Late toxicosis of pregnant women. Separate Groke scale parameters in modification G.M. Savelyeva will help doctors at the cooking stage in assessing the severity of gestosis gestosis against the background of hypertensive disease

Symptoms	Point
Eveny	not	on the legs or pathological gain in weight	on the legs and anterior abdominal wall	generalized
Proteinuria (protein in ‰)	not	from 0.033 to 0.132	from 0.132 to 1.0	1.0 or more
Systolic blood pressure (MM HG)	below 130.	from 130 to 150	from 150 to 170	170 and above
Diastolic blood pressure (MM HG)	up to 85	from 85 to 90	from 90 to 110	110 and higher
The term of pregnancy, in which guests are first diagnosed	not	36-40 weeks	30-35 weeks	24-30 weeks
Futal hypotrophy	not	not	Development lag for 1-2 weeks	Development lag for 3 weeks and more
Background disease	not	manifestation of disease before pregnancy	Disease manifestation during pregnancy	Disease manifestation before and during pregnancy

Gestosis index:

• up to 7 points - a light form of gestosis
• 8-11 points - gestosis of moderate severity
• 12 or more - severe gestosis

To the critical forms of late gestosis, which require rapid delivery, belong:

• preeclampsia, eclampsia, eclampsic coma;
• severe liver damage (Hellp syndrome - acute fatty hepatosis, acute renal and hepatic insufficiency, the gap of the liver capsule);
• premature detachment of placenta, developed against the background of gestosis
• complications of severe eye hypertension (hemorrhage in the vitreous body, retinal detachment)

Preeclampsia - Critical, but reversible condition preceding the hardest form of gestosis - eclampsia.

The pathophysiological basis of the syndrome is the violation and insufficiency of cerebral circulation in combination with the generation of systemic disorders of the liver, kidneys, hemostasis, hemolymicals, light, cardiovascular system.

The various combinations of the following symptoms are characteristic:

• headache, more often in the occipital and temporal areas;
• vision disorder, pellena or flickering flies before eyes;
• pain in the Nadred region and the right hypochondrium, often combined with headaches;
• nausea, vomiting;
• "Convulsive readiness" - hyperreflexia;
• mental excitement or opposite the oppressed state;
• increased blood pressure to critical level 170/110 MM HG and higher;
• oliguria - diuresis 600 ml and below;
• low hourly diuresis - less than 60ml / h;
• generalized swelling;
• skin hemorrhagic syndrome in the form of petechia.

If the period of pre-eclampsia, for any reason missing or therapy was inadequate, ecoMptia develops.

Eclampsia - These are acute brain swelling, high intracranial hypertension, breaking the autoregulation and violation of cerebral circulation, ischemic and hemorrhagic damage to the structures of the brain.

Eclampsia is accompanied by loss of consciousness, convulsions, followed by the development of a comatose state.
A typical attack convulsion continues on average for 1-2 minutes and is composed of 4-6 consistently connected convulsive episodes:

1. Premissant: small fibrillar twitching of the eyelids, quickly extending to the muscles of the face and upper limbs;
2. The period of tonic seizures: the head is thrown back or aside, the body is stretched and tense, the face pale, the jaws are tightly closed, the eyes are "rolled up" up, the duration of the episode is 20-30 seconds.
3. The period of clonic convulsion: hoarse breath that stops at the height of the convulsion, a foam is distinguished from the mouth, gradually convulsions penetrate and stop.
4. Permissions Power Period: Breathing is restored, the face gradually pose, the heart rate stabilizes.

Restoration of consciousness between individual attacks can be rapid and gradual. In some patients, consciousness is not restored, and they fall into a comatose state, which worsens the forecast.
An unfavorable signs are hyperthermia, respiratory disorder, decreased blood pressure, Anuria.

Acute fat hepatosis

Developed in the last trimester of pregnancy against the background of a long-lasting GHG. The pathogenesis of this lesion of the liver is the diffuse fat degeneration of hepatocytes without the reaction of inflammation and necrosis. The main clinical symptoms are: anorexia, sharp weakness, nausea, signs of hemorrhagic diatic (vomiting "coffee grounding", bleeding gums), oliguria. In the later stage - jaundice. The forecast is extremely unfavorable, since mortality is 70-80%

Hellp - syndrome.

The name of this syndrome received on the initial letters of leading symptoms (Hemolysis - hemolysis; Elevated Liver Enzymes is an increase in liver enzymes; Low Platelet - thrombocytopenia). The syndrome develops against the background of combined gestosis, chronic DVS syndrome and renal-liver failure (nephrgeptopathy). The syndrome develops sharply. There is a sharp weakness, shortness of breath, heartbeat, pain in the lower back, often an increase in temperature, a feeling of fear. Changes are characterized on an ECG (increasing the amplitude of the tissue T with the narrowing of its base and the decrease in the top, the offset of the button of the QT interval, slowing down intraventricular conductivity, the disappearance of the teeth P).

Acute hepatic renal failure (OPPN)it is a consequence of the terminal stage of heavy gestosis. Diagnose OPPN is not easy, since the symptoms characteristic of coagulopathy, intoxication, bleeding, preeclampsia predominate.

Acute podcapsula hematomaand the spontaneous branch of the liver is extremely heavy complication of gestosis, as it almost always leads to a fatal outcome. It is based on vascular disorders typical for late gestosis or intrahepatic parenchymatous lesions: acute subcapsular hematoma of the liver, the main symptoms are sharp growing pain in the right hypochondrium, signs of acute blood loss.

Premature placent detachment.
Typical clinical symptoms are sharp pain at the bottom of the abdomen, hypotension, tachycardia. Outdoor bleeding may not be if the detachment has no edge, but a central character.

Treatment at the pre-hospital stage
The heavier the late gestosis, the faster it is necessary to interrupt complicated pregnancy. Concomitant intensive therapy should be the nature of resuscitation.

General principles of intensive therapy for critical forms of gestosis:

1. Hospitalization in the separation of intensive therapy to provide the full volume of resuscitation assistance and the speedy delivery.
2. All manipulations must be carried out under the conditions of drug sedation by the drugs of benzodiazepine rows:

• diazepam (Seduxen, Relanium, Valium 2-5 mg in / in or 10 mg in / m
• midazolam (Dormikum, Flormidal 5-10 mg in / in or 10-15 mg in / m and others.

3. The catheterization of large veins in order to carry out long and adequate infusion therapy, the basis of which on the prehospital stage should be plasma-substituting solutions (200 ml / hour), having several advantages over crystalloids (saline solutions, glucose solutions)

• fast and long-lasting volumetric effect
• increased cardiac output and perfusion pressure
• elimination of high permeability of capillaries
• no toxic action

a) Reopolyglyukin and its derivatives (Reoglumanum). In order to prevent hypoxia and hypotrophy of the fetus, it is advisable to combine the introduction of refooliglukin with a Trental (5 ml).

B) Perechmal preparations (InfoCol, HAES, reform). Reforine - a representative of the last generation of drugs of this group, the advantages of which are longer circulation in the vascular bed, exclusively intravascular distribution of the solution, improving the rheological properties of blood and microcirculation, the least likely to develop coagulopaths. The risk of developing anaphylactoid and anaphylactic reactions from this drug is lower than when applying other plasma reference.

4. Hypotensive therapy.

• Calcium antagonists (sublingual use of nifedipine drugs). The most optimal is the use of Cordaflex in a dose of 10-20 mg, which has a powerful action of peripheral vasodilators. The advantage of this type of therapy is a prolonged effect of 6-12 hours, a decrease in heart rate, an increase in cardiac output.
• Cormagnesin in the form of a / in magnesium sulfate solution. Depending on the dose, the feed is sedative, sleeping pills or narcotic effects. The braking effect on the CNS and the depressing effect on neuromuscular transmission was noted. Magnesium sulfate is an ideal anticonvulsant, in the process of highlighting the kidneys magnesium sulfate enhances diuresis. Magnesium controls the normal functioning of myocardial cells, increases resistance to nervous stress. Competitive antagonism of magnesium and calcium explains the anticoagulant ability of magnesium and, as a result, reducing the thrombosis and improving microcirculation. Intravenously coagnesin is administered by 400-800 mg / injection depending on the severity of the state.

When attacking eclampsia, it is necessary to remember:

4608 0

Many recently existing methods for determining the severity of the GPG-Gesters took into account as criteria only clinical manifestations of gestosis and did not reflect the objective state of pregnant women. This is due to the fact that in recent times the picture of the disease has changed: the presenters often flow atiypically, begin in the II trimester of pregnancy.

The outcome of pregnancy for mother and fetus largely depends not only on generally clinical manifestations of gestosis, but also from the duration of its flow, the presence of fetoplacentage insufficiency and extragationalital pathology. Therefore, the most acceptable currently should be considered the classification of gestosis recommended by the Ministry of Health of the Russian Federation in 1999 and distinguishing between gestosis light, medium and severe. Preeclampsia and eclampsia are treated as complications of heavy gestosis. This classification is convenient for practical doctors, since the criteria used in it do not require expensive and long-term techniques, and at the same time allows adequate to assess the severity of the disease (Table 1). Evaluation up to 5 points corresponds to light, severity, 8-11 - medium, and 12 and higher - heavy.

Table 1

Palkal estimate of the severity of gestosis (Methodical recommendations of the Ministry of Health of the Russian Federation, 1999)

Symptoms	Point
	on the legs or pathological weight gain	on the legs and anterior abdominal wall	common
Proteinuria g / l			1.0 or more
Health systolic MMHG.
Hell diastolic MMHG.
Beginning of gestosis
Futal hypotrophy		I degrees	II-III degree
Extgazenital diseases	Manifestation before pregnancy	Manifestation during pregnancy	Manifestation before and during pregnancy

The objective criteria for severe nephropathy and preeclampsia are the following signs:

• systolic blood pressure 160 mmhg and above, diastolic arterial 110 mmhg and above;
• protenuria to 5 g / day or more;
• oliguria (urine volume per day less than 400 ml);
• hykokinetic type of central maternal hemodynamics with elevated operations (more than 2000 din cm~ 5), pronounced renal blood flow disorders, bilateral violation of blood flow in uterine arteries; Increased PI in the inner carotid artery more than 2.0; Retrograde blood flow in suplocked arteries;
• lack of normalization or deterioration of hemodynamic indicators against the background of intensive gestosis therapy;
• thrombocytopenia (100 10 9 / l), hypocoagulation, increasing activity of hepatic enzymes, hyperbilirubinemia.

The presence of at least one of these features indicates a serious condition of pregnant and often precedes eclampsia.

Treatment of gestosis should be carried out only in the conditions of an obstetric hospital. Complex pathogenetic therapy should be directed to:

• creation of a medical and security mode (normalization of the CNS function);
• restoration of the function of vital organs (hypotensive, infusion-transfusion, disintellation therapy, normalization of water-salt metabolism, rheological and coagulation properties of blood, improving the uterine-placental and intrapalacentary blood circulation, normalization of the structural and functional properties of cell membranes);
• fast and careful delivery.

1. Normalization of the CNS function It is carried out at the expense of sedative and psychotropic therapy. In patients with light and middle severity of gestosis, preference should be given to sedatives of plant origin (Valerian, dyeing extract) in combination with tranquilizers (relaignation, sysksen, phenazepam, nosheps). With severe nephropathy and preeclampsia, all manipulations are carried out against the background of inhalation anesthesia using tranquilizers, neuroleptics and analgesics.

Eclampsia is an indication of intubation and IVL. Translation of the parental in the postoperative period for independent respiration is possible not earlier than 2 hours after the delivery, only when stabilizing systolic blood pressure (not higher than 140-150 mmHg), Normalization of FLOP, heart rate and diuresis (more than 35 ml / h) on the background of recovery of consciousness .

2. Hypotensive therapy It is carried out at the level of systolic blood pressure, exceeding the initial 30 mmhg, and the diastolic - by 15 mmhg. Calcium antagonists are currently recommended (magnesium sulfate, loopamil, norvask), blockers and stimulants of adrenergic receptors (clofellin, atenolol, labetalol), vasodilators (nitroprusside sodium, prazosin, hydralazine), gangliplays (benzenexonium, pentamine).

In gestosis, monotherapy (calcium antagonists, antispasmodics) are used (calcium antagonists), integrated therapy. The following combinations are the greatest efficiency: calcium antagonists + clofellin, vasodilators + clofellin).

With severe gestosis, preeclampsia and eclampsia, comprehensive hypotensive therapy is carried out. With low figures, the CCLD (less than 3 cm of water. Art.) The infusion-transfusion therapy should be preceded by infusion-transfusion therapy. The preparation of choice is magnesium sulfate in a daily dose of at least 12 g during intravenous administration. At the same time, you can use Verepamil or Norvask. In the absence of an effect, pentamine or sodium nitroprusside is used.

3. Infusion-transfusion therapy (ITT) It is applied to normalize the OCC, colloid-osmotic plasma pressure, rheological and coagulation properties of blood, macro- and microhereodynamics. The ITT includes freshly frozen plasma, albumin, refooliglukin, 6% and 10% starch solution (infochol), crystalloids. The ratio of colloids and crystalloids and the amount of ITT is determined by the values \u200b\u200bof hematocrit, diuresis, and a CLAS, protein content in the blood and hemostasis indicators.

4. Normalization of water and salt metabolism It is carried out at the expense of appointing diuretics, the use of which during prestal remains controversial. During gestivity, diuretic phytosborids are used. In the hospital, it is permissible to use potassium-saving diuretics (triampur) within 2-3 days. Saluretics (Laziks) are administered only with heavy forms of gestosis, with normal highlights of the CVD, a common protein in the blood, hyperhydration phenomena and diuresis less than 30 ml / h.

5. Normalization of the rheological and coagulation properties of blood It should include disagrement (Trental, Kuraltil, Aspirin). Therapeutic doses of aspirin are selected individually depending on the indicators of thromboelastogram. With the normalization of the overall state and biochemical indicators, the daily dose of aspirin should be 60 mg / day.

6. Restoration of the structural functional properties of cell membranes and cellular metabolism It is carried out by antioxidants (vitamin E, solkoSeril), membrane-stabilizers (lipostabil, essential).

7. Improvement of uterine-placental and intrapalacentar plates It is carried out due to the above-described complex therapy of gestosis. In addition, a beta mimetics (Ginipral, Passubus) can be used for this purpose in an individual dosage.

8. Extracorporeal methods of detoxification and dehydration - Plasmapheresis and ultrafiltration - are used in severe gestosis. The indication to Plasmapheresse is: a serious degree nephropathy in the absence of the effect on ITT and the need to prolong pregnancy; Hellp syndrome and Ozgb. Indicating to ultrafiltration: post-eclaptic coma, brain swelling, unknown lung edema, anasarka.

Therapy of gestosis should be carried out under strict laboratory and instrumental control:

• FVD (in the range of 5-10 cm water. Art.);
• diuresis (at least 35 ml / h);
• concentration indicators of blood (hemoglobin of at least 70 g / l, hematocrit - at least 0.25, platelets - at least 100 10 9 / l);
• biochemical blood indicators (total protein of at least 60 g / l, transaminase - Act, Ajit, general bilirubin, creatinine, residual nitrogen, urea);
• echocardiography with the determination of the parameters of central maternal hemodynamics and OPS (UI at least 24.7 ml / m2, si at least 2.4 l / min / m2, OPS no more than 1,500 din with cm~ 5);
• dopplerMetric study of the uterine-placental blood flow (NDO in uterine arteries no more than 2.4, in spiral arteries - no more than 1.85);
• dopplerMetric study of the renal blood flow (EDO in renal arteries no more than 2,3);
• a dopplerometric examination of blood flow in the inner sleepy (pi less than 2.0) and suprapic arteries (normally - anti-graded direction of blood flow).

The severity of gestosis must be assessed against the background of treatment every 2-3 days with a mild, every day - with medium and every 2 hours - with severe. The need for this is due to the possible rapid increase in the clinical symptoms of gestosis, despite the intensive therapy. Currently, it is considered to be generally accepted that the treatment time of gestosis should be limited. With a gestivity of a lightly maximum maximum permissible is the treatment for 2 weeks, the average degree - 7 days, severe degree - 24-36 hours. With the ineffectiveness of the therapy during the specified deadlines, as well as the increase in the symptoms of gestosis, it is necessary to address the question of early delivery.

