hypertension in 1.5-2.5%, kidney disease in 5-6%, diabetes mellitus in 1-2%, diseases gastrointestinal tract and hepatobiliary system in 1-3%, etc. According to the most conservative estimates, EGP is diagnosed in 15-20% of pregnant women. According to the report of obstetric hospitals, 70% have extragenital pathology and only 30% are absolutely healthy women.
Consider the most common diseases detected in pregnant women.
Hypertonic disease(GB) - observed in 4-8% of pregnant women. Among pregnant women with hypertension, chronic hypertension is detected in about 30% of cases, gestational (occurring during pregnancy) hypertension in 70%.
Prior pregnancy, even mild arterial hypertension (AH), increases the risk of complications during pregnancy and childbirth by 2 times (increased risk premature birth placental abruption, retinal detachment, eclampsia, massive coagulopathy).
Despite the existence of a unified concept of chronic arterial hypertension, it is important to timely differentiate hypertensive conditions. Symptomatic hypertension of renal origin, occurs with proteinuria and, in parallel with the stabilization of blood pressure, requires treatment of the underlying kidney disease, and such forms of hypertension as pheochromocytoma, renovascular arterial hypertension, primary aldosteronism, arterial hypertension caused by congenital heart disease (CHD) and acquired heart disease (PPP), provide surgical methods treatment.
Vegetative-vascular dystonia (VVD) - functional disorders of the regulation of vascular tone, leading to an increase in blood pressure, which occur in 45% of pregnant women.
Hypertensive VSD can occur in pregnant women of any age. Usually, blood pressure rises with negative emotions, stress and is easily stopped by sedatives. Only the systolic pressure figures increase, while the diastolic pressure remains in the same place.
Light form VSD does not require medical treatment.
Diseases of the cardiovascular system (CVS) - occur in 1% of pregnant women, this is associated with a decrease in rheumatic diseases and, accordingly, a decrease in the number of women with acquired heart defects (ACD).
If before pregnancy the disease of cardio-vascular system were asymptomatic, then the patients tolerate the onset of pregnancy well, but if there are symptoms of circulatory insufficiency, prosthetic surgery is recommended, and then pregnancy.
Big role in diseases of the cardiovascular system has the presence of symptoms of heart failure (HF). For I and II classes cardiovascular pathology when the clinical manifestations of the disease and heart failure are absent or minimal, you can give birth, but it is possible to increase heart failure at 20-34 weeks, due to the volemic load. In class III and IV, mortality from heart failure during pregnancy is high.
Bronchial asthma (BA) - the incidence has increased significantly in the past three decades and, according to the WHO, it is among the most common chronic diseases. The prevalence of bronchial asthma in pregnant women varies from 1 to 8%. At the same time, it has been proven that bronchial asthma leads to a complication of the course of pregnancy. The most frequent of them are preeclampsia (46.8%), threatened miscarriage (27.7%), fetoplacental insufficiency (53.2%). To the immediate causes of the complicated course of pregnancy in patients bronchial asthma include: hypoxia, immune disorders, disorders of hemostasis and metabolism.
Gastroesophageal reflux disease (GERD) – the main symptom is heartburn and occurs in approximately ½ of pregnant women, reaching 80% according to the results of individual examinations.
Exacerbation of gastroesophageal reflux disease, reflux esophagitis, often occurs in the second half of pregnancy. In the first trimester, heartburn and exacerbation of gastroesophageal reflux disease can often be triggered by early preeclampsia - vomiting of pregnant women. Against the background of prolonged heartburn, pain behind the sternum often occurs, belching with air, and salivation increases. The appearance of such symptoms requires additional examination and treatment, since gastroesophageal reflux disease increases the risk of aspiration of gastric contents during childbirth in pregnant women, especially if they are performed under anesthesia.
Chronic venous insufficiency (CVI) , or chronic venous diseases - include varicose veins, post-thrombotic disease, congenital and traumatic anomalies of the venous vessels. According to different authors, from 7 to 35% of women suffer from chronic venous insufficiency during pregnancy; for the first time during pregnancy, chronic venous insufficiency develops in 80% of them. At any degree of clinical manifestation, chronic venous insufficiency requires observation and treatment to prevent thromboembolic complications in childbirth.
I would like to note that at present, with most extragenital diseases, it is possible to safely carry out pregnancy and childbirth under conditions of proper monitoring of a woman during pregnancy and, if necessary, the appointment of timely special treatment.
The normal course of pregnancy is relatively often disturbed by diseases internal organs.. These are the so-called extragenital diseases- therapeutic, surgical, acute and chronic infectious diseases that accompany pregnancy and are not directly related to the dysfunction of the reproductive apparatus or any structural changes in it. Their effect on the development of pregnancy and the unborn child is diverse. Some, starting as early as childhood or adolescence, inhibit the development of a woman's reproductive system with all the ensuing consequences of the influence of an inferior reproductive apparatus on pregnancy.
Extragenital diseases are one of the common causes intrauterine pathology leading to fetal malformations or death.
Any acute infection in a pregnant woman can activate the microflora that is present in enormous quantities on the skin, in the nasopharynx, and in the vagina. At first glance, harmless foci of infection in the pharynx, teeth, paranasal sinuses are usually not accompanied by high fever, do not cause much concern to the woman, and due to their low severity, they often go unattended and treated. But they are one of the common factors premature termination of pregnancy and diseases of children in intrauterine period development of the child, since the pathogen can penetrate the fetus through the placenta, blood, lymphatic system of the mother and cause inflammation of the placenta and intrauterine infection fetus.
