Acute preeclampsia. Preeclampsia (preeclampsia). Classification and stages of development of preeclampsia

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Eclampsia and preeclampsia are pathological conditions that occur during pregnancy. Both conditions are not independent diseases, but are syndromes of insufficiency of various organs, combined with various symptoms of damage to the central nervous system of varying severity. Preeclampsia and eclampsia are pathological conditions that develop exclusively during pregnancy. In a non-pregnant woman or man, neither preeclampsia nor eclampsia can develop in principle, since these conditions are provoked by disturbances in the relationship of the mother-placenta-fetus system.

Since the causes and mechanisms of development of eclampsia and preeclampsia have not yet been finally elucidated, the world has not made an unambiguous decision to which particular nosology these syndromes should be attributed. According to scientists from Europe, the USA, Japan and experts from the World Health Organization, preeclampsia and eclampsia are syndromes related to manifestations of hypertension in pregnant women. This means that eclampsia and preeclampsia are considered precisely as varieties of arterial hypertension in pregnant women. In Russia and some countries of the former USSR, eclampsia and preeclampsia are types of preeclampsia, that is, they are considered a variant of a completely different pathology. In this article, we will use the following definitions of eclampsia and preeclampsia.

Preeclampsia is a syndrome of multiple organ failure that occurs only during pregnancy. This syndrome is a condition in which a woman after the 20th week of pregnancy develops persistent hypertension, combined with generalized edema and excretion of protein in the urine (proteinuria).

Eclampsia- these are the predominant clinical manifestations of brain damage with convulsions and coma against the background of the general symptoms of preeclampsia. Convulsions and coma develop due to severe damage to the central nervous system by excessively high blood pressure.

Classification of eclampsia and preeclampsia

According to the classification of the World Health Organization, eclampsia and preeclampsia occupy the following place in the classification of hypertension in pregnant women:
1. Chronic arterial hypertension that existed before pregnancy;
2. Gestational hypertension that occurs during pregnancy and provoked by the bearing of the fetus;
3. Preeclampsia:

Mild degree of preeclampsia (non-severe);
Severe preeclampsia.

4. Eclampsia.

The above classification clearly illustrates that eclampsia and preeclampsia are varieties of hypertension that develops in pregnant women. Preeclampsia is a condition that precedes the development of eclampsia. However, eclampsia does not necessarily develop with only severe preeclampsia, it can also occur with mild preeclampsia.

In Russian practical obstetrics, the following classification is often used:

Edema of pregnant women;
Nephropathy 1, 2 or 3 degrees;
preeclampsia;
Eclampsia.

However, according to the instructions of the World Health Organization, nephropathy of any severity is classified as preeclampsia, without being separated into a separate nosological structure. It is precisely because of the presence of nephropathy in the Russian classification that obstetricians and gynecologists consider preeclampsia a short-term condition preceding eclampsia. And foreign obstetrician-gynecologists refer to preeclampsia as nephropathy of the 1st, 2nd and 3rd degrees, and therefore they believe that it can last for quite a long period of time. However, as noted by foreign practicing obstetricians, before an attack of eclampsia, the course of preeclampsia is sharply aggravated for a short period of time. It is this spontaneous and abrupt worsening of the course of preeclampsia that is considered a direct precursor of eclampsia, and when it occurs, it is necessary to urgently hospitalize a woman in an obstetric hospital.

Foreign experts diagnose preeclampsia if a woman has hypertension (pressure above 140/90 mm Hg), edema and proteinuria (protein content in daily urine is more than 0.3 g/l). Domestic experts regard these symptoms as nephropathy. Moreover, the severity of nephropathy is determined by the severity of the three symptoms listed (the volume of edema, the magnitude of the pressure, the concentration of protein in the urine, etc.). But if the three symptoms (Zantgemeister triad) are joined by headache, vomiting, abdominal pain, blurred vision (visible "as in a fog", "flies before the eyes"), a decrease in urine output, then Russian obstetricians diagnose preeclampsia. Thus, from the point of view of foreign experts, nephropathy is a serious pathology that must be attributed to preeclampsia, and not wait for a sharp deterioration in the condition preceding eclampsia. In the future, we will use the term "preeclampsia", investing in it an understanding of the essence of foreign obstetricians, since the treatment guidelines used in almost all countries, including Russia, were developed by these specialists.

