6 important rules: what not to do in the third trimester of pregnancy?

Pain Treatment Center

Alekseeva

Oksana Alexandrovna

23 years of experience

Doctor, highest qualification category, member of the European Association of Neurologists, Russian Interregional Society for the Study of Pain (ROIB), Association of Interdisciplinary Medicine. Has experience working in hospital and outpatient services. He has seven published works on neurology.

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In ensuring the normal functioning of the human body, one of the key positions is occupied by the autonomic nervous system (ANS) - a complex of nervous structures responsible for maintaining a constant internal environment (homeostasis). The efforts of the ANS regulate the functioning of the circulatory and lymphatic systems, internal organs, and endocrine glands. The ANS itself is part of the nervous system (NS), but has an important feature - autonomy, that is, a person cannot control it with his own will.

Various disorders in the functioning of the ANS are called vegetative-vascular dystonia (VSD). This term does not mean a separate disease itself, but a syndrome - a condition caused by diseases of certain organs and systems (mental or somatic pathologies, hormonal imbalances).

Main symptoms and signs

The manifestations of VSD are diverse; the general list includes over several dozen items, but patients experience only a few of them (usually from 5 to 20) in different combinations. An important point: with VSD, there is a combination of several symptoms that appear simultaneously, but in the complete absence of organic disorders. A separate manifestation of any of these signs is not a reason for diagnosing vegetative-vascular dystonia, since it usually indicates a specific pathology.

Doctors distinguish several forms of VSD, classifying them on the basis of identifying relatively typical sets of symptoms that resemble the course of certain pathologies of organs or systems.

Respiratory form of VSD

Respiratory vegetative-vascular dystonia is the most common. The patient complains of the inability to take a deep breath, is afraid of suffocating, gasps for air, feels soreness, tightness in the throat, heaviness or pain in the chest, and coughs frequently.

Tachycardial form

Complaints of rapid heartbeat (tachycardia), irregular heart rhythm, sensation of vascular pulsation and heat in the temples and neck. It should not be confused with a similar picture with arrhythmia, paroxysmal tachycardia.

Cardiological form

In the area of ​​the heart, pain of a different nature is noted (long-term aching or sharp, sharp), without a clear localization. During an attack of cardiac vegetative-vascular dystonia, the patient is anxious and breathes heavily. The pain lasts longer than with cardiovascular diseases (angina pectoris, myocardial infarction), does not depend on physical activity and is not relieved by appropriate medications (validol, nitroglycerin and others).

Hypotonic form

Characterized by dizziness, darkening of the eyes, sudden perspiration on the forehead, sweating, weakness, cold palms. Blood pressure drops briefly to 90/60 or below.

Hypertensive form

During an attack, tachycardia and heart pain are observed against the background of a short-term increase in blood pressure. The main difference from real hypertension: the pressure does not exceed 150/90.

Asthenic form

Performance decreases, complaints of fatigue, weakness, inability to concentrate, and sometimes body temperature rises slightly. Tremor (shaking in the hands) is possible, especially with the slightest physical exertion or a stressful situation. Irritability for no apparent reason or due to insignificant reasons, tearfulness.

Visceral form

Manifested by symptoms from the gastrointestinal tract (functioning disorder, nausea, diarrhea, vomiting, irritable bowel syndrome).

Mixed form

It combines certain signs characteristic of all the above forms of VSD, in arbitrary combinations.

Sometimes patients experience acute manifestations of symptoms, so-called attacks of dystonia or vegetative crises. An attack of VSD is characterized by sudden, spontaneous and rapid development, regardless of the circumstances. It can happen both during physical activity or a stressful situation, and at rest or sleep; alone or in a crowded place. Patients are afraid of suffocation, fear of death from respiratory or cardiac arrest, some feel feverish, others feel cold.

Separately, it is worth mentioning pre-syncope and fainting. They can have different origins; based on trigger mechanisms, they are distinguished:

• psycho-emotional - as a result of experiences, fear, reaction to the sight of blood;
• orthostatic - due to a sudden change in position, usually when abruptly getting up from a chair or bed;
• hypotonic – due to a sharp decrease in blood pressure.

Loss of consciousness is usually short-lived, lasting 1-3 minutes, the patient quickly comes to his senses. A history of fainting may indicate more severe pathologies, such as adrenal or cardiovascular insufficiency, nephropathy, or diabetes mellitus.

With such an impressive range of complaints, patients often do not experience any pathological changes in the structure or functioning of organs and systems. They often experience fear of developing a serious pathology, attributing to themselves some kind of disease based on similar signs. So, some fear paralysis due to mild numbness of the limbs or a heart attack due to chest pain.

Do you have symptoms of vegetative-vascular dystonia (VSD)?

Only a doctor can accurately diagnose the disease. Don't delay your consultation - call

Rule 1: do not ignore the advice of the obstetrician-gynecologist who is managing your pregnancy

In the third trimester of gestation, trips to the antenatal clinic become frequent. After 36 weeks of pregnancy, a woman visits an obstetrician-gynecologist every week. What can the doctor advise you during the consultation? First of all, monitor your weight gain, count the amount of fluid you drink and excrete per day.
The amount of fluid you drink is all drinks, soups, and half the volume from fruits and dairy products. The amount of fluid excreted is the volume of urine (diuresis). If these numbers are the same, then everything is great. If the volume of fluid consumed exceeds daily diuresis, this may indicate hidden edema that forms in the intercellular spaces of tissues and organs.

Hidden edema can be a consequence of kidney disease and heart problems. But the most common reason for their appearance is gestosis, which is a complication of pregnancy.

If left untreated, gestosis leads to serious consequences:

• pulmonary edema;
• placental abruption;
• delayed fetal development;
• premature birth.

Preeclampsia is accompanied not only by hidden edema, but also by swelling of the arms and legs, high blood pressure, and proteinuria - the appearance of protein in the urine.

