Preeclampsia gynecology. What is eclampsia? central nervous system

Preeclampsia is a medical condition in pregnant women characterized by high blood pressure, fluid retention (edema) and protein in the urine (proteinuria). The disease is diagnosed most often between the 20th week of pregnancy and the first after childbirth, that is, in the second and third trimesters. However, preeclampsia can develop earlier.

Eclampsia is a severe form of preeclampsia that is accompanied by convulsions or coma. The danger of the disease is early detachment placenta from the uterine wall. In 0.5% of cases, in the absence of timely treatment, eclampsia is fatal.

Preeclampsia affects about 20% of pregnant women, and previously this figure was only 5%, which indicates the progression of the incidence. The disease occurs during the first pregnancy, as well as in women who complained of high blood pressure or disease blood vessels even before pregnancy.

Causes of preeclampsia

To date, it is impossible to say exactly what leads to the development of preeclampsia, since the causes are not yet fully understood. But still, there are risk factors that can affect the incidence of women:

First pregnancy;
Preeclampsia in relatives;
The age of the pregnant woman is over 40;
Diabetes;
Multiple pregnancy;
Obesity;
Arterial pressure;
Arterial hypertension before pregnancy;
Pathology of the kidneys;
Systemic lupus erythematosus;
Rheumatoid arthritis and some others.

Symptoms of preeclampsia

This disease is characterized by symptoms such as an increase in pressure over 140 to 90 mm. rt. Art., swelling of the hands and face, the presence of protein in the urine, which is confirmed only by the appropriate analysis. Sometimes a woman's pressure rises during pregnancy, but does not reach the aforementioned mark, however, if there are other signs, they talk about the diagnosis of "preeclampsia".

Children born to sick mothers are 5 times more susceptible to various disorders and diseases in the first days after birth than those born to women without preeclampsia. These newborns are often underweight or born prematurely.

In addition to the main symptoms of preeclampsia, the following changes in the condition of a woman are observed:

Stomach ache;
Rapid weight gain that does not correspond to the norm;
Dizziness;
Changing reflexes;
Severe nausea and vomiting, atypical for the second and third trimesters;
Decreased amount of urine;
Severe headaches due to high blood pressure.

In severe preeclampsia, the following complications are observed:

Destruction of red blood cells;
A decrease in the number of platelets, which indicates a violation of blood clotting - greatest danger for mother and baby;
An increase in the content of liver enzymes, which indicates damage to this organ.

If a woman has severe preeclampsia, then delivery is performed by caesarean section, as it is the fastest and most affordable method.

Degrees of preeclampsia

In total, there are three degrees of preeclampsia:

Mild pre-eclampsia - an increase in pressure not higher than 150/90 mm Hg. Art. and the concentration of protein in the urine up to 1 g / l. The patient has swelling of the legs. At mild preeclampsia the number of platelets does not fall below 180x109 / l, creatinine - up to 100 µmol. This stage can occur without any pronounced symptoms, so expectant mothers sometimes do not know about the disease. It is not for nothing that gynecologists recommend to undergo scheduled examinations before pregnancy in a timely manner and to be registered in gynecology as early as possible. It is the timely delivery of all necessary analyzes allows you to detect preeclampsia at an easy stage;
The average degree of preeclampsia is characterized by an increase in pressure up to 170/110 mm Hg. Art., protein content in urine - more than 5 g / l, platelets in the blood - from 150 to 180x109 / l, creatinine - 100-300 μmol / l. At this stage, swelling of the lower extremities and the anterior abdominal wall is observed, headaches are possible;
Severe preeclampsia - an increase in blood pressure above 170/110 mm Hg. Art., the concentration of protein in the urine - more than 5 g / l, creatinine - more than 300 μmol / l. Patients suffer from pain in the back of the head and forehead, visual impairment, which is manifested by the flashing of lights or flies. Also, for severe preeclampsia, pain in the liver area is characteristic, which indicates its edema.

Severe preeclampsia often progresses to eclampsia most dangerous form preeclampsia, in which convulsions may occur. Launched stages diseases pose a threat to the health of both mother and child.

Diagnosis and treatment of preeclampsia

To determine the presence and degree of preeclampsia, it is necessary to regularly carry out the following activities as part of gynecological control:

Regularly measure blood pressure;
Track weight gain once a month;
Take a blood test for hemostasis;
Take a urine test for protein content;
Take a blood test for uric acid, urea and creatinine;
Monitor liver enzyme levels with biochemical analysis blood.

Preeclampsia is treated with medication, diet therapy, and bed rest. After the birth of a child, the signs of the disease disappear, but a number of measures must be observed during and after pregnancy so that there are no complications for the baby and mother in the future.

The treatment for preeclampsia is positive results if you use diuretics that remove excess fluid from the body. It is also recommended to reduce your intake of salt, which is known to retain fluid.

During pregnancy diagnosed with preeclampsia, it is necessary to observe bed rest. Most of all, one should lie on the left side, because in this position the pressure on the large vein in the abdominal cavity that carries blood to the heart. As a result, blood circulation improves and the manifestation of symptoms decreases.

To reduce blood pressure, the introduction of magnesium sulfate intravenously is indicated. Even if mild preeclampsia is present, treatment may be needed if sharp deterioration a condition from which no one is immune. In this case, the patient is placed in a hospital and is constantly monitored for all indicators.

If the disease becomes severe, and treatment is ineffective, the pregnancy is terminated surgically. Delivery is carried out only when it was possible to normalize the pressure with the help of medications.

In 25% of cases, eclampsia as a type of preeclampsia manifests itself after childbirth during the first days. Then they use drugs that normalize blood pressure and sedatives. Patients stay in the hospital from several days to several weeks, depending on the indicators of their condition.