In general, to understand the classifications, you should know that preeclampsia is hypertension in combination with proteinuria (protein in the urine at a concentration of more than 0.3 g / l). Depending on the severity of the Zantgemeister triad, mild and severe preeclampsia is distinguished.

Mild preeclampsia is hypertension in the range of 140 - 170/90 - 110 mm Hg. Art. in combination with proteinuria with or without edema. Severe preeclampsia is diagnosed when blood pressure is above 170/110 mm Hg. Art. associated with proteinuria. In addition, severe preeclampsia includes any hypertension associated with proteinuria and any of the following:

Strong headache;
Visual impairment (veil, flies, fog before the eyes);
Pain in the abdomen in the region of the stomach;
Nausea and vomiting;
Convulsive readiness;
Generalized edema of the subcutaneous tissue (swelling throughout the body);
Decrease in urine output (oliguria) less than 500 ml per day or less than 30 ml per hour;
Soreness when probing the liver;
The number of platelets in the blood is below 100 * 106 pieces / l;
Increased activity of hepatic transaminases (AST, ALT) above 90 IU / l;
HELLP syndrome (destruction of red blood cells, high activity of hepatic transaminases, platelet count below 100 * 106 pieces / l);
IUGR (intrauterine growth retardation).

Severe and mild preeclampsia reflect the varying severity of damage to the internal organs of a pregnant woman. Accordingly, the more severe the preeclampsia, the greater the damage to the internal organs, and the higher the risk of developing adverse consequences for the mother and fetus. If severe preeclampsia is not amenable to drug therapy, then the only treatment is abortion.

The classification of preeclampsia into mild and severe is generally accepted in Europe and the United States, as well as recommended by the World Health Organization. The Russian classification has a number of differences. In the Russian classification, mild preeclampsia corresponds to grade I and II nephropathy, and severe preeclampsia is grade III nephropathy. Preeclampsia in the Russian classification is actually the initial stage of eclampsia.

Depending on the moment at which eclampsia develops, it is divided into the following varieties:

Eclampsia occurring during pregnancy(accounts for 75 - 85% of all cases of eclampsia);
Eclampsia in childbirth, arising directly in the process of childbirth (approximately 20 - 25% of all cases of eclampsia);
postpartum eclampsia that occurs within a day after delivery (approximately 2 - 5% of all cases of eclampsia).

All of the listed varieties of eclampsia develop according to exactly the same mechanisms, and therefore have the same clinical manifestations, symptoms and severity. Moreover, even the principles of treatment of any of the above varieties of eclampsia are the same. Therefore, the classification and distinction of eclampsia depending on the time of its occurrence is of no practical importance.

Depending on the prevailing symptoms and damage to any organ, three clinical forms of eclampsia are distinguished:

Typical form of eclampsia characterized by severe edema of the subcutaneous tissue of the entire surface of the body, increased intracranial pressure, severe proteinuria (protein concentration is more than 0.6 g / l in daily urine) and hypertension more than 140/90 mm Hg;
Atypical form of eclampsia most often develops during prolonged labor in women with a labile nervous system. This form of eclampsia is characterized by cerebral edema without subcutaneous tissue edema, as well as slight hypertension, increased intracranial pressure and moderate proteinuria (protein concentration in daily urine from 0.3 to 0.6 g / l);
Renal or uremic form of eclampsia develops in women with kidney disease before pregnancy. The renal form of eclampsia is characterized by slight or no edema of the subcutaneous tissue, but the presence of a large amount of fluid in the abdominal cavity and fetal bladder, as well as moderate hypertension and intracranial pressure.

Eclampsia and preeclampsia - causes

Unfortunately, the causes of eclampsia and preeclampsia are currently not fully understood. Only one thing is known for certain - these conditions develop exclusively during pregnancy, and therefore are inextricably linked with a violation of normal relationships in the mother-placenta-fetus system. There are more than thirty different theories for the development of eclampsia and preeclampsia, among which the following are the most complete and prognostically significant:

Genetic mutations (defects in the eNOS, 7q23-ACE, HLA, AT2P1, C677T genes);
Antiphospholipid syndrome or other thrombophilias;
Chronic pathologies of non-genital organs;
Infectious diseases.