Selected lectures on obstetrics and gynecology

Ed. A.N. Strizhakova, A.I. Davydova, ld Belotserkovtseva

Symptoms	Point
Eveny	not	on the legs or pathological gain in weight	on the legs and anterior abdominal wall	generalized
Proteinuria (protein in g / l)	not	from 0.033 to 0.132	from 0.132 to 1.0	1.0 or more
Systolic blood pressure (t t)	below 130.	from 130 to 150	from 150 to 170	170 and above
Diastive pressure (t t)	up to 85	from 85 to 90	from 90 to 110	110 and higher
The term of pregnancy, in which guests are first diagnosed	not	36-40 weeks	30-35 weeks	24-30 weeks
Futal hypotrophy	not	not	Development lag for 1-2 weeks	Development lag for 3 weeks and more
Background disease	not	manifestation of disease before pregnancy	Disease manifestation during pregnancy	Disease manifestation before and during pregnancy

Severity of gestosis (index):

Up to 7 points - a light form of gestosis

8-11 points - gestosis of moderate severity

12 or more points - severe gestosis form

Preeclampsia. "Preeclampsia is a critical, but reversible condition preceding the hardest form of gestosis - eclampsia" (I.S. Sidorova, 1996). The main clinical manifestation of this heavy complication of pregnancy is the brain circulation disorder syndrome, which joins the existing classic triade, but may develop on the background of monosimptomic nephropathy. Characteristic and disturbing symptoms of preeclampsia are the following:

1) Headache; 2) dizziness;

3) impairment of vision (flashing in the eyes, "fog" in the eyes, temporary loss of vision, etc.);

4) noise in ears, 5) nasal congestion and difficulty breathing;

6) drowsiness; 7) pain in the epigastric region;

8) nausea and vomiting.

Patients are injured or excited, there is a poverty and redness of the face, the pallor of the skin, sometimes acricyanosis and the marble of the skin are possible.

Changes are expressed in the eye bottom: there are signs of hypertension angiopathy, retinopathy and retina edema.

Preeclampsia is a very dangerous state of increased convulsive readiness of the body, when any stimulus (loud sound, bright light, pain, vaginal research) can provoke an eclampsitic convulsive fit with all possible adverse effects for mother and fetus.

The preeclampsia clinic is a manifestation of severe polyorgan deficiency due to the progression of chronic DVS, the damage to the vascular system and microcirculation in the vital organs of the mother, such as kidneys, brain, liver, lungs, hearts. The present diagnosis of preeclampsia is fraught with heavy complications representing real danger and fetus.

Eclampsia. Eclampsia - Culmination in the development of heavy gestosis. It arises against the background of preeclampsia or nephropathy and is characterized by a complex syndromocomplex, indicating violation of the activities of almost all systems and organs. From the head of the brain is acute swelling, a sharp increase in intracranial pressure, breaking the autoregulation and a violation of cerebral circulation with ischemic and hemorrhagic damage to the structures of the brain. In a typical form, it is characterized by the onset of convulsion and the sudden loss of consciousness in the fitness seizure distinguish between four periods:

1 period is characterized by small twitching of the muscles of the face and the upper limbs. Its duration is 20-30 seconds.

2 period - a period of tonic seizures of the entire cross-striped muscles of limbs, torso, head and neck. At the same time, the head is deviated by the stop, the breath stops, the pulse is with difficulty, pupils are expanded, leather and mucous cianotic, the language is often bored. Duration - about 30 seconds.

3 period - a period of clonic convulsion, which lasts about 2 minutes. The convulsions are gradually weakened, hoarse breathing is noted, the foam painted with blood (boning language) appears.

4 Period - Permission period. Breathing is restored. Sick for some time is in a comatose state, consciousness returns gradually, it does not remember anything about what happens.

Fragrance seizures can be repeated through short periods of time. Such a state is called eclampsic status, and the unconscious state of the patient is an eclampsic room. This is a critical state, mortality in which fluctuates in the range of 50-75%.

Complications of gestosis

Head forms of gestosis (eclampsia, preeclampsia, nephropathy III degree) are fraught with serious complications that threaten the lives of mother and fetus. Such complications are:

1. Hemorrhage into the brain, thrombosis, brain swelling, coma.

2. DVS syndrome with the development of hemorrhagic shock.

3. Cardiac insufficiency, accompanied by pulmonary edema.

4. Renal failure.

5. Hemorrhage and retinal detachment.

6. Premature detachment is normal located.

7. Heavy liver damage.

8. Syndrome of acute pulmonary damage (acute respiratory cardress syndrome)

9. Hypoxia, hypotrophy and intrauterine fetal death.

10. Premature childbirth.

In the studies of recent years dedicated to gestosis, special attention is paid to heavy liver damage, the frequency of which according to foreign authors is from 4 to 12% with the serious flow of gestosis. These include HellP syndrome, acute fatty hepatosis of pregnant women, acute hepatic renal failure, acute podcapsulating hematoma and a spontaneous liver break.

Hellp syndrome He was first described in 1982 and received his name on the designation of the initial letters of leading symptoms (Hemolysis -Gemolysis, Elevatid Livez Enzymes is an increase in liver enzymes. Low Platelet - thrombocytopenia). The syndrome develops against the background of combined gestosis, chronic DVS-syndrome and renal and liver failure. It is believed that in the pathogenesis of Hellp-syndrome, autoimmune reactions with the development of autoimmune hemolytic anemia and autoimmune destruction of the endothelium with the formation of microtrombov with blockade of blood flow in intrahepatic sinusoids, dystrophic changes in hepatocytes are important. Thrombocytopenia is caused by platelet depletion due to massive scattered microcurodation. Early symptoms can be nausea, vomiting, epigastria pain and right hypochondrium. The syndrome develops sharply and prohibits aggressively. Jaundice appears quickly. Changes in laboratory indicators are often ahead of clinical manifestations of complications. Increasing the activity of transaminase (ACT and ALT) indicates the necrosis of hepatocytes. The pronounced and growing thrombocytopenia can lead to severe obstetric bleeding. The main clinical manifestations of the Hellp syndrome of the maximum of their development reaches 24-48 hours after childbirth. Mortality reaches 75%. Early diagnosis of complications and immediate delivery can improve the forecast.

Acute yellow liver atrophy - It is a life-threatening complication of a very heavy and long-lasting gestosis. The pathogenesis lies in diffuse fat rebirth of hepatocytes without inflammation and necrosis. A significant role belongs to genetic defects of enzyme liver systems that manifest themselves against the background of gestosis. Developed in 3 trimester of pregnancy. The main clinical symptoms are anorexia, nausea, vomiting of "coffee grounds", heartburn, sharp weakness, increased bleeding, oliguria. Jaundice and skin itching may appear.

The characteristic diagnostic sign of this pathology is the normal values \u200b\u200bof transaminases, which distinguishes acute fatty hepatosis from liver damage during viral hepatitis, where hepatocyte necrosis has. The flow is complicated by the addition of renal failure, acute hemorrhagic pancreatitis. The cause of the death of patients is hepatic and liver and renal failure, shock against the background of acute pancreatitis. Mortality is 70-90%. Main tactic is an immediate interruption of pregnancy on life indications.

Acute hepatic renal failure (OPPN) It is most often due to the terminal stage of heavy gestosis - eclampsia. The symptoms of intoxication, coagulopathy and gestosis prevail in the clinical picture. Studies of the functional state of the liver and kidneys confirm the diagnosis. The provoking factor in the development of OPDs during pretzos is an additional stressful effect (operation, blood loss, massive hemotransphus, purulent-septic complications). It is possible to attach heavy hemorrhagic pancreatitis and pancreatic proceedings, which in 3% of cases complicate the course of eclampsia.

Targeting of the patch hematoma of the liver. The causes of the subcappsional hematoma of the liver are typical vascular disorders for late gestose. In this particular case, this is the defeat of the vessels of the liver capsule or the vessels of the hepatic parenchyma. Under the influence of the provoking factor (cesarean section, childbirth), the formation of the artery, the formation of a separating hematoma, reaching the glisson capsule and perforation of hematoma with massive bleeding into the abdominal cavity. The hematomas are localized exclusively in the right lobe of the liver, and their gap is most often occurring during surgery - cesarean section. Treatment - Immediate Surgical Intervention.

Toxicosis and gestosis - pathological conditions of pregnancy, which are manifested only during pregnancy and, as a rule, disappear after its end or in the early postpartum period.

Complications associated with pregnancy can manifest itself in its early terms, more often in the first 3 months, then they are called toxicosis. If clinical symptoms are most pronounced in the II and III trimesters, then it is more often a gestosis.

Most of the forms of toxicosis are accompanied by dyspeptic disorders and violations of all types of exchange, gestosis - changes in the vascular system and blood flow. Toxicosis includes vomiting of pregnant women (light shape, moderate, excessive) and salivament (birdism), to pre-gestosis - a watering woman of pregnant women, prestal of various gravity, preeclampsia, eclampsia. There are less often such forms of toxicosis as dermopathy (dermatosis), tetania, bronchial asthma, hepatosis, osteomalating of pregnant women, etc.

Toxicosis

Vomiting of pregnant women.Etiology is not fully clarified. The most common neuro-reflex theory, according to which violations of the relations of the central nervous system and internal organs play an important role in the development of the disease. The predominance of excitation in subcortical structures of the CNS (reticular formation, regulation centers of the oblong brain) is essential. In these areas, a vomit and chemoreceptor trigger zone are located, regulating a vomiting act. Next to them are the respiratory, vasomotor, salivation centers, the core of the olfactory brain system. The close arrangement of these centers causes the simultaneous appearance of nausea and a number of concomitant vegetative disorders: reinforcement of savory, recess of breathing, tachycardia, the pallor of the skin due to the spasm of peripheral vessels.

The predominance of the excitation in the subcortical structures of the brain with the occurrence of a vegetative reaction is associated with pathological processes in the genital organs (transferred inflammatory diseases), violating the receptor apparatus of the uterus. It is also possible to damage the fruit egg. This is observed in violation of the physiological relationships of the parent organism and Trofoblast in the early periods of gestation.

Vegetative disorders at the beginning of pregnancy may be due to hormonal disorders, in particular an increase in the level of XG. With multipleness and bubble drift, when a large number of hg is distinguished, pregnant vomiting is observed especially often.

Chronic diseases of the gastrointestinal tract, liver, asthenic syndrome predispose to the development of toxicosis.

In pathogenesisthe vomiting of pregnant defining link is a violation of the neuroendocrine regulation of all types of exchange, which leads to partial (or complete) starvation and dehydration. Under the progression of the disease, water-salt (hypokalemia), carbohydrate, fatty and protein exchange in the mother's body against the background of growing dehydration, exhaustion and weight loss are gradually violated. Due to starvation, glycogen reserves in the liver and other tissues are initially consumed. Then the endogenous carbohydrate resources are reduced, catabolic reactions are activated, fat and protein exchange increases. Against the background of the oppression of the activity of enzyme systems, tissue respiration, the energy needs of the mother's organism are satisfied due to the anaerobic decay of glucose and amino acids. Under these conditions, b-oxidation of fatty acids is impossible, therefore, non-surprising fat metabolites are accumulated in the body - ketone bodies (acetone, acetosus and B-hydroxyma acid), which are allocated with urine. In addition, ketosis is maintained by an enhanced anaerobic decay of ketogenic amino acids. Against this background, ketonuria is developing, the oxygenation of arterial blood decreases, the braid is shifted towards the acidosis.

Changes in the bodies of pregnant first functional, then, as dehydration, catabolic reactions, inxication of unsophisticated products are increasing, are moving into dystrophic - in the liver, kidneys and other organs. The protein-formative, antitoxic, pigment and other liver functions are broken, the excretory function of the kidneys, in the subsequent dystrophic changes are observed in the CNS, lungs, heart.

Clinical picture. Vomiting of pregnant women often (in 50-60%) is observed as a manifestation of uncomplicated pregnancy, and in 8-10% cases is a complication of pregnancy (toxicosis). With normal pregnancy, nausea and vomiting can be no more than 2-3 times a day in the morning, more often on an empty stomach. It does not violate the general state of a woman, treatment is not required. As a rule, at the end of the placentating to 12-13 weeks, nausea and vomiting are terminated.

The toxicosis belongs to vomiting, which is independent of meals, is accompanied by a decrease in appetite, a change in taste and olfactory sensations, weakness, sometimes by weight. Distinguish between pregnant women mild, moderate and excessive. The severity of vomiting is determined by the combination of vomiting with the violations in the body (exchange processes, the functions of the most important organs and systems).

Light vomot Not much different from that with uncomplicated pregnancy, but it occurs up to 4-5 times a day, accompanied by an almost constant feeling of nausea. Despite vomiting, part of the food is held and significant missing pregnant women does not occur. The weight loss is 1-3 kg (up to 5% of the initial mass). The general condition remains satisfactory, but apathy and reduced performance are possible. Hemodynamic indicators (pulse, blood pressure) in most pregnant women remain within normal limits. Sometimes moderate tachycardia (80-90 per minute). The morphological composition of the blood is not changed, diuresis is normal. Acetionalura is absent. Easy vomiting quickly treats or passes independently, but 10-15% of pregnant women are enhanced and can go to the next stage.

Moderate vomit(moderate) arises up to 10 times a day or more. The general state worsens, developing metabolic disorders with ketoacidosis. Vomiting is often accompanied by saliva, as a result of which an additional substantial loss of liquid and nutrients occurs. Progresses dehydration, body weight decreases to 3-5 kg \u200b\u200b(6% of the initial mass). The overall condition of pregnant women deteriorates, significant weakness and apathy arise. The skin is pale, dry, the tongue is covered with a whitish bloom, dry. Temperature of the body is subfebrile (not higher than 37.5 ° C), tachycardia (up to 100 per minute) and hypotension are observed. When studying blood, it is possible to identify light anemia, metabolic acidosis is observed. The diuresis is reduced, acetone can be in the urine. It is often observed constipation. The forecast is usually favorable, but treatment is required.

Excessive vomit It is rare and accompanied by a violation of the functions of vital organs and systems up to the development of dystrophic changes in them due to severe intoxication and dehydration. Vomiting is observed up to 20 times a day, a woman suffers from abundant solubling and constant nausea. General condition is severe. Adamina, headache, dizziness, body weight is rapidly decreasing (up to 2-3 kg per week, over 10% of the base mass). The layer of subcutaneous fatty fiber disappears, the skin becomes dry and dye, the tongue and lips of dry, the octop of acetone is felt, the body temperature is subfebrile, but may increase to 38 ° C, expressed tachycardia, hypotension arise. The diuresis is sharply reduced.

In the blood, residual nitrogen, urea, bilirubin, hematocrit, the number of leukocytes increases. At the same time, there is a decrease in the content of albumin, cholesterol, potassium, chlorides. When analyzing urine, protein and cylindruria are determined, urobilin, bile pigments, red blood cells and leukocytes are detected. The urine reaction to acetone is sharply positive.

Excessive vomiting forecast is not always favorable. Indications for emergency interruption of pregnancy are: increasing weakness, adamis, euphoria or nonsense, tachycardia to 110-120 per minute, hypotension to 90-

80 mm RT. Art, the jaggility of the skin and the scool, pain in the right hypochondrium, reduced diurea to 300-400 ml / day, hyperbilirubinemia in the range of 100 μmol / l, increase the level of residual nitrogen, urea, proteinuria, cylindruria.

Diagnostics.Install the diagnosis of vomiting of pregnant women is easy. To determine the severity of the vomiting of pregnant women, in addition to the clinical examination of the patient, the general analysis of blood and urine, determine the content of bilirubin, residual nitrogen and urea, hematocrit, the amount of electrolytes (potassium, sodium, chlorides), total protein and protein fractions, transaminases, brass indicators , glucose, protuberine. In the urine, the level of acetone, urobilin, biliary pigments, protein is determined. In a significant dehydration and thickening of blood, there may be falselyonormal indicators of the content of hemoglobin, erythrocytes, protein. The degree of dehydration is determined by the level of hematocrit. Hematokritis more than 40% indicates a pronounced dehydration.

Treatmentpatients with a light form of vomiting can be carried out outpatient, medigative and severe vomiting - in the hospital. Of great importance is the diet. In connection with the decline in appetite, it is recommended to be a variety of food in accordance with the desire of a woman. Food should be easily friendly, contain a large number of vitamins. It is given in chilled form, in small portions every 2-3 hours. The patient should be lying in bed. Appoint alkaline mineral water in small quantities 5-6 times a day.

