This document discusses features of pregnancy and childbirth management in women with extragenital pathology. It notes that only 20% of pregnancies proceed without complications, while 30-40% involve extragenital pathology (EGP) such as cardiovascular, kidney, or blood diseases. Pregnancy termination risks are 12% and can affect fetal development. The most common EGP in women ages 21-29 is cardiovascular disease, observed in 7% of cases. Management of pregnancy involves frequent hospitalizations and selecting delivery methods based on the severity of the woman's condition.

1. FEATURES OFPREGNANCY AND CHILDBIRTH
MANAGEMENTWITH EXTRAGENITALPATHOLOGY

2. To date, the health index of pregnant women in Kazakhstan does not exceed
30% (B.I.Abdykalykova, 2009).
An in-depth analysis of the course of pregnancy suggests that pregnancy
proceeds without complications only in 20% and the presence of EGP – in 30-
40% of cases.The threat of termination of pregnancy in 12% undoubtedly
affects the intrauterine development of the fetus and its further development.
https://cyberleninka.ru/article/n/chastota-
vstrechaemosti-ekstragenitalnoy-patologii-u-
beremennyh-zhenschin/viewer

3. The conclusion that EGP prevailed between the ages of 21-29 years (60%)

4. Plan

5. How common are cardiovascular diseases in pregnant women?
• Heart disease is observed in an average of 7 %
• Hypertension - in 4-5 %
• Arterial hypotension - in 1-2 % of pregnant women
What are the causes of pregnancy complications in women suffering
from cardiovascular diseases?

6. An increase in the load is associated with increased
metabolism, an increase in the volume of circulating
blood, the appearance of an additional placental
circulatory system
With an increase in the size of the uterus, the mobility
of the diaphragm is limited, intra-abdominal
pressure increases, the position of the heart in the
chest changes, which ultimately leads to changes in
the working conditions of the heart.
Such hemodynamic changes can be unfavorable and even dangerous for both:
mother and child
The body 's oxygen consumption increases
• At the very beginning of labor, there is an increase in
oxygen consumption by 25-30 %,
• during labor - by 65-100 %,
• In the second period-by 70-85 %, at the height of attempts-
by 125-1 55 %.
+HEART DISEASE

7. What are the main acquired heart defects and what are the features of
pregnancy with them?
Acquired rheumatic heart defects account for 75 to 90 % of heart lesions in
pregnant women.
 The most common form of rheumatic heart disease is mitral stenosis
"pure" or predominant
 The second most common defect (6-7%) is mitral valve insufficiency.
 Mitral valve prolapse.

8. Mitral valve insufficiency
As a rule, with this defect, in the absence of
pronounced regurgitation, cardiac arrhythmias and
circulatory insufficiency, pregnancy does not worsen
the course of heart disease.
Mitral
commissurotomy.
Mitral valve prolapse
The tactics of managing pregnancy and childbirth
in mitral valve prolapse are the same as in
physiological pregnancy.
In patients with severe cardiological symptoms,
attempts should be turned off by applying
obstetric forceps.
In the presence of obstetric pathology (weakness
of labor, large fetus, etc.), delivery by caesarean
section is indicated.

9. What are the main methods of studying the cardiovascular system in pregnant
women?
• Electrocardiography
• Echocardiography
• Load tests
• Studies of the function of external respiration and acid-base state.
What are the indications for early termination of pregnancy?
The issue of preserving pregnancy and its safety for the mother and unborn child should
be resolved not only before the onset of pregnancy, but preferably before the patient
marries.
The issue of termination of pregnancy up to 1-2 weeks is decided depending on the
severity of the defect, the functional state of the circulatory system and the degree of
activity of the rheumatic process.

10. At what time of pregnancy is hospitalization of women with
cardiovascular pathology necessary?
1st hospitalization - at 8-10 weeks of pregnancy to clarify the diagnosis and
resolve the issue of prolongation or termination of pregnancy.
The 2nd hospitalization is at the 28-29 week of pregnancy to monitor the state of
the cardiovascular system and, if necessary, to maintain heart function during the
period of maximum physiological loads. Prevention and treatment of placental
insufficiency.
The 3rd hospitalization is at 37-38 weeks to prepare for childbirth and choose the
method of delivery.

11. In mitral stenosis, beta-blockers are the cornerstone of therapy and only a small
number of patients require balloon valvuloplasty. Regurgitant lesions mostly
require diuretics alone for the treatment of heart failure. The mode of delivery is
usually vaginal; caesarean section is performed in those with obstetrical
indications or in cases with severe stenosis and a poor clinical state. The
postpartum period presents a second high-risk period for maternal adverse events,
with heart failure and arrhythmias being the most frequent.
With excessively pronounced mitral insufficiency with blood regurgitation and
severe hypertrophy of the left ventricle, pregnancy is difficult and can be
complicatedby left ventricular insufficiency.
Maintaining pregnancy in this case is impractical
Management
Blanche Cupido 1, Liesl Zühlke 2, Ayesha Osman 3, Dominique van Dyk 4, Karen
Sliwa
Managing Rheumatic Heart Disease in Pregnancy: A Practical Evidence-
Based Multidisciplinary Approach
https://pubmed.ncbi.nlm.nih.gov/34571164/