Unfortunately, at present there is no test that allows you to find out whether eclampsia will develop in this particular case with or without predisposing factors. Many modern scientists believe that preeclampsia is genetically determined by the insufficiency of the processes of adaptation of the woman's body to new conditions. However, it is known that the trigger for the development of preeclampsia is fetoplacental insufficiency and the risk factors that a woman has.

Risk factors for preeclampsia and eclampsia include the following:
1. Presence of severe preeclampsia or eclampsia during previous pregnancies;
2. The presence of severe preeclampsia or eclampsia in the mother or other blood relatives (sisters, aunts, nieces, etc.);
3. Multiple pregnancy;
4. First pregnancy (preeclampsia develops in 75-85% of cases during the first pregnancy, and only in 15-25% during subsequent ones);
5. antiphospholipid syndrome;
6. The age of the pregnant woman is over 40;
7. The interval between previous and present pregnancy is more than 10 years;
8. Chronic diseases of internal non-genital organs:

Arterial hypertension;
kidney pathology;
Diseases of the cardiovascular system;

Eclampsia and preeclampsia - pathogenesis

Currently, the leading theories of the pathogenesis of preeclampsia and eclampsia are neurogenic, hormonal, immunological, placental and genetic, explaining various aspects of the mechanisms of development of pathological syndromes. Thus, neurogenic, hormonal and renal theories of the pathogenesis of eclampsia and preeclampsia explain the development of pathologies at the organ level, and genetic and immunological - at the cellular and molecular level. Each theory separately cannot explain the whole variety of clinical manifestations of preeclampsia and eclampsia, so they all complement each other, but do not replace.

Currently, scientists believe that the initial link in the pathogenesis of preeclampsia and eclampsia is laid at the time of migration of the cytotrophoblast of the fetal egg. The cytotrophoblast is a structure that provides nutrition and also supports the growth and development of the fetus until the placenta is formed. It is on the basis of cytotrophoblast that a mature placenta is formed by the 16th week of pregnancy. Before the formation of the placenta, trophoblast migration occurs. If the migration and invasion of the trophoblast into the uterine wall is insufficient, then in the future this will provoke preeclampsia and eclampsia.

With incomplete invasion of the migrating trophoblast, the uterine arteries do not develop and do not grow, as a result of which they are not ready to ensure further life, growth and development of the fetus. As a result, as pregnancy progresses, the uterine arteries spasm, which reduces blood flow to the placenta and, accordingly, to the fetus, creating chronic hypoxia conditions for it. With severe insufficiency of the blood supply to the fetus, there may even be a delay in its development.

Spasmodic uterine vessels become inflamed, which leads to swelling of the cells that form their inner lining. Fibrin is deposited on the inflamed and swollen cells of the inner layer of blood vessels, forming blood clots. As a result, the blood flow in the placenta is even more disturbed. But the pathological process does not stop there, since inflammation of the cells of the inner lining of the vessels of the uterus spreads to other organs, primarily to the kidneys and liver. As a result, the organs are poorly supplied with blood and develop a failure of their function.

Inflammation of the inner lining of the vascular wall leads to their strong spasm, which reflexively increases the blood pressure in a woman. Under the influence of inflammation of the inner lining of blood vessels, in addition to hypertension, the formation of pores, small holes in their wall, through which fluid begins to seep into the tissue, forming edema. High blood pressure increases the perspiration of fluid into the tissues and the formation of edema. Therefore, the higher the hypertension, the stronger the edema in preeclampsia in a pregnant woman.

Unfortunately, as a result of the inflammatory process, the vascular wall is damaged, and therefore insensitive to various biologically active substances that relieve spasm and dilate blood vessels. Therefore, hypertension is permanent.

In addition, due to damage to the vascular wall, blood clotting processes are activated, for which platelets are consumed. As a result, the supply of platelets is exhausted, and their number in the blood decreases to 100 * 106 pieces / l. After the platelet pool is depleted, a woman has partial hemophilia, when the blood clots poorly and slowly. Low blood clotting against the background of high blood pressure creates a high risk of stroke and cerebral edema. As long as a pregnant woman does not have cerebral edema, she suffers from preeclampsia. But as soon as the development of cerebral edema begins, this indicates the transition of preeclampsia to eclampsia.