After discharge, it is necessary to take blood pressure medications for some time, as well as visit a doctor every two weeks. If the pressure remains high after 2 months after delivery, then the cause this phenomenon not associated with preeclampsia.

For a woman, it is almost always a stressful period in some sense. This is reflected not only in the psychological experiences of the future mother, but also in the changes that occur in her body. During the entire period of gestation, the pregnant woman's body is rebuilt and prepared for, in connection with which the woman may feel some discomfort. Further in the article we will talk about preeclampsia in pregnant women, find out what it is and figure out how this condition is treated.

What it is

One of the forms is called preeclampsia. This condition usually manifests itself as an increase, as well as a sharp formation of edema on the body. A woman can rapidly gain weight due to water retention in the body, and as a result, experts find protein in the urine.
A condition called preeclampsia usually develops during the second period, or rather, when it is already coming to an end.

What is dangerous for the pregnant woman and the fetus

Due to the presence of pre-eclampsia, nutrients are supplied to the child in a limited amount, the same applies to oxygen. Because of this, it can be in a state of hypoxia for a long time.

The result of this can be physical as well as mental underdevelopment of the unborn child, as well as brain damage to the baby while he is in the womb. In addition, the threat to the child is the risk of premature detachment of the placenta, which can provoke the death of the baby.

Also given state negatively affects the functional work of the brain of a pregnant woman, her kidneys and liver. Eclampsia can be provoked, pulmonary edema develop, as well as a hypertensive crisis.

Did you know? Making love immediately after childbirth is recommended to be postponed. Sex during this period, according to researchers, can be deadly. This is due to the fact that the uterine vessels of a woman at this stage are still greatly dilated. If air gets into them, then this threatens with an embolism - blockage of blood vessels by air bubbles. Scientists report that from 1967 to 1993, 18 cases of such "deadly" sex are known in the UK.

Causes and risk group

Despite the fact that over the past decades, medical researchers have studied many new features of the state of preeclampsia, a significant part of them still remains unknown.
According to experts, the main reasons for the formation and development of such a pathology are placental abnormalities, errors in genetics, the presence of underlying diseases, as well as a reaction to pregnancy from immune system women.

There is also a certain risk group, that is, women who are most likely to develop preeclampsia. The following factors increase this possibility:

Having preeclampsia during a previous pregnancy.
A woman is pregnant for the first time.
The state of preeclampsia was present during pregnancy in close relatives.
Increased arterial pressure chronic form, kidney disease, the presence of sugar.
The pregnancy is multiple.
A woman under the age of 20 or over 35.
Obesity (when BMI is 30 or more).

Symptoms

The clinical picture of preeclampsia during pregnancy is very extensive. The main symptoms are:

Increased blood pressure.
A rapid jump in weight, which is based on fluid retention in the tissues.
Infrequent urination, anuria.
Frequent, which are accompanied by dark circles and spots under the eyes, clouding.
Nausea and vomiting.
Muscular, etc.

Important! You should not take time to see a doctor and hope that the unpleasant manifestations will pass by themselves. It is important to remember that complications can occur at any moment, so you should immediately go to the hospital or call ambulance. Only timely diagnosis and treatment will save the life of the expectant mother and her baby.

If a woman in position notices any of the above indications, you should immediately contact your doctor to conduct timely diagnosis and start treatment. Based on what degree of pathology will be revealed, the doctor will be able to prescribe the correct and effective therapy.

Degrees of preeclampsia in pregnancy

Experts divide the state of preeclampsia into several degrees, based on the individual pathogenesis of the disease.

mild preeclampsia. This degree is characterized by an increase in blood pressure to 150 to 90. Protein is not detected in the urine at this stage.
Moderate preeclampsia. The pressure in pregnant women can already rise to 170 to 110. Protein in the urine is about 5 grams per liter. Swelling of the body is already becoming noticeable.
Severe preeclampsia. With this degree of pathology in pregnant women, the pressure can be the same as with average form(170 by 110). The amount of protein in the urine already exceeds 5 grams. The quality of vision drops noticeably. The swelling is pronounced and strong.

Important! Such a power classification is always used in practical medicine. According to her, the doctor is guided by whether it is necessary to induce labor artificially or whether this is not necessary. Artificial childbirth in some cases, they are necessary, because it happens that this is the only option to save the life of both the mother and the child.

To prevent the last two forms of this pathological condition, you need to be able to establish an easy degree in time. For this, a woman during the period of bearing a child must take urine and blood tests every month. It is important to understand that a severe degree entails the risk of death of the child.

Urgent Care

If you have symptoms of preeclampsia, you need to call an ambulance. Prior to the arrival of doctors, the following actions are recommended:

If a pregnant woman has a threat of convulsions, then she should be laid in a room with subdued light, placing a pillow under her head. Be sure to exclude unnecessary noise in the room.
A roller or spoon can be inserted between the teeth so that the woman does not bite her tongue during convulsions. At this point, you need to ensure that the object in the mouth does not move and does not block the breath.
If there is apnea - a prolonged lack of breathing, you need to make the patient artificial respiration.
Reduce blood pressure to normal state it is possible with the help of drugs Seduxen, Relanium, etc.

Examinations and analyzes

To determine whether a pregnant woman has preeclampsia, the doctor must diagnose the patient's condition by conducting a series of tests.