Diagnostics

To begin with, the doctor, during a conversation with the patient, collects a detailed anamnesis - finds out the complaints, their nature, frequency of occurrence, the presence of a hereditary factor (are there people in the family who suffer from confirmed VSD).

Then a general examination is carried out, attention is paid to the patient’s behavior and his emotional background.

Due to the presence of symptoms similar to those of various other diseases (arrhythmia, hypertension, pathologies of the thyroid gland, gastritis, etc.), each patient with suspected VSD must undergo a detailed therapeutic examination in a clinical setting. To confirm the diagnosis of VSD, it is necessary to absolutely exclude diseases with similar symptoms. For this purpose, laboratory tests are prescribed:

• general blood analysis;
• general urine analysis;
• liver and kidney function indicators;
• analysis of thyroid hormone levels;
• clarifying tests at the discretion of the doctor.

Next, a referral is given for instrumental examinations, of which the most frequently used are:

• electrocardiography (ECG);
• echocardiography;
• 24-hour Holter blood pressure monitoring;
• fibrogastroduodenoscopy;
• Ultrasound of the abdominal organs, kidneys, neck vessels, thyroid gland;
• chest x-ray;
• spirometry;
• bicycle ergometry.

Sometimes the doctor requires additional diagnostic methods, such as computed tomography (CT), magnetic resonance imaging (MRI), electroencephalography, colonoscopy and others. Various functional tests are also carried out (psycho-emotional, orthostatic, physical exercise, pharmacological).

Why you should take vitamin D

There are several reasons for this:

1. It is produced in the body only after contact with direct sunlight. Therefore, a chronic lack of this component is the result of rare exposure to the sun.
2. If it is not possible to obtain the required dose of ultraviolet radiation, this is fraught with health problems. They can only be avoided by regularly taking nutritional supplements that contain vitamin D.
3. There is very little of it in the daily diet. This vitamin is found in fatty sea fish and cod liver. But even with the consumption of these products, its deficiency is not fully compensated.

Back in 2007, scientists from Oregon conducted diagnostics among the local population. There were a total of 976 participants of retirement age. According to research results, only 25% of women and 49% of men have enough vitamin D in their bodies. According to statistics, about 70% of people do not have enough vitamin D, so it is necessary to convey this information to the population and regularly take vitamin D supplements.

The normal amount in the body is considered to be 50 ng/ml. On average, in a healthy person, the concentration of this vitamin should be from 40 to 80 ng/ml. At the same time, the risk of deterioration in health is observed already when its level drops to 10-24 ng/ml.

Causes of occurrence and development

The etiology of VSD, as well as its symptoms, is extremely diverse. Among the main reasons, doctors name:

• pathological changes that occurred during pregnancy or childbirth (intrauterine hypoxia, infectious process, birth injuries, etc.);
• changes in hormonal levels (during puberty or during hormonal therapy);
• hereditary tendency (presence of autonomic disorders in close relatives);
• traumatic brain injuries of any severity;
• traumatic stressful situation, frequent psycho-emotional stress;
• high mental stress;
• excessive, or conversely, insufficient physical activity;
• toxic effects of certain substances;
• unbalanced, irregular nutrition;
• long-term course of chronic diseases (diabetes mellitus, hypertension, coronary heart disease, bronchial asthma, hypo- and hyperthyroidism, gastric ulcer, etc.);
• chronic lack of sleep, sleep disorder;
• sudden changes in weather conditions or prolonged stay in a place with severe climatic conditions;
• the presence of foci of infectious agents (chronic sinusitis, rhinitis, otitis, tonsillitis, etc.);
• bad habits (smoking, alcoholism, drug addiction).

There are certain risk groups, people from whom are more likely than others to develop VSD: people who are underweight or overweight, have low resistance to stress, and occupy responsible positions; girls during puberty, women during pregnancy and menopause.

Analogs

There are several types of analogues of this drug. Some of these are structural analogues: Angiovit and Multitabs B-complex. They are good drug substitutes and are actively prescribed in complex therapy. There are different drugs in the price category.

Neuromultivitis or Milgamma?

There are a number of analogues of Neuromultivit, which are quite ways to replace the drug in certain clinical cases. For example, if we consider the drug Neuromultivit in comparison with Malgamma, we can identify several advantages of each vitamin complex. Thus, both drugs are included in the group of neurotropic vitamins. The active substances included in the drugs are similar. However, Milgamma additionally contains lidocaine hydrochloride. This means that as part of complex therapy, both drugs will function equally, but Milgamma will also provide a more pronounced analgesic effect for pain syndromes.

Neuromultivitis or Combilipen?

Neuromultivit and Combilipen belong to the group of neutrotropic vitamins and have the same composition and contraindications. However, Combilipen also contains the substance lidocaine, which is a strong analgesic. Vitamin complexes have different manufacturers: Combilipen is produced by a domestic pharmaceutical company. In addition, the drug has a wider list of side effects. The price category of drugs is also different. The doctor prescribes this or that complex to the patient strictly according to individual indications.

Neuromultivitis or Neurobion?

Neuromultivit and Neurobion have a similar composition and work according to the same scheme. However, they also have slight differences in composition: Neurobion contains 0.04 mg more cyanocobalamin than Neuromultivit. This allows Neurobion to be prescribed to patients who have a history of diseases of the circulatory system. The specialist prescribes a particular drug based on indicators that are revealed during the collection of a detailed medical history: concomitant diseases, age, individual tolerance of each component, the patient’s well-being for a given period.

Neuromultivit or Pentovit?

Both drugs have a similar composition of vitamins, however, in addition to vitamins B1, B6 and B12, Pentovit also contains nicotinamide and folic acid in small doses. The drugs prevent hypovitaminosis and replenish the supply of vitamins in our body. Pentovit is prescribed in much larger dosages than Neuromultivit, since the latter contains vitamin components with a higher concentration. Neuromultivit has a foreign manufacturer, so its price is much higher than Pentovit.