The period of increased blood clotting and the subsequent development of hemophilia in eclampsia is a chronic DIC.

Eclampsia and preeclampsia - symptoms and signs

The main symptoms of preeclampsia are edema, hypertension, and proteinuria (the presence of protein in the urine). Moreover, for a diagnosis of preeclampsia, a woman does not have to have all three symptoms, only two are enough - a combination of hypertension with edema or hypertension with proteinuria.

Edema in preeclampsia can be of varying severity and prevalence. For example, some women have only swelling on the face and legs, while others have it all over the body. Pathological edema in preeclampsia differs from normal, characteristic of any pregnant woman, in that they do not decrease and do not disappear after a night's rest. Also, with pathological edema, a woman gains weight very quickly - more than 500 g per week after the 20th week of pregnancy.

Proteinuria is the detection of protein in an amount of more than 0.3 g / l in the daily portion of urine.

Hypertension in a pregnant woman is considered to be an increase in blood pressure above 140/90 mm Hg. Art. In this case, the pressure is in the range of 140 - 160 mm Hg. Art. for systolic value and 90 - 110 mm Hg. Art. for diastolic it is considered moderate hypertension. Pressure above 160/110 mm Hg. Art. considered severe hypertension. The division of hypertension into severe and moderate is important in determining the severity of preeclampsia.

In addition to hypertension, edema and proteinuria, in severe preeclampsia, symptoms of damage to the central nervous system and disorders of cerebral circulation are added, such as:

Severe headache;
Visual impairment (a woman indicates blurred vision, a feeling of flies running in front of her eyes and fog, etc.);
Pain in the abdomen in the region of the stomach;
Nausea and vomiting;
Convulsive readiness;
Generalized edema;
Decreased urination to 500 ml or less per day or less than 30 ml per hour;
Soreness when probing the liver through the anterior abdominal wall;
Decrease in the total number of platelets less than 100 * 106 pieces / l;
Increased activity of AST and ALT more than 70 IU / l;
HELLP-syndrome (destruction of red blood cells, low levels of platelets in the blood and high activity of AST and ALT);
Intrauterine growth retardation (IUGR).

The above symptoms appear against the background of increased intracranial pressure and associated moderate cerebral edema.

mild preeclampsia characterized by the obligatory presence of hypertension and proteinuria in a woman. Edema may or may not be present. Severe preeclampsia characterized by the obligatory presence of severe hypertension (pressure above 160/110 mm Hg) in combination with proteinuria. In addition, preeclampsia is classified as severe, in which a woman has any level of hypertension in combination with proteinuria and any one of the symptoms of cerebrovascular accident or CNS damage listed above (headache, blurred vision, nausea, vomiting, abdominal pain, decreased urination, etc.).

When symptoms of severe preeclampsia appear, a woman must be urgently hospitalized in an obstetric hospital and begin antihypertensive and anticonvulsant treatment aimed at normalizing pressure, eliminating cerebral edema and preventing eclampsia.

Eclampsia is a seizure that develops against the background of edema and brain damage due to previous preeclampsia. That is, the main symptom of eclampsia is convulsions in combination with a woman's coma. Convulsions in eclampsia can be different:

Single convulsive seizure;
A series of convulsive seizures following one after another at short intervals (eclamptic status);
Loss of consciousness after a seizure (eclamptic coma);
Loss of consciousness without a seizure (eclampsia without eclampsia or coma hepatica).

Immediately before eclamptic convulsions, a woman may experience an increase in headache, worsening sleep up to insomnia, and a significant increase in pressure. One seizure in eclampsia lasts 1 to 2 minutes. At the same time, it begins with twitching of the facial muscles, and then convulsive contractions of the muscles of the whole body begin. After the violent convulsions of the muscles of the body are over, consciousness slowly returns, the woman comes to her senses, but does not remember anything, therefore she is not able to tell about what happened.

Eclamptic seizures develop due to deep CNS damage during cerebral edema and high intracranial pressure. The excitability of the brain is greatly increased, so any strong stimulus, such as bright light, noise, sharp pain, etc., can provoke a new attack of seizures.