Medical treatment in vomiting of pregnant women should be complex. Prescribed drugs governing the function of the central nervous system and blocking vomit reflex, infusion agents for rehydration, disintellation and parenteral nutrition, drugs normalizing metabolism.

To normalize the CNS function, the hospital and elimination of negative emotions have important importance. With hospitalization, the patient is advisable to put in a separate ward to exclude reflex vomiting.

At the beginning of treatment, under a small gestation period, to eliminate the negative effect of drugs on a fruit egg, it is advisable to assign non-drugs. To restore the functional state of the cerebral cortex and eliminating vegetative dysfunction, central electrical cells, acupuncture, psycho- and hypnotherapy are shown. Non-drug treatment methods are sufficient with a light form of vomiting of pregnant women, and with medium and severe, they allow you to reduce the doses of drugs.

In the absence of effect, the means directly blocking the vomit reflex are used: drugs affecting various neurotiator systems of the oblong brain: M-cholinolities (atropine), antihistamines (TAVEGIL), DOPHAMINY receptor blockers (neuroleptics - haloperidol, Droperidol derivatives of phenothiazine -

takekan), as well as direct dofamine antagonists (Relan, Cerukal).

Infusion therapy in vomiting includes the use of mainly crystalloids for rehydration and means for parenteral nutrition. From crystalloids, a solution of Ringer-Locke, Trisole, Glosol is used. For parenteral nutrition, glucose and amino acid solutions (alvsin, hydrolysin) are taken. For the purpose of better assimilation of glucose, it is advisable to introduce insulin in small doses. The volume of preparations for parenteral nutrition should be at least 30-35% of the total infusion.

With a decrease in the total blood protein, 5.0-5.5 g / l is shown 5-10% albumin to 200 ml.

The total amount of infusion therapy is 1-3 liters depending on the severity of the toxicosis and body weight of the patient. Infusion therapy sufficiency criteria are to reduce dehydration and increase the skin turgora, the normalization of hematocrit, increasing the diuresis.

Against the background of infusion therapy, drugs, normalizing metabolism, mainly riboflavin mononucleotide (1 ml of 1% of the intramuscular solution) are prescribed; Vitamin C (up to 5 ml of 5% solution intramuscularly), 2 ml splinin (intramuscularly).

Complex therapy continues to the resistant termination of vomiting, the normalization of the general condition, gradually increased body weight. Treatment of light and medium-eyed vomiting of pregnant women is almost always effective. Excessive vomiting of pregnant women in the ineffectiveness of complex therapy for 3 days is an indication for the interruption of pregnancy.

Salivation.Saliva ( rt.uAl.i.sM.) lies in high savance and loss of a significant amount of fluid - up to 1 l / day. It can be an independent manifestation of toxicosis or accompany the vomiting of pregnant women. In the development of dissolutes, not only changes in the central nervous system are important in the central nervous system, but also local disorders in salivary glands and ducts under the influence of hormonal perestroika. Estrogens have an activating effect on the epithelial cover of the oral cavity, causing saliva secretion. With pronounced salivation, the appetite decreases, well-being will deteriorate, the skin maceration and the lip mucosa arises, the patient is losing weight, sleep is disturbed; Due to the considerable loss of fluid, signs of dehydration appear.

Treatment.At dilatation, the same treatment is carried out mainly as in vomiting (psychotherapy, physiotherapeutic procedures, infusion of solutions, etc.). Hospital treatment is recommended. Assigns regulating the function of the nervous system, metabolism, with dehydration - infusion drugs. At the same time, the rinsing of the mouth with the infusion of sage, chamomile, menthol is recommended. With a strong salivation, an atropine can be applied subcutaneously to 0.0005 g 2 times a day. To prevent maceration, the skin of the face is lubricated with vaseline. Sluting is usually treatable. After it is eliminated, the pregnancy develops normally.

Jaundiceassociated with pregnancy can be due to cholestasis, acute fatty hepatosis.

For cholestasy Pregnant presented complaints about heartburn, periodic nausea, skin itching, sometimes generalized. Jaundice is light or moderate, although this symptom is inconsistent. Laboratory signs of cholestasis: an increase in the activity of Alt, AST, SFF, direct bilirubin. For the treatment of cholestasis, a diet with a restriction of fried (table No. 5), choleretic drugs, including plant origin, means containing essential fatty acids are administered intravenously crystalloids.

Acute fat gepatosis of pregnant womenespecially developing at primarmerics. During the disease, two periods distinguish. First - Borough-awake -

it can last from 2 to 6 weeks. There is a decrease or absence of appetite, weakness, heartburn, nausea, vomiting and pain in the epigastric area, skin itching, loss of body weight. The second stage of the disease is jaundice. This final stage is expressed by a clinical picture of hepatic renal failure: jaundice, oliganuria, peripheral swelling, cluster of fluid in serous cavities, bleeding, antenatal fetal death. The biochemical markers of acute fat hepatosis are hyperbilmominemia at the expense of direct fraction, hypoproteinemia (below 6 g / l), hypophybrinogenemia (below 200 g / l). The pronounced thrombocytopenia is uncharacteristic, increasing the activity of transaminase is insignificant. At the same time, the complication of pregnancy often develops a hepatic coma with a violation of the function of the brain - from insignificant disturbances of consciousness to its deep loss with oppression of reflexes.

Acute fat gepatosis of pregnant women is an indication for emergency delivery. Intensive preoperative infusion transfusion, hepatoprotective preparation (10% glucose solution in combination with ascorbic acid macrodoses - to

10 g / day), replacement therapy [freshly frozen plasma at least 20 ml / (kg / day)].

Gestosis

Gestosis is a complication of pregnancy associated with generalized angiospasm, leading to deep disorders of the function of vital organs and systems. The frequency of gestosis is 13-18% of all kinds.

The most typical clinical manifestations of gestosis include a triad symptoms: an increase in hell, proteinuria, swelling. Sometimes there is a combination of two SIM-Pets: hypertension and proteinuria, hypertension and swelling, swelling and proteinuria.

Currently, the term "hypertension, insurance", or most countries, including the United States, is used to designate gestosis in some countries. Under the preeclampsia of varying severity, all the above states that precede eclampsia are understood.

Previously generally accepted in our country was the late toxicosis of pregnant women, the stage of development and the form of the manifestation of which are denoted as edema of pregnant women, nephropathy, preeclampsia, eclampsia.

Currently, the Russian Association of Obstetrician-Gynecologists proposes to use Terr-min "Gesters", the following classification.

Wastecast pregnant; Gesters of varying severity:

Easy - the severity of gestosis is determined on the scale (Table 20.1).

Middle 8-11 points,

Severe 12 points and more;

Preeclampsia;

Eclampsia.

In accordance with this, some changes have been made to the classification proposed by the ICD (Table 20.2). For the timely diagnosis of gestosis diseases, it is important to identify the preclinical stage ("Propestosis").

Table 20.1. Estimation of gravity of pregnant gestosis in points

Symptoms	Point
		On the legs or pathological grease weight	On the legs front	General sought
Proteinuria				1.0 or more
Systolic Hell (mm Hg. Art.)
Diastolic Hell (mm Hg. Art.)
The term of appearance gesotosis (week)		36-40 weeks or		24-30 weeks and earlier
			Standing	For 3-4 weeks and more
diseases		Manifestation diseases before pregnancy	Manifestation diseases pregnancy	Manifestation of the disease before and during pregnancy

Up to 7 b - light art., 8-11 b - the middle Art., 12 b and more - severe Art.

Table 20.2. Classification of gestosis on the ICD and offered by the Russian Acusor Gynecologists Association

* The severity of gestosis is determined by the accompanying scale.

To determine the gravity of gestosis, a modified scale GM is offered. Savelyeva et al. In dependence on the presence or absence of background states, gestosis is divided into "clean" and "combined".

The "clean" consider prestal, which occurs in pregnant women with non-declared extragenital diseases. Such a separation to a certain extent is conditionally, since the extragnenital diseases are often hidden (for example, latent pyelonephritis, vegetative dystonia, hormonal disorders, congenital hemostasis defects). "Clean" gestosis occurs in 20-30% of pregnant women. More often there is a combined prestal, which occurs in pregnant women against the background of the preceding disease. Gessel glances in pregnant women with hypertension, kidney disease, liver, endocrinople, metabolic syndrome are most adversely.

Etiologygesotosis is not installed. Supported reasons for the development of gestosis consider neurogenic, hormonal, immune, placental and genetic factors.

Changes underlying the development of gestosis are laid in the early periods of pregnancy. In disruption of the stability of the mechanisms that ensure the tolerance of the parent organism to the antigens of the fetus, which is more often observed during homozygosity of the HLA system (more often than HLA-B), the initial link of transplacentar immunity reactions is blocked - the process of recognition of antigenic differences between the tissues of mother and placenta. As a result, factors contributing to the braking of the migration of the trophoblast in the vessels of the uterus are formed. At the same time, the reputable uterine arteries are not subjected to morphological changes characteristic of pregnancy. They do not transform the muscular layer. These morphological features of the spiral vessels of the uterus as pregnancy progressive predispose them to spasm, a decrease in interval blood flow and hypoxia of placental tissue, which contributes to the activation of factors leading to the structure and functions of the endothelium or a decrease in compounds that protect endotheliums from damage (Scheme 20.1).

Scheme 20.1. Factors contributing to the defeat of the endothelium during gestosis

Changes to endothelium during prestal is specific. A peculiar endotheliosis is developing, which is expressed in swelling of cytoplasm with fibrin deposition around the basal membrane and inside the swollen endothelial cytoplasm. Endotheliosis first local, damages the placenta and uterus vessels, then becomes organic and applies to the kidneys, liver and other organs.

Endothelial dysfunction leads to a number of changes that determine the clinical picture of the gestosis.

Endothelium-dependent dilatation is disturbed, since the synthesis of vasodilators is blocked in the affected endothelium: prostacyclin, endothelial relaxing factor (nitrogen oxide), bradykinin. As a result, the effect of vasoconstructors prevails due to thrombooxane synthesized in platelets. The predominance of vasoconstrictors contributes to vazospasm and hypertension.

The sensitivity of the vessels to the vasoactive substances increases, since the endothelium is defeated in the early stages of the disease, the muscular elastic membrane of vessels with the receptors located in it is exposed to vasoconstrictors.

Decreased tromborette properties of vessels. Damage to the endothelium reduces its antithrombotic potential as a result of a violation of the synthesis of tromboodulin, plasminogen tissue activator, improving platelet aggregation with the subsequent development of chronic DVS syndrome.

Inflammation factors are activated, in particular the formation of peroxidant radicals, tumor necrosis factors, which, in turn, additionally disrupt the morphological structure of the endothelium.

Vascular permeability increases. The defeat of the endothelium along with the change in the synthesis of aldosterone and the delay of sodium and water in cells of developing hypoproteinemia contributes to the pathological permeability of the vascular wall and the exit of the fluid from the vessels. As a result, additional conditions are created for generalized spasm, hypertension, edema syndrome.

The developing dysfunction of the endothelium and changes caused by it lead to a violation of all microcirculation links during gestosis (Scheme 20.2).

Scheme 20.2. Microcirculation disorders in gestosis

Against the background of the progression of vasospasm, hypercoagulation, increasing the aggregation of erythrocytes and platelets, the blood viscosity is formed by a complex of microcirculatory disorders, leading to hypoperfusion of vital organs: liver, kidneys, placenta, brain, etc.

Along with vasospasm, violation of the rheological and coagulation properties of blood in the development of organic hypoperfusion, changes are played by changes in macrohereodynamics, a decrease in the volumetric indicators of central hemodynamics: shock volume, minute volume of the heart, circulating blood volume (OCC), which are significantly less than those in the physiological course of pregnancy. Low values \u200b\u200bof the BCC under prestrase are due to both amazeled vasoconstriction and a decrease in the vascular bed and the increased permeability of the vascular wall and the yield of the liquid part of the blood in the tissue. Another reason for increasing the number of interstitial fluid during gestosis is the imbalance of the colloid-osmotic pressure of plasma and tissues surrounding the vessels, which is caused by hypoprotemiamia, on the one hand, and sodium delay in tissues, and consequently an increase in their hydrophilicity on the other. As a result, pregnant women with gestosis formed a paradoxical combination - hypovolemia against the background of a large amount of fluid delay (up to 15.8-16.6 liters) in an interface, aggravating the reduction of microcirculation.

Developing spasm of blood vessels, violation of the rheological and coagulantic properties of blood, increasing the overall peripheral vascular resistance, hypovolemia form a hypokinetic type of circulation, which is characteristic of most pregnant women with heavy gestosis.

Distrophic changes in the tissues of vital organs are largely due to the violation of the matrix and barrier function of cell membranes.

Changes in the matrix function of the membranes are to violate the mechanism of action of various membrane proteins (transport, enzyme, hormone receptors of antibodies and proteins associated with immunity), which leads to a change in the function of cellular structures.

The violation of the barrier function of lipid bilayer membranes is associated with changing the functioning of channels for ions, primarily calcium, as well as sodium, potassium, magnesium. The massive transition of calcium into the cell leads to irreversible changes in it, to the energy hunger and death, on the one hand, and in addition to muscle contractures and vazospasm - on the other. It is possible that the eclampsia, which is a contracture of transverse muscles, is due to a violation of the permeability of membranes and the massive movement of calcium into the cell ("Calcium paradox"). In the experiment, magnesium, which is calcium antagonist, prevents the development of this process.

As gestosis progresses, necrosis develops in the tissues of vital organs. They are due to hypoxic changes as the finale of hypoperfusion.

Gestosis is almost always accompanied by a severe infringement of the function. kidney - from proteinuria to acute renal failure. Patomorphological changes associated with gestosis are mostly distributed to the tubular apparatus (the picture of the glomerular-capillary endotheliosis), which is expressed in the dystrophy of the convulsion canal, in some cases with the desquamation and the decay of the kidney epithelium cells. This picture is complemented by focal and fine-point hemorrhages under the kidney cap, in a parenchyma -

mostly in the intermediary zone, rarely in the brain layer, as well as in the mucous membrane of cups and pelvis.

Changes in liver There are as a result of chronic circulatory disorder expressing in parenchymal and fatty dystrophy of hepatocytes, liver and hemorrhage necrosis. Nurses can be both focal, small and extensive. The hemorrhages are more often multiple, of various sizes, are combined with subcapsular hematomas, overvoltage of the fibrous sheath of the liver (glisson capsule) up to its rupture.

Functional and structural changes big Brain With pre-prostose varies widely. As in other organs, they are due to the impaired microcirculation, the appearance of thrombosis in vessels with the development of dystrophic changes in nerve cells, perivascular necrosis. At the same time, fine-point or small-scale hemorrhages are developing. It is characterized by the edema of the brain with an increase in intracranial pressure, especially with severe gestosis. A set of ischemic changes in the end may cause an attack of eclampsia.

During pregnant women, pregnant changes are observed in the placenta: obliterating endarteritic, swelling of stromas, vascular thrombosis and intervalic space, necrosis of individual vascular, hemorrhage foci, fat rebirth of placental tissue. These changes lead to a decrease in the uterine-placental blood flow, infusion and transfusion insufficiency of the placenta, the delay in the growth of the fetus, chronic hypoxia.

Clinical picture and diagnostics.Preclinical Stage It is manifested by a complex of changes detected by laboratory and additional methods of research before the appearance of a clinical picture of the disease. Changes may arise from 13-15 weeks. Objective features include a decrease in the number of platelets during pregnancy, hypercoagulation in the cellular and plasma hemostasis links, a decrease in the level of anticoagulants (endogenous heparin, antithrombin III), lymphoprod, increasing the level of plasma fibronectin and a decrease in A 2-microglobulin - endothelium damage markers. Dopplerometry determine the reduction of blood flow in the architectural arteries of the uterus. The preclinical stage of gestosis is evidenced by 2-3 modified markers.

Waswing pregnant women it is the earliest symptom of gestosis. The fluid delay in the body in the first stages of the development of the disease is associated to more with the disorder of the water-salt balance, the delay in sodium salts, an increased permeability of the vascular wall as a result of the destruction of the endothelium and hormonal dysfunction (an increase in the activity of aldosterone and antidiuretic hormone).