On the other hand, pregnancy can increase the manifestations of extragenital diseases in a woman. Therefore, women with diseases of the internal organs before pregnancy should consult with their doctor or obstetrician-gynecologist about the possibility and safety for themselves and the child of pregnancy and childbirth, about the most favorable timing conception, to investigate the state of the childbearing function in order to timely identify possible deviations and carry out, in addition to general treatment, special preparation for pregnancy. Careful preparation women for pregnancy, as a rule, provides her normal development, eliminates the need for treatment while waiting for the child.
Early detection and treatment of extragenital diseases in pregnant women also contributes to the fact that in most cases the pregnancy ends safely and it is necessary to interrupt it for medical reasons only in rare cases. Pregnant women need to understand that drug treatment carried out only by a doctor. Attempts to self-medicate are unacceptable.
Below is a summary of the most common extragenital diseases in pregnant women.
Rheumatism- a common infectious-allergic disease characterized by widespread inflammation of the connective tissue with a predominant involvement in the inflammatory process of the cardiovascular system and joints. The first attack of rheumatism during pregnancy is rare. But pregnancy can exacerbate a previously existing disease, in particular acute articular rheumatism.
Rheumatism usually manifests itself after suffering a sore throat or other streptococcal infection. More often it is erased, atypically: general weakness, sweating, fatigue, loss of appetite, palpitations, shortness of breath during physical exertion, pain in the heart, in the joints only when the weather changes (the joints are not changed), slightly elevated temperature (in some cases, rheumatic heart disease occurs without temperature increase). oxygen starvation, as well as changes in the placenta, due to exacerbation of rheumatism, are sometimes the main cause of malnutrition and intrauterine death of the fetus.
If the described symptoms appear, a woman should immediately consult a doctor. Timely hospitalization and the course of treatment in most cases have a positive effect on the course of pregnancy. Necessary condition prevention of new exacerbations of rheumatism is the elimination of foci of streptococcal infection in the body of a pregnant woman (sanation of the oral cavity, treatment of sinusitis, tonsillitis) and the prevention of colds.
Heart defects - pathological changes in the structure of the heart and the vessels departing from it, complicating the work of the heart and leading to fatigue of its muscles. common cause heart defects is rheumatism transferred in the past. The outcome of pregnancy in patients with heart defects is not always favorable; heart disease is the number one cause maternal mortality. This is explained by the fact that pregnancy makes significant demands on the heart due to the general increase in the weight of the pregnant woman, the presence of placental circulation, the high standing of the diaphragm in the last months of pregnancy, and the increase in minute blood volume.
Usually, a healthy heart copes well with the physiological stress during pregnancy, while a sick heart is not able to cope with new conditions and requirements. There are shortness of breath, cyanosis of the mucous membranes and extremities, tachycardia, breathing quickens, impaired heartbeat, there is suffocation with palpitations, swelling of the cervical veins occurs, edema appears on the legs, an increase and soreness of the liver is noted - heart failure occurs.
Due to special humoral conditions prenatal development heart disease in the mother contributes to the occurrence of congenital heart disease in the fetus.
Each pregnant woman with heart disease is sent to a specialized hospital for a thorough cardiological examination, observation and all necessary activities. Timely detection of heart disease in a pregnant woman, careful treatment in a specialized hospital, depending on the condition, form of the defect and the presence or absence of complications (concomitant valvular disease, narrowing of the holes), makes it possible to resolve the issue of maintaining pregnancy.
Hypertonic disease - chronic illness, characterized by a constant or almost constant increase in blood pressure. Its initial manifestations are often called vegetovascular dystonia, they are not given serious importance. However, hypertension significantly worsens the course of pregnancy and has an adverse effect on the development of the fetus, especially in the middle of pregnancy, when exacerbation of hypertension is often complicated by the development of late toxicosis (the risk of its occurrence increases 6 times).
The state of health of the pregnant woman worsens, headaches intensify, there may be crises, changes in the fundus of the eye progress. Hypertension causes disturbances in the system of utero-placental-fetal circulation. As a result, the fetus lacks nutrients, primarily oxygen, with all the ensuing consequences (spontaneous abortion, malnutrition, intrauterine fetal death). The placenta is very sensitive to increased pressure in the mother and quickly responds by reducing the minute volume of blood flowing to the fetus. Even with low blood pressure, such patients may experience a “silent death” of the fetus in the uterus at any stage of pregnancy. Children from hypertensive women are born, as a rule, weakened and hypotrophic, and subsequently grow painful.
Treatment of hypertension in pregnant women complex, it provides for compliance with the regime (emotional peace, proper organization work and rest), diet (food should be varied, rich in vitamins, with restriction of salt, liquid, animal fats, meat and fish broths are excluded, you can eat lean meats and fish in boiled form) and medications. Pregnant women with hypertension are periodically placed in a hospital, and 2 weeks before the due date they are hospitalized.
Hypotension- lowering blood pressure. It does not always remain low and can be normal from time to time, for example, after sleep, rest, in the first half of the day, or increases during unrest, but then quickly decreases. It is believed that hypotension is a symptom of hormonal deficiency in women. With hypotension during the day, the state of health changes several times, dizziness, general weakness, fatigue, palpitations, pain in the heart area, fainting, sweating are observed. In women with hypotension, pregnancy is accompanied by complications 5 times more often than in healthy women, there are early (nausea, vomiting, feeling unwell, constant low blood pressure) and late (edema, protein in the urine, low blood pressure is replaced by normal or high) toxicosis. A direct relationship has been established between hypotension and spontaneous abortion (most often after 16 weeks).
Pregnant women with hypotension are registered at the dispensary and undergo treatment at the antenatal clinic. They should avoid overwork, visit more fresh air. Nutrition should be sufficiently high-calorie, with a high content of protein, vitamins, especially group B and vitamin C - natural stimulants of the body, including cardiovascular tone. As stimulants, you can use (preferably in the first half of the day) tea, coffee, the Sayany drink. In severe cases of hypotension, and especially in the event of complications, treatment is carried out in a hospital. 2 weeks before the due date, pregnant women with hypotension are hospitalized.
