3. Basic part

Disease of the cardiovascular system

Cardiac insufficiency is inability of heart to provide circulation of blood, corresponding metabolic processes of organism in the period of pregnancy and labor. For pregnant insufficiency of circulation of blood mostly develops at the purchased and congenital defects of heart, illness of myocardium, chronic diseases of heart.

In the first months of pregnancy insufficiency of circulation of blood develops rarely. It more frequently arises up at the end of to 2 trimesters of pregnancy, so as to 26-28 weeks of blood circulation volume maximally increases during pregnancy, as well as intensity of work of heart. In labor and early puerperium haemodynamic violations appear: repeated in-flow of blood 400-800 ml at every uterine contraction, over-load by blood vessels of abdominal region after labor, rapid decompression of bottom veins, pain syndrome which provokes development of insufficiency of circulation of blood. These conditions are critical.

Chronic heart failure

Classification of heart failure of New York association of cardiologists (1995)

Functional class I	Sick with a disease hearts but limitation of activity	No-symptom dysfunction of the left ventricle
FC ІІ	Sick with a disease hearts are with small limitations of physical activity	Mild heart failure
FC ІІІ	Sick with a disease hearts, considerable limitation of physical activity	Moderate heart failure
FC IV	Sick with a disease hearts in which even minimum physical exercise causes discomfort	Severe heart failure

In our country the accepted classification of chronic heart failure by Н.Д.Стражеско-В.Х.Василенко.

1^st stage: symptoms of violation of circulation (of blood of dyspnoea, palpitation, fatigue appearing only after physical effort).

2^nd stage A: stuffiness and palpitation become almost permanent or appear at very easy physical effort; the symptoms of heart dilatation and stagnant phenomena appear in the small circle of circulation of blood at left-ventricle insufficiency, in liver at insufficiency of right part of heart.

2^nd stage B: the blood sludge expressed as in small so in the large circle of circulation (symptoms circulation disorders are present in liver, kidneys, edemas are acutely expressed at insufficiency of right heart) of blood

3^rd stage: the irreversible dysfunctions of all organs are expressed: the signs of dysfunction of all organs develop in them; the signs of metabolic, feed, of dystrophic changes develop in them.

It is known that normal pregnancy can be complicated by appearance of symptoms of insufficiency of blood circulation. A characteristic to healthy pregnant hyperpnoe gives the impression of presence of stuffiness sometimes. For healthy pregnant there can be periodic tachycardia (up to 100 beats in 1 min), extrasystols and other violations of rhythm, edema on feet, dizziness, weakness, stethalgia.

Rheumatism is the system disease which includes inflammation of connecting tissue with recurrent localization of process in the organs of circulation of blood.

A causative agent is β-hemolytic streptococcus of group А.

Classification of rheumatism by А.І. Нестеров:

1 - mild. It is characterized by weak expression of clinical symptoms of active rheumatism, almost complete absence of signs of exsudate to the component inflammation in organs. Laboratory indexes or not deviate from a norm, or changed minimum.

2 - moderate. It is characterized by the moderate clinical displays of rheumatic attack with a not high fever or without her, without the expressed exsudate to the component inflammation in the staggered organs. The laboratory signs of activity of process are mildly expressed. Leucocytosis can be absent, RSE and other laboratory indexes is mildly increased.

3 - severe. Characteristic used for setting inflammation and local displays of disease with a fever with advantage of exsudate to the component inflammation in the organs involved (acute polyartritis, diffuse myocarditis, pancarditis, rheumatic pneumonia. In blood expose neutrophilic leucocytosis, high RSE, С-reactive albumen, growth of level of Fibrinogenum etc.

During pregnancy it is very important clarification of activity of rheumatic process, so as it determines not only the necessity of treatment, prophylaxis but also obstetric tactics, id est activity is the criterion of possibility of maintenance or necessity of terminating pregnancy, also choice of method of labor tactics.

Pregnant who suffers rheumatism has to be under strict clinical supervision of internist in the female dispensary. At suspicion on activity of rheumatic process for diagnosis and treatment the pregnant must be hospitalized in therapeutic department or a maternity hospital is specialized.