They are as follows:

Analysis of complaints of a pregnant woman, as well as an anamnesis of the disease. The doctor will clarify whether headaches are present and when they appeared. Find out if there is a violation of the quality of vision, if there are elevated blood pressure indicators. You will also need information about changes in the woman's weight.
Doctor will analyze clinical history women, will clarify whether there have been surgical interventions whether there were injuries. You should also inform your doctor about chronic kidney disease and infectious diseases, if any.
A gynecological history will be taken, during which the doctor will clarify which infections and diseases of the gynecological field have occurred in the life of a woman.
The doctor will examine the patient's body for swelling of the face and limbs, also analyze the color of the skin and diagnose the presence of lethargy and lethargy.
A urine sample will be taken for a general analysis for the subsequent detection of sugar and protein in it, as well as leukocytes. It will also be necessary to conduct a blood test to identify and determine the presence of signs of inflammation processes.
Consultation with an ophthalmologist (examination of the fundus).

What to do

To determine the methods of treatment for preeclampsia, the doctor must first determine the degree of development of the condition, as well as the maturity of the fetus.

With a mild form of the pathological condition, a woman should observe bed rest. Experts recommend lying on your left side or on your back to improve blood circulation. With a mild degree, therapeutic maintenance of the pregnant woman at home is allowed, but the doctor will have to examine the patient every two days.
If the dynamics of the pathology will increase, then you will need to resort to drug treatment. Most often, at this stage, drugs are used that lower blood pressure, as well as prevent the formation of seizures. If home treatment is ineffective, the patient will have to be hospitalized.
In the presence of severe preeclampsia, the patient will need to be hospitalized. Maintaining a normal state will be carried out with the help of magnesium sulfate, which will stop the development of pathology. Antihypertensive therapy will also be used to help reduce blood pressure.

If specialists do not observe positive dynamics as a result of treatment, and the symptoms will only continue to grow, then it may be necessary to stimulate labor by artificial means or to conduct it.

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How is childbirth

In the maternity hospital, a pregnant woman will be given intravenous magnesium sulfate in order to stop convulsions. After that, if necessary, they will stabilize the pressure with the help of intravenous drugs.

At the same time, doctors will monitor the condition of the patient and the fetus. If the woman feels better, then the birth will be carried out in the standard mode. natural childbirth is the best option in this situation.
But if the doctors see a threat to the life of the baby or mother, a caesarean section will be performed. After delivery, mothers will continue to inject magnesium sulfate. This will continue until all the symptoms of preeclampsia have disappeared.

Prevention

There is no specific prevention of preeclampsia for pregnant women. But still there are a number of recommendations that you should definitely listen to.

Planning and preparation for pregnancy. unwanted pregnancy should be excluded. It is important to enter into such a state of absolutely healthy. If there is a desire to have a child, you need to undergo a complete medical examination in order to identify all possible diseases and treat them before conception.
After a woman finds out that she is expecting a baby, you should register in time with the local antenatal clinic. This must be done before the 12th week of pregnancy.
You need to visit a gynecologist regularly, without postponing it for later. In the first trimester, you should visit the doctor every month, in the second trimester - once every two to three weeks, in the third trimester you need to go to the doctor every seven to ten days.
You should responsibly follow all the recommendations of your doctor: take necessary tests undergo examinations, and treat diseases.

As you can see, the state of preeclampsia is a very serious pathology that can lead to extremely Negative consequences. To avoid complications, a pregnant woman should carefully monitor her health, respond to various manifestations of your body.

If you develop any symptoms that may indicate the development of preeclampsia, you should immediately notify your doctor.

Preeclampsia and eclampsia are severe stages of preeclampsia and are a formidable complication of pregnancy. According to statistics, the percentage of preeclampsia is 5-10%, and eclampsia 0.5% among the total number of women in labor, pregnant women and puerperas.

Preeclampsia is a preconvulsive condition characterized by a significant rise in blood pressure, high protein content in the urine, and severe edema (not a major prognostic sign).

Eclampsia is a seizure that either resolves or progresses to a coma.

Kinds

Preeclampsia and eclampsia are classified according to the period associated with pregnancy:

preeclampsia and eclampsia of the pregnant;
preeclampsia and eclampsia of the mother;
preeclampsia and eclampsia of the puerperal.

Preeclampsia has 2 levels of severity: moderate and severe.

Eclampsia, depending on the prevailing manifestations, is divided into cerebral, coma, hepatic and renal.

Causes

The causes of preeclampsia and eclampsia are still not exactly established. There are 30 or more theories that explain the causes and mechanisms of development of preeclampsia and eclampsia. But the general opinion of all doctors is the presence of placental pathology, the formation of which is disturbed in the early stages of pregnancy.

When placental attachment is disturbed (superficially implanted placenta) or there is a deficiency of receptors for placental proteins, the placenta begins to synthesize substances that cause vasoconstriction (vasoconstrictors), which leads to a generalized spasm of all blood vessels in the body to increase pressure in them and increase the supply of oxygen and nutrients. substances to the fetus. It leads to arterial hypertension and multiple organ damage (primarily affects the brain, liver, kidneys).

An important role in the development of preeclampsia and eclampsia is played by heredity and chronic diseases.

Symptoms of eclampsia and preeclampsia

Signs of preeclampsia

Preeclampsia is only a short interval between nephropathy and a seizure. Preeclampsia is a violation of the functions of the vital organs of the body, the leading syndrome of which is damage to the central nervous system:

the appearance of flies before the eyes, flickering, vagueness of objects;
noise in ears, headache, feeling of heaviness in the back of the head;
nasal congestion;
memory disorders, drowsiness or insomnia, irritability or apathy.

Also, preeclampsia is characterized by pain in the upper abdomen (“under the spoon”), in the right hypochondrium, nausea, and vomiting.

An unfavorable prognostic sign is an increase in tendon reflexes (this symptom indicates convulsive readiness and a high likelihood of developing eclampsia).

With preeclampsia, edema increases, sometimes within a few hours, but the severity of edema in assessing the severity of the condition of the pregnant woman does not matter. The severity of preeclampsia is established on the basis of complaints, proteinuria and arterial hypertension (an increase in blood pressure for normotonic patients above 140/90 mm Hg should be alarming). If arterial hypertension is 160/110 or more, they speak of severe preeclampsia.

