PREGNANT TOXICOSIS - pathological conditions of pregnant women, causally associated with a 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 salivation (ptyalism).
Vomiting occurs in about 50-60% of pregnant women, but only 8-10% of them need hospital treatment. Severe forms of vomiting are more common with multiple pregnancy and cystic drift.
It is customary to distinguish three degrees of severity of vomiting of pregnant women: I - mild, II - moderate and III - severe (indomitable, or excessive, vomiting). With I severity, vomiting occurs up to 5 times a day, on an empty stomach or can be associated with food intake and unpleasant odors; the general condition of the pregnant woman is not disturbed. With II severity, vomiting increases up to 10 times a day, symptoms of intoxication appear. Grade III 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, sharp 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 liver dystrophy. Possible fetal hypertrophy .
Treatment of vomiting of pregnant women of I degree of severity is carried out on an outpatient basis under the control of the dynamics of the body weight of the pregnant woman and with repeated urine tests for acetone. Prescribe frequent fractional nutrition, rinsing the mouth with astringents; recommend frequent changes in the environment (walking, etc.), 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 treatment failure, termination of pregnancy is necessary. It is also indicated for persistent subfebrile 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. With severe salivation, the loss of saliva per day may exceed 1 liter. Profuse salivation depressingly affects the psyche of a pregnant woman, leads to dehydration, hypoproteinemia. Treatment of severe salivation should be carried out in a hospital. Atropine is prescribed, rinsing the mouth with infusion of sage, chamomile or oak bark. With significant hypoproteinemia, plasma transfusion is indicated. Hypnosis and acupuncture have a positive effect.
Some dermatoses are also referred to as early toxicosis. The most common dermatosis of pregnant women is itching of the skin, which can be local (in the vulva) or spread throughout the body. Itching is sometimes painful, causes insomnia, irritability. With itchy skin in pregnant women, it is necessary to exclude diabetes , fungal skin diseases, trichomoniasis , an allergic reaction. Treatment is reduced to the appointment of sedative and hyposensitizing agents, ultraviolet radiation.
Women who have experienced early toxicosis of pregnant women often develop late toxicosis, and therefore they require especially careful follow-up.
Late toxicosis of pregnant women, nowadays it is more often called "OCG-gestosis" (the abbreviation means edema - O, proteinuria - P, hypertension - G). OCG gestosis is observed in 8-12% of pregnant women.
OPH gestosis often develops in women who have had it during previous pregnancies , as well as in patients with pyelonephritis, glomerulonephritis, hypertension , and diabetes mellitus (these pregnant women are at risk for developing OPH gestosis).
The main clinical symptoms of OCG preeclampsia are pathological weight gain, edema, proteinuria, hypertension, convulsions and (or) coma . There are 4 clinical forms (stages) of OCG 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, edema can be hidden. At the same time, a positive “symptom of the ring” is noted (the ring on the finger moves with difficulty), excessive increase in body weight. Visible edema appears first on the lower extremities, then in the area of the vulva, trunk, upper limbs and face. The general condition of the pregnant woman is usually not disturbed. Pregnancy usually ends in childbirth on time. Sometimes nephropathy of pregnant women develops.
The basis of therapy for dropsy of pregnant women is diet. It is recommended to limit salt and liquid (up to 1000 ml per day), the use of products containing high-grade 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. Sedatives (decoction of motherwort and valerian root) and antispasmodics ( no-spa , papaverine , aminophylline tablets), drugs that strengthen the vascular wall ( ascorbic acid , rutin ) are also recommended. 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, less often only proteinuria or arterial hypertension.
There are three degrees of severity of nephropathy: I degree - swelling of the lower extremities, increased blood pressure to 150/90 mm RT. Art., proteinuria up to 1 g / l; II degree - edema of the lower extremities and the anterior abdominal wall, increased blood pressure to 170/100 mm RT. Art., proteinuria up to 3 g / l; III degree - pronounced edema of the lower extremities, anterior abdominal wall and face, blood pressure above 170/100 mm RT. Art., proteinuria more than 3 g / l. The transition to preeclampsia and eclampsia is possible with II and even with I severity of nephropathy.