An active rheumatic process is contra-indication for pregnancy, especially at the acute and subacute flow of disease. Pregnancy is contra-indicated in case when after the rheumatic attack of passed less than 6 months.

At minimum activity of process (1st degree), if pregnant insists, pregnancy can be saved. Thus it follows to take into account that medications of treatment of intensifying of rheumatism in a 1 trimester are very limited (salicylates are contra-indicated). At FC 1 or 2 and at an active rheumatic process conducted the stage of delivery through natural labor ways with the exception of pushing efforts (imposition of obstetric forceps). In case of decompensation of blood circulation caesarian section is indicated.

Treatment:

• etiotropic therapy-penicillines;

Steroid and non-steroid medications give an anti-inflammatory effect and are symptomatic but not nosotropic medications.

• corticosteroids + prednisolon - 5 mg, dexametazone - 0,5 mg. They are indicated in case of severe carditis, pericarditis, in case of unbearableness or inadequacy of salicylates.

• aspirin and other non-steroid drugs are indicated in case of weakly expressed carditis. It should be remembered that under act of aspirin the chromosomal aberration increase in lymphatic cages, that specifies on possibility of mutagene effect. Preparation represses the biosynthesis of простагландинів of Е and F2 also, which stimulate reduction to the myometrium which can become reason of the protracted labor or переношування of вангітності.

• at unbearableness of salicylates shown analgin, бутадіол.

Prophylactic treatment is conducted 3 times during pregnancy: 12 weeks, 28-32 weeks, in post-natal period.

Acquired defects of heart

Rheumatism strikes a mitral valve, less frequently aortic and tricuspidal valves.

Mitral stenosis is stenosis of the left atrioventricular aperture.

At mitral stenosis the violation circulation of blood begins not at once. The left venous aperture must be narrowed on 60%, id est a to 2 cm (in a norm a 6-7 cm).

During pregnancy heart must anymore transport the blood, so as blood circulation volume increases on 30-50% regardless of the state of heart. And it can result in a pulmonary edema and cardiac asthma.

Mitral stenosis most severe type of defect of heart in connection with that he causes over-load of small circle of circulation of blood, at the same time at pregnancy in itself there are conditions for a bradyhemarrhea in lungs.

Labor for pregnant with mitral stenosis is quite serious clinical situation. For pregnant with the expressed mitral stenosis during labor of oscillation arterial and venous pressure is arrived at by large amplitude, pulse of 110 beats in 1 min, 24 breathings in 1 min

The method of labor is determined by the degree of insufficiency of circulation of blood and activity of rheumatism.

Mitral stenosis is diagnosed for pregnant as well as not for pregnant. At palpation there is the "cat-like purring" on an apex. On an apex a slamming 1 tone, pre-systolic or diastolic murmur, accent of 2^nd tone on a pulmonary artery. At an auscultation accent 2^nd tone on the pulmonary artery is present, prolongation of QT-interval on ECG. Heart ultrasound and Doppler investigation will confirm the diagnosis.

At mitral stenosis pregnancy is contra-indicated, if from the beginning of pregnancy there are signs of insufficiency of circulation of blood or rheumatic activity, blinking arrhythmia, pulmonary hypertension and embolic complications.

The prognosis for pregnancy and labor gets better after surgical treatment of stenosis. A mitral commissurotomy is technically accessible at the late term of pregnancy, but it’s better to conduct it on 10-11 up to 18 weeks of pregnancy. It is not desirable to do an operation in days which correspond menstruation, 2-3 months of pregnancy, which are accompanied by regress of corpus luteum, term after 19-20 week, when uterus increases not due to the height of muscle fibres, but due to by a stretching by growing fetus, in 26-28 weeks of pregnancy, when haemodynamic load on a heart arrives at a maximum. Later 28 week of pregnancy not desirable operation.

Insufficiency of mitral valve

At this defect blood during a systole enters not only aorta but also in back-flow direction in the left ventricle. Because of the strong left ventricle of minute volume of blood supported at normal level and decompensation develops lately. Most pregnant with "isolated" mitral insufficiency carry pregnancy without no signs of insufficiency of circulation of blood Insufficiency of valve is not contra-indication for pregnancy at the compensated defect.

