TOXYCOSES OF PREGNANT WOMEN
TOXICOSIS OF PREGNANT WOMEN - pathological conditions of pregnant women, causally associated with a developing fetal egg and, as a rule, disappear in the postpartum period. Toxicosis, which manifests itself in the first 20 weeks of pregnancy , is usually called early, after 20 weeks of pregnancy - late.
Early toxicosis pregnant. The most common forms of early toxemia are vomiting and drooling (poultalism).
Vomiting occurs in about 50–60% of pregnant women, but only 8–10% of them need hospital treatment. Pronounced forms of vomiting are more common with multiple pregnancies and vesicular drift.
It is customary to distinguish between three severity of vomiting of pregnant women: I - mild, II - moderate and III - severe (indomitable, or excessive, vomiting). When I severity of vomiting occurs up to 5 times a day, on an empty stomach or is associated with food intake and unpleasant odors; the general condition of the pregnant is not disturbed. When II severity of vomiting increases up to 10 times a day, symptoms of intoxication appear. Grade III is characterized by repeated vomiting - up to 20 times a day or more, leading to a rapid decrease in body weight, and impaired function of vital organs. In severe vomiting, severe weakness, agitation or apathy, subfebrile condition, tachycardia , hypotension are observed, acetone appears in the urine, and often protein and cylinders. Sometimes with severe vomiting, jaundice occurs, and in rare cases, toxic liver degeneration. Possible fetal hypertrophy .
Treatment of vomiting of pregnant women I severity is carried out on an outpatient basis under the control of the dynamics of the body weight of the pregnant and with repeated urine tests on acetone. Assign frequent fractional nutrition, rinsing the mouth with astringents; recommend frequent change of environment (walks, etc.), acupuncture is effective.
Treatment of vomiting of pregnant women of II and III severity is carried out in the hospital. It should be complex and include the restoration of the loss of nutrients and fluids, correction of electrolyte balance and acid-base balance. If treatment fails, abortion is necessary. It is also indicated for persistent low-grade body temperature, severe tachycardia , progressive weight loss, proteinuria, cylindruria, acetonuria, jaundice .
Salivation often accompanies vomiting of pregnant women, less often occurs as an independent form of early toxicosis. In severe drooling, the loss of saliva per day can exceed 1 liter. Excessive drooling depresses the mind of the pregnant woman, leads to dehydration, hypoproteinemia. Treatment of salivation should be carried out in the hospital. Atropine is prescribed, rinsing the mouth with an infusion of sage, chamomile or oak bark. With significant hypoproteinemia, plasma transfusion is indicated. Hypnosis and acupuncture have a positive effect.
Some dermatoses also belong to the early toxicosis. The most common dermatosis in pregnant women is itching of the skin, which can be local (in the area of the vulva) or spread throughout the body. The itch is sometimes painful, causes insomnia, irritability. In case of itchy skin in pregnant women, it is necessary to exclude diabetes mellitus , fungal skin diseases, trichomoniasis , an allergic reaction. Treatment is reduced to the appointment of sedative and hyposensitizing agents, ultraviolet radiation.
Women who have undergone early toxicosis of pregnant women often develop late toxicosis, and therefore they require particularly careful follow-up.
Late toxicosis of pregnant women, nowadays it is more often called “OPG-gestosis” (abbreviation means edema — O, proteinuria — P, hypertension — G). OPG-gestosis occurs in 8-12% of pregnant women.
OGD-gestosis often develops in women who have had it in previous pregnancies , as well as in patients with pyelonephritis, glomerulonephritis, hypertension , diabetes (these pregnant women are at risk of developing OGG-gestosis).
The main clinical symptoms of OPG-gestosis are abnormal weight gain, edema, proteinuria, arterial hypertension, convulsions, and / or coma . There are 4 clinical forms (stages) of OPG-gestosis: dropsy, nephropathy, preeclampsia and eclampsia.
Dropsy of pregnant women is characterized by persistent edema in the absence of protein in the urine and normal blood pressure. Initially, the swelling may be hidden. At the same time, there is a positive “symptom of the ring” (the ring on the finger moves with difficulty), an excessive weight gain. Visible edema appears first in the lower limbs, then in the area of the vulva, torso, upper limbs, and face. The general condition of the pregnant woman is usually not disturbed. Pregnancy usually ends in childbirth within the prescribed period. Sometimes nephropathy develops pregnant.
The basis of treatment of edema of pregnant women is diet. It is recommended to limit the salt and liquid (up to 1000 ml per day), the use of products containing complete proteins (meat, fish, cottage cheese), as well as fruits, vegetables, juices. Every 7 - 10 days should be fasting days (cottage cheese, apple). Vitamin therapy is indicated. It is also recommended sedatives (decoction of motherwort and valerian root) and antispasmodic ( no-spa , papaverine , aminophylline tablets) means, drugs that strengthen the vascular wall ( ascorbic acid , rutin ). Dropsy of pregnant women can be treated on an outpatient basis, if it is possible to eliminate all adverse factors at home and at work.