Phlebeurysm- a disease of the veins, which is expressed in an increase in their size, a change in shape and a decrease in elasticity. In pregnant women, veins are susceptible to this disease. lower extremities and rectum.
Especially often observed varicose veins of the lower extremities. Patients complain of a feeling of heaviness in the legs, dull aching pain, convulsions in calf muscles, feeling of numbness, crawling, fullness, fatigue of the legs. These sensations are more pronounced when standing than when moving, and disappear when lying down. Pregnancy in women with varicose veins can be complicated by toxicosis, improper attachment of the placenta and its premature detachment.
To prevent the development of complications, it is necessary to persistently carry out preventive measures (limitation of prolonged standing and sitting, refusal to wear tight belts and round rubber garters, limiting fluid intake, wearing loose clothing, underwear and shoes with low heels), which give the greatest effect in early period diseases when the expansion of the veins is insignificant. Therefore, you should consult a doctor as soon as possible and carefully follow his advice.
At expressed forms varicose veins need rest, high position of the legs, wearing elastic stockings. Known healing effect gives bandaging with an elastic bandage. must be adhered to the following rules: 1) the bandage is applied in the morning, without getting out of bed, on a slightly raised leg, the foot should be raised at a right angle to the lower leg, in other cases, before bandaging, you should lie down for at least 20-30 minutes with a raised leg; 2) the pressure of the bandage around the circumference should be uniform throughout the limb; 3) the bandage should not have folds, each turn of the bandage covers half of the previous move, which ensures the retention of the bandage; 4) due to the fact that the bandage is more often confused in its initial part (on the foot), it is recommended to put a strip of adhesive plaster on the first turn of the bandage.
Regular bandaging of the legs or wearing well-fitted elastic stockings leads to an acceleration of blood flow in the veins, restoration of venous circulation, improvement of venous outflow, reduction of congestion and swelling. If these requirements are not met, inflammation of the veins with the appearance of blood clots may develop.
Anemia, or anemia- a blood disease characterized by a decrease in the number of red blood cells and hemoglobin. Most frequent form Anemia during pregnancy is iron deficiency anemia, which develops as a result of the increased use of iron by the growing fetus. More often appears in the second half of pregnancy and mainly in women suffering from secretory insufficiency of the stomach, enterocolitis, liver disease.
There are general weakness, fatigue, dizziness, sometimes fainting, palpitations, shortness of breath when physical activity, which is due to a lack of oxygen in the body of a pregnant woman.
With significant anemia, the skin and mucous membranes become pale. There is a violation in the placental circulation, “as a result, the fetus lacks oxygen and nutrients. Of particular importance is balanced diet pregnant - diet with great content iron (beef meat, liver, eggs, carrots, walnuts, buckwheat, pomegranates). AT severe cases after a thorough examination, treatment is carried out in a hospital.
Pulmonary tuberculosis- an infectious disease characterized by the formation of specific inflammatory changes in the lungs. Pregnancy has an adverse effect on the course of pulmonary tuberculosis, causing an exacerbation of the process, in turn, tuberculosis affects the course of pregnancy, often complicating it with abortion or premature birth (due to intoxication, high fever and constant stress with a strong cough). Tuberculosis progresses during pregnancy, mainly in patients who have been less than a year since the last outbreak. Quiet processes with a tendency to reverse development usually do not worsen either during pregnancy or after childbirth.
Early detection of tuberculosis in pregnant women makes it possible to prevent the development running forms diseases, and systematic treatment in a hospital allows you to save the pregnancy.
Appendicitis- inflammation of the appendix of the caecum. Pregnancy can contribute to the occurrence of primary and exacerbation of chronic appendicitis. Most often observed in the first 6 months of pregnancy.
Special danger of appendicitis and other acute diseases of organs abdominal cavity(inflammation of the pancreas, gallbladder, intestinal obstruction, etc.) during pregnancy is due to the fact that their early diagnosis is difficult due to the atypicality and blurring of clinical manifestations. Pain in the abdomen with appendicitis in pregnant women are mildly pronounced, do not have a clear localization in the right iliac region due to the upward displacement of the appendix by the growing pregnant uterus.
The spread of inflammation from the appendix to other organs of the abdominal cavity, the pregnant uterus, the peritoneum occurs very quickly, which aggravates the patient's condition and worsens the prognosis. Spontaneous early termination of pregnancy is an almost constant companion of acute appendicitis.
Every pregnant woman should know: if pains of any severity and localization occur in the abdomen, especially if they are accompanied by nausea or vomiting, you should immediately call an ambulance doctor. In the presence of acute appendicitis or exacerbation of chronic, regardless of the gestational age, an operation is performed. The earlier the operation is done, the better the outcome for the mother and fetus. With a timely operation, it is often possible to save the pregnancy.
Heartburn- a burning sensation along the esophagus, more pronounced in its lower section. In pregnant women, heartburn occurs as a result of neurohumoral (neuroendocrine) restructuring of the body associated with the development of the fetus, and disappears without treatment by 8-12 weeks of pregnancy. From the diet exclude spicy, fried, limit the intake of carbohydrates.
Constipation- chronic stool retention for more than 48 hours or daily, but insufficient bowel movements. Pregnant women are often prone to constipation. If constipation occurs for a long time, then they can cause general malaise, nausea, lack of appetite, hemorrhoids, complication of pregnancy. The best way to deal with constipation is through a balanced diet. In these cases, it is recommended to drink yogurt or one-day kefir at night, drink a glass on an empty stomach in the morning cold water, eat raw vegetables and fruits (prunes, apples, carrots), which enhance intestinal motility. A beneficial effect on bowel function is the intake of black bread with food. Pregnant women should not take laxatives without a doctor's prescription, as this can cause uterine contractions.