Kidney damage manifests itself in the form of a decrease in the amount of urine excreted (oliguria and anuria), as well as a high protein content in the urine (0.3 grams per daily amount of urine).

Signs of eclampsia

Eclampsia is an attack of seizures, which consists of several phases:

First phase. The duration of the first (introductory) phase is 30 seconds. In this stage, small contractions of the muscles of the face appear.
Second phase. Tonic convulsions are a generalized spasm of all the muscles of the body, including the respiratory muscles. The second phase lasts 10-20 seconds and is the most dangerous (the death of a woman may occur).
Third phase. The third phase is the stage of clonic convulsions. The motionless and tense patient ("like a string") begins to beat in a convulsive fit. Convulsions go from top to bottom. The woman is without a pulse and breathing. The third stage continues for 30-90 seconds and is resolved deep breath. Then breathing becomes rare and deep.
Fourth phase. Seizure is allowed. Characterized by the release of foam with an admixture of blood from the mouth, a pulse appears, the face loses cyanosis, returning to normal color. The patient either regains consciousness or falls into a coma.

Diagnostics

Differential diagnosis of preeclampsia and eclampsia should first of all be carried out with an epileptic seizure (“aura” before an attack, convulsions). Also, these complications should be distinguished from uremia and brain diseases (meningitis, encephalitis, hemorrhages, neoplasms).

The diagnosis of preeclampsia and eclampsia is established by a combination of instrumental and laboratory data:

Measurement of blood pressure. An increase in blood pressure to 140/90 and maintaining these numbers for 6 hours, an increase in systolic pressure by 30 units, and diastolic pressure by 15.
Proteinuria. Detection of 3 or more grams of protein in the daily amount of urine.
Blood chemistry. An increase in nitrogen, creatinine, urea (kidney damage), an increase in bilirubin (erythrocyte breakdown and liver damage), an increase in liver enzymes (AST, ALT) - a violation of liver function.
General blood analysis. An increase in hemoglobin (a decrease in the volume of fluid in the vascular bed, that is, a thickening of the blood), an increase in hematocrit (viscous, "viscous" blood), a decrease in platelets.
General urine analysis . Detection of protein in urine in large quantities (normally absent), detection of albumin (severe preeclampsia).

Treatment of eclampsia and preeclampsia

A patient with preeclampsia and eclampsia must be hospitalized in a hospital. Treatment should be started immediately, on the spot (in the emergency room, at home in case of an ambulance call, in the department).

An obstetrician-gynecologist and a resuscitator are involved in the treatment of these complications of pregnancy. The woman is hospitalized in the intensive care unit, where a therapeutic-protective syndrome is created (a sharp sound, light, touch can provoke a seizure). Additionally, sedatives are prescribed.

The gold standard for the treatment of these forms of gestosis is the intravenous administration of a solution of magnesium sulfate (under the control of blood pressure, respiratory rate and heart rate). Also, to prevent seizures, droperidol and relanium are prescribed intravenously, possibly in combination with diphenhydramine and promedol.

At the same time, the volume of circulating blood is replenished (intravenous infusions of colloids, blood products and saline solutions: plasma, reopoliglyukin, infucol, glucose solution, isotonic solution, etc.).

Blood pressure is controlled by prescribing antihypertensive drugs (clophelin, dopegyt, corinfar, atenolol).

In pregnancy up to 34 weeks, therapy is carried out aimed at maturation of the fetal lungs (corticosteroids).

Emergency delivery is indicated in the absence of a positive effect from therapy within 2-4 hours, with the development of eclampsia and its complications, with placental abruption or suspicion of it, with acute oxygen deficiency (hypoxia) of the fetus.

First aid for an attack of eclampsia:

Turn the woman on her left side (to prevent aspiration respiratory tract), create conditions that reduce the traumatization of the patient, do not apply physical strength to stop convulsions, after an attack, clear the oral cavity of vomit, blood and mucus. Call an ambulance.

Medical relief of an attack of eclampsia:

Intravenous administration of 2.0 ml of droperidol, 2.0 ml of relanium and 1.0 ml of promedol. After the attack is over, the lungs are ventilated with a mask (oxygen), and in the case of a coma, the trachea is intubated with further holding IVL apparatus.

Complications and prognosis

The prognosis after an attack (coma) of eclampsia and preeclampsia depends on the severity of the patient's condition, the presence of extragenital diseases, age and complications.

Complications:

placental abruption;
acute intrauterine fetal hypoxia;
hemorrhages in the brain (paresis, paralysis);
acute hepatic and kidney failure;
HELLP syndrome (hemolysis, increased liver enzymes, decreased platelets);
pulmonary edema, cerebral edema;
heart failure;
coma;
death of a woman and / or fetus.

Some research on pregnancy

This is a severe variant of preeclampsia, which occurs after the 20th week of gestational age, is characterized by multiple organ disorders with a primary lesion of the central nervous system, preceded by eclampsia. Manifested by headaches, nausea, vomiting, visual disturbances, hyperreflexia, lethargy, drowsiness or insomnia. Diagnosed on the basis of 24-hour blood pressure monitoring data, general analysis urine, coagulogram, transcranial dopplerography. For treatment, infusion therapy, anticonvulsant, antihypertensive, anticoagulant, membrane stabilizing agents are used. With the ineffectiveness of appointments, an emergency caesarean section is indicated.

