Kardiyovasküler sistem hastalıkları ve gebelik, anne ve çocuk mortalitesi yönünden, önemli bir yer işgal eder. Eskiye oranla daha etkin tedavi ve daha az gebeliğe son verme zorunluluğuna rağmen, anne mortalitesi hâlâ %3,9 ve çocuk mortalitesi %10-50 arasında değişmektedir. Normal gebelik değişmeleri (Kan volumünün artması, vasküler yatağın genişlemesi, ekstraselluler önemli su retansiyonu gibi), kalbi geçici de olsa, büyük bir yük altına sokmaktadır. Organik lezyonlu bir kalbin, rezerv gücü daralmış bulunduğu için, gebeliğin getirdiği yeni şartlara uyum sağlayamaması, anne ve çocuk için tehlikeli olabilir. Pregnancy and Heart Diseases The doctor's responsibility is very heavy: He will decide whether the pregnancy should continue or not. If the pregnancy is to continue, the mother will need to avoid any behavior that may burden the heart.
Causes of Pregnancy and Heart Diseases
Causes of Pregnancy and Heart DiseasesKalp hastalıkları ve gebelik, tüm gebelerin %2,5-%1-0,5’ini kapsamaktadır. Bunların % 80-90’ı geçirilmiş romatizmaya bağlıdır. %3- 3’ü kongenital kalp hastalığıdır. Romatizmal vakaların %75-80’i mitral stenozu vakalarıdır.
Anne mortalitesi: %39, Çocuk mortalitesi: %10-50’dir.
Hafif ve kompanse kalp hastalarında çocuk mortalitesi: %10
Ağır dekompanse vakalarda :%50
Doğan çocukların dismatüre ve prematürelik oranı :%50’dir.
Diagnosis:
Early diagnosis is very important. However, even in normal pregnant women, diagnosis is quite difficult, as dyspnea, tachycardia, extrasystole and sulphate can be observed due to the heart being pushed upwards by the diaphragm and changes in circulatory conditions. Air hunger that occurs during daily tasks in the first months of pregnancy,
Edema, tachycardia attacks and pathological strain, if any, should definitely suggest the possibility of heart disease.
Pregnancy and Heart Diseases The functional adequacy of the myocardium is more important than its quality. For this reason, pregnant women are divided into 4 categories according to their complaints. This compartment has practical importance in prognosis and treatment. New York Heart Disease. This recommendation of the Association has been adopted by many clinics.
1. derece: (%49) Semptom vermeyen, çalışma gücünü kısıtlamayan organik kalp hastalığı.
2. derece: (%39) Solunum zorluğu ve çabuk yorulma, günlük uğraşıları kısıtlar, istirahatte veya çok hafif işlerde kendilerini iyi hissederler. İş zorlaşınca şikâyetler ortaya çıkar.
Mortality in these two groups is %0.5 – %1.
Grade 3: (% 8) They have difficulty even in light activities. daily work
are highly restricted. Mortality %5.
4. derece: (% 4) En hafif işe bile dayanamazlar. İstirahatte bile yetersizlik belirtileri vardır. Bu grupta mortalite yüksektir. %22.
Pregnancy and birth of pregnant women who are in grades I and II can be completed successfully under prenatal care and heart control.
Pregnant women who are in grade III and IV need to be under frequent control and be hospitalized and monitored. It may be necessary to resort to medical abortion in some of the patients who are at grade IV. Although a classification based solely on subjective complaints has great practical value, it is also important to consider the characteristics of each case listed below:
a) Recent rheumatic infection,
b) Cases with subfebrile and evolutive course,
c) Cases with continuous tachycardia and arrhythmia,
d) Auricular fibrillation,
e) Cases that have just recovered from decompression,
f) Heart patients who cannot rest,
g) Cases whose condition has worsened during previous pregnancies and births should be subject to special evaluation.
In another classification KPregnant Women with Alpine DiseaseThey are divided into two categories: suitable and inappropriate cases.
Suitable cases:
(1) There is no hypertrophy of the heart. There is only diastolic suffle.
(2) Has not yet decompensated.
(3) There is no anomaly in cardiac conductivity.
(4) There are no complications related to other organs. Even in suitable cases.
a- If the rheumatic lesion concerns two valves,
b-If the patient is over 35 years of age,
c-If there are symptoms of preeclampsia,
d- If an intercurrent infection is involved,
Heart failure can begin at any time.
Ineligible cases:
(1) Diastolic strain and associated cardiac hypertrophy,
(2) There is a history of decompensation in a previous pregnancy and outside pregnancy.
(3) Heart rhythm is severely disturbed.
(4) There are additional medical complications.