The severity of gestosis is evidenced by its early onset and a long course, fetal malnutrition. With severe nephropathy, there is a danger of premature placental abruption , premature birth , and fetal death . Nephropathy can go into preeclampsia and eclampsia.
Treatment of nephropathy of pregnant women should be carried out in a hospital. The objectives of therapy include the creation of a protective regimen, the elimination of arterial hypertension, edema and proteinuria. Bed rest, small tranquilizers (trioxazine, chlozepide, etc.) are shown, antihistamines ( diphenhydramine , diprazine ) are prescribed simultaneously with tranquilizers to enhance the sedative effect.
Antihypertensive therapy is carried out under the control of blood pressure. A rapid decrease in diastolic blood pressure below 80 mm Hg. Art. poses a threat to the fetus, the critical figure is 60 mm Hg. Art. Of the antihypertensive drugs, magnesium sulfate is widely used, which has a hypotensive, sedative, diuretic and anticonvulsant effect; a more pronounced effect is observed with its intravenous administration. With intravenous administration, the dose and rate of administration of magnesium sulfate are selected depending on the level of mean arterial pressure (ADsr). ADSR calculated by the formula:
ADp = BP systole + 2AD diastole.
Normally, ADav is 90-100 mm Hg.
When ADSr 111 - 120 mm RT. Art. 30 ml of a 25% solution of magnesium sulfate (7.5 g dry matter) are introduced in 400 ml of reopoliglukin at a rate of 1.8 g / h; with ADsr 121 - 130 mm RT. Art. - 40 ml of a 25% solution (10 g of dry matter) in 400 ml of reopoliglyukin at a speed of 2.5 g / h; with ADsr more than 130 mm RT. Art. - 50 ml of a 25% solution (12.5 g of dry matter) in 400 ml of reopoliglyukin with a speed of 3.2 g / h.
Antihypertensive drugs are recommended to be used in combination with antispasmodics ( no-spa , papaverine , dibazole , aminophylline ), which allows prolonging their effect.
When prescribing diuretics, the severity of renal concentration and excretory function disorders should be taken into account. These drugs are used very carefully. Indications for the appointment of diuretics are generalized edema, diastolic pressure of 120 mm RT. Art. and more, left ventricular heart failure , pulmonary edema. In these cases, 20–40 mg of Lasix can be administered intravenously.
To improve uteroplacental circulation, treat hypoxia and malnutrition of the fetus, a glucose-novocaine mixture, 5% glucose solution, partusisten, sigetin, corglycon, cocarboxylase are administered dropwise. The restoration of microcirculation in the placenta is facilitated by intravenous drip infusion of reopoliglukin and heparin. The treatment complex for special indications to reduce uterine tone and prolong pregnancy include tocolytic drugs (partusisten, orciprenaline sulfate, etc.).
Preeclampsia is characterized by the appearance of symptoms of a central nervous system lesion: against the background of increased blood pressure, headache , dizziness , visual impairment (flickering of “flies” and feeling of veil in front of the 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 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 against the background of preeclampsia or nephropathy.
At the beginning of a convulsive seizure, twitching of the muscles of the face is observed for 20-30 seconds, then tonic cramps of all skeletal muscles, accompanied by respiratory arrest, facial cyanosis, dilated pupils, loss of consciousness. After 20-30 s, tonic convulsions give way to clonic convulsions, after another 20-30 s irregular hoarse breathing appears with the release of foam from the mouth (due to biting the tongue, it can be stained with blood). After the cessation of seizures, the coma (eclampsic coma) usually lasts no more than 1 hour, sometimes several hours or even days. A convulsive seizure can be single or a series of seizures are observed, recurring at short intervals (eclampic status). Sudden loss of consciousness without an attack of seizures is possible.