12. In what cases is it possible to conduct childbirth through the natural
birth canal?
Delivery through the natural birth canal is allowed with compensation of blood
circulation in patients with mitral valve insufficiency, combined mitral heart disease
with predominance of stenosis of the left atrioventricular orifice, aortic heart defects,
congenital heart defects of the "pale type". Anesthesia of childbirth is mandatory

13. In what cases is it possible to conduct childbirth through the natural
birth canal?
Delivery through the natural birth canal is allowed with compensation of blood
circulation in patients with mitral valve insufficiency, combined mitral heart disease
with predominance of stenosis of the left atrioventricular orifice, aortic heart defects,
congenital heart defects of the "pale type". Anesthesia of childbirth is mandatory
What are the indications for cesarean delivery in pregnant women with
heart disease?
Until now, many doctors believed that delivery on time by caesarean section reduces
the load on the cardiovascular system and reduces the mortality of pregnant women
suffering from heart defects.
However, many authors recommend for severe degrees of heart defects to carry out
delivery by caesarean section, but not as a last resort for prolonged labor through the
natural birth canal, complicated by decompensation of cardiac activity, but as a
preventive measure carried out on time.

14. Recently, the indications for caesarean section in patients with
cardiovascular diseases have been somewhat expanded. These
include the following:
1. Circulatory insufficiency of stage II B-III.
2. Rheumocarditis of II and III degrees of activity.
3. Severe mitral stenosis.
4. Septic endocarditis.
5. Coarctation of the aorta or the presence of signs of high arterial hypertension or
signs of incipient aortic dissection.
6. Severe persistent atrial fibrillation.
7. Extensive myocardial infarction and signs of worsening hemodynamics.
8. Combination of heart disease and obstetric pathology.

15. Anemia of pregnant women

16. What forms of anemia are distinguished?
Anemia of pregnant women is divided into acquired (deficiency of iron, protein, folic acid)
and congenital (sickle cell).
The frequency of anemia, determined by lowering the level of hemoglobin in the blood
using WHO standards, varies in different regions of the world in the range of 21-80%.
There are two groups of anemia: those diagnosed during pregnancy and those that
existed before its onset. Anemia that occurs during pregnancy is most often observed.
The severity of anemia is determined according to laboratory data:
- Lightweight: Hb 120-110 g/L,
- - Moderate (moderate severity): Hb 109-70 g/l, red blood cell count 3.9–
2.5×1012/l, Ht37-24%;
- - Severe: Hb 69-40 g/l; number of erythrocytes 2.5–1.5×1012/l, Ht 23-13%;-
- - Very severe: Hb = 40 g/l; the number of red blood cells less than 1.5 = 1012
/ l, Ht = 13%.

18. • Asiderotic anemia
it occurs in 20-30% of pregnant women (normal HB - 110 g / l)
it develops after 20 weeks of gestation in 65% of pregnant women
• Preventive courses 12, 20, and 32 weeks of lactation
• Оbstetric tactics - independent labor, taking into account the expected
• Blood loss of 0.3% by weight of the body of a pregnant
Aplastic anemia
• It occurs in 0.4% of pregnant women. The analysis indicated a decrease
in red blood cells, reticulocytes, leukocytes.
• In the early period indicated termination of pregnancy,after 28 weeks -
caesarean section with splenectomy
Hemolytic anemia
• Detect abnormal red blood cells (spherocytes), there is a violation of the
immune system
• In laboratory assays microspherocytosis, reticulocytosis up to 80% with
a sharp decrease in osmotic resistance of red blood cells, a positive
Coombs, splenomegaly
• Obstetric tactics: in early pregnancy - abortion, in the period after 28
weeks of pregnancy - independent labor

19. Diseases of the kidneys and urinary tract
Among extragenital pathology in pregnant kidney disease and
urinary tract infections are the second after diseases of the
cardiovascular system and can be dangerous for both mother
and fetus.
During pregnancy, there is hypotension, and the expansion
of the renal pelvis and ureter system due to the impact of
placental progesterone, the uterus is deflected to the right

20. • ascending path (from the urethra, bladder)
• descending - lymphogenous (from the intestine, especially for
constipation)
• hematogenous (in various infectious diseases)
Pathogens
- Enterobacteriaceae (Escherichia coli, Proteus, Klebsiella),
enterococcus, streptococcus, fungi Candida type, Staphylococcus
aureus, Pseudomonas aeruginosa.
Common clinical forms:
Pyelonephritis, hydronephrosis, asymptomatic bacteriuria. Less
glomerulonephritis, urolithiasis, tuberculosis, kidney disease,
abnormalities of the urinary tract, pregnancy with a single kidney.