Önceki gebeliklerinde dekompanse olan bir hastanın, şimdiki gebeliğinde %75 oranında yetersizlik beklenmelidir. Bu tip hastalar sıkı kontrol altında ve bakımla idare edilebilir. Atrial fibrilasyon sık görülen ve konjestif kalp hastalığı ile beraber bulunan vakalarda emboli ve ani ölümler görülebilir. Romatizma geçirmiş bir kadına,, ancak bir senelik ara verdikten sonra, gebe kalmasına izin verilebilir. Pulmoner hipertansiyonda, prognoz karanlıktır. Gebe kalmalarına izin verilmemelidir. Konjenital kalp hastalarından, pulmoner stenozlu ve aorta stenozlu gebeler, kontrol altında gebelik ve doğumu atlatabilirler. Bu vakalarda dekompanse oluş %15, çocuk ölümü %10-20 arasındadır.
In patients with Cyanose, if the hematocrit is above 60, the child mortality rate is high. Normal progress can be expected below 50. However, the rate of premature birth (Prematurity), underweight (Small for date) and Dysmature children is high. Pregnancy and Heart Diseases It should not be forgotten that heart failure may occur at any time. The most common failure is seen in the 6th, 7th and 8th months. In addition, a febrile illness, severe anemia and pregnancy toxicosis are also factors that can lead to heart failure.
Romatizmaya bağlı gebelik ve kalp hastalıkları (%90): %10-15’inde aorta stenozu da beraberdir. Mitral stenozlu gebelerin %90’ı birinci ve ikinci dereceye giren hastaları oluştururlar. %10’u III. ve IV. gruptakiler, yüksük rizikolu kalp hastalarıdır. Mortalite bu kategoride yüksektir. Mitral stenozlu vakalarda, pulmoner basınç fazlalığının neden olduğu, akciğer ödemi ve sağ kalp yetersizliği tehlikeleri vardır. Bu tehlike en sık 6.-8. aylarda ve bir de travayın ıkıntılı ağrıları sırasında sık görülür. Bir Kalpine diseases It needs to be closely monitored by a specialist.
The leading signs of danger are increased dyspnea, tachycardia, crackles in the lung bases and then pulmonary edema. It is useful to keep suspicious cases under observation in a clinic in the last months.
Mitral regurgitation: Mitral regurgitation alone is the most benign cases. With stenosis, the situation can become serious at any time. In these cases, medical interruption should be made from the very beginning.
Aorta stenozu (%10): Gebelik ve doğum arızasız geçer. Sol kalpte myokard lezyonu varsa prognoz kötüdür. Yetersizlik ağır seyreder.
Aortic insufficiency: Tolerance is good. However, in decompensated cases, pregnancy should be terminated on time.
Endocarditis: In a treated case, pregnancy cannot be allowed until at least 6 months have passed. Recurrence is not expected during pregnancy. Since bacterial flare-ups may occur after tooth extraction, treatment should be carried out under antibiotic pressure. Monitoring and delivery of a pregnant woman with endocarditis, rheumatic heart disease
It should be done according to the principles of the diseases. Deconpensation is 6 times more common than other heart diseases. For septicemia proliphylaxis, delivery should be concluded under high-dose antibiotic pressure. And the pressure is continued throughout the first week of postpartum.
Congenital pregnancy and heart diseases: (%1-3) (Septum defects, pulmonary stenosis, open ductus arteriosus, coarctation aortae, aortic stenosis).
They fall into groups I and II, gmidwifery and birth It goes smoothly. Death rarely occurs. Congenital heart diseases are divided into two groups: cyanotic and non-cyanotic. In aortic isthmus stenoses that cause cyanosis, mortality is %7. Aortic rupture, brain hemorrhage, and decompensation may occur. In these cases, the sectio indication should be broad. However, the prognosis is quite good in cases with atrial defect, open ductus Botalli, and ventricular septum defect.
Pregnancy passes without any problems, but the biggest danger can occur during and immediately after birth: sudden changes in hemodynamic conditions (arterial and venous left-right shunt) also change the direction of the shunt. This leads to inadequacy. With the excess venous blood mass flowing to the right heart, the pressure increases and begins to mix with arterial blood. The danger of shunt is also greater in sectio.
Vacuum or forceps should be preferred for exit. Pregnancy is very rare in blue disease, which does not give a chance to survive until birth. Patients with tetralogy of Fallot also have difficulty reaching childbearing age. Mother-child mortality is high in these. They should not be allowed to become pregnant. Sectio can be lethal.
Coronary disease: Even though pregnancy is rare, it is dangerous. 7.-8. It should be kept under very strict control during the months and after birth. (Cardiac arrest, severe failure, myocardial infarction).