There are hidden and obvious swelling. About hidden edema testify:

Pathological (300 g and more than a week) or uneven weekly weight gain;

Reducing diurea to 900 ml and less under normal water load;

Niktric;

A positive "ring" symptom "(ring, which is usually carried on an average or unnamed finger, have to wear a little finger).

In the prevalence, the degree of explicit swelling distinguish: I degree - swelling of the lower extremities; II degree - swelling of the lower limbs and abdomen; III degree - swelling of the legs, the walls of the abdomen and face; IV degree - Anasar.

Edema begin usually with ankle area, then gradually spread up. Some women at the same time with the ankles begins to swell and face that becomes fined. Features are sad, especially noticeable swelling on centuries. When distributing swelling on the belly over the pubic, a test pillow is formed. Often swelling sex lips. In the morning, the edema is less noticeable, because during the night recreation, the liquid is evenly distributed throughout the body. During the day (due to the vertical position), the edema descend on the lower limbs, the abdomen. It is possible to accumulate liquid in serous cavities.

Even with pronounced edema, the general condition and the well-being of pregnant women remain good, they do not prevent complaints, and with clinical and laboratory research, significant deviations are detected from the norm. A number of obstetricians consider swelling with physiological phenomenon, since they do not have much influence on the outcome of pregnancy, perinatal morbidity and mortality, if the mother has no hypertension and proteinuria. However, only 8-10% of patients, the patients do not switch to the next stage of the disease, the rest to the edema join hypertension and proteinuria, so the edema should be attributed to the pathological phenomenon.

The diagnosis of water of pregnant women is based on the detection of edema, independent of extragenital diseases. To correctly evaluate the water of pregnant women, it is necessary to eliminate diseases of the cardiovascular system and kidneys, at which fluid delay in the body is also possible.

Gestosis Includes triad symptoms: hypertension, proteinuria, explicit or hidden edema. Often there are only two symptoms.

Hypertension It is one of the important clinical signs of gestosis, it reflects the severity of angiospasm. The initial figures of blood pressure are important. The hypertension of pregnant women shows an increase in systolic blood pressure on 30 mm Hg. Art., and diastolic - by 15 mm Hg. Art. And higher in relation to the original. When progressing gestosis, blood pressure may be excessively pronounced - 190/100 mm Hg. Art. Of particular importance is the increase in diastolic pressure and a decrease in the pulse equal to normal an average of 40 mm Hg. Art. A significant decrease in pulse pressure indicates a pronounced arteriole spa and is prognostically unfavorable. The increase in diastolic blood pressure is directly in proportion to a decrease in placental blood flow by the frequency of the hypoxia of the plazide until its death. Even a slight increase in systolic pressure with a high diastolic and low pulse can be promoted by preeclampsia and eclampsia. The severe effects of gestosis (bleeding, premature detachment of a normally located placenta, the antenatal fetal death) is sometimes due to not high arterial pressure, and its sharp fluctuations.

For proper assessment of hypertension, the average blood pressure (Garden) is taken into account, which is calculated by the formula:

Garden \u003d (hell syst + 2 hell dist) / 3

Normally, the garden is 90-100 mm Hg. Art. Arterial hypertension is diagnosed with a Garden of 105 mm Hg. Art. or higher.

Proteinuria (The appearance of protein in the urine) is an important diagnostic and prognostic sign of gestosis. The progressive increase in proteinuria testifies to the deterioration of the course of the disease. In gestosis in the urine, there is usually no precipitate, as for kidney diseases (erythrocytes, wax cylinders, leukocytes).

Simultaneously with the development of the triads of symptoms, diuresis reduces pregnant women. The daily amount of urine is reduced to 400-600 ml and less. The less urine stands out, the worse the forecast of the disease. Unregistered Oliguria may indicate renal failure.

In addition to these symptoms, the condition of pregnant women and the outcome of pregnancy is determined by additional factors, in particular the duration of the disease. Long-term beds, whose symptoms appear until the 20th week, almost in 80% of cases resistant to therapy. Early start and long-term course of the disease in 65% of cases lead to a delay in the growth of the fetus, which also affects the course, progression and severity of the disease.

The severity of the state of pregnant women during gestosis also depends on the extragnenital pathology at which it takes a protracted flow with frequent relapses, despite the therapy conductive. The condition of pregnant women during prestal is estimated in the scores on the scale presented in Table. 1. Light gestosis is estimated to 7 points and less, medium-heavy - 8-11 points, heavy - 12 points or more. Palkal assessment may vary against the background of therapy.

Preeclampsia it is a short-term interval before the development of convulsion (eclampsia) and is accompanied by a violation of the function of vital organs with predominant damage to the central nervous system.

Against the background of the symptoms of gestosis at preeclampsia, 1-2 of the following symptoms appear:

Heaviness in the back of the head and / or headache;

Violation of vision: his weakening, the appearance of "pellens" or "fog" before the eyes, flickering of flies or sparks;

Nausea, vomiting, pain in the epigastric region or in the right hypochondrium;

Insomnia or drowsiness; Memory disorder; Irritability, lethargy, indifference to the surrounding.

These symptoms can be both central genes and the result of the damage caused by the clinical picture of the disease.

Disorder of view is associated with circulatory impairment in the occipital part of the brain cortex or with the appearance of "eclaptic" retinopathy, i.e. damage to the retinet in the form of retinit, hemorrhage into it, detachment.

The pain in the epigastric region can be determined by hemorrhage in the walls of the stomach, the gastralgia due to the impairment of the nervous regulation.

Pain in the right hypochondrium testify to the color of the liver glisson capsule as a result of its edema, and in severe cases - hemorrhage into the liver.

In case of preeclampsia, there is a constant danger of eclampsia seizures. After a few days or a few hours and even minutes under the influence of various stimuli, the seizures begin.

Syolic arterial pressure 160 mm Hg is considered the criteria for the severity of the state of pregnant women during gestosis and the high probability of the development of elampsia. and higher; Diastolic blood pressure 110 mm Hg. and higher; proteinuria (protein content up to 5 g / day or more); Oliguria (urine less than 400 ml / day); Brain and visual disorders, dyspeptic phenomena; thrombocytopenia, hypocoagulation; Violation of the liver function.

Eclampsia (from Greek. eklampsis - Flash, ignition, ignition) -thruding stage of gestosis with a complex symptom complex. The most characteristic symptom is the seizures of the transverse muscles of the whole body. Eclampsia is the most severe manifestation of gestosis. Relatively rare convulsions appear without harbing. They distinguish the eclampsia of pregnant women, eclampsia of the feminine, eclampsia of the porms.

Causes develop against the background of the symptoms of severe gestosis and preeclampsia. The appearance of the first convulsive seizure of the eclampsia is often provoked by any external stimulus: bright light, sharp knock, pain (in injections, vaginal studies), strong negative emotions, etc. A typical seizure of convulsion continues on average for 1-2 minutes and consists of four consistently replacing periods.

The first period is the introductory: small fibrillar twitching muscles of the face, eyelids. The look becomes fixed, the eyes are fixed, pupils are expanding, deviating up or to the side. After a second, the eyes are closed with a frequent twitching age, so pupils go under the top eyelid, the protein becomes visible. The angles of the mouth are delayed down the book; Fast fibrillar twitching of the Mimic muscles of the face, including the eyelids, quickly spread from top to bottom, from face to the upper limbs. Hand brushes shrink in fists. The introductory period lasts about 30 s.

The second period is a period of tonic convulsions - the Tetanus of all body muscles, including respiratory muscles. Following the top of the upper extremities, the patient's head leans back. The body pulls out and strains, the spine bent, the face is pale, the jaw is tightly compressed. The patient during the seizure does not breathe, cyanosis is rapidly growing. The duration of this period is 10-20 s. Despite short-term, this period is the most dangerous. A sudden death may come, most often from blood hemorrhage.

The third period is clonic convulsions. Motionlessly lying before, stretching into a string, the patient begins to beat in continuously following each other clonic convulsions spreading from the body from top to bottom, as a result of which she boots in bed, moving hands and legs. The patient does not breathe, the pulse is irrelevant. Gradually, convulsions become stronger and weak and, finally, stop. The patient makes a deep noisy breath, accompanied by snoring and turning into deep rare breathing. The duration of this period is from 30 seconds to 1.5 minutes, sometimes more.

The fourth period is the resolution of the seal. A foam painted with blood is distinguished from the mouth, the face is gradually pose. Begins to take care of the pulse. Pupils are gradually narrowed.

After the seizure follows a comatose state. The patient is unconscious, breathing loudly. This state may soon pass. The woman comes into consciousness, does not remember anything about what happened, complains of headache and overall basis. Sometimes a comatose state without waking after a while goes into the next seizure. The number of seizures may be different. At the end of the XIX, the beginning of the twentieth century described cases of eclampsia to 50-100 seizures. Currently, it is rare to observe 3-4 seas. The complete restoration of consciousness in pauses between the seizures is of a favorable value, and a deep coma marks the difficult course of the disease. If the deep coma continues for hours, days, then the forecast is bad even when the seizures are stopped.

Coma is determined in greater exaccation of the brain (the result of the violation of the autoretum of cerebral blood flow on the background of acute hypertension). With intracranial hemorrhages, the forecast is deteriorated as a result of the cerebral vessels.

Exacerbate the forecast of hyperthermia, tachycardia, especially at normal body temperature, motor anxiety, jaundice, non-coordinated movements of eyeballs, oliguria.

There is also a dismissed eclampsia - it is very rare and extremely severe. The picture of the disease is peculiar: pregnant complains of severe headache, darkness in the eyes. Suddenly, a complete blindness (amavricosis) may occur, the patient flows into a comatose condition at high arterial pressure. Very often the incomplete form of eclampsia is associated with hemorrhage in the brain. In this case, a fatal outcome is possible due to hemorrhage into the stem portion of the brain.

As a rule, the recognition of the eclampsia difficulties does not represent. Differential diagnosis with epilepsy and uremia, some brain diseases (meningitis, brain tumors, sinus thrombosis, hemorrhage) should be carried out. Epilepsy is evidenced by anamnestic data, the absence of pathology in urine tests, normal blood pressure, epileptic aura and epileptic cry in front of the seizure.

Diagnosis of gestosis Install on the basis of clinical and laboratory data. For timely diagnosis of the disease, it is necessary to study the coagulation properties of blood, the number of blood cells, hematocrit, hepatic enzymes, biochemical analysis of blood, general and biochemical analysis of urine, diurea, measuring blood pressure in the dynamics on both hands, control over body weight, concentration function of the kidneys, condition Eye bottom. It is advisable to carry out ultrasound, including the blood flow dopplerometry in the vessels of the mother-placental-fruit system. Advisory examinations are needed by the therapist, nephrologist, neuropathologist, an ophthalmologist. A violation of cerebral circulatory circulatory in gestosis is usually reflected in the form of a spasm of the arteries of retina (angiopathy) on the eye day, leading to a disorder of retinal blood circulation and a loosening edema. If, along with a significant and resistant spasm of the retinal vessels on its periphery, swelling and dark stripes are determined, the risk of retinal detachment is determined.

Pregnant women with gestozing previously 20 weeks of pregnancy, especially in the presence in the history of perinatal losses or severe gestosis, it is necessary to investigate the blood for congenital hemostasis defects.

Complications of gestosis.The complications of gestosis include:

Lung swelling as a result of a shock lung or incorrectly conducted infusion therapy;

Acute renal failure due to sewage and cortical necrosis, hemorrhages;

Brain coma;

Hemorrhages in adrenal glands and other vital organs;

Premature detachment of a normally located placenta;

Placental insufficiency, chronic hypoxia, antenatal fetal death.

In recent years, the frequency of complications associated with impaired liver functions has increased. In gestosis, specific liver changes are developing, combined in Hellp syndrome [N ( hemolysis) - hemolysis; Il ( e1E.vated. lIVER. enzymes.) - improving the level of liver enzymes; Lp ( 1Ow. P1Atelet. SOunt.) - thrombocytopenia]. With severe nephropathy and eclampsia, Hellp syndrome develops in 4-12% of cases and is accompanied by high maternal and perinatal mortality.

One of the cardinal symptoms of nonll-syndrome is hemolysis of erythrocytes (microangiopathic hemolytic anemia). Blood smears are determined by wrinkled and deformed erythrocytes, their fragments (schistocytes) and polychromazy. In the destruction of red blood cells, phospholipids are exempt, leading to permanent intravascular coagulation (chronic DVS syndrome). Increasing the level of hepatic enzymes with nonlr-syndrome is caused by the blockade of blood flow in intrahepatic sinusoids due to the deposits of fibrin in them, which leads to the degeneration of hepatic cells. When obstruction of blood flow and dystrophic changes in hepatocytes, the glisson capsule with typical complaints (pain in the right hypochondrium and epigastria) occurs. Increased intrahepatic pressure can lead to subcapsular hematoma of the liver, which can be broken under the slightest mechanical damage (increase in intra-abdominal pressure during the delivery through the natural generic paths, the use of the presidor method). Thrombocytopenia (less than 93104) is caused by platelet depletion due to the formation of microtrombov against the violation of the vascular endothelium. In the development of nonLLP syndrome, autoimmune reactions are important. At the same time, the following stages are passed: an autoimmune lesion of endothelium, hypovolemia with blood thickening, the formation of microtrombov with subsequent fibrinolysis.

Nellp syndrome, as a rule, arises in the third trimester, more often under a period of 35 weeks. Symptoms such as thrombocytopenia and violation of the liver function reach a maximum 24-28 hours after emergency delivery. The clinical picture of nonllp syndrome is manifested by aggressive flow and rapid growth of symptoms. The initial manifestations are nonspecific and include headache, fatigue, malaise, nausea and vomiting, diffuse or localized pain in the right hypochondrium. Subsequently, typical symptoms appear: jaundice, vomiting with blood admixture, hemorrhage in injections, increasing liver failure, convulsions and pronounced coma. Often there is a gap of the liver with bleeding into the abdominal cavity. In the postpartum period, non-violation of the coagulation system may arise profuse uterine bleeding.

Treatment of gestosis.With water, the I degree is possible therapy in the conditions of female consultation. With water II-IV degree, light and moderate gestosis, treatment is carried out under hospital. Pregnant women with severe gestosis, preeclampsia, eclampsia is advisable to hospitalize in perinatal centers or hospitals of multi-profile hospitals having a resuscitation department and a department for having premature babies. With severe gestosis, preeclampsia and eclampsia therapy begins from the moment when the doctor saw the patient for the first time -

houses, in the process of transportation, in the receiving department of the hospital.

The treatment of gestosis is aimed at restoring the function of vital organs and timely delivery.

A definite value in the treatment of pregnant women with gestosis has a diet and water regime, taking into account the diurea and daily weight gain. With a weight gain of a body of 400 g and more appropriate to conduct two unloading days per week, limit the amount of cook salt in food; In unloading days, the patient gives low-fat fish or meat to 200 g, low-fat curd 200 g, apples up to 600 g, 200 ml of kefir or other liquid.

We need daily 2-3-hour holidays in bed, which contributes to an increase in blood flow in placenta, kidneys and normalization of diuresis.

An important place in comprehensive therapy is to normalize the function of the CNS, a decrease in central and reflex hyperactivity. For this apply various psychotropic drugs. With water, light preference is given to various phytosborators, physiotherapeutic measures.

Pregnant with a labile nervous system, insomnia can be prescribed to diazepam.

Normalization of microdynamics in pregnant women with gestosis is carried out by appointment hypotensive drugs. Many effective anti-generation hypotensive drugs are contraindicated during pregnancy (for example, ACE inhibitors - Quinapril). In this regard, pregnant women continue to use not so effective drugs, but not affecting the fetal state, for example, antispasmodics.

Hypotensive therapy It is carried out with systolic blood pressure exceeding the original to pregnancy by 30 mm Hg, and with a diastolic, exceeding 15 mm Hg. The combination of drugs with various mechanism of action is justified: antispasmodics, adrenoblockers, peripheral vasodilators, inhibitors of vasoactive amines, gangliplockers. In case of light gestosis, monotherapy uses, with moderate - complex therapy for 5-7 days, in case of efficiency, followed by the transition to monotherapy.

It is advisable to use hypotensive drugs under the control of daily monitoring of blood pressure (Garden) and hemodynamic indicators. This allows you to individually choose the type of medicinal product and its dose.