Aortic stenosis

It is 16% of all heart organic defects. Diagnose is difficult. An area of the aortic opening is a 2,6- 3,5 cm. Its narrowing twice is not reflected on the state of pregnant. The period of complete indemnification of defect can proceed 20-30 years. At an area a 0,75-0,5 cm patients grumble about a weakness, stuffiness, loss of consciousness. Develops dilatation of cavities of the left ventricle, in him pressure rises and diminishes cardiac extrass. For stenosis of aorta systolic murmur above an aorta is a diagnostic sign. 2nd tone on an aorta is weak. At "isolated" aortic stenosis a pulse rarely is more frequent 60-65 beats per 1 min, systolic pressure is decreased to 90-100 mm of mercury column, diastolic pressure is some increased.

Clinical flow during pregnancy

If aortic stenosis is compensated pregnancy is not contra-indicated. But even initial signs of insufficiency of circulation of blood are contra-indication to pregnancy. More frequent patients die not in a gestational period, in but a year after labor.

Insufficiency of valve of aorta

Second on frequency rheumatic defect of heart. A defect usually coincides with stenosis of estuary of aorta.

At aortic insufficiency during a diastole part of blood from an aorta flows in зворотньому direction in the left ventricle, as pressure in an aorta in this period does not exceed pressure in a ventricle.

Patients complain at aortic insufficiency on the strong shoves of heart, pulsation of vessels of neck, dizziness and loss of consciousness at the change of position of body, pain in area of heart for as a stenocardia. Characteristic pallor of skin covers, pulsation of sleepy and other peripheral arteries, a pulse is rapid. Systolic pressure is increased, diastolic is acutely decreased.

In default of relapses of rheumatism aortic insufficiency does not cause decompensation of circulation of blood, runs across of high quality and is not contra-indication for pregnancy. Insufficiency with the signs of insufficiency of circulation of blood results the valve of aorta in death in 1-2 years. That is why pregnancy in this situation is contra-indicated.

Congenital defects of heart

To the congenital defects of heart there are 50 nosologic forms of anomalies of development of cardiac system.

Classification of congenital defects (М. П. Чернова, 1977)

• Defects with the extrass of blood from (defect of atrial membrane, open arterial channels, defect of ventricular septa) left to right

• Defects with the extrass of blood on the right on left and with arterial hypoxemia (Fallo tetrade, transposition of main vessels, syndrome of hypoplasia of the left heart)

• Defects are with the barrier of blood stream (stenosis of pulmonary artery, stenosis of aorta, co-arctation of aorta)

Most frequent expectant mothers have defects with the extrass of blood from left to right. Good flow of pregnancy have patients with the defect of muscular part of v membrane, with the small defect. If a disease is accompanied by insufficiency of circulation of blood, pulmonary hypertension or extrass of blood from right to left, then pregnancy must be terminated.

Congenital malformations with the extrass of blood from right to left are most severe. Fallo tetrade and transposition of large vessels is a testimony to terminating pregnancy.

Congenital defects with an obstacle to the blood stream in default of insufficiency of circulation of blood are not contra-indication to pregnancy.

At coarctetion aortas pregnancy is possible only at the moderate narrowing, but even in such case conducted caesarian section.

Pregnancy and hypertensive disease

There is not only classification on this time.

Classifications by WHO:

a 1 .- increase of propulsion MODULE is a from 160/95 to 179/104 mm of рт century without the organic changes of the cardiovascular system; Propulsion MODULE and can change during twenty-four hours.

a 2 ст.- increase of propulsion MODULE is a from 180/105 to 199/114 mm of рт century with the hypertrophy of the left ventricle, but without the signs of damage of other organs;

a 3 ст.- increase of propulsion MODULE is a 200/115 mm of рт century and higher with the damage of heart and other organs (brain, retina of eye)

Hypertensive illness negatively influences on flow of pregnancy. The most common complication is a late gestosis.

For determination of tactic/pl of conduct of pregnancy most essential is an estimation of weight of disease and exposure of possible complications. Therefore the first hospitalization is conducted to 12 weeks to pregnancy.

At 1 century pregnancy proceeds under surveillance of internist and accoucheur. At 2 and century pregnancy can be stored in default of violations of ССС and pochard, 2б and 3 century-contra-indications for pregnancy.