Eclampsia - periods

A convulsive seizure in eclampsia consists of the following consecutive periods:
1. Preconvulsive period lasting for 30 seconds. At this time, the woman begins to have small twitches of the facial muscles, her eyes are covered with eyelids, and the corners of her mouth are lowered;
2. Period of tonic convulsions , which also lasts an average of about 30 seconds. At this moment, the woman's torso is stretched, the spine is bent, the jaws are tightly compressed, all the muscles are contracting (including the respiratory ones), the face turns blue, the eyes look at one point. Then, when the eyelids tremble, the eyes roll up, as a result of which only the whites become visible. The pulse stops being felt. Due to the contraction of the respiratory muscles, the woman does not breathe during this period. This phase is the most dangerous, because sudden death can occur due to respiratory arrest, most often from cerebral hemorrhage;
3. Period of clonic convulsions lasting from 30 to 90 seconds. With the beginning of this period, lying motionless with tense muscles, the woman begins to literally convulse. Convulsions pass one after another and spread through the body from top to bottom. The convulsions are violent, the muscles of the face, trunk and limbs twitch. During convulsions, the woman does not breathe, and the pulse is not felt. Gradually, the convulsions weaken, become less frequent and, finally, completely stop. During this period, the woman takes her first loud breath, begins to breathe noisily, foam comes out of her mouth, often stained with blood due to a bitten tongue. Gradually breathing becomes deep and rare;
4. Seizure resolution period lasts several minutes. At this time, the woman slowly regains consciousness, her face turns pink, the pulse begins to be felt, and the pupils slowly narrow. There is no memory of the seizure.

The total duration of the described periods of eclamptic convulsions is 1-2 minutes. After the seizure, the woman's consciousness may recover, or she may fall into a coma. A coma develops in the presence of cerebral edema and continues until the moment when it subsides. If a coma during eclampsia lasts for hours and days, then the prognosis for the life and health of a woman is unfavorable.

Eclampsia and preeclampsia - principles of diagnosis

To diagnose eclampsia and preeclampsia, the following studies should be performed regularly:

Identification of edema and assessment of their severity and localization;
Blood pressure measurement;
Urinalysis for protein content;
Blood test for hemoglobin concentration, platelet count and hematocrit;
Blood at the time of clotting;
Electrocardiogram (ECG);
Biochemical blood test (total white, creatinine, urea, AlAT, AsAT, bilirubin);
Coagulogram (APTT, PTI, INR, TV, fibrinogen, coagulation factors);
fetal CTG;
fetal ultrasound;
Dopplerometry of the vessels of the uterus, placenta and fetus.

These simple examinations allow you to accurately diagnose preeclampsia and eclampsia, as well as assess their severity.

Emergency care for eclampsia

With eclampsia, it is necessary to lay the pregnant woman on her left side to reduce the risk of vomit, blood and gastric contents entering the lungs. The woman should be laid on a soft bed so that during convulsions she does not inflict accidental injuries on herself. It is not necessary to hold by force during a convulsive eclamptic seizure.

During convulsions, it is recommended to supply oxygen through a mask at a rate of 4 to 6 liters per minute. After the convulsions are over, it is necessary to clean the oral and nasal cavities, as well as the larynx from mucus, blood, foam and vomit by suction.

Immediately after the end of the seizure, magnesium sulfate should be administered intravenously. First, 20 ml of a 25% solution of magnesia is injected within 10-15 minutes, then they switch to a maintenance dosage of 1-2 g of dry matter per hour. For maintenance magnesium therapy, 80 ml of 25% magnesium sulfate is added to 320 ml of saline. The finished solution is administered at 11 or 22 drops per minute. Moreover, 11 drops per minute corresponds to a maintenance dose of 1 g of dry matter per hour, and 22 drops, respectively, 2 g in a maintenance dosage, magnesium sulfate should be administered continuously for 12 to 24 hours. Magnesia therapy is necessary to prevent possible subsequent seizures.

If, after the introduction of magnesia, convulsions recur after 15 minutes, then you should switch to Diazepam. Within two minutes, 10 mg of diazepam should be administered intravenously. With the resumption of seizures, the same dose of Diazepam is re-introduced. Then, for maintenance anticonvulsant therapy, 40 mg of Diazepam is diluted in 500 ml of saline, which is administered over 6 to 8 hours.