Nephropathy of pregnant women in typical cases is characterized by proteinuria, edema, arterial hypertension . Often there are two of these symptoms, rarely only proteinuria or arterial hypertension.
There are three severity of nephropathy: Grade I - edema of the lower extremities, an increase in blood pressure to 150/90 mm Hg. Art., proteinuria up to 1 g / l; Grade II - swelling of the lower extremities and the anterior abdominal wall, increase in blood pressure to 170/100 mm Hg. Art., proteinuria up to 3 g / l; Grade III - pronounced swelling of the lower extremities, anterior abdominal wall and face, blood pressure above 170/100 mm Hg. Art., proteinuria more than 3 g / l. Transition to preeclampsia and eclampsia is possible with II and even with I grade of nephropathy.
The severity of preeclampsia is indicated by its early onset and prolonged course, fetal hypotrophy. In severe nephropathy, there is a risk of premature detachment of the placenta , premature birth , intrauterine death of the fetus . Nephropathy can turn into preeclampsia and eclampsia.
Treatment of nephropathy in pregnant women should be carried out in a hospital. The tasks of therapy include the creation of a protective regimen, the elimination of arterial hypertension, edema and proteinuria. It is shown bed rest, small tranquilizers (trioxazin, hlozepid , etc.), to enhance the sedative effect along with tranquilizers prescribe antihistamines ( diphenhydramine , diprazin ).
Antihypertensive therapy is carried out under the control of blood pressure. A rapid decrease in diastolic blood pressure below 80 mmHg. Art. represents a threat to the fetus, the critical figure is 60 mm Hg. Art. Of the antihypertensive drugs, magnesium sulfate is widely used, providing hypotensive, sedative, diuretic and anticonvulsant action; a more pronounced effect is observed when administered intravenously. When administered intravenously, the dose and rate of administration of magnesium sulfate is selected depending on the level of mean arterial pressure (BPA). BPA is calculated by the formula:
BPA = BP systole + 2AD diastole.
Normally, BPA is 90–100 mm Hg.
When APs 111 - 120 mm Hg. Art. 30 ml of a 25% solution of magnesium sulfate (7.5 g of dry matter) in 400 ml of reopolyglucine are injected at a rate of 1.8 g / h; with BPA 121 - 130 mm Hg. Art. - 40 ml of a 25% solution (10 g of dry matter) in 400 ml of reopolyglucine at a rate of 2.5 g / h; with BPA more than 130 mm Hg. Art. - 50 ml of a 25% solution (12.5 g of dry matter) in 400 ml of reopolyglucine at a rate of 3.2 g / h.
Antihypertensive drugs are recommended to be used in combination with antispasmodics ( no-spa , papaverine , dibazol , aminophylline ), which allows you to prolong their action.
In the appointment of diuretics should take into account the severity of impaired concentration and excretory functions of the kidneys. These drugs are used very carefully. The indication for the appointment of diuretics are generalized edema, diastolic pressure of 120 mm Hg. Art. and more, left ventricular heart failure , pulmonary edema. In these cases, you can intravenously enter 20-40 mg lacix.
To improve uteroplacental circulation, to treat hypoxia and fetal hypotrophy, a glucose-novocaine mixture, 5% glucose solution, partusisten, sygetin, corglycon, cocarboxylase are injected intravenously. The recovery of microcirculation in the placenta is promoted by intravenous drip infusion of reopolyglukine and heparin. In the complex of treatment for special indications to reduce the tone of the uterus and prolong pregnancy include tocolytic drugs (partusisten, ortsiprenalin sulfate, etc.).
Preeclampsia is characterized by the onset of symptoms of CNS damage: on the background of increased blood pressure, headache , dizziness , blurred vision (flashing of "flies" and feeling of veil before eyes), pain in the epigastric region, nausea , vomiting , and sometimes drowsiness occur. These symptoms can occur in various combinations, their severity varies, they can occur periodically and quickly disappear or have a persistent nature. Possible premature detachment of the placenta , premature birth , fetal death . As gestosis progresses, cerebral circulation is disturbed, which leads to the appearance of convulsive readiness and eclampsia - convulsions and (or) loss of consciousness. Eclampsia usually develops on the background of preeclampsia or nephropathy.
At the beginning of a convulsive seizure, facial muscles twitch for 20–30 s, followed by tonic convulsions of all skeletal muscles, accompanied by respiratory arrest, facial cyanosis, dilated pupils, and loss of consciousness. After 20–30 s, tonic convulsions are replaced by clonic ones, after another 20–30 s, irregular hoarse breathing appears with the release of foam from the mouth (due to biting of the tongue, it can be colored with blood). After the cessation of seizures, the coma (eclampic coma) usually lasts no more than 1 hour, sometimes several hours and even days. Convulsive seizure may be single or there is a series of seizures, repeated at short intervals of time (eclamptic status). Possible sudden loss of consciousness without an attack of convulsions.