Second hospitalization in 28-32 weeks, третя-за 2-3 weeks to labor.

Labor conduct through natural maternity ways with the adequate anaesthetizing at continuation of hypotension therapy and early amniotomy. 2 periods are shortened, conducting перінеотомію or imposition of obstetric tongs. A bleeding prophylaxis is conducted in 3 periods.

Disease of breathing organs

Bronchitis for pregnant, as a rule primary, infectious or viral genesis, at cooling of body often combines with laryngitis, tracheitis, acute respiratory disease, asthma state. Reason of bronchitis can be productive harmfulness. Basic clinical signs are a rheum, cough, pain in a thorax, sputum. What badly distinguished. Pregnancy does not assist a disease, but peculiar to pregnancy of flowdown of mucous membrane of bronchial tubes bothers sputum. On flow of pregnancy an acute bronchitis does not influence, but the intrauterine infecting of fetus is possible. Shown frequent warm drink (tea with honey, milk with a soda, lime tea), which facilitates expectoration, alkaline inhalations. For the output of bronchial spasm it can beta it is used euphylline. If necessary there can be the used antibiotics. Simple and effective mustard plasters, banks.

A chronic bronchitis flows lasted with the periods of intensifying and remissions. Disease is characterized by the protracted periods of cough with the two-bit/pl of sputum.

A неускладнений chronic bronchitis is not contra-indication for pregnancy and labor. At the expressed respiratory insufficiency the exception of pushing is shown.

In transition the used for setting fire process there is a bronchopneumonia or catarrhal pneumonia on pulmonary fabric. A patient has a fever, cough, general weakness which testifies to the acute beginning of pneumonia; a pulmonary percussion sound is kept or dulling appears on the limited area. Breathing is with wheezes. A disease lasts 2-3 weeks, possible abscess and pneumosclerosis. Shown antibiotics, anti-fungal medications, coughing up facilities, banks, mustard plasters, respiratory gymnastics, massage of chest.

Bronchial asthma

Frequency in 1% of pregnant, a disease can be to pregnancy and arise up during her. The origin of asthma is related to the changes of sensitiveness to endogenous prastaglandines.

The pregnant have clinicopathologic forms:

• atopic;

• infectiously-dependent (infectiously-allergic);

• auto-immune;

• dyshormonal;

• nervously-psychological;

• cholinergic.

Pregnancy runs across under act of the cute nervous system, considerably the level of pregnenetrioldione increases in blood. All these changes of good influence on flow of pregnancy. At the same time in the organism of woman, changes which worsen the prognosis of disease pass: activating of respiratory center, physiology overventilation, oppression of the system of immunity passes for a mother. Foreseeing worsening of the state of pregnant is impossible.

Treatment is determined by the form of disease and includes the use of medications recognition, by influence term of pregnancy on a fetus.

For cut short of attack use:

• group of salbutamol;

• mustard plasters, banks;

• 1 ml of 5% esadrin;

• 2,4% 10 ml of euphylline;

• prednizolone is for 30 ml in 3 hours;

Conduct of pregnancy and labor

In the early terms of pregnancy the shown hospitalization is in therapeutic permanent establishment for an inspection and decision of question about maintenance of pregnancy.

There is obligatory hospitalization 2-3 weeks prior to labor. Bronchial asthma which arose up during pregnancy after labor can diminish. Labor are conducted through natural maternity ways.

Disease of blood

Anaemia of pregnant is a decline of amount of haemoglobin and red corpuscles. Frequency of anaemia for pregnant of 30-35% and there is a tendency to the increase. At anaemia a basic function - delivery to oxygen is violated to the different organs and tissues, a hypoxia which influences on normal flow of pregnancy and fetus develops. Iron-deficient anaemia appears in 90% of pregnant. Indexes of normal vibrations of Hb are 115-145 gs/of л (11,5-14,5г%) and red corpuscles 3,7*1012 - 4,7*1012.

At iron-deficient to anaemia (ЗДА) there is a decline of amount of iron in the serum of blood, marrow, high concentration of estrogen hormones, which assists the dyspoiesis of haemoglobin What causes anamia: wrong feed, violation of suction of iron (disease of intestinal highway), vomiting, bleeding, multifetation, lactation, too frequent pregnancies.