Neuromultivitis or Berocca?

The drugs Neuromultivit and Berocca are complexes of B vitamins and have a similar composition. However, the drug Berocca contains trace elements such as calcium, magnesium, as well as nicotinamide, pantothenic acid and biotin. There are more indications for taking Berocca. Neuromultivitis is prescribed for more serious diseases, since its action is based solely on the vitamin B complex. Specialists prescribe both drugs, but each patient is selected a medicine strictly individually.

Treatment

Therapeutic measures consist of a set of effective methods, each of which is selected individually. Since most of the occurrences of VSD occur due to stress, it makes sense to pay attention to ways to combat them:

• normalization of sleep;
• rejection of bad habits;
• building an adequate work and rest regime, if necessary, the issue of changing jobs is considered;
• nutritious nutrition in compliance with the meal schedule;
• performing special sets of physical exercises, therapeutic exercises, yoga;
• work with a psychologist (individual or group classes, psychological trainings, consultations);
• physiotherapeutic procedures (massage, electrophoresis, contrast and therapeutic showers, etc.);
• Spa treatment.

All of the above methods are quite effective; when used, not only the disappearance of VSD symptoms is noted, but also an overall positive effect on the body as a whole.

Drug interactions

It is not recommended to take the drug simultaneously with antiparkinsonian drugs. One of them is levodopa. This reduces the effectiveness and performance of the antiparkinsonian drug and reduces the effectiveness of its use to zero. In case of unintentional violation of the instructions, you should postpone taking the vitamin complex.

The drug Neuromultivit should not be prescribed with other vitamin complexes containing B vitamins, as this can lead to an overdose.

Preparations that contain the substance ethanol can also reduce the efficiency of absorption of the vitamin complex. The benefit of taking drugs of this nature at a time is minimal.

Drug therapy for VSD

Prescription of medications is resorted to in case of ineffectiveness of non-drug measures. Treatment of VSD involves the use of medications strictly as prescribed by the doctor. Only a specialist determines the necessary drugs, their dosage and frequency of administration in each specific case. Among the main groups of medications are:

• sedatives of plant origin (normalize sleep, have a mild and effective effect);
• antidepressants – reduce anxiety, relieve headaches of varying intensity and duration;
• tonic and restorative drugs (improve tone, increase resistance to stress, physical and mental stress);
• metabolic agents – improve and normalize metabolic processes in the body, in particular in the brain and nervous system;
• tranquilizers - prescribed with caution, as they have clear indications and many side effects;
• microelements and vitamins;
• drugs aimed at eliminating various specific symptoms and their causes (hypotensive, antiarrhythmic, prokinetics, antispasmodics, etc.).

The patient must understand that VSD does not belong to the category of severe pathologies. With proper treatment and strict adherence to medical recommendations, recovery is guaranteed. The right attitude towards recovery plays an important role, when a person is not afraid of the manifestations of dystonia, but strives to overcome them. This is especially true for attacks of anxiety, restlessness, and various phobias - as soon as the groundlessness of such fears is realized, they gradually disappear forever.

Therefore, it is very important not to be afraid to talk about the problem. Sometimes patients are embarrassed by this and are in a vicious circle when they cannot cope with the problem on their own, but do not dare to visit a doctor. And it’s completely in vain, because already during a conversation with a specialist it turns out that it is much easier to cope with the situation together, moreover, the prognosis is favorable.

Rule 6: don’t forget to prepare for the upcoming birth

In the third trimester of pregnancy, it is imperative to prepare for childbirth. Of course, it is better to do this in advance. But even if you only have a few weeks or days left before giving birth, be sure to try to get as much useful information as possible.

Important questions that a pregnant woman should know the answers to:

1. How are contractions different from the precursors of labor?
2. What to do if your water breaks?
3. When should you go to the maternity hospital?
4. What happens during the first, second and third stages of labor?
5. How long does the birth process last?

This information will help you overcome the fear of childbirth and successfully cope with such a difficult task as the birth of a baby.

Doctors treating VSD

In addition to the attending physician, a neurologist, endocrinologist, otolaryngologist, ophthalmologist, and instrumental diagnostic specialists take part in the process of diagnosing VSD. Depending on the symptoms, you may need to consult a specialist doctor - cardiologist, gastroenterologist, pulmonologist, urologist and other related specialties.

At the clinic of JSC “Medicine”, a comprehensive approach allows us to accurately establish the mechanisms of the occurrence and development of VSD, triggers, and timely identify or exclude concomitant pathologies. Doctors of the highest category with many years of experience, doctors of medical sciences, practice here. This is the key to successful treatment, but much depends on the patient himself: how timely he sought qualified medical help, how carefully he followed the doctor’s instructions for diagnosis and treatment.

Illness in the first months of the period under review

A very common point of view is that VSD and pregnancy are incompatible. But we can confidently say that if you follow simple rules, it is quite possible to significantly reduce the impact of vegetative-vascular dystonia on the body of a pregnant woman if treatment is prescribed and carried out under the supervision of a professional doctor.

VSD most often appears in the first months of pregnancy and can occur immediately before birth. It is impossible to say exactly how the disease will progress - different women feel differently. Before prescribing appropriate treatment, a specialist objectively studies the body and the probable causes of signs of vegetative-vascular dystonia, determining what type it is: hypotonic, hypertonic or mixed.

According to medical research, VSD of the hypotonic type can provoke the occurrence of placental insufficiency and anemia. A pregnant woman may be underweight. With VSD of the hypotonic type, the fetus may experience a lack of oxygen and nutrients, which can have a negative impact on its subsequent development.

More than 9,000 people have gotten rid of their psychological problems using this technique.

Typically, VSD of the hypertensive type can provoke the development of late toxicosis. Additionally, a pregnant woman may have headaches and panic attacks after stress.