The preparation of choice during gestosis at the stage of the stage is magnesial therapy, the effectiveness of which with moderate gestosis is up to 82-85%. Magnesium sulfate remains an effective anticonvulsant and temperate vasodilator. Magnesium sulfate has a depressive effect on the CNS, inhibits the excitability and the reduction of smooth muscles, reduces the level of intracellular calcium, allocates expression by the nerve endings of acetylcholine, inhibits the release of catecholamines. Magnesium sulfate eliminates cerebral and renal vasospasm, improves uterine blood flow. The therapeutic level of the drug in the blood plasma ranges from 4 to 8 MEKV / L, and the toxic effect is observed at its concentration of 10 MEQ / l. To create a therapeutic concentration of magnesium sulfate in the blood at the beginning of treatment, it is introduced simultaneously intravenously at a dose of 2-4 g, and subsequently transition to a long administration at a rate of from 1 to 3 g / h (daily dose to 10 g of dry matter). The toxic effect of magnesium sulfate can be the result of either an absolute overdose, or a long-term infusion while reducing the kidney function. Overdose may be accompanied by weakness, respiratory and heart failure, decreased by the excretory function of the kidneys. The first sign of overdose is the weakening of deep tendon reflexes. Antidot of magnesium sulfate - calcium salts, they should be entered during symptoms of overdose.

With ineffectiveness of magnesial therapy at the second stage in the hypokinetic and eukineotic type of central macrohemeodynamics, it is advisable to apply the stimulants of central adrenoreceptors (clofelin, methyldop), with hyperkinetic - selective B-blockers (metoprolol).

The choice of hypotensive drugs is of particular importance, if prestal developed against the background of hypertension, and the woman is forced to take a long-term drug. In this situation, preparations are preferred by one of the following groups:

β-adrenoblays selective (metaprolol) and non-selective (propranolol);

α and β -adrenoblocators (labetalol);

Stimulants of central A2-adrenoreceptors (methyl dopa, clofelin);

Calcium antagonists (nifedipine, cordaflex).

When prescribing hypotensive agents, especially β -adrenoblators, it should be remembered that they, having favorably affecting the mother, may not lead to a significant improvement in the state of the fetus, since under conditions of excessive decrease in blood pressure, it is possible to reduce the uterine-placental blood flow.

One of the leading places in pathogenetic therapy gestosis belongs infusion therapy. Its purpose is to normalize the volume of circulating blood, colloid-osmotic plasma pressure, rheological and coagulation properties of blood, macro- and microhereodynamics.

Indications for infusion therapy are light gestosis with relapses, medium-heavy and heavy gestosis, pre-eclampsia and eclampsia, as well as a delay in the growth of the fetus, regardless of the severity of the disease. Therapy is carried out under the control of hematocrit (0.27-0.35 g / l), FLAL (2-3 cm of water. Art.), Protein content (at least 50 g / l), central hemodynamic states (blood pressure, pulse) , Diurea (at least 50 ml / h), hemostasis indicators (antithrombin III - 70-100%, endogenous heparin - 0.07-0.12 units / ml), hepatic transaminases (within the physiological norm), bilirubin concentrations ( within the physiological norm), the state of the fundus.

The composition of infusion therapy includes both crystalloids and colloids. From crystalloids - a solution of the Gatman, Chloss, Lactosol, Mafusol from colloids is used by freshly frozen plasma in the violation of hemostasis, a 10% starch solution. The ratio of colloids and crystaloids, the volume of infusion therapy is primarily determined by the content of protein in the blood and diuresis (scheme 20.3).

Scheme 20.3. The volume and composition of infusion therapy in gestosis

With the beginning of infusion therapy, it is possible to introduce solutions into a peripheral vein, since the catheterization of the central vein is fraught with severe complications. In the absence of the effect of therapy, if diuresis is not restored, the catheterization of the metering veins can be made to determine the CCD and the further administration of solutions.

With a forced diuresis, hyponatremia is possible, against the background of which the stupor, fever, chaotic movements of the limbs appear. Hypologiamia causing severe arrhythmias can develop.

When conducting infusion therapy, the rate of fluid introduction and its ratio with diuresis is important. At the beginning of the infusion, the volume of solutions is 2-3 times higher than hourly diuresis, subsequently against the background or at the end of the fluid administration, the amount of urine should exceed the volume of the injected fluid by 1.5-2 times.

Normalization water salt balanceit is achieved by restoring diuresis. During its normalization, diuretic phytosborgs are used for the light and medium-width of presence and the inefficiency of the bed mode, and in the absence of the effect - the potassium-saving diuretics (triampur 1 tablet within 2-3 days).

Salurates (Laziks) are introduced with moderate and severe gestosis after the restoration of the FED to 4-6 cm. Art. and the content of the total protein in the blood is at least 60 g / l, hyperifolding phenomena, less than 30 ml diuresis.

Important place in gestosis therapy belongs normalization of the rheological and coagulation properties of blood. For this purpose, disaggregants (Trental, Kuraltil) and Anticoagulants (Heparin, Fractional, Kleksan) are used.

In case of light gestosis, it is possible to prescribe disagrements (Trental, Kuraltil) inside, with moderate and severe, periodic infusions of these drugs with a break of 1-3 days amid the use of tableted forms. The duration of the application of disaggregants should be at least 3-4 weeks, under the control of indicators of the aggregation of blood cells.

Indications for the purpose of anticoagulants: reduction of endogenous heparin to 0.07-0.04 units / ml and below, antithrombin III - up to 85.0-60.0% and lower, chronometric and structural hypercoagulation (according to thromboelasticogram), improving aggregation Platelet induced by ADF, up to 60% and above, the appearance of fibrin / fibrinogen degradation products, D-dimer, congenital hemostasis defects. Preference should be given to low molecular weight preparations (fractioniparin, cracks). Heparin can be used in inhalations. It should not be prescribed during thrombocytopenia, pronounced hypertension (blood pressure 160/100 mm Hg. Art. And above), since under these conditions there is a threat of hemorrhage into the brain.

An important place in the complex therapy of gestosis belongs antioxidants and membranestabilizerscomprising polyunsaturated fatty acids. With a light, medium-wing gestosis and the normal state of the fetal, one of the antioxidants are prescribed: vitamin E (up to 600 mg / day for 3-4 weeks), ActoPine (600 mg / day), glutamic acid (1.5 g / day), ascorbic Acid (0.3 mg / day) with essential-forte or lipostabil. In case of light gestosis, prescribed inside Essence-Forte or Lipostabil (2 capsules 3-4 times a day), with moderate and severe, these preparations are administered intravenously (5-10 ml). If necessary, relatively rapidly increase the content of essential fatty acids in the membranes, in particular during the gestivity of moderate severity, the delay in the growth of the fetus to 32 weeks is advisable to use simultaneously with lipofundine antioxidants in 100 ml intravenously 2-3 times a week.

The complex therapy of gestosis is also aimed at the normalization of the uterine-placental blood circulation. Additionally, b-mimetics can be used for this purpose (Ginipral, Brikanil in individually portable doses).

If the treatment is effective, its duration is determined by the weight of gestosis, the state of the fetus. With light gestosis, treatment in the hospital should take at least 2 weeks, with moderate - 2-4 weeks, depending on the state of the fetus. Pregnant women can be written from the hospital with recommendations to continue anti-relapse therapy (phytosborg, antispasmodics, disagreganites, antioxidants, membranestabilizers). Treatment of extragnenital pathology is carried out according to the testimony before the delivery. With severe gestosis, despite the effectiveness of therapy, the patient is left in the hospital before the delivery. When the fetal growth is delayed, the reference tactics is determined by a number of factors. If the growth of the fetus corresponds to a gestational term, no chronic hypoxia, therapy gives effect, then pregnancy can be prolonged up to 36-38 weeks. When preserving the signs of gestosis, the absence of a fetal growth or with non-stop chronic hypoxia of the fetus, early delivery is necessary. The method of choice in this situation is a cesarean section, especially if the term of pregnancy does not exceed 35-36 weeks.

Treatment of heavy gestosis, preeclampsia and eclampsia It should be carried out in conjunction with resuscitative in the separation of intensive therapy in monitor observation of vital organs.

Treatment of heavy forms of gestosis often has to be carried out with small pregnancy (up to 30-32 weeks), when the delivery is associated with the birth of children with a very low and extremely low body weight. The purpose of treatment in this situation is pregnancy prolongation.

Treatment of pregnant women with ecloxia.

It is carried out in order to prepare for operational delivery by cesarean section.

The principles of the treatment of pregnant women, pupils and femalenits with heavy forms of gestosis are as follows:

1) relief and prevention of eclampsia attacks;

2) restoration of the function of vital organs, primarily the cardiovascular, central nervous and excretory systems.

At the moment of attack eclampsia Intravenously introduced magnesium sulfate (4-6 g

inkjano), then maintaining a dose - 2 g / h. At the same time, they shift the uterus to the left (roller under the right buttock), pressure on the pisteless cartilage is carried out, oxygenation is carried out. If the convulsive syndrome was not possible to stop, then additionally from 2 to 4 g of magnesium sulfate for 3 minutes, as well as 20 mg of diazepam intravenously, and in the absence of effect - general anesthetics, muscle relaxants with the translation of the patient on the IVL.

The translation into the IVL also implemented in respiratory failure and the absence of a patient's consciousness. Rhodework is carried out under general anesthesia.

In addition, the readings to the IVL are:

Complications of gestosis (hemorrhage to the brain, bleeding, aspiration with gastric content, swelling of the lungs);

Polyorgan deficiency.

With the normal function of respiratory, cardiovascular systems, after an attack of eclampsia, it is possible to rapidly under regional anesthesia, which, with severe gestosis, is both treatment, contributing to, in particular, a decrease in blood pressure.

Hypotensive and infusion therapy is carried out according to the same principles as in gestosis. With severe gestosis, infusion therapy should be controlled taking into account the monitoring data of central and peripheral hemodynamics, diurea, blood protein.

The advantage is given to crystalloids, high-molecular dextranum (infoCol), the introduction of which should warn tissue hyperflowing.

Pregnant treatment with eclampsia should quickly prepare it for operational delivery. Subsequently, hypotensive and infusion therapy continues, aimed at restoring the functions of vital organs.

With the ineffectiveness of the above therapy, discrete plasmapheresis and ultrafiltration of plasma are shown.

Plasmapheresis helps to stop the hemolysis, eliminating the DVS-syndrome, the elimination of hyperbilirubinemia.

Indications for ultrafiltration: post-eclampsic coma; brain swelling; non-coming pulmonary swelling; Anasarka.

Treatment of pregnant womenHellp.-Sintere. The complex includes:

Intensive preoperative preparation (infusion transfusion therapy).

Urgent abdominal delivery;

Replacement, hepatoprotective and immunosuppressant therapy;

Prevention of massive blood loss during surgery and in the postpartum period by correction of hemostasis;

Antibacterial therapy.

In pregnant and herds with Hellp-syndrome every 6 h, the number of erythrocytes and platelets, the content of the general protein and bilirubin, the prothrombin index, the AFTT, the time of blood coagulation by Lee-White, liver transaminases is determined.

The urgent abdominal delivery is carried out against the background of complex intensive therapy. Infusion-transfusion therapy is supplemented by the appointment of hepatoprotectors (10% glucose solution in combination with ascorbic acid at a dose of up to 10 g / day), replacement therapy - freshly frozen plasma plasma of at least 20 ml / (kg of day), transfusion of thromboconcentrate (at least 2 doses) platelet level 50x109 / l. In the absence of thromboconcentrate, it is permissible to introduce at least 4 doses of plasma enriched with platelets.

In order to further correlate the hemochaguance disorders in the preoperative period and intraoperatively intravenously, at least 750 mg of transamamine is imposed.

Indication for early delivery is medium-heavy predosis in the ineffectiveness of treatment within 7 days; Heavy gestosis, preeclampsia in case of unsuccessful intensive therapy for 2-6 hours; Gesters of any gravity in the delay in the growth of the fetus and the ineffectiveness of treatment; Eclampsia and its complications (comatose states, anouria, non-syndrome, hemorrhage in the brain, retinal detachment and hemorrhage into it, amavrosis, etc.).

Rhodework methods. Conducting birth.Indications for Cesarean section: severe forms of gestosis, including preeclampsia for therapy inefficiency for 2-6 hours, eclampsia and its complications, intrauterine growth delay and chronic fetal hypoxia. Cesarean section is carried out under endotracheal anesthesia or with regional anesthesia. The last kind of anesthesia is more appropriate.

Through the natural generic paths, the delivery is carried out under the availability of appropriate conditions (satisfactory condition of pregnant women, effective treatment, the absence of intrauterine suffering of the fetus according to ultrasound and cardiac research).

With unprepared generic pathways and the need for a delivery to improve the functional state of the uterus and preparation of the cervix to childbirth into the cervical canal or in the rear vaginal arch, prostaglandin gels are introduced or in the cervical canal of laminaria. With the prepared neck of the uterus, reception is carried out with the opening of the fetus bubble and the subsequent introduction of uterotonic means.

During childbirth, hypotensive infusion therapy is carried out, adequate anesthesia. The method of choice during gestosis is epidural anesthesia. Relationship or activation of generic activities during its weakness depends on the state of pregnant and fetus. With satisfactory condition, the introduction of uterotonic drugs is possible. With the deterioration of the condition: hypertension, the appearance of brain and symptoms of nausea, vomiting, hypoxia of the fetus) shows the operational delivery.

In the second period of birth, regional anesthesia continues, perineoyli episotomy is carried out. If regional anesthesia is impossible for regional anesthesia, gangliplockers or the impulse of obstetric tongs are shown. On the dead fruit perforation of the head perforation.

In the third period of childbirth, pregnant women with gestosis there is a threat of bleeding.

Comprehensive gestosis therapy should be carried out in the postpartum period before stabilizing the state of the parent.

Prevention of heavy forms of gestosis.Preventive measures at the preclinical stage are shown in patients with extragnenital pathology (metabolic syndrome, hypertension, kidney pathology, endocrinopathy, congenital hemostasis defects, combined extragenital pathology) and in previous pregnancies undergoing pregnancies.

Preventive measures to prevent gestosis in the risk group are beginning with 8-9 weeks of pregnancy with non-drug events. Assign " bed rest." , diet, conduct treatment of extragnenital pathology (according to indications). The energy value of the diet is not more than 3,000 kcal, the products of milk-plant and animal origin are recommended. Dishes must be boiled and moderately unfavorable. They exclude sharp and fried food, causing thirst. The amount of fluid is 1300-1500 ml / day. Pregnant women should receive vitamins in the form of herbal vitamin fees or in tablet form, antioxidants.

From 12-13 weeks in the preventive complex, herbs, possessing sedative properties (Valerian, dye), normalizing vascular tone (hawthorn) and kidney function (renal tea, birch kidneys, tolnicancan, leaf lover, deer, corn, etc. .), Hofitol with liver diseases. To eliminate potassium deficiency, calcium, magnesium uses drugs (Asparkamka, Panangin, Magne B 6), food products (raisins, kuraga, etc.).

If there are laboratory data on the change in hemostasis (hypercoagulation, signs of the engine), fractioniparine is used; With hypercoagulation in the cellular hemostasis, violation of the rheological properties of blood -

deangregants (Trental, Kuraltil).

Simultaneously, when activating the level of the floor, antioxidants are prescribed (vitamin E, tocopherol), membranestabilizers (Essentialy-Forte, Lipostabil, Rutin) for 3-4 weeks. With a satisfactory condition of pregnant and normal growth of the fetus, the normalization of hemostasis parameters, the floor level makes a break in the reception of drugs for 1-2 weeks. At the specified period, the use of phytosborns with the appointment of disagregantes and membranestabilizers under the control of laboratory data is possible to stabilize the state. If, despite the conduct of preventive measures, the early symptoms of gestosis appear in pregnant women, it is hospitalized. Phytosborg, disagrements and membranestabilizers are necessarily prescribed after extracting from the hospital during the remission of gestosis.

Gestosis (from Latin "- Estatio" - pregnancy) is a complication of physiologically occurring pregnancy, characterized by a deep disorder of the function of vital organs and systems, developing, as a rule, after 20 weeks of pregnancy. The classic triad symptoms are: increase hell, proteinuria, edema.

The basis of gestosis is a generalized spasm of vessels, hypovolemia, changes in the rheological and coagulation properties of blood, microcirculation disorders and water-salt metabolism. These changes cause tissue hypiperphous and develop dystrophy to necrosis.

Code of the ICD-10

The Russian Association of Gynecologists was decided to use the term "Gesters", in connection with this, in accordance with the name of the disease on the ICD with the proposed definition (Table 31-2).