Classification on the degree of weight :

• mild - Нb 91-110 gs/of л;

• moderate - Нb a 81-91 g/of л;

• severe degree - Hb not below 80 gs/л.

Clinical features. The pregnant compains about a weakness, stuffiness and dizziness at insignificant physical effort, dizziness and headache. As a result of diminishing of enzymes iron is included in composition of which, observed there are trophic violations (psilosis, change of taste, fragility of nails). The some pregnant do not express at presence of anaemia of complaints. There is a pallor of skin covers and scleras at a review. Sometimes there is subfebrile temperature. At anaemia there are scray changes for the increase of oxygenation of tissues: increase of volume of plasma, cardiac extrass and speed of blood stream. At an auscultation above the apex of heart hearkened to systolic noise. There is the frequent breathing. Almost in half with anaemia arterial low blood pressure is determined. A liver and spleen at ЗДА is not megascopic. The diagnosis of ЗДА is based on the changes of next indexes is a decline of Hb below 115 gs/of л, diminishing of content of iron in blood of to 10,7 mmol/l, decline of Ht less than 33%, colour index below 0,85. There is less of red corpuscles, anisocytosis is norm or amount them increased. RSE is increased always. For pregnant from ЗДА the gestosiss of the second half of pregnancy develop often, in 15-42% is terminating pregnancy in different terms, often there is a high water-level, ФПН, hypoxia of fetus, СЗРП. Labor at every third case at anaemia become complicated ill-timed outpouring of amniotic fluid, weakness of labor (15%), by the increase of blood loss in labor - in 10%. In this connection labor must be conducted actively with the prophylaxis of weakness of childlabor, asphyxia of new-born, bleeding in an early puerperium. Even insignificant blood loss is badly carried by women and can result in a collapse. A puerperium can become complicated by septic diseases in 12%. Anemia can result in a hypoxia, oligotrophy and development of anaemia of fetus. For children, born from mothers with anaemia, often there is oppression of erythrogenesis.

Treatment: rational feed (meat, liver, bread, is leguminous, soy-bean, dill, parsley). Day's ration must contain albumens to 120г (50% of animal origin), limitation of fats to 70г on twenty-four hours and carbohydrates to 350-400г. apply medications of iron, vitamins, other medications. Most effective are medications of iron supply. To apply medications of iron better in all with ascorbic acid. Unrationally to apply at ЗДА medications which stimulate an erythrogenesis (folicacid, vitamin of В12). It is necessary to remember that an effect from treatment comes not early than as in 3 weeks. Blood transfusion is not conducted in connection with an of short duration effect and immunization of pregnant. Prophylaxis: early exposure and timely hospitalization, treatment.

Megaloblast anaemia - it anaemia at which is violated ripening of cages of red row, conditioned by the deficit of vitamin of В12 or folic acid. Typical for such anaemias is a presence in marrow of megaloblasts, reason of increase of which is a dyspoiesis of DNA. В12-anaemias are hyperchromatic, characterized by the atrophy changes of tongue, gullet, stomach, changes of the nervous system. The deficit of vitamin of В12 can be constrained from disorder of absorbtion (atrophy changes of mucous membrane of stomach), by the invasion of helmints, inherited violations of гемопоезу. A clinic consists of anaemic syndrome, violations, changes of the nervous system (feeling of crawl of ants, numbness of extremities, violation of deep sensitiveness, spastic парапарез). For a blood test characteristic presence of hyperchromatic anaemia, macro- and anisocytosis of red corpuscles, diminishing of amount of leucocytes, moderate hyperbilirubinemia. In marrow megascopic amount of megaloblasts.