Causes of preeclampsia

The etiology of the disorder, as well as other forms of gestosis, has not been finally established to date. A likely factor contributing to the development of preeclampsia is the pathological reaction of the body of a predisposed woman to physiological changes during pregnancy. More than 30 reasoned etiopathogenetic theories of the onset of the disease have been proposed by specialists in the field of obstetrics, the main of which are:

hereditary. The role of genetic factors in the development of preeclampsia is confirmed by its more frequent diagnosis in patients whose mothers suffered from preeclampsia. Patients have defects in the genes 7q36-eNOS, 7q23-ACE, AT2P1, C677T. The mode of inheritance is presumably autosomal recessive.
immune. Penetration into the maternal circulation of foreign antigens of the fetus is accompanied by the response production of antibodies. Precipitation of the formed immune complexes in various fabrics launches complex defense mechanisms which are manifested by activation of endothelial cells and acute endotheliosis.
Placental. Some authors associate preeclampsia with impaired cytotrophoblast invasion. As a result, there is no transformation of the smooth muscle layer of the uterine arteries, which subsequently leads to their spasm, deterioration of intervillous blood flow, hypoxia and, as a result, damage to the endothelium.
Cortico-visceral. Proponents of the theory consider preeclampsia as a neurotic hemodynamic disorder caused by a violation of the relationship between the cortex and subcortical regions. This approach explains the provoking role of severe stress and is confirmed by functional changes in the EEG.

Since individual theories cannot fully explain all the clinical manifestations of the disease, it is justified to consider preeclampsia as a polyetiological condition with common mechanisms of pathogenesis. The immediate causes of the development of preeclampsia are improperly selected therapy for dropsy of pregnancy and nephropathy, non-compliance by the patient with medical recommendations, and high therapeutic resistance of milder variants of gestosis.

Pathogenesis

The key link in the mechanism of development of preeclampsia is the generalization of acute endotheliosis and vasoconstriction, initially localized in the placenta, with involvement in pathological process brain tissues. Vascular dysfunction leads to damage to cell membranes, disruption of neuronal metabolism with the occurrence of hypersensitivity and hyperexcitability nerve cells. The defeat of suprasegmental subcortical structures is accompanied by polysystemic autonomic disorders, detected in more than 90% of patients with severe forms of preeclampsia.

In parallel, pregnant women and women in labor with preeclampsia develop pyramidal insufficiency, which indicates a disorder at the level of the cortical sections and is manifested by tendon-periosteal hyperreflexia, anisoreflexia, the occurrence of pathological reflexes, and an increase in convulsive readiness. The last to be affected are the brain stem regions. Destructive processes caused by microcirculation disorders also occur in other organs - the liver, kidneys, lung tissue. The situation is aggravated by coagulopathic disorders characteristic of gestosis.

Symptoms of preeclampsia

Usually, the disorder occurs against the background of previous nephropathy. Existing edema, arterial hypertension, moderate astheno-vegetative symptoms (dizziness, weakness, insufficient sleep, meteotropism, emotional lability) are accompanied by signs of CNS damage and increased intracranial pressure. The patient complains of intense headache, heaviness in the back of the head, fatigue, looks lethargic, lethargic, indifferent, sometimes responds inappropriately. There is increased drowsiness or insomnia, trembling of outstretched fingers, sweating of the palms and feet.

In 25% of women with a clinic of preeclampsia, visual disorders are detected - a feeling of blurred vision, flickering of sparks or flies, fear of light, double vision, loss of individual fields of vision. Perhaps the appearance of nausea, vomiting, pain in the epigastrium and right hypochondrium. In severe cases, there are muscle twitches, delirium, hallucinations, petechial rash, indicating a violation of blood clotting. The pre-eclamptic state is relatively short, lasting no more than 3-4 days, after which it is stopped by the correct therapy or passes into eclampsia.

Complications

The most formidable complication of preeclampsia is eclampsia, the most severe type of preeclampsia with high rates of maternal and perinatal mortality. In 1-3% of patients there is a loss of vision (amaurosis) caused by edema, vascular changes, retinal detachment or ischemia of the occipital lobe of the cortex due to circulatory disorders in the posterior cerebral artery. Perhaps the development of a hypertensive crisis, cerebral edema, stroke, HELLP syndrome, detachment of a normally located placenta, the occurrence of postpartum coagulopathic bleeding and DIC. Fetoplacental insufficiency is usually aggravated, signs of intrauterine fetal hypoxia are growing.

Women who have had preeclampsia are 4 times more likely to develop cardiovascular diseases(hypertension, angina pectoris, heart attacks, strokes, congestive heart failure), the risk of developing diabetes 2nd type. In a third of patients, gestosis is diagnosed in subsequent pregnancies.

Diagnostics

Timely diagnosis of preeclampsia is usually not difficult if the pregnant woman long time was under the supervision of an obstetrician-gynecologist about the previous nephropathy. At the initial visit of a patient with characteristic complaints, an examination plan is recommended with the identification of specific markers of preeclampsia:

Blood pressure control. Daily monitoring with automatic measurement of blood pressure using a special device is shown. In patients with preeclampsia, blood pressure usually exceeds 180/110 mm Hg. Art. with a pulse amplitude of more than 40 mm Hg. Art. The arterial hypertension index is 50% or more.
Assessment of the hemostasis system. Preeclampsia is characterized by coagulopathy of consumption and activation of the fibrinolytic system. It is recommended to investigate the content of fibrinogen, its degradation products (SFMK), antithrombin III, endogenous heparin, evaluate APTT, prothrombin (MHO), thrombin time.
General urine analysis. Proteinuria is an important symptom of preeclampsia. The protein content in the urine exceeds 5 g / l, granular casts, leukocyturia can be detected. Hourly urine output is often reduced to 40 ml or less. To assess the severity of kidney damage, the daily amount of protein in the urine is determined.
TCDH of cerebral vessels. It is used for an objective assessment of cerebral blood flow. In the course of transcranial Doppler sonography, the presence of signs of an increase in cerebral perfusion pressure and a decrease in vascular resistance, characteristic of preeclampsia, is confirmed.