Vegeto - vascular dystonia of the mixed type combines the consequences of the 2 above types. This is the most unpleasant type of illness because it creates the greatest discomfort. Treatment can effectively eliminate a number of unpleasant consequences, the recommendations of which the patient will follow completely.

Indications for treatment

The main indication is a clinically confirmed diagnosis of vegetative-vascular dystonia. Since VSD is a syndrome, the indications for its therapy correspond to disorders of various etiologies: vascular, psychological, neurological, cardiological and many others.

If your professional responsibilities involve high mental and emotional stress, stressful situations, overwork, or if you have a hereditary predisposition to VSD, sign up for a consultation with a specialist. Timely prevention will help avoid worsening problems, because the disease is easier to prevent than to treat.

special instructions

Under no circumstances should the drug be administered in the form of a solution for intramuscular injection into the vascular bed intravenously. This may entail the risk of adverse reactions of the body: deterioration of the condition as a whole or allergic reactions in the form of anaphylactic shock. If you violate the instructions, you should contact a specialist.

The absorption time of thiamine increases when the vitamin complex is consumed simultaneously with alcohol or strong tea.

Neuromultivit is a drug containing a component of vitamin B6. For persons with a history of peptic ulcers or intestinal disorders, the dosage is reduced or the drug is replaced. If the renal system and liver are not functioning satisfactorily, you should also be careful in using this drug.

The course of treatment is 4 weeks. When using a complex of vitamins for a longer period, dysfunctions of the nervous system may occur: the appearance of symptoms of neuralgia.

For persons whose profession involves driving vehicles and working with complex mechanisms, there are no special instructions or prohibitions. There are strictly individual cases when the situation requires specialist consultation.

Neuromultivit is also used in complex therapy in the treatment of heart failure and vascular disease.

Contraindications

Contraindications for the treatment of VSD are determined by the methods used. If we talk about drug therapy, then almost every drug has contraindications for use. The same can be said about physiotherapeutic procedures. That is why the course and tactics of treatment are determined by a highly qualified doctor who is able to take into account all factors.

There is one contraindication that is simultaneously applicable in all cases - self-treatment. In the case of VSD, this is especially true, since such patients are often excessively suspicious and tend to attribute severe pathologies to themselves. In an attempt to treat a non-existent disease, they can not only significantly aggravate their situation, but also cause irreparable harm to the body.

pharmachologic effect

B vitamins play an important role in the human body: in addition to combating hypovitaminosis and vitamin deficiency, their function is to influence the regulation of metabolism in the central nervous system. The active ingredients of the drug also allow you to achieve an analgesic effect, which is effective in the fight against neuralgia and pain. After reading the manufacturer's instructions, you can find out that the vitamin complex copes with metabolic disorders.

Many vitamins are not able to be formed spontaneously in the body, so a person needs to replenish their supply in more accessible ways, taking a complex of vitamins in the form of tablets or suspensions.

In case of disturbances in the functioning of the nervous system, doctors also prescribe a course of B complex vitamins. This is due to the fact that the components included in the drug provide direct stimulation to trigger the natural restoration of areas of nervous tissue. Thanks to active neurotropic substances, which, in turn, play the role of coenzymes in the processes of the central and peripheral nervous system, the active course of intermediate metabolism is triggered.

In addition, the drug is non-toxic, which means it will not cause harm to human health. The course is prescribed to both children and adults according to the prescribed dosage.

Pharmacodynamics

The components included in the drug have the leading properties for stimulating pharmacological action. The drug contains substances such as thiamine, pyridoxine and cyanocobalamin, vitamins B1, B6, B12, respectively. A lack of these components in the human body can lead to neurological disorders, in particular in the peripheral nervous system.

B vitamins have anti-inflammatory degenerative properties, which have a beneficial effect on the functioning of the nervous system and the musculoskeletal system. In addition to these functions, Neuromultivit actively regulates blood flow, and its components participate in the most important biochemical reactions of the body and are an indispensable catalyst.

Neuromultivitis plays an important role in the regulation of protein, carbohydrate and fat metabolism. Vitamin B1 is also a source for conducting nerve impulses at synapses. A complex of vitamins is used in the treatment of neuralgia, radiculitis, peripheral paresis and paralysis. Thiamine content in large quantities is observed in striated muscles, in particular in the myocardium.

Pharmacokinetics

Thiamine after intramuscular administration is absorbed from the gastrointestinal tract. The distribution in the body is uneven, but the vitamin is found in red blood cells in large quantities, equal to 75 percent. It is excreted by the kidneys immediately after 20 minutes. The final metabolites are pyramine, thiaminecarboxylic acid and others. Thiamine is considered a vitamin that is stored in the body in the lowest concentrations.

Pyridoxine. After the vitamin is administered intramuscularly, it enters the bloodstream and is evenly distributed throughout the body. A larger amount of the vitamin binds to blood plasma proteins. Pyridoxine is evenly distributed throughout the body. It is excreted in urine after 2–2.5 hours.

Cyanocobalamin. When administered parenterally, the cyanocobalamin component forms a bond with the transport protein. Absorbed by the liver and bone marrow. Able to penetrate the placental barrier.

Cost of initial appointment, diagnostic examinations and treatment

As for the initial appointment, its cost in most cases is low; in fact, it is a consultation procedure. But one should not neglect its importance - an experienced doctor is able to recognize characteristic symptoms and notice even small but important manifestations of abnormalities.

The price of diagnostic procedures and laboratory tests may vary significantly in different clinical cases. For one patient, general tests and several examinations will be enough; for another, diagnosis may take longer and require additional studies and tests. This is due to both the complex nature of VSD and the individual characteristics of each patient’s body.

A similar picture is typical for treatment. Its cost is determined by many factors; sometimes the therapeutic process has to be adjusted. To roughly navigate the prices for diagnosis and treatment of VSD in Moscow, you can familiarize yourself with the corresponding table of costs for the most common diagnostic procedures.