Cholecystitis- inflammation gallbladder. Pregnancy can be a factor provoking the disease, since it causes mechanical difficulties for bile secretion due to an altered position of the liver, intestinal atony, constipation, and an increase in cholesterol in the blood. Cholecystitis is characterized by sudden attacks of colicky pain in the right hypochondrium, fever. Sometimes an attack is preceded by gastrointestinal disorders. Often associated with jaundice. Palpation reveals pain in the gallbladder area. The pain is often unbearable and usually radiates to the right shoulder and shoulder blade. If any of these signs appear, a pregnant woman should immediately consult a doctor.
Urinary tract diseases during pregnancy may occur as a result of changes in hormonal balance, as well as a violation of the outflow of urine from the kidneys due to compression of the ureters by an enlarged uterus. However, more often there is an exacerbation of chronic diseases (pyelonephritis, nephritis, cystitis), which were present before pregnancy. They are mainly inflammatory in nature, since functional changes in the body contribute to the development of urinary tract infections. Observed heat, chills, lower back pain (often on the right), sometimes vomiting, constipation (with pyelonephritis), edema (with nephritis), painful, frequent (after 10-15 minutes), small portions of urination and cutting, burning, dull pains, intensifying at the end of urination (with cystitis).
In connection with the violation of the release of toxic metabolic products of the mother and fetus, the fetus is poisoned. Numerous heart attacks are noted in the placenta, which often leads to premature detachment of the placenta and spontaneous abortion. The mother can also suffer (up to death) as a result of acute renal failure, most often occurring during second half pregnancy complicated by late toxicosis. With all variants of urinary tract disease, pregnant women are hospitalized for examination and treatment.
Diabetes- an endocrine disease in which, due to a lack of pancreatic hormone insulin in the body, disorders of all types of metabolism develop. May occur during pregnancy, complicating it. Among endocrine diseases, diabetes mellitus is the most dangerous with adverse consequences for the fetus. Patients have general weakness, a feeling of dry mouth, a feeling of thirst, obesity, sometimes increased appetite with simultaneous weight loss, itching of the skin, especially of the external genital organs. Most of the condition worsens in the second half of pregnancy. Pregnancy is often spontaneously interrupted (late miscarriage, premature birth). There are complications: late toxicosis, polyhydramnios, very large fruit, fetal malformations. With a favorable course of the disease, pregnancy can be full-term.
It is necessary to systematically monitor the content of sugar in the blood and daily urine, visit a doctor 2 times a month up to 32 weeks of pregnancy and weekly after this period. For delivery, pregnant women are hospitalized for a period of 35-37 weeks.
Angina- an infectious disease characterized by inflammation of the palatine tonsils. At the same time, there is malaise, heaviness in the head, pain when swallowing, dryness and soreness in the throat. Often there is an abortion, intrauterine death of the fetus. One of the preventive measures is the timely treatment of chronic tonsillitis.
infectious hepatitis or Botkin's disease,- viral disease liver. May occur at any stage of pregnancy. Susceptibility to the disease increases mainly in the second half of it. The disease begins gradually with the appearance of weakness, fatigue, a slight increase in body temperature. There is a decrease in appetite, a feeling of bitterness in the mouth, belching, heartburn, nausea, vomiting, and abdominal pain.
Sometimes the first symptoms are cough, runny nose, headache, often - pain in the muscles and joints. In the future, body temperature can rise to 40 °. There is a darkening of urine (the color of beer), the stool becomes gray-white (reminiscent of putty), the skin and sclera of the eyes are stained in yellow with an orange tint.
The disease often complicates the course of pregnancy and childbirth, has a negative effect on the condition of the fetus - its malnutrition occurs as a result of general intoxication, hypoxia and placental insufficiency; the percentage of stillbirth, prematurity increases, and in case of illness in the most early dates pregnancy, the development of deformity in the fetus is noted.
With early diagnosis, timely hospitalization and treatment infectious hepatitis more often passes without serious consequences for a woman, which cannot be said about a child, general development which is often delayed. If left untreated, a serious complication can occur in a pregnant woman - acute liver dystrophy with a fatal outcome.
Flu- a viral infectious disease that occurs with symptoms of general intoxication (fever, weakness, headache, nausea, sometimes vomiting) and damage to the mucous membrane respiratory tract. The combination of the disease with pregnancy is unfavorable for the course and outcome of pregnancy and intrauterine development of the fetus. It is possible for the virus to pass through the placenta into the fetus, which leads to intrauterine disease.
Influenza is dangerous at all stages of pregnancy (miscarriage, deformities, intrauterine death of the fetus, premature birth). A pregnant woman who has the flu, even if normal temperature needs especially careful medical supervision (exemption from work, rest, rational nutrition and treatment). Timely treatment can prevent the adverse effects of the disease on fetal development. A pregnant woman should protect herself from communicating with influenza patients. During influenza epidemics, you should not go to public places.
Rubella- an acute viral infectious disease that affects the fetus. It is characterized by fever (38-39 °), minor catarrhal symptoms (runny nose, cough), enlargement and soreness of the occipital lymph nodes and the appearance of a rash on the skin. pale pink. If the disease develops in the first 12 weeks of pregnancy, that is, during the period of organogenesis, then birth defects development (cataract, microcephaly, heart defects, anomalies in the development of teeth, deafness) occur in 50% of newborns. When infected with rubella in more than late dates In pregnancy, viral damage to the fetus is manifested in anemia, damage to internal organs. With this disease, spontaneous abortion is often observed in the early and late periods.
Pregnant women who have recovered from rubella should immediately contact the office of medical genetics to decide whether it is advisable to continue this pregnancy. Pregnant women should beware of contact with sick people, because even the carriage of the rubella virus without clinical manifestations of the disease can cause damage to the fetus.
