TOXICOSE OF PREGNANCY

TOXICOSE OF PREGNANCY - pathological conditions of pregnant women, causally related to the developing fetal egg and, as a rule, disappearing in the postpartum period. Toxicosis, manifested in the first 20 weeks of pregnancy , is usually called early, after 20 weeks of pregnancy - late.

Early toxicosis of pregnant women. The most common forms of early toxicosis are vomiting and drooling (birdism).

Vomiting occurs in about 50 - 60% of pregnant women, but only 8-10% of them need inpatient care. Expressed forms of vomiting are more common in multiple pregnancy and bladder skidding.

It is accepted to distinguish three degrees of severity of vomiting of pregnant women: I - mild, II - medium severity and III - severe (indomitable, or excessive, vomiting). At I degree of severity, 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 woman is not violated. At the II degree of severity, vomiting becomes more frequent 10 times a day, symptoms of intoxication appear. III degree of severity 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. With severe vomiting, severe weakness, agitation or apathy, subfebrile condition, tachycardia , arterial hypotension are noted, acetone appears in the urine, often protein and cylinders. Sometimes with severe vomiting jaundice occurs, in rare cases - toxic dystrophy of the liver. Possible fetal hypertrophy .

Treatment of vomiting of pregnant women of I degree of severity is performed on an outpatient basis under the control of the dynamics of the body weight of the pregnant woman and repeated studies of urine on acetone. Assign frequent fractional nourishment, rinsing the mouth with astringent agents; Recommend frequent changes in the surrounding environment (walks, etc.), and acupuncture is effective.

Treatment of vomiting of pregnant women of II and III severity is carried out in a hospital. It should be comprehensive and include restoration of loss of nutrients and fluids, correction of electrolyte balance and acid-base balance. In case of failure of treatment, pregnancy termination is necessary. It is also shown with persistent subfebrile body temperature, pronounced tachycardia , progressive weight loss, proteinuria, cylindruria, acetonuria, jaundice .

Salivation often accompanies the vomiting of pregnant women, rarely occurs as an independent form of early toxicosis. With pronounced salivation, the loss of saliva per day may exceed 1 liter. Abundant drooling acts depressingly on the psyche of a pregnant woman, leads to dehydration, hypoproteinemia. Treatment of pronounced salivation should be carried out in a hospital. Assign atropine , mouth rinse with sage infusion, chamomile or oak bark. With significant hypoproteinemia, plasma transfusion is indicated. A positive effect is provided by hypnosis and acupuncture.

To early toxicosis also include some dermatoses. The most frequent dermatosis of pregnant women is the itching of the skin, which can be local (in the vulva) or spread throughout the body. Itching is sometimes painful, causing insomnia, irritability. If the skin itches in pregnant women, it is necessary to exclude diabetes mellitus , fungal skin diseases, trichomoniasis , allergic reaction. Treatment is reduced to the appointment of sedative and hyposensitizing agents, ultraviolet irradiation.

In women who have experienced an early toxicosis of pregnant women, often develops a late toxicosis, and therefore they need a very careful follow-up care.

Late toxicosis of pregnant women, now it is often called "OPG-gestosis" (abbreviation means edema - O, proteinuria - P, hypertension - G). OPG-gestosis is observed in 8-12% of pregnant women.

OPG-gestosis often develops in women who have experienced it in previous pregnancies , as well as in patients with pyelonephritis, glomerulonephritis, hypertension , diabetes mellitus (these pregnant women constitute a risk group for developing OPG-gestosis).

The main clinical symptoms of OCG-gestosis are abnormal weight gain, swelling, proteinuria, hypertension, seizures 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. In the beginning, swelling can be hidden. In this case, there is a positive "symptom of the ring" (ring on the finger moves with difficulty), excessive weight gain. Visible edema appears first on the lower limbs, then in the vulva, trunk, upper limbs and face. The general condition of the pregnant woman is usually not disturbed. Pregnancy, as a rule, ends with childbirth at the set time. Sometimes nephropathy of pregnant women develops.

The basis of therapy for dropsy pregnant is diet. It is recommended to limit salt and liquid (up to 1000 ml per day), the use of foods containing high-grade proteins (meat, fish, cottage cheese), as well as fruits, vegetables, juices. Every 7 - 10 days should be carried out unloading days (curd, apple). Vitaminotherapy is indicated. We also recommend sedatives (decoction of the motherwort and valerian root) and spasmolytic ( no-spa , papaverine , euphyllin in tablets), 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 unfavorable 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, less often only proteinuria or hypertension.