21. Pyelonephritis
It is the most common disease in pregnancy (6 to 12%), at
which suffers the concentration ability of the kidneys.
There gestational pyelonephritis - pyelonephritis, appearing
for the first time during pregnancy.
Pyelonephritis has an adverse effect on pregnancy and the
fetus.
Clinical presentation and laboratory
evidence in pyelonephritis
Fever, tachycardia
Pain in the lumbar region
Headache, nausea, weakness
Pain during urination
Laboratory data:
leukocytosis
Pyuria, bacteriuria
Anemia

22. Glomerulonephritis
• Glomerulonephritis - 0.1 - 0.2% in pregnant women.
• The causative agent of B-hemolytic streptococcus group A.
It occurs 10-15 days after undergoing a sore throat. There are acute
and chronic.
• Pregnant chronic glomerulonephritis occurs in the following forms
hypertension, nephrotic mixed and latent.
Obstetric tactics in the form of latent and nephrotic gestation
pregnancy is not contraindicated.
• In hypertensive and mixed form in combination with azotemia pregnancy
is absolutely contraindicated.

23. The course of pregnancy and childbirth in
renal disease
• Premature delivery
• Preeclampsia
• Septic complications during the postpartum period
• Indications for termination of pregnancy in renal disease:
• Hypertensive and mixed form of glomerulonephritis
• Pyelonephritis, hydronephrosis single kidney
• Bilateral hydronephrosis
• Tuberculosis of the kidney with renal scarring

24. Diabetes and Pregnancy
The problem of pregnancy in women with diabetes is
relevant worldwide. It adversely affects fetal development,
increased frequency of malformations, perinatal morbidity
and mortality.
Diabetes is divided:
• type I diabetes - insulin-dependent (IDDM);
• type II diabetes - insulin dependent (NIDDM);
• diabetes type III - gestational diabetes (GD), which
develops during pregnancy and is a violation of transient
utilization of glucose in women during pregnancy.

25. DDM and NIDDM
There are 3 types of diabetes.
 The most common IDDM. The disease is usually
diagnosed in girls in childhood, during puberty.
It is characterized by absolute insulin deficiency, prone to
ketoacidosis and progression of vascular complications.
 NIDDM meet in older women (over 30 years) and occurs
less severe, often against a background of obesity is
characterized by relative insulin deficiency often occurs
without vascular complications.
 Gestational diabetes is first diagnosed during pregnancy is
more common in 27-32 weeks of pregnancy.

26. Physiological changes in pancreatic function in pregnancy
In physiological pregnancy, the following changes of the
pancreas:
• Lowering glucose tolerance
• Reduced sensitivity to insulin
• Intensified insulin decay
• Increased circulation of free fatty acids
• Change of carbohydrate metabolism due to the influence of
placental hormones placental lactogen, estrogen,
progesterone, corticosteroids.
• Insulin - an anabolic hormone that promotes glucose
utilization and biosynthesis of glycogen, fat and protein.

27. Risk factors for gestational diabetes:
Obesity (> 90 kg. Or 15% of the weight before pregnancy)
Family history
Childbirth large fetus
Polyhydramnios
Glycosuria
Recurrent candidiasis, repeated urinary tract infection.
Diabetes type of sugar according to the WHO curve fasting
7 mmol / L after 1 hour (100g.) Glucose - 11.1 mmol / L, 2
hours- 7.8 mmol / l and glycosuria
In the I trimester of pregnancy. Marked improvement in the
disease course, increased insulin sensitivity, decreased
blood glucose levels, may develop hypoglycemia, which is
associated with increased glucose utilization fruit.
insulin dose reduced by 1/3.
In the II trimester of pregnancy is deteriorating
carbohydrate tolerance, marked hyperglycemia,
ketoacidosis can be.
With 32 weeks for diabetes improves. By the end of
pregnancy again improves carbohydrate tolerance, due to
the influence of the fetal insulin and glucose utilization
mother to fetus. insulin dose reduced by 20-30%.
Current diabetes during
pregnancy
Risk factors for
gestational diabetes:

28. Diabetes in Pregnancy
Need 3 fold hospitalization up to 12 weeks or in thediagnosis of pregnancy, 20
24 weeks, 32-34 weeks.
Joint management with the endocrinologist
At 14-18 weeks, the definition of blood alphafetoprotein.
Obstetric complications in the second half of pregnancy
(Diabetes 75-85% of cases):
• preeclampsia;
• polyhydramnios;
• urinary tract infections;
• malformations of the fetus.
• The current supply is complex:weakness of labor activity;untimely
discharge of amniotic fluid;the presence of a large fetus;development of a
functionally narrow pelvis;
• Difficulty the birth of the shoulder girdle;birth trauma of the mother and
fetus.

29. Treatment.
Contraindications diabetes in pregnancy
Treatment:
Insulin therapy is required during pregnancy, even in mild forms of diabetes.
Contraindications to pregnancy in diabetes
• The presence of rapidly progressive vascular complications:
microangiopathy, retinopathy,
• Nephrosclerosis
• insulin-resistant diabetes labile forms
• The combination of diabetes with active tuberculosis
• The combination of diabetes with sensitization
• Diabetes mellitus of both parents

30. Thanks for your
attention