For at least three recent years official medical statistics state a bleak fact: more than 70% of women of reproductive age have one pathology or another. In the vast majority of cases, we are talking about extragenital diseases, that is, those that are not related to gynecological and obstetric pathologies. At the same time, only about 40% of births proceed without complications.
Any obstetrician-gynecologist who leads a pregnancy constantly faces a dilemma: treat at all costs or take a position of maximum non-intervention. In his report at the II International Interdisciplinary Congress Nadezhda Andreeva I tried to answer a difficult question. And although the main message of her report was addressed to doctors, many aspects of the speech will be of interest to a wide audience.
No need to "treat" pregnancy
The goals of modern obstetrics are simple at first glance:
- reduction of maternal and perinatal mortality;
- minimization of obstetric traumatism;
- minimizing adverse pregnancy outcomes (miscarriages, complications of pregnancy and childbirth).
Nadezhda Andreeva
Associate Professor of the Department of Obstetrics, Gynecology and Reproductive Health of BelMAPO, Ph.D.
Pregnancy and childbirth is physiological process. But lately it feels like we forgot about it. We want to treat everyone, but from what? From pregnancy? From childbirth? Behind this "treatment" the dominant is lost happy motherhood. It sometimes happens that a pregnant woman comes to the doctor's office just to get a new prescription, another drug, or she herself asks to prescribe something else for her so that she can carry the pregnancy and give birth safely. Over the past 10 years, there has been a 70% increase in the use of medicines during pregnancy. But women didn't get sick as much as they used drugs more often.
All that is often necessary, the expert believes, is to learn to wait, observe and give the right recommendations. To recommend not a permanent set of drugs, but healthy bearing, healthy motherhood, healthy life. Eat regularly and varied, get enough sleep, drink water, walk in the fresh air, work, raise children, love your husband, in a word, live an ordinary life. This is the natural and healthy bearing and motherhood. If we learn all this, our women will come to childbirth happier and more confident.
Pregnancy is a physiological process, not a set of diagnoses.
Area of special attention
But, of course, pregnant women with cardiovascular diseases, diabetes, and malignant neoplasms require special attention. Extragenital pathology is especially pronounced in them.
Extragenital pathology is a combination of various diseases or syndromes that are not related to gynecological or obstetric diseases.
A team of highly qualified doctors of related specialties should accompany such a woman throughout her pregnancy: obstetrician-gynecologists, cardiologists, oncologists, endocrinologists, and therapists. Even more attention is required by expectant mothers who have decompensated extragenital diseases. They are only 2% of total pregnant. But it is their pregnancy that requires coordinated work and supervision by a team of like-minded doctors.
Over the past 4 years, the proportion of pregnant women with diseases of the cardiovascular system has significantly decreased: from 23% in 2014 to 10% in 2017. But the percentage of pregnant women with oncology has doubled. Stably high (about 35%) remains the proportion of pregnant women suffering from.
Nadezhda Andreeva
Associate Professor of the Department of Obstetrics, Gynecology and Reproductive Health of BelMAPO, Ph.D.
Diabetes is really serious disease with a chronic course. However, medical science has advanced so far that women with diabetes for more than 20 years are delivered at full term. This is victory. Yes, behind it is hard work, great knowledge, experience and skill of doctors. But not to a lesser extent, and the woman herself. Trust me, it's valuable. practical value what matters is not increasing the doses of drugs and not changing one remedy for another, but knowing oneself, and scrupulous diary keeping helps in this.
As for oncological pathology, 10 years ago we talked about the fact that cancer is a fatal disease. Today, the characteristics are fundamentally different: it is a disease that has a chronic relapsing character. That is, in some ways it does not differ from the same diabetes. In its treatment, it is possible and necessary to achieve a stable remission.
Oncologists say cancer thyroid gland in oncology - "runny nose". With such a disease, it is quite possible to prolong the pregnancy, carry the fetus to spontaneous childbirth and give birth through the natural birth canal.
Nadezhda Andreeva
Associate Professor of the Department of Obstetrics, Gynecology and Reproductive Health of BelMAPO, Ph.D.
In oncology, the most important thing is to quickly start treatment, today even against the background of pregnancy. According to the experience of 10 years of work with pregnant women with oncological diseases, those patients who rejected treatment, categorically did not believe that they could be cured, had negative pregnancy outcomes.
According to the latest data, about 200 women with oncology carry and give birth to healthy children every year in Belarus. Only 2% of pregnancies oncological diseases terminated for medical reasons. As a rule, this happened in those cases when a malignant tumor was detected in the first trimester of pregnancy and there was an urgent need for urgent radiation therapy. With regard to chemotherapy courses, Belarus adheres to world trends: treatment is prescribed immediately, as soon as a diagnosis is made, with preservation of pregnancy if the period exceeds 12 weeks. In the recent history of Belarusian obstetrics, about 20 women underwent courses of chemotherapeutic treatment with an established oncological diagnosis during pregnancy, delivered to term and gave birth to healthy babies.
Risks of pregnancy in extragenital pathology
Nevertheless, any extragenital pathology carries certain risks for happy pregnancy, women's and children's health.
These include:
- aggravation of an existing disease during pregnancy;
- obstetric complications;
- reduced ability to diagnose and take drugs;
- risk to the life of a pregnant woman;
- premature birth;
- hypoxia and hypotrophy of the fetus;
- macrosomia ( big weight fetus: more than 4000–4500 g);
- fetal cardiomyopathy.
But even these very real risks should not be a reason to offer a woman to terminate the pregnancy, firmly convinced expert.
Nadezhda Andreeva
Associate Professor of the Department of Obstetrics, Gynecology and Reproductive Health of BelMAPO, Ph.D.