Rhythm disorders: In a normal pregnant woman, the pulse may be above 100. Differentiate from sinus tachycardia
zordur. Halbuki bu tip taşikardi yaklaşan bir kalp yetersizliğinin ön habercisi olabilir. Taşikardi ani başlamışsa, emboli, infeksiyon, kanama gibi nedenler aranmalidir. Sinuzal bradikardi selimdir. Kısmi veya tam blok ciddidir. Esas hastalık prognozu tayin eder. %55 sonradan ortaya çıkan pregnancy and heart diseases ile bağlıdır. %19’a kadar varan mortaliteye neden olur. Konjenital olanlarda prognoz daha iyidir. Tüm ritm bozukluklarında tedavi esas hastalığa yönelmelidir. Yetersizlik ve emboll prognozu kötüleştirir.
Kyphoskolyos: During pregnancy, the chest cavity becomes completely narrow. The heart is forced into an extremely horizontal position. Vital capacity decreases. There is a danger of right heart failure. It should not be left to persistent pain. Anesthesia can be dangerous. Often sectio is mandatory. Attention should be paid to blood loss (Hypovolemic collapse).
TREATMENT OF PREGNANTS WITH HEART DISEASE
The following two complications are expected at any time during pregnancy, birth and puerperium.
1- Pulmoner ödem (Mitral stenoz %80-90): (Paroksismal dispne + öksürük + köpüklü balgam + bazen hemoptizi) akciğerlerde yaş raller, bronkospazm taşikardi ile belli olur. Heyecanda, harekette, coitte, yatarken, uykuda ortaya çıkar. Çok ciddi bir komplikasyondur.
11-Congestive heart failure: Dyspnea increases, neck veins fill, liver enlarges, edema begins in the feet. Myocardial lesions are together. There is cardiac hypertrophy and atrial fibrillation. Myocardium has failed.
Pregnancy and Heart Diseases Treatment: It is the same as other heart diseases.
- After physical exertion, long rest is necessary.
- It is important to protect yourself from infections. Anemia should be prevented, attention should be paid to nutrition, gaining excess weight may be dangerous. Also, pay attention to salt and water.- 28.-32. Pregnancy weeks are a critical period. It requires rest and close observation.
- III. In this group of pregnant women, physical activity should be minimal and they should be checked in the clinic in the last two months.
- Starting from the 36th week, III. and IV. This group of patients must be admitted to the clinic. Pregnancy toxicosis varsa (%20) kaloriden fakir protein ve vitaminlerden zengin, tuzsuz rejim uygulanır (kilo, tansiyon).
- Kalp hastası gebeleri bir kardiolog gözlemeli ve tedavi etmelidir. Anemi varsa artan 0₂ gereksinmesini kalp, dakika volumünü artırarak ve taşikardi ile karşılaşır. Hemoglobin %80 (100 ml./11/7 gr.) altına düşmemelidir. Loğusalarda yüksek antibiyotik baskısı ile romatizma infeksiyonunun alevlenmesi önlenmelidir.
- In mitral stenosis, if there is an indication, the operation is carried out on the 4th-7th day. It is done in months.
Birth follow-up: In case of decompensation, no intervention should be made for birth. However, the conservative attitude is abandoned in the following two cases:
a) Paroxysmal dyspnea during pregnancy: pulmonary edema may begin at any time. Hemoptysis may become severe. It may be necessary to terminate the pregnancy immediately or even have an emergency valvulotomy operation.
b) If there is insufficiency and toxicosis and it gets worse, the pregnancy is terminated immediately with abdominal hysterectomy. In others, birth should be as vaginal as possible.
– The third period should not last more than 1 hour and should be assisted with forceps or vacuum.
– Help should be given with a mask against cyanosis. Antibiotic pressure should be started against exacerbation of endocarditis. Analgesics and remedial agents should be minimized. The risk of infection, anesthesia, blood loss and embolism is high in Sectio.
During childbirth: There is a danger of decompensation and pulmonary edema due to increased blood volume. Rest under medical supervision is a must. It is true that heart patients can have more successful births with antenatal control and care, and new treatment opportunities. Risk, gmidwifery and Heart Diseases depends on the situation.
III.-IV. If patients in this group cannot be corrected with treatment, they should terminate the pregnancy. A pregnant woman seen in the last three months should be advised not to become pregnant again. If the birth is compromised, the tubes must be tied. The successful contributions of heart surgeries are a fact.
Today, to a pregnant woman with severe mitral stenosis:
(1) The chance of pregnancy and birth can be given with heart surgery.
(2) Or the pregnancy is terminated first. Then heart surgery is performed.
(3) Or the pregnancy continues under strict control.
There is a constant fear of hypoxia leaving sequelae in the child. Open heart operations have eliminated these drawbacks (mental retardation, defects). Pregnancy should be allowed again 3 years after heart surgery.