Neuromultivitis for children

To date, the safety of the drug for children under 12 years of age has not been clinically proven. There is an opinion that when this drug is prescribed to small patients, they develop hypervitaminosis, which is extremely important to prevent in a child. Hypervitaminosis develops due to the fact that the drug contains B vitamins, the daily dose of which is intended only for adults. However, there are cases where pediatricians still prescribe analogue drugs to children over 3 years of age. The pediatrician tries to take into account all the individual characteristics of the child and the clinical case.

After a thorough examination of the child and collection of a detailed, reliable history, the doctor decides on the advisability of prescribing the drug.

Advantages of treating VSD at the clinic of JSC "Medicine"

Vegetative-vascular dystonia is a multifactorial disorder in the body; its successful treatment requires an integrated approach and coordinated work of doctors of many specialties. Among the undeniable advantages of JSC “Medicine” (clinic of academician Roitberg), it is worth mentioning 3 key points:

1. High professionalism of doctors - the staff consists of more than 300 experienced practicing doctors and diagnosticians of 67 medical specialties. Leading corresponding members of the Russian Academy of Sciences, academicians, professors, doctors and candidates of medical sciences advise here. The clinic was the first in Russia to receive accreditation according to the international standards for assessing the quality of medical care JCI. Joint Commission International, considered the highest level of accreditation worldwide.
2. Ultra-modern technical base - equipped with the latest generation diagnostic and treatment equipment from the world's leading manufacturers. This allows you to create your own scientific and clinical developments in almost all medical areas. For many years, the clinic of JSC "Medicine" has served as a clinical base for the Department of Therapy and Family Medicine of the Russian National Research Medical University named after N.I. Pirogov (RNIMU) and is among the innovatively active healthcare institutions in Moscow.
3. High-quality medical care - the effectiveness and safety of treatment is guaranteed by the principle of Academician N.A. Semashko, which states: “One patient - one doctor.” The attending physician is assigned to each patient and works closely with colleagues from related medical specialties. A developed diagnostic base and medical care technology built according to international standards make it possible to make a diagnosis at an unprecedented speed. In just 1 day from the moment of the initial examination and diagnostic measures, you can receive detailed results of laboratory tests, detailed diagnostic reports and doctor’s recommendations.

It is important to know: VSD is not a critically severe disorder, but can provoke one in the absence of proper medical care. In case of early access to a doctor, treatment time is significantly reduced and financial costs are reduced. Don’t delay your visit, make an appointment at a time convenient for you, and we will help you regain your health!

About the problem of pregnancy with Crohn's disease and ulcerative colitis

The relevance of the problem of managing women with inflammatory bowel diseases (IBD) during pregnancy is beyond doubt due to the fact that almost all women suffering from ulcerative colitis (UC) or Crohn's disease (CD) develop these diseases during their childbearing years.

The question of the possibility of pregnancy in women with IBD is still controversial. The lack of information from doctors about the peculiarities of the course of pregnancy and the safety of modern treatment methods leads to unfounded conclusions about the inadmissibility of pregnancy in this category of patients. At the same time, refusal to bear children leads to severe psychosocial consequences and negatively affects the quality of life of women.

Most of the works accumulated to date on the study of IBD during pregnancy are uncontrolled and performed on small clinical material. Based on the results of these studies, it is not always possible to judge the characteristics of the course of IBD in women during pregnancy. From this point of view, a large prospective controlled randomized study completed in 2008 under the leadership of ECCO (European Crohn's and colitis organization) deserves attention. The study involved 500 patients [10]. The purpose of this and a few other controlled multicenter studies: to find an answer to a number of hitherto unresolved questions related to the course of IBD in women of reproductive age. The first step was to determine whether IBD affects fertility.

IBD and fertility. Until recently, it was believed that fertility in patients with UC and CD was significantly reduced (66% in CD and 49% in UC) [21]. However, the data accumulated and summarized to date indicate that a decrease in fertility in patients with IBD is observed only in 7–12% of cases [28, 50].

An analysis of the results of a number of studies shows that a smaller number of pregnancies in patients with established IBD may be due to the woman’s reluctance to have a pregnancy against the background of IBD and their compliance with contraception [14, 25].

In patients with CD, a decrease in the pregnancy rate may be associated with impaired menstrual function against the background of high disease activity and as a result of the development of adhesions in the pelvis after surgical interventions [4, 14, 25, 33].

As for UC, it is currently believed that in women suffering from this disease, the ability to conceive is not significantly impaired [25]. However, it should be noted the possibility of decreased fertility after surgical interventions (total or subtotal colectomy, resection of the colon with ileoanal anastomosis or ileostomy), due to the development of adhesions in the abdominal cavity [27, 43, 45].

Thus, in patients with IBD, the lower number of pregnancies is determined by a number of reasons. Analysis of the data available in modern literature and the experience of our own observations give reason to conclude that the positive outcome of pregnancy largely depends on the degree of activity of the process in the intestines at the time of its onset, therefore, it is necessary to include recommendations for the management of patients in the pregnancy management program at the stage of planning conception .

The second equally important issue discussed in the literature concerns the influence of the inflammatory process in the intestines on the course of pregnancy.

The impact of IBD on the course of pregnancy. To date, the prevailing opinion is that the impact of IBD on the course and outcome of pregnancy is determined by the activity of UC and CD at the time of conception and during pregnancy [5, 7, 12, 13, 14, 19, 20].

Among the complications of pregnancy are: miscarriage (premature birth, spontaneous miscarriages) and fetal malnutrition [6, 14, 21, 28, 39, 48].