There are three degrees of severity of nephropathy: I degree - swelling of the lower extremities, increasing blood pressure to 150/90 mm Hg. Art., Proteinuria up to 1 g / l; II degree - swelling of the lower extremities and anterior abdominal wall, increase of blood pressure to 170/100 mm Hg. Art., Proteinuria up to 3 g / l; III degree - marked swelling of the lower extremities, anterior abdominal wall and face, blood pressure above 170/100 mm Hg. St, proteinuria more than 3 g / l. The transition to preeclampsia and eclampsia is possible at II and even at I severity of nephropathy.

The severity of gestosis is indicated by its early onset and prolonged course, fetal hypotrophy. With severe nephropathy, there is a risk of premature detachment of the placenta , premature birth , intrauterine fetal death . Nephropathy can be transformed into preeclampsia and eclampsia.

Treatment of nephropathy in pregnant women should be carried out in a hospital. The objectives of therapy include the creation of a protective regime, the elimination of arterial hypertension, edema and proteinuria. Indicated bed rest, small tranquilizers (trioxazine, hlozepid , etc.), to strengthen the sedative effect simultaneously with tranquilizers prescribe antihistamines ( diphenhydramine , diprazine ).

Hypotensive therapy is performed under the control of blood pressure. Rapid reduction in diastolic blood pressure below 80 mm Hg. Art. Represents a threat to the fetus, the critical figure is 60 mm Hg. Art. Of the antihypertensive drugs, magnesium sulfate is widely used, which exerts hypotensive, sedative, diuretic and anticonvulsant action; A more pronounced effect is observed with its intravenous administration. With intravenous administration of the dose and the rate of administration of magnesium sulfate is selected depending on the level of mean arterial pressure (ADP). ADP is calculated by the formula:

ADP = AD systole + 2AD diastole.

In the norm, ADR is 90-100 mm Hg.

At an arterial pressure of 111 - 120 mm Hg. Art. 30 ml of a 25% solution of magnesium sulfate (7.5 g of dry matter) in 400 ml of rheopolyglucin are introduced at a rate of 1.8 g / h; With an arterial pressure of 121 - 130 mm Hg. Art. - 40 ml of a 25% solution (10 g of dry matter) in 400 ml of rheopolyglucin at a rate of 2.5 g / h; When ADP is more than 130 mm Hg. Art. - 50 ml of a 25% solution (12.5 g of dry matter) in 400 ml of reopolyglucin at a rate of 3.2 g / h.

Hypotensive drugs are recommended to be used in combination with antispasmodics ( no-shpa , papaverine , dibazol , euphyllin ), which allows prolonging their effect.

When appointing diuretics should take into account the severity of violations of the concentration and excretory function of the kidneys. These drugs are used very carefully. Indications for the appointment of diuretics are generalized edema, a diastolic pressure of 120 mm Hg. Art. And more, left ventricular heart failure , pulmonary edema. In these cases, 20-40 mg of lasix can be administered intravenously.

To improve utero-placental circulation, treatment of hypoxia and fetal hypotrophy intravenously, a glucose-novocaine mixture, 5% glucose solution, partusystene, sigetin, korglikon, kokarboksilazu is injected. Restoration of microcirculation in the placenta is facilitated by intravenous drip infusion of rheopolyglucin and heparin. In the complex of treatment for special indications to reduce the tone of the uterus and prolong the pregnancy include tocolytic drugs (partusisten, orciprenaline sulfate, etc.).

Pre-eclampsia is characterized by the appearance of symptoms of the CNS: a headache , dizziness , blurred vision (flashing of flies and a sensation of blister before the eyes), pain in the epigastric region, nausea , vomiting , and sometimes drowsiness occur against the background of increased blood pressure. These symptoms can occur in various combinations, their severity varies, they can occur periodically and quickly disappear or have a persistent character. Premature detachment of the placenta , premature birth , fetal death are possible. As gestosis progresses, cerebral circulation is disturbed, which leads to the appearance of convulsive readiness and to eclampsia - convulsions and (or) loss of consciousness. Eclampsia usually develops on the background of pre-eclampsia or nephropathy.

At the beginning of a convulsive fit, twitching of the facial muscles is observed for 20 to 30 seconds, then tonic convulsions of all skeletal muscles, accompanied by a stop of breathing, cyanosis of the face, dilated pupils, loss of consciousness. After 20 - 30 s, tonic convulsions are replaced by clonic convulsions, another 20 to 30 s there is irregular hoarse breathing with the release of foam from the mouth (due to the biting of the tongue, it can be stained with blood). After cessation of convulsions, coma (eclampsic coma) is usually maintained for no more than 1 hour, sometimes several hours and even a day. A seizure may be a single fit or a series of seizures repeated at short intervals (eclampsic status). A sudden loss of consciousness without an attack of seizures is possible.