Taking into account possible obstetric complications the patient is shown ultrasound of the uterus and placenta, dopplerography of the uterine placental blood flow, CTG, fetometry, fetal phonocardiography. Differential diagnosis is carried out with diseases of the brain (thrombosis of the sinuses of the hard shell, meningitis, tumors, stroke), non-convulsive forms of epilepsy, retinal detachment. A pregnant woman is consulted by an anesthesiologist-resuscitator, therapist, neuropathologist, ophthalmologist, cardiologist, nephrologist.

Treatment of preeclampsia

The patient is urgently admitted to the intensive care unit of the nearest hospital with a delivery room. The main therapeutic task is to reduce reflex and central hyperreactivity, prevent convulsive syndrome, stabilize vital functions, and correct multiple organ disorders. A pregnant woman with preeclampsia is shown a strict medical and protective regimen. The treatment regimen includes the appointment of the following groups of drugs:

Anticonvulsants. The “gold standard” is the introduction of magnesium sulfate through an infusomat. The drug has a sedative, anticonvulsant, antispasmodic, hypotensive effect, effectively reduces intracranial pressure. Simultaneously with the improvement of cerebral hemodynamics, it relaxes the myometrium and increases the intensity of blood flow in the uterus. If necessary, tranquilizers are additionally used.
Antihypertensive drugs. Imidazoline derivatives are preferred, which have a central α2-adrenomimetic effect, stimulate I1-imadazoline receptors in the nucleus of the solitary tract and thereby increase the parasympathetic effect on the myocardium. Perhaps parenteral administration of peripheral vasodilators, hybrid β- and α1-blockers with a rapid antihypertensive effect.
Infusion formulations. To normalize oncotic and osmotic pressure, colloidal, protein, balanced crystalloid solutions are injected intravenously. Infusion therapy improves the rheological properties of blood, central and peripheral hemodynamics, tissue perfusion, reduces the severity of multiple organ disorders, and restores water and electrolyte balance.

According to indications, sedatives, direct-acting anticoagulants, antioxidants, membrane stabilizers, drugs to improve blood flow in tissues, and prevent fetal respiratory distress syndrome are used. With the ineffectiveness of intensive therapy within a day from the moment of hospitalization, an emergency delivery by caesarean section is recommended. Patients with rapidly increasing symptoms of preeclampsia undergo surgery within 2-4 hours. Natural childbirth with high-quality anesthesia (long-term epidural anesthesia), perineotomy or episiotomy is possible only with a significant improvement in the patient's well-being, persistent stabilization of blood pressure, and laboratory parameters.

Forecast and prevention

The outcome of gestation in pregnant women with symptoms of preeclampsia depends on the availability medical care and the correct choice of tactics of conducting. In any case, the prognosis for the mother and fetus is considered serious. Maternal mortality rate in last years managed to reduce to 0.07 per 1000 births, perinatal mortality ranges from 21 to 146 per 1000 observations. Prevention of preeclampsia involves regular examinations at the antenatal clinic, monitoring of pressure and laboratory parameters in patients with dropsy of pregnancy, nephropathies, careful implementation of all medical prescriptions, normalization of sleep and rest, psycho-emotional peace, control of weight gain, protein-enriched diet with low salt content.

What is preeclampsia? We will analyze the causes of occurrence, diagnosis and treatment methods in the article of Dr. A. A. Dubova, an obstetrician with an experience of 11 years.

Definition of disease. Causes of the disease

Preeclampsia- a complication of the second half of pregnancy, in which, due to an increase in the permeability of the vascular wall, disorders develop in the form of arterial hypertension, combined with the loss of protein in the urine (proteinuria), edema and multiple organ failure.

In fact, the cause of preeclampsia is pregnancy: it is during it that pathological events occur, ultimately leading to the clinic of preeclampsia. Preeclampsia does not occur in non-pregnant women.

The scientific literature describes more than 40 theories of the origin and pathogenesis of preeclampsia, and this indicates the lack of common views on the causes of its occurrence. It has been established that young and nulliparous women are more likely to suffer from preeclampsia (from 3 to 10%). In pregnant women with a planned second birth, the risk of its occurrence is 1.4-4%.

The starting point in the development of preeclampsia in modern obstetrics is a violation of placentation. If the pregnancy proceeds normally, from the 7th to the 16th week, the endothelium (the inner lining of the vessel), the inner elastic layer and the muscular plates of the spiral artery section, are replaced by the trophoblast and fibrin-containing amorphous matrix (components of the precursor of the placenta - the chorion). Because of this, the pressure in the vascular bed decreases and additional blood flow is created to meet the needs of the fetus and placenta. Preeclampsia is associated with the absence or incomplete invasion of the trophoblast into the region of the spiral arteries, which leads to the preservation of sections of the vascular wall, which has a normal structure. In the future, the impact on these vessels of substances that cause vasospasm leads to a narrowing of their lumen to 40% of the norm and the subsequent development of placental ischemia. At normal flow pregnancy, up to 96% of the 100-150 spiral arteries of the uterus undergo physiological changes, with preeclampsia - only 10%. Studies confirm that the outer diameter of the spiral arteries in pathological placentation is half that of normal.

Symptoms of preeclampsia

Previously, in domestic obstetrics, what is now called the term "preeclampsia" was called "late gestosis", and directly under preeclampsia they understood a severe degree late preeclampsia. Today, in most regions of Russia, they switched to the classification adopted by WHO. Previously, they talked about the so-called OPG-gestosis (edema, proteinuria and hypertension).