The whole civilized world is aimed at maintaining pregnancy. In Belarus, the list of diseases for which termination of pregnancy is really justified is also getting smaller every year. In the case of cancer, the need for interruption depends on the stage, degree, differentiation of the disease and the duration of pregnancy. And the sooner treatment is started, the better the prognosis for both the woman and the child.
Extragenital diseases- These are diseases not associated with pregnancy. Without a doubt, disease and pregnancy usually negatively affect each other.
When registering a pregnant woman, specialists examine her and decide whether the possibility of carrying a pregnancy.
Pregnancy cardiovascular pathology comes with complications. In the active phase, heart defects are much more likely to be premature birth, edema and pulmonary infarction, pneumonia, thrombophlebitis. The presence of chronic hypoxia in a pregnant woman, changes in the placenta are the cause of malnutrition, and sometimes intrauterine death of the fetus.
Hypertonic disease significantly worsens the course of pregnancy, its premature termination is noted, combined late preeclampsia, its severe course, premature detachment of a normally located placenta, hypoxia and fetal hypotrophy.
In pregnant women with diseases of the urinary system(pyelonephritis , (nephritis, urolithiasis) there are a number of functional changes that contribute to the development of urinary tract infection (urinary tract dyskinesia, compression of the ureters by the growing uterus, expansion of the pelvis and ureters, constipation).
The course of pregnancy is complicated by the occurrence late gestosis, premature births occur, perinatal mortality is increased.
At diabetes characteristic sytdsyfibdfybt? premature birth, frequent development of late preeclampsia, high perinatal mortality, fetal malformations.
Acute infectious diseases in a pregnant woman they can occur under the same conditions as in a non-pregnant woman, but in pregnant women these diseases sometimes take a more severe course, especially if the activity of the most important organs - the heart, lungs, and kidneys - is impaired as a result of infection and intoxication.
In connection with the disease, the course of childbirth and the postpartum period is aggravated. Due to the serious condition of the mother and the risk of infection of the child, breastfeeding is sometimes contraindicated.
Acute infections have a detrimental effect on the fetal egg. The facts of infection of the fetal egg with the same microbes that caused the disease of the pregnant woman have long been established. In the placenta, these microbes are found in in large numbers. The consequence of infection is the death of the fetal egg, miscarriage and premature birth.
For acute infectious diseases subsequent and early postpartum period are often complicated by bleeding. In the postpartum period, in the presence of a general infection, septic diseases of the puerperal easily occur.
Tuberculosis and pregnancy are mutually exclusive processes. Tuberculosis of the lungs, transferred or cured a few years before the onset of pregnancy, with good general condition pregnant woman does not pose a danger to her or to the fetus.
Syphilis untreated or insufficiently treated is one of the severe complications of pregnancy. Syphilitic infection is transmitted from mother to fetus and can cause spontaneous miscarriage and premature birth. But even in cases where childbirth occurs in a timely manner, children are often born dead with signs of a syphilitic infection.
Gonorrhea genital organs has a pronounced effect on childbearing function. Adhesions lead to infertility. If a woman becomes pregnant, then there may be an exacerbation of inflammatory diseases of the internal genital organs, spontaneous miscarriage, premature birth, cervical rigidity and glued uterine os during childbirth, weakness labor activity, anomalies of placental abruption, etc. There may be an ectopic pregnancy.
Pregnant gonorrhea is dangerous for the fetus: the development of an inflammatory process in the conjunctiva of the eye (blennorrhea), in the vagina (in girls), and sometimes in the rectum (especially with breech presentation)
Toxoplasmosis, listeriosis, causes of developmental anomalies and stillbirths. There may be intrauterine infection of the fetus, CNS damage, retinal disease.
The Role of the Nurse
With extragenital pathology, it consists in the fact that she participates in the examination of pregnant women (taking blood, smears, urine for tests, for serological testing, testing for tuberculosis, etc.), performs doctor's prescriptions and nursing care in the treatment of these patients in a hospital , conducts dispensary observation of these patients, who are simultaneously observed in the antenatal clinic and in the medical institution where this pathology is observed and treated (polyclinic, TB dispensary, dermatovenerologic dispensary, etc.).
The nurse must control how her patient visits the antenatal clinic, whether the recommendations of the obstetrician-gynecologist are followed, whether the examination and prescribed treatment are timely.
She should conduct sanitary and educational work, supply the pregnant woman with information material. Special meaning here has medical ethics and deontology.
The most important task is the prevention of influenza, sexually transmitted diseases, tuberculosis.
BLEEDING DURING PREGNANCY AND DELIVERY
In the first half of pregnancy
Bubble skid- a peculiar change in the chorion, expressed in a sharp increase in villi, along which bubble-like extensions of various sizes are formed.
Clinic. First, some signs of pregnancy appear (amenorrhea, nausea, vomiting, etc.). After 2-3 months, spotting appears. Allocation of drift bubbles (an absolute sign of a disease) is observed seldom. It is characteristic that the size of the uterus exceeds the gestational age, in the second half of pregnancy there are no reliable signs. For timely recognition of this disease, ultrasound is recommended.
Treatment. With the onset of bleeding, urgent hospitalization, complete removal of the cystic mole. Operation: curettage of the uterine cavity
Neck pregnancy. Almost never full term. Pregnancy is interrupted most often before 12 weeks. When examining the neck in the mirrors, it looks barrel-shaped, with a displaced external pharynx, with severe cyanosis, bleeds easily during examination. The bleeding is always very profuse.
Treatment. Emergency care - tight tamponade of the vagina, calling a medical team, contact with a vein, preparation for surgery - extirpation of the uterus
Ectopic pregnancy
Miscarriage or abortion- This is an abortion before 28 weeks.
Abortions are spontaneous and artificial.
Spontaneous abortion occurs without any intervention, contrary to the desire of the woman. If spontaneous abortions are repeated, they talk about a habitual miscarriage.
induced abortion called intentional abortion. If the termination is not carried out in accordance with the law, one speaks of a criminal abortion.