At the same time, the degree of activity of the inflammatory process in the intestines largely determines the prognosis of the course and occurrence of pregnancy complications. It is believed that with high CD activity, the percentage of uncomplicated pregnancies is only 54%, while with inactive disease it is 80% [1, 17]. It is known that the percentage of complicated pregnancies increases manifold with IBD activity during pregnancy. Thus, with active CD, the risk of premature birth increases by 3.5 times, spontaneous miscarriages - by 2 times [17]. With this disease, artificial termination of pregnancy and cesarean section are more often performed [10].

In UC, the likelihood of developing adverse pregnancy outcomes also depends on the activity of the inflammatory process. With an active process in the intestine, the frequency of premature birth increases by 2 times, and spontaneous miscarriages by 2.3 times compared with pregnancies occurring against the background of an inactive disease [17]. The onset of IBD during pregnancy significantly increases the risk of complications, both pregnancy and the disease itself [7, 41].

Thus, in general, the prognosis for perinatal outcomes in IBD is favorable if there is no activity of UC and CD during pregnancy.

Researchers studying the problem of IBD in women of childbearing age have been trying for many years to find out whether pregnancy has an impact on the course of the process in the intestines. Below is the status of this problem at this stage.

The influence of pregnancy on the course of IBD. It is known that when IBD is in remission at the time of pregnancy, in 2/3 of cases remission remains during pregnancy [29, 36, 39, 50]. The incidence of exacerbations of UC and CD does not differ from that observed in non-pregnant patients. If at the time of conception there was an exacerbation of IBD, then in approximately 30% of cases the activity remains, in 35% it increases and in 35% it subsides. Exacerbations often develop in the first trimester of pregnancy, after abortion and after childbirth. In a study by Modagam et al. exacerbation of IBD in the postpartum period was observed in 13% of cases in patients with inactive disease during pregnancy, while in patients with active disease - in 54% of cases [36].

Relapses of IBD often occur as a result of women refusing to take medications during pregnancy [7]. Despite the fact that taking 5-aminosalicylic acid (5-ASA) drugs (mesalazine) is approved by the FDA (Food and Drug Administration, USA) for use during this period (at a dose of up to 2–3 g/day), many patients stop treatment from the moment of pregnancy.

The clinical example presented below demonstrates the active course of UC during pregnancy, which occurred against the background of moderate disease activity and the absence of adequate therapy.

Case 1. Patient X., 20 years old. He has been suffering from UC since the age of 17, when he first began to experience frequent, pasty stools up to 15 times a day mixed with blood and mucus. During the examination, a total form of UC was diagnosed. Treatment was carried out with sulfasalazine and suppositories with prednisolone with a positive effect. Subsequently, exacerbations of the disease occurred 3–4 times a year. Three years after the onset of the disease, the first pregnancy occurred against the background of moderately active inflammation in the intestines. The patient refused to take maintenance therapy with 5-ASA drugs due to fear of adverse effects of therapy on fetal development. From 8 weeks of pregnancy and throughout its entire duration, frequent bowel movements were observed up to 7–8 times a day, mixed with blood and mucus. The pregnancy proceeded with signs of threatened miscarriage, and laboratory signs of iron deficiency anemia and hypoproteinemia were observed. However, the patient refused treatment. From 34 weeks of pregnancy, sulfasalazine was started at a dose of 1.5 g per day without significant clinical effect. Spontaneous birth occurred at 39 weeks of gestation. A boy was born weighing 3100 g and 50 cm tall. In the postpartum period, the patient continued to have frequent stools up to 7–8 times a day mixed with blood. During therapy with 5-ASA drugs (Salofalk) and hydrocortisone enemas, remission of the disease occurred. 5-ASA (Salofalk) at a dose of 2 g/day was prescribed as maintenance therapy.

This clinical case shows that moderate activity of UC at the time of conception with inadequate treatment can contribute to the persistence and increase in activity of IBD both during pregnancy and in the postpartum period. All this indicates the need to plan pregnancy during the period of IBD remission, and if an exacerbation occurs, to carry out appropriate therapy.

In order to study the characteristics of reproductive function, the course of pregnancy and childbirth in women suffering from IBD, we examined 219 women of reproductive age. From this number of patients, an in-depth study group of 64 people was selected (38 UC, 26 CD). Depending on the presence of IBD at the time of pregnancy, two subgroups were identified: women who had a pregnancy before the onset of IBD - subgroup I, and women in whom pregnancy occurred against the background of IBD or the disease arose during pregnancy - subgroup II.

In general, women in the observed group had a total of 180 pregnancies. Of this number, 100 pregnancies (55.6%) occurred before the development of IBD and 80 (44.4%) occurred against the background of IBD. Based on the results of the survey, the reasons for the lower number of pregnancies in the second subgroup were identified: the woman’s reluctance to have a pregnancy, problems with pregnancy and changes in the sexual sphere against the background of an active disease.

Difficulties in achieving pregnancy with IBD were more often observed in patients of the second subgroup.

It was noted that only 90 pregnancies (50%) were wanted and prolonged. Of this number, 52 pregnancies (57.8%) occurred before the onset of the first symptoms of IBD and 38 (42.2%) - against the background of established IBD.

Wanted pregnancies resulted in normal births in the study group in 53 cases (60%), while in the control group - in 89%. Complicated pregnancy occurred in 11 cases (21.2%) in subgroup I and in 19 cases (50.0%) in subgroup II of observation. In the control group this figure was 30.1%. In the group of women with IBD, a wide range of complications was identified (miscarriage, congenital malformations of the fetus, antenatal fetal death, fetal malnutrition). 26 women who had pregnancies before developing IBD had 42 children during that period, while 28 women who had pregnancies with IBD had 32 children. Congenital malformations of the fetus were observed in 1.9% of cases in the first subgroup and in 5.3% in the second. Termination of pregnancy for medical reasons was carried out in 1.9% of cases in the first subgroup and in 13.2% in the second. Cases of fetal malnutrition in the first subgroup were identified in 18.2% of cases, in the second - in 27.8% of cases. In the second subgroup, the average weight of newborns was lower than in the first: in patients with UC this difference was 427 ± 114 g, in patients with CD - 352 ± 123 g.