Complications of eclampsia can be heart failure, pulmonary edema, acute respiratory failure; bronchopneumonia; cerebral edema , hemorrhage, thrombosis ; retinal detachment and hemorrhage in it, an acute form of disseminated intravascular coagulation, liver failure (due to necrosis, hemorrhage in the liver tissue), renal failure (due to necrosis and hemorrhage in the kidney). Possible hemorrhages in the spleen, intestines, pancreas, adrenal glands. The most serious complication of eclampsia is a coma that develops against a background of brain damage (hemorrhage, ischemia, edema).
With eclampsia, premature detachment of the placenta, premature termination of pregnancy are possible. During respiratory arrest, the fetus may die as a result of exacerbation of hypoxia.
When symptoms of preeclampsia appear, intensive care is performed. An important role in the treatment is played by controlled hemodilution and controlled arterial hypotension. The advantage of controlled hemodilution and controlled hypotension is not only the effectiveness of the treatment of preeclampsia, but also the ability (if necessary) to prolong pregnancy. With the threat of premature birth, often complicating severe OPG-gestosis, managed tocolysis is successfully used - the use of magnesium sulfate and partusisten simultaneously with hemodilution.
With eclampsia, the main objectives of therapy are the relief and subsequent prevention of seizures, the elimination of arterial hypertension, and the prevention of impaired external respiration. At the prehospital stage, for the relief of seizures, 25% magnesium sulfate solution (up to 15 - 20 ml), 0.5% sibazon solution (up to 4 ml) are intravenously administered. The hypotensive effect of magnesium sulfate can be enhanced by the intravenous administration of dibazole, papaverine, no-shpa, aminophylline.
The patient should be laid on a flat hard surface, turn the head to one side, use a spatula or spoon to open the mouth and clean the mouth from the contents, ensuring patency of the upper respiratory tract. While maintaining or rapid restoration of respiration, oxygen is inhaled. When cardiac arrest and breathing stop, resuscitation is necessary. The patient should be transported to the hospital after the relief of seizures by an intensive care team, which, if these measures are ineffective, can use anesthesia to stop seizures.
All medical and diagnostic measures for eclampsia are carried out under conditions of effective analgesia and neurolepsy, which is achieved by the use of neuroleptanalgesia. Epidural anesthesia gives a good analgesic effect.
The absolute indications for mechanical ventilation are eclampsic status, a combination of eclampsia with massive blood loss, cardiopulmonary failure, eclampic coma. To prevent complications, including acute renal and renal hepatic insufficiency, inflammatory septic diseases, it is necessary to compensate for blood loss in childbirth (with 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.
P r about gn oz depends on the severity of OCG-gestosis. The prognosis is less favorable with eclampsia, especially with eclampsic coma against the background of diffuse cerebral edema, ischemia and cerebral hemorrhages. Mortality in eclampsic coma reaches 50%.
Prevention includes the detection and treatment of pregnancy before kidney disease, hypertension, neuroendocrine disorders; careful monitoring of pregnant women at risk of developing OCG-gestosis in a 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 its second half. At 20–22 weeks, 28–33 weeks, and 35–37 weeks of pregnancy for 10–15 days, diet No. 7, vitamins, infusions of medicinal plants (valerian root, motherwort herbs, etc.), oxygen-vitamin-herbal, are prescribed for prophylactic purposes. 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 OCG-gestosis and detectable only with a 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 in a sitting position), a pulse pressure of 30 mm Hg. Art. and less, a decrease in the oncotic density of urine, a decrease in daily urine output to 900 ml, insignificant proteinuria and excessive weight gain.
For the treatment of pretoxicosis and the prevention of its transition to OCG-gestosis, the elimination of adverse factors in everyday life and at work is necessary; rational nutrition with a restriction of carbohydrates up to 300 g, fats up to 80 g, salt up to 5 g, liquids up to 1000 ml per day; taking multivitamin preparations (for example, genderite ); increase in the duration of night sleep (at least 9-10 hours) and stay in the fresh air; a special set of physical exercises. Acupuncture is indicated to improve uteroplacental circulation. In order to normalize the tone of the vessels of the brain and improve cortical neurodynamics, electroanalgesia is successfully used (4-8 procedures lasting 45-90 minutes each).