Table 31-2. MKB-10 and classification offered by the Russian Acouver Gynecologists Association

MKB-10.	Classification of the Russian Association of Gynecologists
O11 existed earlier AG with the joined proteinuria	Combined Gesters *
O12.0, o112.1, o12.2 caused by pregnancy edema with proteinuria	Otkiproteinuria pregnant women *
O13 caused by Maternity AG without significant proteinuria. Light preeclampsia (nephropathy easy)	Light degree
O14 caused by a pregnancy ag with significant proteinuria	Gestosis *
O14.0 Preeclampsia (nephropathy) of moderate severity	Gesters of moderate severity *
O14.1 Heavy preeclampsia	Severe degree *
O14.9 Preeclampsia (Nephropathy) Uncomfortable	Preeclampsia
O15 Eclampsia	Eclampsia
O15.0 eclampsia during pregnancy	Eclampsia during pregnancy
O15.1 Eclampsia in childbirth	Eclampsia in childbirth
O15.2 Eclampsia in the postpartum period	Eclampsia in the postpartum period
O15.3 Eclampsia, not specified by time	Eclampsia, unsuccessful
O16 AG from Mother Uncomfortable	AG Mother Uncomfortable
O16.1 Transient AG during pregnancy	Transient ag during pregnancy

* The severity of gestosis is determined by the score scale (see below).

EPIDEMIOLOGY

The frequency of gestosis varies widely (3-21%).

Classification of gestosis

Classification includes several forms of gestosis.

Gesters of varying severity:
- easy degree [up to 7 points on the scale of G.M. Savelieva (Table 31-3)];
- moderate (8-11 points);
- severe degree (12 points or more).
Preeclampsia.
Eclampsia.

For timely diagnosis of diseases, the preclinical stage of gestosis is distinguished, the so-called Prophestosis.

Depending on the background states there is a division into "clean" and "combined" gestosis. The "pure" gestosis consider the one that occurs in pregnant women with non-declared extragenital diseases. More often (in 70-80% of pregnant women) are observed with combined gestosis, developing against the background of the preceding disease. Gessel glances in pregnant women with hypertension, kidney disease, liver, endocrinople, metabolic syndrome are most adversely. Such a division is in a certain extent conditionally, since often extragenital diseases are hidden (for example, latent flow of pyelonephritis, congenital hemostasis defects).

Table 31-3. Estimation of gravity of pregnant gestosis in points

Symptoms	Point
	0	1	2	3
Otki.	Not	On the legs or pathological increase in body weight	On the legs, anterior abdominal wall	Generalized
Proteinuria	Not	0,033-0.132 g / l	0.132-1 g / l	1 g / l and more
Systolic hell	Below 130 mm Hg.st.	130-150 mm Hg.	150-170 mm Hg.st.	170 mm Hg.st. and higher
Diastolic hell	Up to 85 mm Hg.	85-95 mm Hg.st.	90-110 mm Hg.st.	110 mm Hg.st. and higher
The term of the appearance of gestosis	Not	36-40 weeks or in childbirth	35-30 weeks	24-30 weeks and earlier
Sip	Not	Not	Lag for 1-2 weeks	Loge for 3-4 weeks and more
Background disease	Not	Manifestation of disease before pregnancy	Disease manifestation during pregnancy	Disease manifestation before and during pregnancy

The total number of points taking into account all the criteria at a light degree of gestosis is less than 7, with an average - 8-11, with heavy - 12 or more.

To determine the severity of gestosis there is a scale, modified by G.M. Savelieva et al. (Table 31-3).

Etiology and pathogenesis of gestosis

Currently, as at the beginning of the XX century, Gesstoz remains theories disease. According to modern ideas, guest stations are considered as genetically deterministic insufficiency of the processes of adaptation of the parent organism to new conditions of existence, which arise with the development of pregnancy. Each separately taken theory cannot explain the variety of clinical manifestations, but objectively recorded deviations confirm the pathogenesis of changes occurring during pre-priest.

There are a number of the theories of the pathogenesis of gestosis of pregnant women (neurogenic, hormonal, immunological, placental, genetic). On the example of gestosis, the development of theories can be traced and the transition of them from the organ level of the interpretation of the etiology of the disease (neurogenic, hormonal, renal) to cellular and molecular (genetic, immunological, etc.).

Currently, it is believed that the basics of gestosis are laid at the time of the migration of the cytotrofoblast. There is a braking of the migration of the trophoblast in the spiral artery of the uterus, i.e. Insufficiency of the second wave of invasion of the cytotrofoblast. The mechanisms of this complex process, with a violation of which immunological, genetic, hemostatic factors are intertwined, not fully known.

Possible factors that reduce the invasive ability of the Trofoblast, consider the relationship between humoral and transplant immunity on the one hand and immunological tolerance - on the other; Mutations of genes responsible for the synthesis of compounds regulating the tone of vessels (cytokines, integrins, angiotensin II); The blockade of fibrinolysis inhibitors.

With the defective invasion of the cytotrofoblast, the uterine arteries are not subjected to morphological changes characteristic of pregnancy, i.e. There is no transformation of their muscular layer. These morphological features of the spiral vessels of the uterus as pregnancy progressing is predisted to their spasm, a decrease in intervalic blood flow and hypoxia. Hypoxia developing in placental tissue helps to activate the factors leading to a violation of the structure and functions of the endothelium or a decrease in compounds that protect endotheliums from damage.

In this case, the endothelium dysfunction contributes: activation of lipid peroxidation, increasing phospholipase activity (F2), circulating neurogormones (endothelin, acetylcholine, catecholamines), thrombooxane, decrease in the activity of the inhibitor of protease α2-macroglobulin, the presence of innate hemostasis defects, homocysteinemia, etc.

Changes to endothelium during prestal is specific. A peculiar endotheliosis is developing, which is expressed in swelling of cytoplasm with fibrin deposition around the basal membrane and inside the swollen endothelial cytoplasm. Endotheliosis is initially local in the vessels of placenta and uterus, then becomes organic and applies to the kidneys, liver and other organs.

Endothelial dysfunction leads to a number of changes that determine the clinical picture of the gestosis.

With the defeat of the endothelium, the synthesis of vasodilators (prostacycline, bradykinin, endothelial relaxing factor - NO) is blocked, as a result of which endothelium-dependent dilatation is disturbed.
With the defeat of the endothelium in the early stages of the disease, the muscular-elastic membrane of vessels with the receptors located in it are exposed to vasoconstrictors, which leads to an increase in the sensitivity of the vessels to vasoactive substances.
Decreased tromborette properties of vessels. Damage to the endothelium reduces its antithrombotic potential due to a violation of the synthesis of thromboduodulin, plasminogen tissue activator, increase the aggregation of platelets, followed by the development of the chronic form of the DVS syndrome.
Inflammation factors are activated, peroxidant radicals, tumor necrosis factors, which in turn further disrupt the endothelium structure.
Vascular permeability increases. The defeat of the endothelium along with the change in the synthesis of aldosterone and the delay in response to this sodium and water in cells, developing hypoproteinemia contributes to the pathological permeability of the vascular wall and the exit of the fluid from the vessels. As a result, additional conditions are created for a generalized spasm of vessels, ag, ethnic syndrome.

Developing the endothelium dysfunction and changes caused by it lead to violation of all microcirculation links (Fig. 31-1).

Fig. 31-1. Scheme of microcirculation disorders during gestosis.

Against the background of the progression of spasm of vessels, hypercoagulation, increasing the aggregation of erythrocytes and platelets and, accordingly, an increase in blood viscosity is formed by a complex of microcirculatory disorders, leading to hypoperfusion of vital organs (liver, kidneys, placenta, brain, etc.).

Along with the vessels of the vessels, a violation of the rheological and coagulation properties of blood in the development of organic hypoperfusion, changes in macrohereodynamics play, a decrease in the volumetric indicators of central hemodynamics: the shock volume, the minute volume of the heart, the BCC, which are significantly less than those in the physiological course of pregnancy. Low values \u200b\u200bof the BCC under prestosis are due to both amazeled vasoconstriction and a decrease in the volume of the vascular bed and the increased permeability of the vascular wall and the exit of the liquid part of the blood in the tissue. At the same time, there is an imbalance of the colloid-osmotic pressure of plasma and tissues surrounding the vessels, which is due, on the one hand, hypoproteinemia, and on the other hand, sodium delay in tissues and increase their hydrophilicity on one side. As a result, pregnant women with gestosis formed a characteristic paradoxical combination - hypovolemia and a delay in a large amount of fluid (up to 15.8-16.6 liters) in an interstitation, aggravating the violation of microhemodynamics.

Distrophic changes in the tissues of vital organs are largely formed due to the violation of the matrix and barrier functions of cell membranes. Changes in the matrix function of the membranes are to deviate the mechanism of action of various membrane proteins (transport, enzyme, receptors of AT hormone and proteins associated with immunity), which leads to a change in the functions of cellular structures.

The violation of the barrier function of the lipid bilayer membranes leads to a change in the functioning of channels for Ca2 + ions. The massive transition of Ca2 + ions into the cell causes irreversible changes, energy hunger and death, on the one hand, and on the other - the muscular contracture and spasm of the vessels. Perhaps the eclampsia is due to a violation of the permeability of membranes and the massive movement of Ca2 + ions into the cell ("Calcium paradox").

This is confirmed by this fact that in the M - 2+ experiment, being an antagonist CA2 +, prevents the development of this process. As you know, in pregnant women with eclampsia M-2+ has an anticipant action.

As gestosis progresses, necrosis caused by hypoxic changes are developing in the tissues of vital organs.

Gestosis, especially a hard degree, is almost always accompanied by a serious impairment of kidney functions.

Pathological changes associated with gestosis are mostly distributed to the tubular apparatus (the picture of glomerular-capillary endotheliosis), which is reflected in the dystrophy of the convinced tubules with a possible desquamation and the decay of the kidney epithelium cells. Focal and finely purified hemorrhages are observed (from single to multiple) under the kidney capsule, in a parenchyma - mainly in the intermediary zone, rarely in the brain layer, as well as in the mucous membrane of cups and loyal.

Changes in the liver are presented by parenchymal and fatty dystrophy of hepatocytes, necrosis and hemorrhages. Necrosis can be like focal, so extensive. The hemorrhages are more often multiple, different magnitudes, due to them there is a surge of the liver capsule up to its rupture.

Functional and structural changes of the brain in pre-prostose varies widely. They are due to disruption of microcirculation, the formation of thrombosis in vessels with the development of dystrophic changes in nerve cells and perivascular necrosis. It is characteristic (especially with severe gestosis) the head of the brain with an increase in intracranial pressure. A set of ischemic changes in the end may cause an attack of eclampsia.

During pregnant women, pregnant changes in the placenta are observed: obliterating endarteritic, the edema of stromas, vessel thrombosis, and intervalic space, necrosis of individual vascular, hemorrhage, fat rebirth of placental fabric. These changes lead to a decrease in the uterine-placental blood flow, infusion and transfusion insufficiency of placenta, SPP, chronic hypoxia.

Clinical picture (symptoms) of gestosis

Preclinical stage.

For timely diagnosis of diseases, it is important to identify the preclinical stage of gestosis (previously called "Protezoz"), which is manifested by a complex of changes found on the basis of laboratory and additional research methods. Changes may appear from 13-15 weeks of pregnancy. The earliest symptom of gestosis - swelling.

Gestosis.

For classical gestosis, a triad of symptoms is characterized: edema (explicit or hidden), ag, proteinuria.

However, only two symptoms in different combinations are often celebrated. In case of severe gestosis, the classic triad is observed in 95.1% of cases.

AG is an important clinical sign of gestosis, as it reflects the severity of angiospasm. The initial blood pressure is important. About aga pregnant women shows an increase in systolic blood pressure by 30 mm Hg. from the initial, and diastolic - by 15 mm Hg. and higher. Of particular importance is the increase in diastolic blood pressure and a decrease in the pulse, equal to normal on average 40 mm Hg. A significant reduction in the latter indicates a pronounced arteriole spa and in prognostic plan is an unfavorable symptom.

An increase in diastolic blood pressure is directly proportional to a decrease in placental blood flow and an increase in perinatal morbidity and PS. Even a minor increase in systolic blood pressure with high diastolic and low pulse should be considered as a prognostically unfavorable indicator.

Heavy consequences in pre-priest (bleeding, PRRP, the antenatal fetal death) are sometimes due to high blood pressure, and its sharp fluctuations.

Proteinuria (the appearance of protein in the urine) is an important diagnostic and prognostic sign of gestosis. Useful screening tool - verification of urine samples test strip on protein. Changing the test with a negative on a positive is considered a warning symptom. The progressive increase in proteinuria testifies to the deterioration of the course of the disease. The selection of protein with urine during gestosis usually flows without the appearance of urine precipitate characteristic of kidney diseases (erythrocytes, wax cylinders, leukocytes).

Simultaneously with the development of the triads of symptoms, diuresis reduces pregnant women. The daily amount of urine is reduced to 400-600 ml and below. The less urine stands out, the worse the forecast of the disease. Unregistered Oliguria may indicate renal failure.

In addition to these symptoms, the condition of pregnant women and the outcome of pregnancy is determined by additional factors: the duration of the disease, the presence of placental insufficiency, the SIR, the extragnenital pathology, against which prissta develops. Both the main symptoms and additional allow us to estimate the severity of gestosis (see Table 31-3). Palkal assessment may vary against the background of therapy.

Preeclampsia is a short-term interval before developing seizures (eclampsia). It is characterized by a violation of the function of vital organs with preferably damage to the central nervous system.

On preeclampsia may indicate the appearance against the background of the symptoms of the gestosis of one or two of the following symptoms:

Heaviness in the back of the head and / or headache;
violation of vision (weakening, appearance of "pellets" or "fog" before the eyes, flickering "flies" or "sparks");
nausea, vomiting, pain in the epigastric region or in the right hypochondrium;
insomnia or drowsiness; Memory disorder; Irritability, lethargy, indifference to the surrounding.

These symptoms can be both central genes and caused by the defeat of the body responsible for the clinical picture of the disease.

Preeclampsia implies a constant danger of seizures (eclampsia). It can pass several days or a few hours, even minutes, and under the influence of various stimuli, seizures begin.

The criteria of the severity of the state of pregnant women during gestosis and the most likely to develop eclampsia are the following signs:

An increase in systolic blood pressure (160 mm Hg and above);
an increase in diastolic blood pressure (110 mm Hg and above);
proteinuria (up to 5 g per day or more);
oliguria (urine volume per day less than 400 ml);
Brain and visual disorders;
dyspeptic phenomena;
thrombocytopenia, hypocoagulation;
Violation of liver functions.

The presence of at least one of these features is evidenced by a serious condition of pregnant and about the possibility of developing eclampsia.

Eclampsia (from Greek. Eklampsis - flash, ignition, fire) is a heavy stage of gestosis characterized by a complex symptom complex. They distinguish the eclampsia of pregnant women, eclampsia of the feminine, eclampsia of the porms.

The most typical symptom is the attacks of the convulsion of the cross-striped muscles of the whole body, which are more often developing against the background of the symptoms of heavy gestosis and preeclampsia. However, in 30% of cases, Eclampsia is developing unforeseen. This is especially characteristic of eclampsia during childbirth or in the postpartum period, when the slightly pronounced symptoms of gestosis do not take into account and do not conduct adequate events.

A typical seizures of convulsion continues on average for 1-2 minutes and consists of four consistently connected moments.

The first point is the introductory, characterized by small fibrillar fibrils of the face muscles, eyelids. The introductory period lasts about 30 s.

The second point is a period of tonic convulsions - the Tetanus of all body muscles, including respiratory muscles.

The patient during the seizure does not breathe - cyanosis increases rapidly. Despite the fact that this period lasts only 10-20 s, it is the most dangerous. A sudden death may come, most often from blood hemorrhage.

The third moment is a period of clonic convulsion. Motionlessly lying before, stretching into a string, the patient begins to beat in continuously following each other clonic cramps spreading from the body from top to bottom. The patient does not breathe, the pulse does not feel. Gradually, convulsions become stronger and weak and, finally, stop. The patient makes a deep noisy breath, accompanied by snoring, turning into a deep rare breathing. The duration of this period is from 30 ° C to 1.5 minutes, and sometimes more.