Complications of eclampsia can be heart failure, pulmonary edema, acute respiratory failure; bronchopneumonia; swelling of the brain , hemorrhage, thrombosis ; retinal detachment and hemorrhage into it, an acute form of disseminated intravascular coagulation, hepatic failure (due to necrosis, hemorrhages in the liver tissue), renal failure (due to necrosis and hemorrhages in the kidneys). Hemorrhages in a spleen, intestines, a pancreas, adrenal glands are possible. The most severe complication of eclampsia is coma , which develops on the background of brain damage (hemorrhage, ischemia, edema).
With eclampsia, premature placental abruption, premature termination of pregnancy are possible. During respiratory arrest, the fetus may die as a result of increased hypoxia.
When symptoms of pre-eclampsia occur, intensive therapy is performed. Guided hemodilution and controlled arterial hypotension play an important role in the treatment. The advantage of methods of controlled hemodilution and controlled hypotension is not only the efficacy of the treatment of preeclampsia, but also the possibility (if necessary) to prolong the pregnancy. With the threat of premature birth, often complicating severe OPG-gestosis, managed tocolysis is successfully used - the use of magnesium sulfate and partusistenna simultaneously with hemodilution.
In eclampsia, the main objectives of therapy are stopping and subsequent prevention of seizures, elimination of arterial hypertension, and prevention of disturbed breathing. At the prehospital stage, a 25% solution of magnesium sulfate (up to 15-20 ml), a 0.5% solution of sibazone (up to 4 ml) is injected intravenously to relieve seizures. The hypotensive effect of magnesium sulfate can be enhanced by intravenous administration of dibazol, papaverine, no-shpy, aminophylline.
The patient should be laid on a flat hard surface, turn the head to the side, with a spatula or spoon, open the mouth and clean the mouth of the contents, ensuring the upper airway. With the preservation or rapid restoration of respiration spend inhalation of oxygen. When cardiac and respiratory arrest is necessary, resuscitation is necessary. The patient must be transported to the hospital after the relief of seizures by an intensive care team, which, if the indicated measures fail, can be anesthetized to stop the seizures.
All therapeutic and diagnostic measures for eclampsia are carried out under conditions of effective analgesia and neurolepsy, which is achieved by using neuroleptic aluminum. A good analgesic effect is given by epidural anesthesia.
The absolute indications for artificial ventilation of the lungs are eclamptic status, a combination of eclampsia with massive blood loss, cardiopulmonary insufficiency, eclampsic coma. To prevent complications, including acute renal and renal-hepatic insufficiency, inflammatory and septic diseases, it is necessary to compensate for blood loss during childbirth (for caesarean section in the early postpartum period), as well as active antibacterial therapy. Early delivery and the use of combination therapy are the basis for reducing mortality in eclampsia.
The problem depends on the severity of OPG-gestosis. The least favorable prognosis for eclampsia, especially for eclamptic coma with diffuse cerebral edema, ischemia and hemorrhages in the brain. Mortality in eclamptic coma reaches 50%.
Prevention includes the identification and treatment of pre-pregnancy kidney disease, hypertension, neuroendocrine disorders; careful monitoring of pregnant women at risk of developing gang-gestosis in antenatal clinic. An obstetrician-gynecologist should examine them at least 1 time in 2 weeks in the first half of pregnancy and 1 time per week in the second half. At 20–22 weeks, 28–33 weeks, and 35–37 weeks of gestation, for 10–15 days, with a prophylactic purpose they prescribe No 7 diet, vitamins, extracts of medicinal plants (valerian root, motherwort herbs, etc.), oxygen-vitamin-herbal cocktails.
A reliable preventive measure is the timely detection and treatment of pretoxicosis - a complex of pathological changes in the pregnant woman’s body, preceding the clinical manifestations of OPG-gestosis and detected only by special examination. Signs of pretoxicosis are, in particular, the asymmetry of blood pressure on the hands (a difference of 10 mm Hg. Art. And more when sitting), a pulse pressure of 30 mm Hg. Art. and less, a decrease in the oncotic density of urine, a decrease in daily diuresis to 900 ml, insignificant proteinuria and an excessive increase in body weight.
For the treatment of pretoxicosis and the prevention of its transition to the OCG-preeclampsia, the elimination of adverse factors in everyday life and at work is necessary; rational nutrition with the restriction of carbohydrates to 300 g, fat to 80 g, salt to 5 g, liquid up to 1000 ml per day; taking multivitamin preparations (for example, gendevita ); the increase in the duration of night sleep (at least 9-10 hours) and stay in the fresh air; special complex of physical exercises. To improve the uteroplacental circulation shown acupuncture. In order to normalize the vascular tone of the brain and improve cortical neurodynamics, electroanalgesia is successfully used (4–8 procedures, 45–90 minutes each).