Treatment: diet (meat, eggs, milk, liver, kidneys), vitamin of В12 (100-200 мг/twenty-four hours, in/a m, folic acid 5-15 мг/twenty-four hours, vitamin of С to 100 мг/twenty-four hours). Day's requirement of pregnant in фолієвій acid is 300-mcg (for unpregnant she is 100мкг). The depot of folic acid in the organism of man is absent, and the exchange of her very unstable, that is why the deficit of her at pregnancy arises up very quickly. A wrong feed, frequent pregnancies, protracted reception of hormonal contraceptives, assists it. Hyperchromatic anaemia is 1% from all cases of anaemias. For this form not the typical is expressed clinical flow (Hb within the limits of a 80-100 g/of л). Treatment to iron of effect medications is not given. A clinic is expressed in absence of appetite, characteristic vomiting, diarrhea, burning of tongue. There can be signs of hemorragic diathesis of skin, mucous membrane, scleras. There is an increase of spleen, fervescence. There is a decline of amount of red corpuscles in blood, in the strokes of blood is a presence of мегалоцитів, anisocytosis and grittiness and nuclear forms of red corpuscles. The amount of RBC is diminished. The amount of leucocytes increases from to the left. An early sign is a presence of the hypersegmented leucocytes. At pregnancy there can be next complications: wilful abortions, anomalies of development of fetus, complication of labor. A prophylaxis and treatment of anaemia consist in a valuable feed (green goods and fetus, meat foods, milk, nuts), setting of medications of фолієвої acid (5-15мг/доб), vitamin of С to 100мг/day.

Hypoplasticanaemias - it a disease at which is observed acute oppression of hematogenesis. The hypoplasia of hematogenesis arises up at the action of external factors: action of ionizing radiation, use of some medicinal medications and chemicals. It is important have chronic infections - hepatitis, pyelonephritis. On occasion reason is self-aggression against to the antigen of cages of marrow. Consider that pregnancy is the possible etiologic factor of development of immune conflict.

A clinic consists of three syndromes:

anaemic syndrome;

hemorragic syndrome;

septic syndrome.

The picture of blood is characterized by the expressed anaemia: Hb goes down a to 50 g/l relative lymphocytosis.

In bone marrow almost complete absence of elements and substituting for them takes place by fatty fabric. There is an increase of content of iron in the serum of blood which results in the hemosiderosis of organs and tissues. The flow of disease is various. On occasion rapid progress of disease. A death rate is 60,5%; in another cases a disease runs across with periodic remissions, complete recovery is possible.

Treatment: blood tranfusion, prednizolone, splenectomy, transplantation of allogenic marrow. Combination of anaemia with pregnancy is observed very rarely. Prognosis for the mother is unfavorable, lethality is observed at 45% cases.

In case of occurring of disease during pregnancy (more frequent in the second half), clinical displays appear quickly: Hb 80-38 gs/of л, low platelets 45*109/л. There are signs of hemorragic diathesis. The flow of disease is very heavy, possible death of mother. At breaking to pregnancy there can be hearths of necrosis in the place of operation. If pregnancy comes for a sick woman, then there is intensifying of process. At the exposure of anaemia it is necessary to set her character and hemophthisis, terminating pregnancy is conducted in early terms. As it is quicker all necessary to conduct a splenectomy. If a woman renounces terminating pregnancy it is necessary to conduct dynamic control after the indexes of blood. Worsening of the state of pregnant (Hb of 60г/л, amount of leucocytes less than 1,5*109/л, less than 20%, proof relative lymphocytosis (anymore 60%), origin of hemoragias, infectious processes) forces to conduct terminating pregnancy.

Hemolytic anaemia

The inherited anaemias are constrained from the impairment structure of membranes of red corpuscles, by violation of activity of enzymes and synthesis of hematohistone. Immune anaemias are related to operating of autoantibodies on red corpuscles. Thus there is diminishing of amount of red corpuscles. The level of bilirubin rises in blood, an icterus appears for patients. Most often at pregnancy there is (due to defect of structure of membrane to the red corpuscles) hemolytic anaemia. The defect of membrane assists penetration in the red corpuscles of water. The spherical form of red corpuscles assists the increased destruction of red corpuscles in a spleen. A basic syndrome is hemolytic (icterus, anaemia). A bilirubin at intensifying rises to 102-119 мкмоль/л. There is an urobilinuria.. The picture of blood is characterized by the presence of microspherocytosis, decline of osmotic of red corpuscles, clasmocytoma.

A disease has cyclic flow. Intensifying more frequent arise up at infectious at pregnancy.

Treatment. Blood transfusion is shown only at considerable анемізації. Most effective at treatment of this anaemia is surgical treatment - splenectomy.