The fourth moment is the resolution of the seizure. A foam painted with blood is distinguished from the mouth, the face is gradually pose. Begins to take care of the pulse. Pupils are gradually narrowed.

After the seizure it is possible to restore consciousness or comatose state. The patient lies unconscious, breathing loudly. This state may soon pass. The patient comes into consciousness, not remembering anything about what happened, complains of headache and overall basis. Coma is more determined by the brain's edema. If the deep coma continues for hours, days, then the forecast is considered unfavorable, even if the seizures are stopped.

When intracranial hemorrhages, due to the break vessels, the disease prediction deteriorates.

Additionally worsen the forecast of hyperthermia, tachycardia (especially at normal body temperature), motor anxiety, jaundice, non-coordinated movements of eyeballs, oliguria.

A very rare and extremely heavy form of eclampsia is dismissed, for which a peculiar clinical picture is characterized: Pregnant is complaining of severe headache, darkness in the eyes. Suddenly, complete blindness (amavricosis) may come, and the patient falls into a comatose state with high blood pressure. Very often the incomplete form of eclampsia is associated with hemorrhage in the brain. Especially dangerous hemorrhage in the stem portion of the brain, leading to a fatal outcome.

In gestosis, specific liver changes are developed combined in Hellp syndrome. With severe nephropathy and eclampsia, this syndrome develops in 4-12% of cases and is characterized by high MS and PS.

One of the cardinal symptoms of nonll-syndrome - hemolysis (microangiopathic hemolytic anemia) is characterized by the presence of crossed and deformed erythrocytes in the blood, their destroyed fragments (schistocytes) and polychromasia. In the destruction of red blood cells, phospholipids are released, leading to permanent intravascular coagulation (chronic DVS syndrome). The increase in the level of liver enzymes with a nonll-syndrome is caused by the blockade of blood flow in intraverter sinusoids due to the deposits of fibrin in them, which leads to the degeneration of liver cells. When obstruction of blood flow and dystrophic changes in hepatocytes, the glisson capsule occurs, accompanied by typical complaints (pain in the right of hypochondrium and epigastria). Increased intravenous pressure can lead to subcapsular hematoma of the liver, which can be broken at the slightest mechanical damage (increase in intra-abdominal pressure during the delivery through the natural generic paths, the use of the presidor method).

Thrombocytopenia (less than 100 × 109 / l) is caused by the depletion of platelets due to the formation of microtrombov against the violation of the vascular endothelium. In the development of nonLLP syndrome, autoimmune reactions are important. The stages of the disease are presented as follows: autoimmune defeat of the endothelium, hypovolemia with blood thickening, the formation of microtrombov with subsequent fibrinolysis. Nellp syndrome, as a rule, arises in the third trimester of pregnancy, more often under a period of 35 weeks. Such signs like thrombocytopenia and violation of the liver function reaches a maximum 24-28 hours after the delivery.

The clinical picture of nonllp syndrome is manifested by aggressive flow and rapid growth of symptoms.

The initial manifestations are nonspecific and include headache, fatigue, malaise, nausea and vomiting, diffuse or localized pain in the right hypochondrium. The most characteristic of jaundice, vomiting with blood impurity, hemorrhage in injections, increasing liver failure, convulsions and pronounced coma. Often there is a gap of the liver with bleeding into the abdominal cavity. In the postpartum period, due to violation of the coagulation system, profuse uterine bleeding can be.

Complications of gestosis:

Employed edema as a result of shock light or incorrectly conducted infusion therapy;
OPN due to the channel and cortical necrosis, hemorrhages;
brain coma;
hemorrhages in adrenal glands and other vital organs;
PRRP;
Placental insufficiency, chronic hypoxia, antenatal fetal death.

Diagnosis of gestosis

Preclinical Stage

The most objective changes in the pre-concentration stage include a decrease in the number of platelets during pregnancy, hypercoagulation in the cellular and plasma hemostasis link, a decrease in the level of anticoagulants (endogenous heparin, antithrombin-III), lymphopinge, increasing the level of plasma fibronectin and decrease in α2 microglobulin - endothelium damage markers; According to Dopplerometry - a decrease in blood flow in the arcate arteries of the uterus. The preclinical stage of gestosis is evidenced by the presence of 2-3 markers.

Gestosis

The diagnosis of gestosis is to identify its characteristic symptoms: edema, ag, proteinuria.

The diagnosis of explicit enemy does not represent difficulties. It is based on detecting edema during pregnancy, independent of extragenital diseases. To correctly estimate the edema of the water of pregnant women, it is necessary to exclude diseases of the cardiovascular system and kidneys, at which fluid delay in the body is also possible.

About hidden eath testifies:

Pathological (300 g and more than a week) or uneven weekly increase in body weight;
Reducing daily diurus to 900 ml and less under normal water load;
Niktric;
Positive "Ring Symptom" (ring, which is usually carried on an average or unnamed finger, have to wear a little finger).

To properly assess the degree of AG, it is advisable to take into account the mean AD, which is calculated by the formula:
Average hell \u003d (adsist + 2addiast) / 3

Normally, the average blood pressure is 90-100 mm Hg, AG is diagnosed at the level of medium blood pressure, above 100 mm Hg.

The most optimal method for determining the level of AG is the daily monitoring of blood pressure, in which the blood pressure is measured by a special device for 24 hours.

At the same time, the values \u200b\u200bof day, night and average-daeous blood pressure are determined, the daily profile of blood pressure, mean blood pressure, pulse blood pressure, the time-time index (percentage of time, when the blood pressure values \u200b\u200bwere higher than the threshold values), the VOL variability. These indicators are used to diagnose hypertension, border aging, exceptions of the "White Kolatta hypertension", determining the effectiveness of antihypertensive therapy.

In clinical practice, the classification of the degree of hypertension is used according to the daily monitoring of blood pressure: if the percentage of increased adhesion is less than 25%, then they are talking about the labile ag (all the time monitoring is taken for 100%); If 25-50%, then hypertension is considered stable. The heavy ag diagnose if the hell was increased over 50% of the monitoring time. There are assumptions that the lack of an adequate reduction in night blood pressure (below 10% of the average daily) may indicate transitions.

Proteinuria is determined by protein content in daily urine.

Eclampsia

As a rule, the recognition of the eclampsia difficulties does not represent.

Laboratory and Instrumental Studies

During the diagnosis of the disease, it is necessary to study the coagulation properties of blood, the number of blood cells, HT, liver enzymes, biochemical analysis of blood, total and biochemical analysis of urine, diurea, measuring blood pressure in the dynamics on both hands, control over body weight, concentration function of the kidneys, the state of the eye don .

It is advisable to carry out ultrasound, including the blood flow dopplerometry in the vessels of the mother-placental-fruit system.

In pregnant women, whose pre-20 weeks of gestation appears, especially those who have a history of perinatal losses or heavy presets, it is advisable to explore the blood for congenital hemostasis defects.

Differential diagnosis

It is necessary to carry out a differential diagnosis of eclampsia with epilepsy and uremia, some brain diseases (meningitis, brain tumors, solid cerebral sinus thrombosis, hemorrhage). The epilepsy is evidenced by the anamnestic data, normal urine tests, the absence of increased blood pressure, epileptic aura and epileptic cry before the seizure.

Indications for consultation of other specialists

Consultative inspections of the therapist, nephrologist, neuropathologist, oculist are needed. The violation of the brain circulation during gestosis is usually reflected in an ophthalmoscopic picture in the study of the eye dna in the form of a spasm of the arteri of the retina (angiopathy), leading to the rift circulatory disorder and the recipillary edema. If, along with a significant and resistant spasm of the retinal vessels on its periphery, solidity and dark stripes are determined, this indicates a high risk of retinal detachment.

Treatment of gestosis during pregnancy

Treats of treatment

The purpose of treating gestosis is the restoration of the functions of vital organs and the fetoplacentar system, elimination of symptoms and preventing the severity of gestosis, prevention of cramps, optimal delivery. The "gold standard" is intravenous administration of magnesia in the necessary quantities, depending on the severity of the disease, OSMO-oncotherapy, taking into account the deficit of protein and the BCC.

Indications for hospitalization

With edema of the I degree, therapy is possible in female consultations. With edema of II-IV degree, gestosis of light and moderate severity, pregnant women are hospitalized and treatment is carried out in a hospital. Pregnant women with severe degree, preeclampsia, eclampsia is advisable to hospitalize in perinatal centers or hospitals of multidisciplinary hospitals, having a resuscitation department and a department for having premature babies. In case of severe gestosis, preeclampsia and eclampsia, therapy begins from the moment when the doctor first saw a pregnant (at home, at the time of transportation, in the receiving department of the medical hospital).

Therapy is advisable to implement together with a resuscitator anesthesiologist. Treatment should be pathogenetically reasonable and depend on the severity of gestosis. The tactics of the doctor during pretzos is aimed at restoring the function of vital organs, timely delivery.

Non-media treatment

Special attention in the treatment of pregnant women with prestitosis should be given a diet (food enriched with protein, without salt abuse) and water regime, taking into account the diuresis and daily weight gain. With an increase in body weight in the range of 400-500 g per week and more appropriate to assign unloading days (no more than 1 time in 7 days), when only low-fat fish or meat is included in the diet (up to 200 g), low-fat cottage cheese (200 g), Apples (up to 600 g), 200 ml of kefir or other liquid.

Medicia treatment

Important importance in complex therapy is given to normalization of the CNS function, a decrease in central and reflex hyperactivity. For this purpose, various psychotropic drugs are prescribed. The concept of the hospital formulated by the Russian obstetrician V.V. Stroganov still at the end of the last century (1899), relevant and currently. Under the gestosas of light and moderate severity, preference should be given to various phytosborators with a sedative effect (Valerian extract for 2 tables. 3 times a day, a dye tincture of 0.5 tablespoons 3 times a day, a decoction of sedative herbal fees of 30.0 ml 3-4 times a day).

Pregnant with the labile nervous system, insomnia is possible to assign diazepama.

In the treatment of gestosis, follow the following provisions should be followed:

Normalization of osmotic and oncotic pressure;
Impact on the CNS in order to create a medical and security regime;
removal of the generalized spasm of the vessels;
normalization of vascular permeability, liquidation of hypovolemia;
improving blood flow in the kidneys and stimulation of their urinary function;
regulation of water and salt metabolism;
Normalization of metabolism;
normalization of the rheological and coagulation properties of blood;
antioxidant therapy;
carrying out the prevention and treatment of intrauterine hypoxia and hypotrophy of the fetus;
Preventing the weighing of gestosis by the timely gentle browser;
conducting birth with adequate anesthesia, early amniotomy, the use of managed normony (short-acting gangliblockers) or the impression of obstetric tongs in the second period of birth;
carrying out the prevention of bleeding and coagulation disorders in childbirth and early postpartum period;
Treatment of gestosis in the postpartum period.

The pathogenetically substantiated gold standard of gestosis therapy is considered to be Osmonkotherapy, which includes intravenous administration of magnesium sulfate (dose and method of administration, see below), hydroxyethyl starch and protein solutions (albumin, freshly frozen plasma). Complement to therapy with hypotensive drugs (central and peripheral antispasmodics, β-adrenoblays, block plates of slow calcium channels, gangliplockers, etc.). We also conduct therapy aimed at eliminating vascular disorders, hypovolemia, chronic DVS-syndrome, normalization of water-electrolyte, protein, carbohydrate metabolism, bloodstone, uterine-placental blood flow, etc.

Magnesium sulfate was currently widely distributed in the treatment of gestosis. In addition to the light narcotic effect, magnesium sulfate has a diuretic, hypotensive, anticonvulsant, antispasmodic effect and reduces intracranial pressure. It has a weak hypotensive effect, however, despite this, its effectiveness in gestosis is obvious. Magnesium sulfate is a moderately generalized vasodilator - inhibits the CNS, as well as excitability and reduction of smooth muscles, reduces the content of intracellular calcium, suppresses the release of acetylcholine by nerve endings, inhibits the selection of catecholamines. The drug eliminates the spasm of cerebral and renal vessels, improves uterine blood flow.

The therapeutic level of the drug in the blood plasma ranges from 4 to 8 MEKV / L, and toxic effects effect at a concentration of 10 MEKV / L (Table 31-4). The introduction of magnesium sulfate is temporarily stopped if diuresis is less than 30 ml / h.

Table 31-4. Magnesium Sulfate Therapy Effects

Preferably, the intravenous administration of magnesium sulfate by infusomat, which leads to a more rapid onset of therapy effects and the absence of complications associated with its intramuscular administration. The dose of the drug is determined by the initial level of blood pressure and body weight of pregnant. The following doses of magnesium sulfate per day (dry matter in grams) are admissible.

With gestosis of light degree - up to 12 g;
With gestosis of the average degree - up to 18 g;
in gestivity of a heavy degree and preeclampsia - 25 g;

During the first 20 minutes, 2-4 g. The supporting dose of administration of magnesium sulfate is 1-2 g / hour, depending on the severity of the treatment of gestosis. The accuracy of the dosing and the rhythm of administration reaches due to the use of infusomat *.

* Toxic influence of magnesium sulfate can be the result of either absolute overdose, or long-term infusion while reducing the kidney function.

The overdose of magnesium sulfate can be accompanied by respiratory and / or CH, a decrease in the excretory function of the kidneys and tendon reflexes. The antidote of magnesium sulfate is calcium, which should be administered at the first symptoms of an overdose, therefore, during overdose, intravenously, 10 ml of a 10% calcium solution of gluconate and give oxygen, is slowly injected. In the absence of the effect of restoring the function of the lungs go to the IVL.

Hypotensive therapy. The normalization of microdynamics in pregnant women with gestosis is achieved by the appointment of hypotensive drugs. Many effective anti-generation anti-generation hypotensive drugs are contraindicated during pregnancy (for example, an angiotensin surgery enzyme inhibitors). In connection with this, pregnant women continue to prescribe ineffective drugs that do not have an impact on the state of the fetus, for example spasmolytic.

Currently, there are no clear criteria for both hypotensive therapy and its choice.

A differentiated approach to hypotensive therapy should be followed depending on the nature of hypertension (hypertension, prestosis).

In gestosis, hypotensive preparations are prescribed with systolic blood pressure, exceeding the original to pregnancy by 30 mm Hg, and with diastolic, exceeding the initial 15 mm Hg.

In gestosis, the lung and moderate is carried out by monotherapy, with a difficult degree - complex.

Hypotensive drugs should be applied under the control of daily monitoring of blood pressure and hemodynamic indicators, focusing on which it is possible to choose an individual dose and a type of medicine.

With an insufficient hypotensive effect of therapy with magnesium sulfate, it is advisable to appreciate the stimulants of central adrenoreceptors (clonidine, methyldop), cardio selective β-adrenoblockers (atenolol, metoprolol, nebivolol) or block plants of slow calcium channels (nifedipine).

Currently, discussions are underway on the effect of β-adrenoblockers on the state of the fetus. There are guidance on the fact that they contribute to the development of the SIR. However, the results of the research conducted do not confirm this.

Need careful monitoring of the blood pressure. At the same time, magnesium sulfate and blockers of slow calcium channels (nifedipine) are not prescribed because there is a sharp hypotension.

The choice of hypotensive drugs is essential in pregnant women, in whom States developed against the background of hypertension, as a result of which they are forced to take long-term drugs. In this case, most preferably the purpose of one of the following groups of drugs:

Selective β-adrenoblays (atenolol, metoprolol, nebivolol) under the control of the state of the fetus;
Blockers of slow calcium channels (nifedipine, including prolonged action);
α- and β-adrenoblays (labetalol);
α2-adrenomimetics (methyldop, clonidine).

The most studied drugs that do not have a negative impact on the state of the fetus - methyldop, clonidine.

When appropriating hypotensive drugs, it should be remembered that they, having favorably affecting the mother, may not lead to a significant improvement in the state of the fetus, since in conditions of excessive decrease in blood flow, the uterine-placental blood flow is possible.

Infusion therapy. One of the leading places in the pathogenetic therapy of gestosis belongs to infusion therapy (component of Osmoncotherapy), the purpose of which is the normalization of the BCC, the colloid-osmotic pressure of the plasma, the rheological and coagulation properties of blood, macro- and microhereodynamics.