Complications of eclampsia may include heart failure, pulmonary edema, acute respiratory failure; bronchopneumonia; Cerebral edema, hemorrhage , thrombosis; Retinal detachment and hemorrhage, acute form of disseminated intravascular coagulation syndrome, hepatic insufficiency (due to necrosis, hemorrhages in the liver tissue), renal failure (due to necrosis and hemorrhages in the kidneys). Possible hemorrhages in the spleen, intestines, pancreas, adrenal glands. The most severe complication of eclampsia is coma , which develops against the background of brain damage (hemorrhage, ischemia, edema).

With eclampsia, premature detachment of the placenta, premature termination of pregnancy is possible. During the stoppage of breathing, the fetus may die as a result of aggravation of hypoxia.

When symptoms appear, pre-eclampsia is given intensive therapy. An important role in treatment is played by controlled hemodilution and controlled arterial hypotension. Advantage of controlled hemodilution and controlled hypotension is not only the effectiveness of treatment of pre-eclampsia, but also the possibility (if necessary) to prolong pregnancy. With the threat of premature births, often complicating severe OPG-gestosis, successfully administered controlled tocolysis - the use of magnesium sulfate and partusistene simultaneously with hemodilution.

In eclampsia, the main tasks of therapy are arresting and subsequent prevention of seizures, elimination of arterial hypertension, prevention of external respiration disorders. At the pre-hospital stage, 25% magnesium sulfate solution (up to 15-20 ml), 0.5% solution of sibazone (up to 4 ml) is injected intravenously for the cramping of seizures. The hypotensive effect of magnesium sulfate can be enhanced by intravenous administration of dibazole, papaverine, no-shpa, and euphyllin.

The patient should be laid on a flat hard surface, head turned to one side, using a spatula or spoon to open the mouth and clean the oral cavity of the contents, ensuring patency of the upper respiratory tract. With the preservation or rapid recovery of breathing, oxygen inhalation is carried out. When cardiac arrest and breathing are stopped, resuscitation is necessary. Transportation of the patient to the hospital after the cramping of seizures should be carried out by an intensive care team, which, if ineffective measures for the cramping of seizures are ineffective, apply anesthesia.

All medical and diagnostic measures with eclampsia are performed under conditions of effective analgesia and neurolepsy, which is achieved by the use of neuroleptanalgesia. A good analgesic effect is provided by epidural anesthesia.

Absolute indications for artificial lung ventilation are eclampsic status, combination of eclampsia with massive blood loss, cardiopulmonary insufficiency, eclampsic coma. To prevent complications, including acute renal and renal-hepatic insufficiency, inflammatory-septic diseases, mandatory compensation for blood loss in labor (at a caesarean section in the early postpartum period), as well as active antibiotic therapy. Timely delivery and the use of complex therapy are the basis for reducing mortality in eclampsia.

Prognosis depends on the severity of OPG-gestosis. The least favorable prognosis for eclampsia, especially with eclampsic coma on the background of diffuse cerebral edema, ischemia and hemorrhages in the brain. Mortality with eclampsic coma reaches 50%.

Prevention includes the detection and treatment before the onset of kidney disease, arterial hypertension, neuroendocrine disorders; Careful monitoring of pregnant women from the group at risk of developing OPG-gestosis in a female consultation. Obstetrician-gynecologist should examine them at least once every 2 weeks in the first half of pregnancy and once a week in the second half. At 20 to 22 weeks, 28-33 weeks and 35 to 37 weeks of pregnancy for 10-15 days with a preventive purpose prescribed diet No 7, vitamins, infusions of medicinal plants (valerian root, motherwort leaves, etc.), oxygen-vitamin-herbal Cocktails.

A reliable preventive measure is the timely detection and treatment of pre-toxicity - a complex of pathological changes in the body of a pregnant woman, preceding clinical manifestations of OPG-gestosis and Detectable only with a special examination. Signs of pre-toxicity are, in particular, the asymmetry of BP in the arms (a difference of 10 mm Hg and more in the sitting position), 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, a slight proteinuria and excessive weight gain.

To treat pre-toxicity and prevent its transition to OPG-gestosis, it is necessary to eliminate unfavorable factors in the home and at work; Rational nutrition with a restriction of carbohydrates up to 300 g, fats up to 80 g, table salt up to 5 g, liquid up to 1000 ml per day; Taking multivitamin preparations (for example, gendevita ); Increase the duration of night sleep (at least 9-10 hours) and stay in the open air; A special set of physical exercises. To improve uteroplacental blood circulation, acupuncture is indicated. To normalize the tone of the vessels of the brain and improve cortical neurodynamics successfully use electroanalgesia (4 - 8 procedures lasting 45-90 minutes each).