1. Arterial hypertension

Preeclampsia is characterized by systolic blood pressure>140 mm Hg. Art. and / or diastolic blood pressure> 90 mm Hg. Art., measured twice with an interval of 6 hours. At least two elevated values BP is the basis for diagnosing hypertension during pregnancy. If in doubt, ambulatory blood pressure monitoring (ABPM) is recommended.

2. Proteinuria

To diagnose proteinuria, it is necessary to identify the quantitative determination of protein in the daily portion (normal during pregnancy - 0.3 g / l). Clinically significant proteinuria during pregnancy defined as the presence of protein in the urine ≥ 0.3 g/l in a daily sample (24 hours) or in two samples taken with an interval of 6 hours; when using a test strip (protein in urine) - indicator ≥ "1+".

Moderate proteinuria is a protein level > 0.3 g/24 hours or > 0.3 g/l, determined in two portions of urine taken 6 hours apart, or a "1+" value on a test strip.

Severe proteinuria is a protein level > 5 g/24 hours or > 3 g/L in two urine samples taken 6 hours apart, or a 3+ dipstick value.

To assess the true level of proteinuria, it is necessary to exclude the presence of a urinary tract infection, and abnormal proteinuria in pregnant women is the first sign of multiple organ lesions.

3. Edema syndrome

The triad of signs described by Wilhelm Zangemeister in 1912 (OPG preeclampsia) is found today in only 25-39%. The presence of edema in modern obstetrics is not considered a diagnostic criterion for preeclampsia, but it is important when you need to assess its severity. When the pregnancy is normal, edema occurs in 50-80% of cases, outpatient management is safe for a mild edematous symptom. However, generalized, recurrent edema is often a sign of combined preeclampsia (often against the background of kidney pathology).

The American surgeon and illustrator Frank Henry Netter, who was rightly nicknamed the "Michelangelo of Medicine", very clearly depicted the main manifestations of preeclampsia.

The pathogenesis of preeclampsia

In response to ischemia in violation of implantation (see figure), placental factors, including anti-angiogenic factors and inflammatory mediators that damage endothelial cells, begin to be actively produced. When the compensatory mechanisms of blood circulation are running out, the placenta, with the help of pressor agents, actively “adjusts” the blood pressure of the pregnant woman to itself, while temporarily increasing blood circulation. As a result of this conflict, endothelial dysfunction occurs.

With the development of placental ischemia, a large number of mechanisms are activated, leading to damage to endothelial cells throughout the body, if the process is generalized. As a result of systemic endothelial dysfunction, the functions of vital organs and systems are disrupted, and as a result, we have clinical manifestations of preeclampsia.

Violation of placental perfusion due to pathology of the placenta and vasospasm increases the risk of fetal death, intrauterine growth retardation, the birth of children small for term and perinatal mortality. In addition, the condition of the mother often causes abortion at early stage- that is why children born to mothers with preeclampsia have more high rate incidence of respiratory distress syndrome. Placental abruption is very common among preeclamptic patients and is associated with high perinatal mortality.

Classification and stages of development of preeclampsia

Moderate preeclampsia	Combination of two main symptoms: I. Systolic blood pressure 141-159 mm Hg. Art. and / or diastolic blood pressure, 91-99 mm Hg. Art. at double measurement with an interval of 6 hours II. Protein content in daily urine 0.3 g. and more
heavy preeclampsia	I. BP numbers 160/100 mm Hg. Art. and above, measured at least twice with an interval of 6 hours in a horizontal position of a pregnant woman and/or II. Proteinuria 5 grams per day or more or 3 grams in separate portions of urine obtained twice with a difference of 4 hours or more and / or joining the symptoms of moderate preeclampsia at least one of the following: - oliguria, 500 ml per day or less; - pulmonary edema or respiratory failure (cyanosis); - pain in the epigastrium or right hypochondrium, nausea, vomiting, deterioration of liver function; - cerebral disorders (headache, impaired consciousness, visual impairment - photopsy); - thrombocytopenia (below 100x109/ml); - severe fetal growth retardation; - beginning before 32-34 weeks and the presence of signs of fetoplacental insufficiency.
The diagnosis of severe preeclampsia is established by the presence of: - two main criteria for severe (AH and proteinuria) or - one main criterion of any degree and an additional criterion. Eclampsia is a condition in which the clinical manifestations of preeclampsia are dominated by brain lesions, accompanied by a convulsive syndrome that cannot be explained by other causes, and the period of resolution following it. Eclampsia can develop against the background of preeclampsia of any severity, and is not a manifestation of the maximum severity of preeclampsia.

Complications of preeclampsia

The main complications of preeclampsia are:

hypertensive encephalopathy;
hemorrhagic stroke;
subarachnoid hemorrhage;
premature detachment of the placenta (7-11%);
DIC (8%);
acute fetal hypoxia (48%) and intrauterine fetal death;
pulmonary edema (3-5%);
pulmonary heart failure (2-5%);
aspiration pneumonia (2-3%);
visual impairment;
acute renal failure (5-9%);
liver hematoma (1%);
HELLP syndrome (10-15%);
postpartum psychosis.

Diagnosis of preeclampsia

Diagnosis of preeclampsia is primarily to establish the presence of the above symptoms. In some cases, the differential diagnosis of preeclampsia and arterial hypertension that existed before pregnancy is difficult.