The testimony for infusion therapy is the gestosis of a light degree in the presence of recessive, gestosis of the average and heavy degree, preeclampsia and eclampsia, the PRE, regardless of the severity of the disease. Infusion therapy is carried out under the control of HT, the decrease in which below 27% indicates hemodilution, an increase of up to 45% and more - about hemokoncentration (0.27-0.35 g / l); FOLD (2-3 cm Vod.st.), proteinhemia (at least 50 g / l), central hemodynamic states (blood pressure, pulse), diuresis (at least 50 ml / hour), hemostasis indicators (APTTV, prothrombin index, fibrinogen , D dimer - within the norm), activity of liver transaminases (within the physiological norm), bilirubin concentrations (within the physiological norm), the state of the fundus.

In order to normalize the oncotic pressure and treatment of hypoproteinemia, intravenous drip administration of blood substitutes or blood components (400 ml of hydroxyethyl stroke solution, 200-250 ml of a single-logular fresh frozen plasma or a 10-20% albumin solution is prescribed.

Basic therapy gestosis (oncoosotherapy)

Healing and components:

Hydroxyethyl starch;
albumen;
Freshly frozen plasma.

Currently, preference is preferred to combat hypovolemia and microcirculation disorders, which is able to bind and hold water from an interstitial space into intravascular.

The composition of infusion therapy includes both colloids and crystalloids. From colloids, a fresh frozen plasma is used in violation of hemostasis (12-15 ml / kg), a 6% hydroxyethyl starch solution (130 / 0.4) [molecular weight], from crystalloids - Ringer's solution, 0.9% sodium chloride solution. The ratio of colloids and crystalloids, the volume of infusion therapy is determined primarily by the content of protein in the blood, diuresis (Fig. 31-2).

Fig. 31-2. The volume and composition of infusion therapy in gestosis.

With gestoses, it is necessary to refrain from the introduction of large volumes of fluid, as it is possible to develop hyperifolding and edema of the lungs. Under the gestoses of light and moderate severity, the volume of infusion therapy is 500 ml (maximum - 800 ml), with heavy gestoses, the volume of infusion therapy should not exceed 700-900 ml (1000-1200 ml).

Starting infusion therapy, it is possible to introduce solutions into a peripheral vein, since the catheterization of the central vein is fraught with heavy complications. In the absence of an effect on the therapy (if diuresis is not restored), you can produce the catheterization of the metering vein to determine the CCD and the further administration of solutions.

With infusion therapy, the rate of fluid introduction and the ratio of it with diuresis is important. At the beginning of the infusion, the volume of solutions is 2-3 times higher than hourly diuresis, subsequently against the background or at the end of the fluid administration, the amount of urine should exceed the volume of the injected fluid by 1.5-2 times.

The normalization of the water and salt metabolism reaches the recovery of the diurea, for which during gestosis of the light and moderate severity in the absence of the effect from the bed mode, diurendic phytosborgs are prescribed (kidney tea, birch kidneys, tolnican leaves, lingonberry, cornframes, grass of the field, flowers of blue ), but in the absence of the effect of the last - potassium-saving diuretics (triamteren).

Loop diuretics (furosemide) are prescribed when restoring the FLOD to 4-6 cm water. and the content of the total protein in the blood is at least 50 g / l, hyperfedration phenomena, diuresis less than 30 ml / hour. With a forced diuresis, hyponatremia is possible, against the background of which the stupor, fever, chaotic limbs developing. Hypologiamia may develop, causing heavy arrhythmias.

Deangregants and anticoagulants. An important place in gestosis therapy belongs to the normalization of the rheological and coagulation properties of blood. For this purpose, disaggregants (pentoxifylin, dipyridamol) and anticoagulants are prescribed (sodium heparin, ozroparin calcium, sodium enocaperin). Deagregants are used under the control of indicators of platelets and red blood cells aggregation.

When lighting gestosis, tableted disagrements (pentoxifillin, dipyridamol) are prescribed, with an average and heavy degree - their periodic infusions with a break of 1-3 days amid the use of tableted preparations. The duration of the application of disaggregants should be at least 3-4 weeks.

Indications for the purpose of anticoagulant - a decrease in endogenous heparin to 0.07-0.04 units / ml and below, antithrombin-III to 85-60% and lower, chronometric and structural hypercoagulation (according to thromboelastogram), the appearance of fibrin / fibrinogen degradation products, D-dimers, innate hemostasis defects. Currently, preference should be given to low molecular weight drugs (sodium ozroparin, euxaparine sodium). Sodium heparin can be used by inhalation; It should not be prescribed during thrombocytopenia, pronounced ag (AD 160/100 mm Hg and above), since under these conditions there is a threat of hemorrhage.

Antioxidants and membranestabilizers. Despite the absence of randomized studies in domestic obstetrics, an important place in the treatment of gestosis belongs to antioxidants and membranestabilizers, including polyunsaturated fatty acids. Simultaneous use in comprehensive therapy is considered the optimal option. With gestosis of light and moderate severity and normal state of the fetus, one of the antioxidants are prescribed: vitamin E (up to 600 mg / day for 3-4 weeks), Actovegin (600 mg / day), glutamic acid (1.5 g / day) , ascorbic acid (0.3 mg / day) with lipostable (2 capsules 3-4 times a day). With a light form of gestosis, tableted forms of membranestabilizers are shown, with an average and severe degree, especially in the SIR, - intravenous infusion of these drugs (5-10 ml).

Antioxidants and membranestabilizers are advisable to apply under the control of the content of essential fatty acids, the level of lipid peroxidation level.

The conducted complex therapy of gestosis is directed simultaneously to normalize the uterine-placental blood circulation, which is carried out by the toxolisis of magnesium sulfate. In addition, β2- adreminimetals (hexoprenaline, terbutalin in individually portable doses can be prescribed.

With a positive effect of therapy, the duration of treatment is determined by the degree of gravity of gestosis, the state of the fetus, the term of gestation. With gestosis of light and moderate severity, the duration of treatment in the hospital should be at least 2 weeks. Pregnant can be discharged from a hospital with recommendations to continue anti-relapse therapy, including compliance with the power mode, phytosborg, antispasmodics, disagreganites, antioxidants, membranestabilizers. Treatment of extragnenital pathology is carried out according to the testimony before the delivery. In the treatment of heavy gestosis can be achieved, as a rule, the temporary effect.

The need to treat heavy forms of gestosis is often dictated by small periods of gestation (up to 30-32 weeks) when the root separation is associated with the birth of children with a very low and extremely low body weight (the percentage of mortality and morbidity in such children is high). The goal of treatment in this situation is subject to pregnancy prolongation.

Prolongation of pregnancy allows the prevention of the PDS of the fetus. After 34-35 weeks, heavy gestosis therapy is largely aimed at preparing for the delivery. If there is an effect from the treatment, obstetric tactics is determined by the term of gestation and the state of the fetus. When the SIR tactics are depends on the dynamics of its growth.

If the growth of the fetus corresponds to the term of gestation, there is no chronic hypoxia, the effect of therapy is noted, then pregnancy can be prolonged to 36-38 weeks. When preserving the signs of gestosis, the lack of growth of the fetus or non-compatible chronic hypoxia of the fetus is necessary early delivery. The method of choice in this situation is considered to be CS, especially if the period of gestation does not exceed 35-36 weeks.

Treatment of preeclampsia and eclampsia

Treatment of preeclampsia and eclampsia should be carried out in conjunction with resuscitation in the department of intensive therapy in monitor observation of vital organs.

Principles of treatment for pregnant women, pupils and fencers with preeclampsia and eclampsia:

The relief and prevention of eclampsia attacks;
Restoration of the function of vital organs (first of all, cardiovascular, central nervous system, excretory).

At the time of the attack of the eclampsia, magnesium sulfate (4-6 g of the inkinosino, the daily dose of 50 g of dry matter) is shifted, they shift to the left (roller under the right buttock), is carried out pressure on the pisteless cartilage, oxygenation is carried out. All specified events are carried out simultaneously.

Magnesium sulfate is then introduced at a speed of 2 g / h (supporting dose). If the convulsive syndrome is not possible to stop, it is additionally introduced from 2 to 4 g of magnesium sulphate for 3 minutes, as well as 20 mg of diazepam intravenously, and in the absence of effect - general anesthetics, muscle relaxants with the translation of the patient on the IVL.

The translation into the IVL is also carried out in respiratory failure and the absence of consciousness after an attack of eclampsia. The delivery is carried out under general anesthesia.

In addition, the testimony to the IVL serve such complications of gestosis as hemorrhage into the brain, bleeding, aspiration of gastric content, emitting, as well as polyorgan deficiency (PON).

With the normal function of the respiratory, cardiovascular systems after the attack of eclampsia, it is possible to a root separation under regional anesthesia, which, with severe gestosis, acts as a method of treatment, contributing, in particular, decreased blood pressure.

Hypotensive and infusion therapy is carried out according to the same principles as in gestosis. With heavy forms of gestosis, infusion therapy must be controlled and carried out taking into account the monitoring data for central and peripheral hemodynamics, diuresis, blood protein.

The advantage is given to crystaloids (Ringer's solution of 40-80 ml / h), high-molecular dextranum, the introduction of which should eliminate hypovolemia and prevent tissue hyperflowing. Albumin is administered with the content of it in blood less than 25 g / l.

Treatment of pregnant women with eclampsia should be carried out, taking into account the rapid preparation for the delivery, after which they perform a rowor-engraving operation.

In the postpartum period, hypotensive, infusion and therapy with magnesium sulfate (at least 24 hours) continue, as well as therapy aimed at restoring the functions of vital organs. According to the testimony, the prevention of thrombotic complications and antibacterial therapy are carried out.

In the absence of the effect of this therapy after the delivery, extracorporeal methods of detoxification and dehydration are shown: plasma ultrafiltration, hemosorption, hemodailtration.

Indications for ultrafiltration:

Postexxpix coma;
brain edema;
non-counterfeit eaters;
Anasarka.

Treatment of pregnant women with HellP syndrome

The complex includes:
intensive preoperative preparation (infusion transfusion therapy);
urgent abdominal delivery;
replacement, hepatoprotective and immunosuppressant therapy (from 10 mg of dexamethasone intravenously every 12 h), transfusion of fresh frozen plasma;
Prevention of massive blood loss during the operation and in the postpartum period by correction of hemostasis;
Antibacterial therapy.

The treatment of pregnant and herds is carried out with the definition every 6 hours of erythrocytes and platelets, the content of general protein and bilirubin in the blood, the values \u200b\u200bof the prothrombin index, the ABTV, the time of blood intake, liver transaminases.

Urgent abdominal delivery is carried out against the background of complex intensive therapy. Infusion-transfusion therapy is complemented by the appointment of hepatoprotectors (10% solution of glucose in combination with large doses of ascorbic acid, up to 10 g per day), replacement therapy (freshly frozen plasma of at least 20 ml / kg per day, thromboconcentrate) at platelet levels 50 × 109 / l. In the absence of thromboconcentrate, it is permissible to introduce at least four doses of plasma enriched with platelets.

For additional correction of hemokoagulation disorders in the preoperative period and intraoperatively intravenously, not less than 750 mg of transamic acid are introduced.

Terms and methods of the Rhodework

Indications for early delivery in gestosis:

Gestosis of the average severity in the absence of the effect of treatment within 7 days;
heavy forms of gestosis in the unsuccessfulness of intensive therapy for 2-6 hours;
Guest radias regardless of severity in the SIR III degree and the absence of its growth against the background of treatment;
Eclampsia and its complications for 2-3 hours (comatose states, Anururia, Nellp syndrome, hemorrhage into the brain, detachment and hemorrhage in the retina, Amavrosis, etc.).

The testimony of caesarean section consider the heavy forms of gestosis, including preeclampsia, in the absence of effect on therapy for 2-4 hours; Eclampsia and its complications, growth delay and chronic hypoxia of the fetus. The most optimal method of anesthesia during cesarean section is regional anesthesia.

Through the natural generic paths, the delivery is carried out with a satisfactory condition of pregnant, the presence of the effect of treatment, the absence of intrauterine suffering of the fetus (according to the ultrasound and cardiomonitorial research).

With the unprepared generic paths and the need for a delivery to improve the functional state of the uterus and the preparation of the cervix to childbirth, laminaries are introduced into the cervical channel. Perhaps the introduction of prostaglandine gels into the rear arch. With the prepared neck of the uterus, relatively exclishes with the opening of the fruit bubble and followed by the introduction of uterotonic means.

In the first period of birth, magnesium sulfate is prescribed and hypotensive therapy according to the testimony. Infusion therapy is reduced to a minimum and mainly carried out only as a water load with regional anesthesia.

The method of choice for the anesthesia of childbirth in gestosis is long-term epidural anesthesia, having a number of advantages. This is the high efficiency of anesthesia (92-95%), preservation of the patient's consciousness, the presence of a sympathetic blockade that improves the blood supply to the uterus and kidney; lack of depressing influence on the contractile activities of the uterus and the state of the mother and the fetus; Efficiency.

Relationship or activation of generic activity in its weakness is carried out depending on the state of pregnant and fetus. With satisfactory condition, it is possible to introduce uterotonic drugs (oxytocin, dinofrost). With the deterioration of the condition (ag, brain and dyspeptic symptoms, the hypockey of the fetus) shows the operational delivery.

In the second period of childbirth, regional anesthesia is also shown. Conduct perineotomy or episotomy. If it is impossible to perform regional anesthesia, managed by gangliplockers managed.

It is possible to use obstetric tongs. The dead fruit serves as an indication of the fertilizing operation (perforation of the head).

At the end of the second period and in the third period of birth, the femalenits with gestosis conducts the prevention of bleeding with oxytocin or dynogost (intravenously drip). Comprehensive gestosis therapy should be carried out in the postpartum period before stabilizing the state of the parent.

Prevention of gestosis

Specific medication prevention of gestosis does not exist.

Preventive measures should be carried out at the preclinical stage in the group of risk of developing gestosis, to which include:

Pregnant women with extragenital pathology (metabolic syndrome, hypertension, kidney pathology, sd, endocrinopathy, APS, congenital hemostasis defects, homozygility of the T235 gene responsible for angiotensin metabolism);

Pregnant women with presence of gestosis in previous pregnancy and in close relatives on the maternal line.

Preventive measures to prevent gestosis in the risk group, which should be started with 8-9 weeks of pregnancy, include non-drug therapy methods. Assign "Bed REST", diet; Conduct treatment of extragenital pathology (according to indications). The corresponding diet is recommended, the energy value of which does not exceed 3000 kcal, with the inclusion of vegetable and animal products, fatty fish.

Diet includes boiled, moderately disadvantaged foods; From the diet, exclude sharp, fried dishes, causing a feeling of thirst. The amount of fluid is about 1300-1500 ml / day.

From the 12th and 12th week in the prophylactic complex, it is necessary to additionally enter herbs with sedative properties (Valerian, mother-in-law), normalizing vascular tone (hawthorn) and kidney functions (kidney tea, birch kidneys, tolkinyanka, leaf lover, deer, corn storks) , artichoke leaves extract (with liver disease). With potassium deficiency, calcium, magnesium prescribe drugs containing these trace elements, and food products (Raisins, Kuraga).

In the presence of laboratory data on the change of hemostasis (hypercoagulation, signs of the DVS-syndrome), the calcium is used. In the hypercoagulation in the cellular hemostasis, the violation of the rheological properties of blood is prescribed disaggregants (pentoxyphyllen, dipyridamol).

With the activation of the limit oxidation of lipids, antioxidants are prescribed (vitamin E), membranestabilizers (rutoside, essential phospholipids). The duration of the use of drugs is 2-3 weeks depending on the indicators. After applying disagrements, membranetabilizers with a satisfactory condition of pregnant and normal growth rates of the fetus, the normalization of the parameters of the hemostasis is possible a break in the reception of drugs for 1-2 weeks. At the specified period, the appointment of phytosborns is possible to stabilize the state. The reappointment of disaggregants and membranestabilizers is possible only under the control of laboratory data. When the early symptoms of gestosis appear in pregnant symptoms, despite the conduct of preventive measures, it should be hospitalized.

After discharge from the hospital during the remission of the gestosis, it is necessary to prescribe a prophylactic complex, including phytosborns, disagrements and membranestabilizers.

Information for the patient

When planning pregnancy, women with extragnenital pathology should be aware of the possibility of the development of gestosis and in a timely manner to conduct therapy aimed at stabilizing the state.

During pregnancy, the observance of the diet and the water-salt regime is important, fulfilling the advice of the doctor. According to the testimony - timely hospitalization.