There are abortions for medical and social reasons.
Distinguish the following clinical stages of spontaneous abortion.
I. Threatened abortion
Clinic: cramping pains in the lower abdomen. Bleeding is absent or insignificant. During vaginal examination, the external os is closed, the uterus corresponds to the gestational age.
Treatment in the gynecological department:
1. Strict bed rest.
2. Therapeutic and protective regime.
3. Diet is normal (exclude spices, bitter, salty, fried).
4. Sexual rest.
5. Antispasmodics (nosh-pa), suppositories with papaverine).
6. Vitamin E.
7. Progesterone according to indications. The course of treatment is 10-14 days.
P. Initiated abortion
Clinic: cramping pains and spotting are more pronounced, which indicates the onset of detachment of the fetal egg.
Treatment should be continued, if there is no effect - curettage of the uterine cavity.
III. Abortion in progress
Clinic: bleeding intensifies. At vaginal examination: the cervical canal is open, in it is a detached fetal egg. Pregnancy can not be saved.
Treatment. Curettage of the uterine cavity.
IV. incomplete abortion
Clinic: bleeding. Part of the fetal egg came out, and part remained in the uterine cavity.
With a vaginal examination, the cervical canal passes a finger, the size of the uterus does not correspond to the gestational age (it is smaller).
Treatment. Curettage of the uterine cavity.
V. Complete abortion
Clinic: the fertilized egg is completely out of the uterus. There is no pain. Discharges are bloody, smearing. During vaginal examination - the external opening of the cervical canal passes a finger, the uterus is small, dense
Complete abortion
incomplete abortion.
1. in the uterus, all membranes were delayed.
2.in the uterus, the remains of the fetal egg
Implantation of the ovum ectopic pregnancy
1-in the interstitial part of the tube;
2-in the isthmic part of the tube;
3- in the ampullar part of the tube;
4 - in the ovary;
5 - in the abdominal cavity;
6 - uterine cavity
Premature detachment of a normally located placenta- this is a detachment that occurred before the III stage of labor, more often it happens in the second half of pregnancy, maybe in the I or II periods of labor. Abortions happen without complications and with complications: febrile abortion, septic abortion.
At febrile abortion the infection spreads outside the uterus; the uterus is painful on palpation; uterine appendages, pelvic peritoneum and fiber are not changed.
At septic abortion the woman's condition is severe, sleep is disturbed, there is no appetite, the skin is pale. Chills, fever, tachycardia are early signs of septic abortion. Inflammatory processes expressed in the pelvis.
The role of the nurse with this pathology is significant, since she observes these pregnant women in the gynecological department, fulfills the doctor's prescriptions, conducts the nursing process, prepares tools for scraping the uterine cavity, assists the doctor during the operation, acts as an operating sister and anesthetist sister.
The main nursing problem is the loss of the unborn child of a pregnant woman. It is necessary to reassure the patient, explain her behavior after discharge from the hospital, methods of contraception, hygiene of sexual life, instill confidence in a successful outcome.
Extragenital pathology (EGP) is a set of diseases and syndromes that affect the course of pregnancy, not related to gynecological abnormalities and complications of pregnancy in the field of obstetrics. However, there is a great danger of the influence of EGP on the lethal outcome of mothers and newborns.
In this regard, a pregnant woman is strongly recommended to be observed by a family doctor and highly specialized specialists during and after childbirth for diagnosis, as well as correction of the disease and the successful course of pregnancy and childbirth.
EGP classification
Extragenital pathology can be caused by various diseases in nature and effect on pregnant women and newborns, so different methods of treatment can be prescribed. As a result, extragenital diseases are divided into several types:
According to statistics, the level of extragenital pathology in pregnant women increases every year and reaches 60-70% of young women bearing a fetus.
Approximately 30% of pregnant women carry newborns without toxicosis throughout the entire period of pregnancy, the threat of miscarriage, EGP and give birth to babies without pathological abnormalities.
Thanks to modern medicine, proper observation and adequate treatment of pregnant women, if necessary, in many cases, women with EGP manage to safely endure and give birth to a healthy baby.
Also, all significant extragenital pathologies can be divided into two classes:
| Significant extragenital pathology (EGP) | ||
|---|---|---|
| Primary EGP (not related to pregnancy) |
Secondary EGP (occurs during pregnancy) |
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| Chronic form | acute form | Pathological conditions that occur directly during pregnancy and suddenly disappear after childbirth. The most common diseases include:
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Pathologies that arose before the onset of pregnancy as a result of diseases:
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Pathologies that first appeared during pregnancy as a result of
|
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Many pregnant women with extragenital pathologies after diagnosis are forbidden to give birth naturally in order to avoid physical and emotional stress. This is due to diseases that can lead to grave consequences, in connection with which a planned cesarean section.
Difficulties with diagnosis and treatment caused by EGP
There are many problems associated with extragenital pathology, the correct resolution of which requires time to study. Some of the difficulties caused by EGP are objective, while others may be atrogenic, i.e. developing at the psychological level, after contact between the doctor and the patient.
Difficulties caused by EGP may be related directly to the mother and/or the perinatal process. Maternal difficulties, in turn, are divided into two types: somatic or therapeutic action and obstetric.
Somatic and therapeutic difficulties
Somatic or therapeutic difficulties are caused by the negative impact of pregnancy on extragenital diseases, i.e. there are difficulties in diagnosing and necessary treatment pregnant due to the presence of a fetus.
The course of pregnancy, depending on the period, is divided into different phases, during which various changes occur in female body. It is these metabolic changes that can negatively affect various somatic diseases.
For example, normal gestational (during pregnancy) circulatory changes have a negative impact on heart disease. In pregnant women, there is an increase in circulating blood volume and cardiac output, a decrease in vascular resistance, which leads to the progression of cardiovascular diseases.