Antenatal fetal death was not observed in the first subgroup, while in the second subgroup it was 5.3%. A significant percentage of pregnancy complications in women suffering from IBD was observed mainly against the background of pronounced activity of the inflammatory process in the intestines (78% of cases).

Thus, women with active IBD during pregnancy constitute a risk group for perinatal complications.

The results of our study showed that pregnancy does not have a significant effect on the course of IBD. However, if an exacerbation occurs during pregnancy (37.9%), then in the absence of adequate treatment in 72.7% of cases, the activity of the inflammatory process in the intestine remains and may be accompanied by the development of complications, especially in the postpartum period. In 27.3% of cases, spontaneous remission occurs. This gives grounds for the conclusion that it is necessary to plan pregnancy during the period of remission of UC and CD, and if an exacerbation occurs during pregnancy, to carry out adequate therapy for the disease.

The question of the method of delivery in IBD remains a subject of debate.

Childbirth in patients with IBD . It is known that patients with IBD are more likely to be delivered by cesarean section than in the general population [26, 32]. The reasons for such interventions: the presence of an ileostomy or an active form of CD with perianal lesions and cicatricial changes in the perineum.

The choice of method of delivery in women with IBD is determined by obstetric indications. The exception is patients with perianal forms of CD, in the presence of an intestinal stoma and pouch anastomosis. In these cases, a caesarean section is advisable.

The issue of an increased risk of developing perianal complications of CD after episiotomy remains controversial. Recent data indicate that there is no significant risk of perianal fistulas after episiotomy [17].

There are a number of features of examining patients with IBD during pregnancy.

Diagnosis of IBD during pregnancy. Opportunities for diagnostic measures during pregnancy are limited. The diagnostic value of laboratory tests (hemoglobin and albumin levels) during pregnancy is reduced due to physiological hemodilution. Determination of the level of C-reactive protein can be used as a marker of the activity of the inflammatory process [49]. Of the endoscopic research methods, gastroscopy and sigmoidoscopy are relatively safe. In the second and third trimesters, sigmoidoscopy is difficult due to the displacement of the colon by the pregnant uterus and should be carried out with extreme caution, as it can cause contractions.

The use of radiation diagnostic methods during pregnancy is undesirable due to possible adverse effects on the fetus and should be reserved only for emergency situations in the development of complications of IBD.

Ultrasound examination of the abdominal cavity and intestines is noninvasive, safe for the mother and fetus, and provides valuable information about disease activity, extent of lesions, and development of complications.

In recent years, particular attention has been paid to the problem of treating IBD in pregnant women.

Treatment of IBD during pregnancy . Standard therapy for IBD, depending on the severity, includes 5-ASA drugs (mild and moderate forms), corticosteroids (moderate and severe forms), immunosuppressants (moderate and severe forms when steroids are ineffective). The problem of treating patients with IBD during pregnancy remains a subject of debate. Most drugs cross the placental barrier and may affect the developing fetus. Recommendations for drug use and dosage are often theoretical due to a lack of clinical trials. However, it must be emphasized that treatment of IBD during pregnancy poses a lower risk of adverse effects than active disease. Currently, to assess the risk of adverse effects of drug therapy in pregnant women, classifications of risk categories for the use of drugs during this period have been developed. The most convenient to use and often used in practice is the FDA classification, although there are others (FASS classification - Swedish Catalog of Approved Drugs (Sweden) and ADEC classification (Australia) - Australian Drug). According to the results of most controlled studies, 5-ASA drugs (Mesalazine, Sulfasalazine), glucocorticoids, and Cyclosporine are approved for the treatment of patients with IBD during pregnancy.

However, there are a number of conditions under which the above drugs can be used during pregnancy. This primarily applies to Sulfasalazine, which consists of sulfapyridine combined with 5-ASA (Mesalazine). Sulfasalazine and its metabolites cross the placental barrier, inhibit the transport and metabolism of folic acid and can displace bilirubin from its protein binding, which may increase the risk of fetal kernicterus. Despite the fact that numerous observations have not revealed cases of side effects in pregnant women [35], treatment with Sulfasalazine should be carried out with simultaneous administration of folic acid (2 mg/day) to prevent defects in the formation of the neural tube in the fetus [25].

As for 5-ASA drugs (Salofalk and others), controlled studies have proven the effectiveness and safety of their use during pregnancy in women with IBD at a dose not exceeding 2–3 g/day (category B). In this case, drugs are used both for the treatment of active forms of IBD and for the prevention of relapses [16, 17].

There are many objections to the use of corticosteroids (category B) in pregnant women, based mainly on experimental data. According to many authors, their use during pregnancy should be limited as much as possible, and the prescribed doses should be reduced as much as possible [1]. The effectiveness of immunosuppressants (6-mercaptopurine and azathioprine (category D)) has been proven for the treatment of complicated, steroid-dependent and steroid-resistant forms of IBD. However, the potential teratogenic and mutagenic effect of these drugs, obtained in the experiment, dictates the need to exclude their use during pregnancy [3, 23].

Methotrexate (category X) has mutagenic and teratogenic properties. Its use is strictly contraindicated during pregnancy [20].

Cyclosporine (category D) is a powerful immunosuppressive drug with a high incidence of side effects on the fetus [8]. Its use is considered acceptable in cases of steroid-refractory forms of the disease as an alternative to surgical treatment [35].

In many controlled studies, metronidazole (category B) has been shown to be effective in the treatment of active forms of CD, especially in lesions located in the colon and perianal region. The use of Metronidazole during pregnancy is limited to the second and third trimesters of pregnancy with short courses due to the potential risk of adverse effects on the fetus [1, 17].