Differential diagnosis of hypertensive complications of pregnancy

Clinical signs	Chronic hypertension	Preeclampsia
Age	often age (more than 30 years)	often young (years)
Parity pregnancy	multi-pregnant	primigravida
The emergence of clinical signs	up to 20 weeks	≥ 20 weeks
Degree of hypertension	moderate or heavy	moderate or heavy
Proteinuria	absent	usually available
increase body weight	gradual	significant in a short time period of time
Serum urea blood more than 5.5g/l (0.33mmol/l)	rarely	there is practically Always
Hemoconcentration	absent	present in severe degree
Thrombocytopenia	absent	present in severe degree
Hepatic dysfunction	absent	present in severe degree
Ophthalmoscopic painting	arteriovenous crossovers, exudates	spasm, swelling
Myocardial hypertrophy left ventricle	Often	rarely

Treatment of preeclampsia

1. Delivery- the most effective and the only pathogenetically substantiated method of treatment.

With moderate preeclampsia, the pregnant woman should be hospitalized to clarify the diagnosis and carefully monitor her condition and the fetus, but it is possible to continue gestation up to 37 weeks. With a deterioration in the condition of the mother and fetus, delivery is indicated.
In severe preeclampsia, you must first stabilize the mother's condition, and then decide on delivery, preferably after the prevention of fetal respiratory distress syndrome, if the pregnancy is less than 34 weeks.

2. Antihypertensive therapy

Purpose of treatment- maintain blood pressure within the limits that are kept on normal level indicators of utero-fetal blood flow and reduce the risk of developing eclampsia.

Antihypertensive therapy should be carried out, constantly monitoring the condition of the fetus, because a decrease in placental blood flow provokes its progression functional disorders. The criterion for initiating antihypertensive therapy is BP ≥ 140/90 mm Hg. Art.

Main medicines used to treat hypertension during pregnancy:

Methyldopa (dopegyt)- antihypertensive drug of central action, α2-adrenergic agonist (first-line drug);
Nifedipine- calcium channel blocker (second-line drug);
β-blockers: metoprolol, propranolol, sotalol, bisoprolol;
According to indications: verapamil, clonidine, amlodipine.

3. Prevention and treatment of seizures

For the prevention and treatment of seizures, the main drug is magnesium sulfate (MgSO 4). The indication for anticonvulsant prophylaxis is severe preeclampsia if there is a risk of developing eclampsia. With moderate preeclampsia - in some cases, the council decides, because this increases the risk of caesarean section and there are a number side effects. The mechanism of action of magnesium is explained by a violation of the flow of calcium ions into the smooth muscle cell.

In addition, it is necessary to control the water balance, pay attention to the treatment of oliguria and pulmonary edema when they occur, normalize the function of the central nervous system, the rheological properties of blood, and improve fetal blood flow.

Forecast. Prevention

Today, up to 64% of deaths from preeclampsia are preventable.

The main factors of high-quality and timely assistance:

identifying women at high risk;
quality management of pregnancy until clinical complications of pregnancy;
adequate tactics after the clinical manifestation of an obstetric complication.

Unfortunately, today there are no sufficiently sensitive and specific tests that would provide early diagnosis/detection of the risk of developing preeclampsia.

Risk factors for developing preeclampsia:

1. antiphospholipid syndrome;

2. kidney disease;

3. history of preeclampsia;

4. forthcoming first birth;

5. chronic hypertension;

6. diabetes mellitus;

7. residents of highland areas;

8. multiple pregnancy;

9. cardiovascular diseases in the family (strokes / heart attacks in close relatives);

10. systemic diseases;

11. obesity;

12. history of preeclampsia in the patient's mother;

13. age 40 and older;

14. weight gain during pregnancy over 16 kg.

It has been established that preeclampsia is characterized by insufficient angiogenesis - the process of vessel formation. It involves about 20 stimulating and 30 angiogenesis-inhibiting factors, their list is constantly updated. The most studied and of particular interest from the point of view of studying the pathogenesis of preeclampsia are two proangiogenic factors: vascular endothelial growth factor (VEGF) and placental growth factor (PlGF), antiangiogenic factor - Fms-like tyrosine kinase (Flt-1) and its soluble form (sFlt -1).

An increase in the content of this sFlt-1 with a simultaneous decrease in VEGF and PlGF begins 5-6 weeks before clinical manifestations preeclampsia. This fact allows predicting the development of preeclampsia in women at risk in the first trimester of pregnancy. However, other researchers noted that despite the high sensitivity of the test (96%), the isolated determination of sFlt-1 cannot be used in the diagnosis of preeclampsia due to low specificity. Thus, detection of changes in the ratio of PlGF and sFlt-1 levels during pregnancy may play an important supporting role in confirming the diagnosis of preeclampsia.

Today, there are commercial kits that allow you to conduct an enzyme immunoassay to determine the likelihood of developing preeclampsia, based on the determination of the content of PlGF (DELFIA Xpress PlGF kit, PerkinElmer; USA), screening tests for the prediction and early diagnosis of preeclampsia, based on the determination of the ratio of sFlt-1 and PlGF (Elecsys sFlt-1/PlGF, Roche, Switzerland).

Due to impaired trophoblast invasion, vascular resistance in the uterine artery increases and placental perfusion decreases. An increase in uterine artery pulse index and systole-diastolic ratio at 11-13 weeks of gestation is the best predictor of preeclampsia and is highly recommended for use in clinical practice in pregnant women at risk.

Due to the fact that there is no comprehensive information on the etiology and pathophysiology of preeclampsia, the development of effective preventive measures presents certain difficulties.

Only proven acceptance today 2 groups of drugs for the prevention of preeclampsia:

Aspirin at low doses (75 mg per day) from 12 weeks before delivery. In this case, it is necessary to take the written informed consent of the patient, since according to the instructions for use, taking aspirin is contraindicated in the first trimester.

Pregnant women with low calcium intake (<600 мг в день) назначают calcium preparations- not less than 1 gr. in a day. The average calcium intake in Russia is 500-750 mg/day, and the current physiological daily intake for pregnant women is at least 1000 mg.