Pregnancy also negatively affects diabetes. An increase in hormone levels in expectant mothers makes the course of the disease more unstable. In non-diabetic patients, blood glucose decreases. This is due to the consumption of glucose by the fetus.
It can also be noted that for women bearing a fetus, a state of increased concentration of insulin in the blood plasma is characteristic in relation to the composition of glucose.
On different terms pregnancy (first trimester and recent weeks) changes the need for insulin, which can lead to a strong decrease or increase in blood sugar.
During the antenatal period (carrying a fetus), there is an exacerbation of varicose diseases, venous insufficiency and an increase in the formation of blood clots in the venous system.
The progression of these diseases is caused by an increase in the concentration of the female steroid hormone progesterone, resulting in a decrease in the tone of the venous walls, an increase in the diameter of the veins, an increase in vascular permeability, and a tendency to swelling.
Infectious diseases of the urinary tract are caused by the action of progesterone, the pH level in the urine increases, and the volume of the bladder increases.
These are just some of the most common PEG-related illnesses that are adversely affected by the gestation period. The family doctor or local therapist should know the symptoms and methods emergency treatment EGP diseases in pregnant women, as well as be able to provide qualified assistance in time. There are a number of diseases that are positively affected by the antenatal period, resulting in a remission process of the course of the disease, reducing the need for diagnosis and treatment, for example, in diseases of the stomach and duodenum, rheumatoid arthritis, etc.
obstetric difficulties
Obstetric difficulties are negative impact EGP on the development and course of pregnancy, a favorable birth process and the postpartum period, the possible occurrence of problems associated with the threat of abortion or an urgent birth process ahead of time.
The difficulties associated with the perinatal process depend on the complexity of the disease. They have the effect of extragenital pathology on the fetus, medications, and prematurity.
Depending on the nature of the disease, there may be a danger of placental abruption, early labor, as well as convulsions in children and women in labor, which often leads to death.
Difficulties in diagnosis and therapy
Complications of diagnosis during pregnancy cause atypical symptoms for the course of the disease, for example, sharp pain caused by appendicitis may not have pronounced pain symptoms. Atypical symptoms can be with such diseases of the abdominal cavity as intestinal obstruction, acute pancreatitis, hepatic colic, and many others. others
It is possible to simulate the symptoms of EGP, which is directly related to the pregnancy itself. So, the diagnosis of hepatitis can be recognized as acute fatty hepastosis or obstetric cholestasis, because against the background of the antenatal period, these diseases have similar symptoms.
During normal course pregnancy, in the body of a woman, the norms of many indicators increase, it is important to pay attention to them, because an increase in the same indicators can indicate not only pregnancy, but also the presence of a serious pathology.
Quite often there are false changes in diagnostic indicators during pregnancy, so only experienced specialists can make the correct diagnosis. When in doubt, the doctor may prescribe additional research and analyzes to clarify the correctness of the diagnosis.
Unfortunately, doctors are not able to influence the accuracy and methods of examinations, so the prevention of diseases that can lead to extragenital pathology is very important.
Limited treatment and diagnosis is another fairly common problem. This difficulty is directly related to the danger to the life of the fetus. Many medicines have side effects that are possible only during pregnancy. For example, some drugs have an inhibitory or stimulating effect on motor uterine activity.
During pregnancy with extragenital pathologies are prohibited:
- invasive diagnostics (fence biological material fetus for further study);
- radioactive iodine treatment;
- practically no surgical operations are performed, because the risk of miscarriage and damage to the fetus is too high.
However, modern technologies are actively developing, which allows expanding the range of treatment and diagnostic options in the antenatal period, making it absolutely safe for the health of the mother and fetus. best method treatment of EGP still remains prophylaxis, in order to avoid irreversible consequences.
Preventive measures and therapy of EGP in pregnant women
Prevention is the most effective way for the normal course of the antenatal period in conditions of extragenital pathologies. In order to prevent absolutely all pregnant women, as well as women planning motherhood, obstetrician-gynecologists prescribe and recommend:
For the treatment of pregnant women different trimesters with extragenital pathology is prescribed medicinal product Utrozhestan in combination with other medicines that contribute to the extinction of the focus of the disease. Utrozhestan is synthetic analogue progesterone, administered both orally and intravaginally to preserve the fetus at different stages of pregnancy. You can find out more about how to drink Utrozhestan during pregnancy.
Patient A., 28 years old. Admitted with a diagnosis of extragenital pathology on the background of exacerbation of aplastic anemia, pregnancy 15-16 weeks. Permanent hospitalization with maximum isolation was recommended. Glucocorticoids were prescribed, blood transfusion - 2.5 liters, supportive therapy.
In the period of 27-28 weeks there were signs of abortion. Utrozhestan was appointed. At the 32nd week, the patient had various bleeding symptoms, oxygen deficiency of the fetus developed. At 35 weeks, a caesarean section was performed. A girl was born: weight 1930 grams, height 42 cm. Mom and baby are healthy, they were discharged on the sixteenth day.
Patient K., 27 years old. Admitted with a diagnosis of systemic lupus erythematosus, multiple visceral lesions, anemia in pregnancy; pregnancy 24-25 weeks. Hospitalization was recommended. Utrozhestan was appointed, bed rest. Utrozhestan was canceled at the 35th week. At 38 weeks, an urgent birth process began. A girl was born: weight 2830 grams, height 49 cm. Mom and baby are healthy, they were discharged on the fifth day.
In all cases with extragenital pathologies, patients were prescribed Utrozhestan, due to the fact that this particular drug has a number of advantages:
As practice shows, almost all EGP diseases respond well to therapy if preventive measures, diagnosing is carried out correctly, the recommendations of the attending physician are followed, in a timely manner, if necessary, specialized health care. Health to you and your children!