Auto-immune anaemia arise up at formation of antibodies to the own red corpuscles at violations in the immunocompetency system. Distinguish symptomatic (at system red lupus, heterospecific ulcerous colitis, chronic hepatitis) and due to unknown reason anaemias.

The clinic of anaemia is characterized by the presence of weakness, pain in area of heart, stuffiness, palpitation, icteruses. There is unbearableness of cold at this form of anaemia.

At acute crises content of haemoglobin arrives at subzero numbers. The amount of immature RBC rises mildly. A reliable laboratory test is a test of Kumbs.

The most effective treatment of anaemia is application of steroids. For liquidation of the phenomena appoint the large doses of prednizolone (from 50-60 to 80 мг/day). At the heavy intensifying blood transfusion is recommended after an individual Also indicated splenectomy.

At pregnancy in combination with anaemia. Often there is a threat of terminating pregnancy. A prognosis is for the mother of good. The artificial breaking of pregnancy is not shown.

Treatment is conducted with the use of prednozolone in the dose of 80мг/доб., blood transfusions until normalization of indexes of blood. A dose is reduced in future, a support dose (10-15мг/доб) is recommended. Labor it is recommended to conduct conservatively. During labor the dose of prednizolone it follows to increase.

Leucoses are malignant diseases of hematogenesis tissue

Classification:

1. Lymphoblastic.

2. Myeloblastic.

3. Monoblastic.

4. Prometrin.

5. Erythroblastic

6. Plasmoblastic.

7. Megacaryoblastic.

Syndromes:

1. Hyperblastic (increase of lymphatic knots, liver, spleen).

2. Hemorragic (diffuse bleeding).

3. Anaemic.

4. Intoxication.

At the beginning of disease flows without symptoms. A diagnosis is proposed only morphologically is an exposure of бластних cages of blood or marrow.

The separate forms of leucosis differentiate only tissue researches.

Pregnancy worsens the state of patient (not how many pregnancy, how many her completions), often becomes complicated by abortions.

At a acute leucosis necessarily to terminate pregnancy in the first trimester. In the second trimester of terminating pregnancy it is better to conduct conservatively. At development of acute leucosis at the end of pregnancy and compensated state of patient is a temporizing tactic/pl and conduct of labor conservatively.

Thrombocytopenia is a decline of amount of thrombocytes, related to the increased destruction, necessity and their insufficient education.

There is destruction of thrombocytes most frequently. Distinguish to the inheritance and the purchased forms. There is a change of functional properties of thrombocytes at the inherited form. It is divided into immune and related to the action of factors.

In basis of pathogeny a disease lies insufficient amount of thrombocytes and diminishing of components is related to it in the displacing system of blood. It is known that an important role is taken in the system to гемостазу to the thrombocytes.

At platelets insufficiency arises up as a result of the increased fragility of vessels, so as a result of exit of red corpuscles from a vascular river-bed through capillaries. The sanguifluousness appears at the decline of amount of thrombocytes to 50*109/л (normal content is from 150*109/л of to 400*109/л).

Clinically it shows up as rash on front of feet, trunk. Often there are hemorrhages in the places of injections, at the insignificant damage of vessels (measuring of arteriotony, , grinding of skin covers).

The amount of thrombocytes diminishes in peripheral blood, factors of hemopexis in a norm, and their increase is possible. Bleeding time is prolonged. Broken retraction of faltung. In marrow megascopic amount of megacaryocytes. A diagnosis is set on the basis of characteristic clinical signs and indexes of blood.

A flow of disease can be acute and chronic recrudescent.

Nosotropic treatment consists of the use of steroids and splenectomy. If an effect from these measures is not observed, then immunodepressants are used. Treatment immunodepressants during pregnancy contra-indicated. Combination of this and pregnancy is often enough. Flow of pregnancy and labor depends on the form of disease and character of treatment which was preceded to pregnancy. During pregnancy, intensifying of anaemia is unoften. Sometimes intensity of symptoms of disease diminishes during pregnancy. Some authors consider that intensive bleeding during pregnancy and it is not arisen up up to labor. Pregnancy is contra-indicated at:

1. To the acute form.

2. Bleeding is from a nose and gums.

3. A hemorrhage is in a brain.

4. A chronic form is with frequent recidives.