In recent years, infliximab (Remicade), which is an antibody to tumor necrosis factor (category B), has been used to treat fistulous and resistant forms of Crohn's disease. The same drug has now begun to be used in the treatment of UC. However, the number of studies regarding the use of infliximab in pregnant women with IBD is extremely small.

The high risk of developing pregnancy complications in the group of women with IBD, according to literature data and the results of our own observations, allowed us to develop schemes for a differentiated approach to the treatment of IBD depending on the reproductive plans of women. Three schemes have been identified.

The first scheme provides for the treatment of women of reproductive age who are not planning a pregnancy. In this group, IBD therapy does not differ from generally accepted regimens and depends on the severity of the disease and the presence of complications.

The second regimen is used to treat women planning pregnancy. The results of our research indicate that the optimal time for conception is the period of stable remission of IBD. Therefore, in the presence of an inflammatory process in the intestines, this group of women is given aggressive therapy depending on the severity of the disease. Upon achieving remission, it is acceptable to prescribe 5-ASA drugs in doses not exceeding 2 g/day as maintenance therapy. The use of immunosuppressants must be stopped at least three months before the intended conception due to the high risk of developing teratogenic effects. An important place in preparing for pregnancy is occupied by the method of hyperbaric oxygenation (HBO). Our experience of including HBO in complex therapy for IBD at the end of an exacerbation and as a measure to maintain remission indicates a gradual improvement in the state of the intestinal microflora and restoration of the intestinal mucosa with annual use of HBO for at least 6 years [2]. This allows you to maintain remission for a long time, which is especially important for patients planning pregnancy. Therefore, women with IBD who are preparing for pregnancy are recommended to undergo annual HBOT courses consisting of 10 sessions.

The third regimen is used in a situation where an exacerbation of IBD occurs during pregnancy or the postpartum period. In these cases, 5-ASA preparations are used in doses not exceeding 3 g per day. For moderate and severe forms of IBD, glucocorticoid drugs can be used. If conservative therapy is ineffective, cyclosporine can be used as an alternative to surgical treatment in combination with folic acid 2000 mcg per day to prevent malformations of the fetal nervous and cardiovascular systems. With the development of complications of IBD or severe exacerbations that are resistant to conservative therapy, surgical treatment is performed.

In case of severe exacerbations in the postpartum period, requiring the administration of high doses of glucocorticoids, it is necessary to transfer the child to artificial feeding.

The indications for surgical treatment during pregnancy are the same as outside pregnancy. After colectomy and ileostomy operations performed during pregnancy, pregnancy usually proceeds without complications.

In our message dedicated to the problem of pregnancy in IBD, we cannot ignore the group of men of childbearing age suffering from UC and CD, and bring to the attention of doctors the need to inform men planning to become fathers.

IBD in men. It is believed that the ability to have children is generally intact in men with IBD. At the same time, abscesses and fistulas in the pelvic area in CD in some cases lead to erectile dysfunction and ejaculation [1, 17]. Similar disorders can occur in patients after surgical interventions, especially after the formation of an ileoanal anastomosis. In some patients, oligozoospermia may be the result of prolonged exposure to active disease, malabsorption syndrome.

With long-term (at least two months) use of sulfasalazine, in 85% of patients, the volume of seminal fluid decreases, the content of sperm in it decreases, and their structure and motility are impaired [44]. According to the results of published studies, three months after discontinuation of the drug or when switching to mesalazine, sperm count and motility are normalized [37].

Data on the effect of glucocorticoids on male fertility are limited. Increased levels of endogenous steroids can lead to decreased sperm concentration. Therefore, the use of glucocorticoids should not be prolonged.

The question of the adverse effect of 6-Mercaptopurine and Azathioprine on pregnancy outcomes if the father took these drugs is controversial. Although there has been no increase in the risk of pregnancy complications in this situation, a few studies have reported an increase in the number of spontaneous miscarriages and congenital anomalies of the fetus in cases where the father received these drugs within three months before conception [46].

According to the FDA classification, Methotrexate is classified as safety category X during pregnancy. In this regard, it is recommended to stop taking Methotrexate at least three months before the expected conception.

Conclusion

Thus, the high risk of developing pregnancy complications in people suffering from UC and CD dictates the need to counsel patients even at the stage of starting a family and planning pregnancy. The optimal period for conception is a period of stable remission of UC and CD.

Patients of childbearing age require a differentiated approach to treatment at different stages of the reproductive period and joint monitoring by a gastroenterologist and obstetrician-gynecologist during pregnancy.

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Key words: inflammatory bowel diseases, pregnancy, colitis, Crohn's disease, 5-aminosalicylic acid (5-ASA), hyperbaric oxygenation method.

Yu. B. Uspenskaya , Candidate of Medical Sciences G. A. Grigorieva , Doctor of Medical Sciences, Professor of MMA named after. I. M. Sechenova , Moscow

Prevention of the disease

Perhaps the key principle for the prevention of vegetative-vascular dystonia is a stress-free life, when it is possible not only to work in comfortable conditions, but also to fully relax.

Constant physical activity can resist the manifestation of the disease, in particular:

• a ride on the bicycle;
• Athletics;
• swimming;
• walking;
• fitness.

In case of an increased risk of illness, sessions of balneotherapy, acupuncture, and massage can have a beneficial effect.

Before you get pregnant, you need to undergo a full medical examination, after which possible problems in the body will be visible. Prenatal preparation of the body and compliance with the recommendations of specialists can significantly reduce the risk of vegetative-vascular dystonia.

Miracles of Pregnancy

There are cases where expectant mothers were not afraid to get pregnant with an existing diagnosis of VSD, and after giving birth they felt significantly better. This is due to the fact that under the influence of hormones that are released during pregnancy, the body changes its functioning. After the birth of the baby, the symptoms of the disease may either weaken or disappear forever. This natural treatment occurs in 10% of cases.

If you don’t want to give up and are ready to really, and not in words, fight for your full and happy life, you may be interested in this article .