Regardless of the gestational age, eclampsia is not an indication for emergency delivery, since it is first necessary to stabilize the woman's condition and achieve cessation of seizures. Only after the relief of convulsive seizures can the question of delivery be considered, which is carried out both through the natural birth canal and through caesarean section.

Eclampsia and preeclampsia - principles of treatment

Currently, there is only symptomatic treatment for preeclampsia and eclampsia, which consists of two components:
1. Anticonvulsant therapy (prevention or relief of seizures against the background of eclampsia);
2. Antihypertensive therapy - lowering and maintaining blood pressure within normal limits.

It has been proven that only antihypertensive and anticonvulsant therapy is effective for the survival and successful development of the fetus and woman. The use of antioxidants, diuretics to eliminate edema, and other treatment options for preeclampsia and eclampsia are ineffective, do not benefit either the fetus or the woman, and do not improve their condition. Therefore, today, with eclampsia and preeclampsia, only symptomatic therapy is carried out to prevent seizures and reduce pressure, which, in most cases, is effective.

However, symptomatic therapy of preeclampsia and eclampsia is not always effective. After all, the only remedy that can completely cure preeclampsia and eclampsia is getting rid of pregnancy, since it is the bearing of a child that is the cause of these pathological syndromes. Therefore, if symptomatic antihypertensive and anticonvulsant treatment is ineffective, an urgent delivery is performed, which is necessary to save the mother's life.

Anticonvulsant therapy

Anticonvulsant therapy for eclampsia and preeclampsia is performed using intravenous administration of magnesium sulfate (magnesia). Magnesia therapy is divided into loading and maintenance doses. As a loading dose, 20 ml of 25 magnesia solution (5 g in terms of dry matter) is injected intravenously within 10-15 minutes for a woman once.

Then a solution of magnesia in a maintenance dose, which is 1 - 2 g of dry matter per hour, is injected continuously for 12 - 24 hours. To obtain magnesia in a maintenance dosage, it is necessary to combine 320 ml of saline with 80 ml of a 25% magnesium sulfate solution. Then the finished solution is injected at a rate of 11 drops per minute, which is equivalent to 1 g of dry matter per hour. If the solution is injected at a rate of 22 drops per hour, then this will correspond to 2 g of dry matter per hour.

With continuous administration of magnesium, symptoms of magnesium overdose should be monitored, which include the following:

Breathing less than 16 per minute;
Decreased reflexes;
Reducing the amount of urine less than 30 ml per hour.

If the described symptoms of an overdose of magnesium appear, the infusion of magnesium should be stopped and an antidote should be immediately administered intravenously - 10 ml of a 10% solution of calcium gluconate.

Anticonvulsant therapy is given intermittently throughout pregnancy as long as preeclampsia or the risk of eclampsia persists. The frequency of magnesium therapy is determined by the obstetrician.

Antihypertensive therapy

Antihypertensive therapy for preeclampsia and eclampsia is to bring the pressure to 130 - 140/90 - 95 mm Hg. Art. and keeping it within the specified limits. Currently, the following antihypertensive drugs are used to reduce pressure in eclampsia or preeclampsia of pregnant women:

Nifedipine- take 10 mg (0.5 tablets) once, then 30 minutes later another 10 mg. Then during the day, if necessary, you can take one tablet of Nifedipine. The maximum daily dose is 120 mg, which corresponds to 6 tablets;
Sodium nitroprusside - is administered intravenously slowly, the initial dosage is calculated from the ratio of 0.25 mcg per 1 kg of body weight per minute. If necessary, the dose can be increased by 0.5 mcg per 1 kg of body weight every 5 minutes. The maximum dosage of sodium nitroprusside is 5 mcg per 1 kg of body weight per minute. The drug is administered until normal pressure is reached. The maximum duration of sodium nitroprusside infusion is 4 hours.

The above drugs are fast-acting and are used only for a single pressure reduction. For its subsequent maintenance within normal limits, preparations containing as an active substance methyldopa(for example, Dopegyt, etc.). Methyldopa should be started at 250 mg (1 tablet) once a day. Every 2-3 days, the dosage should be increased by another 250 mg (1 tablet), bringing it to 0.5-2 g (2-4 tablets) per day. At a dosage of 0.5 - 2 g per day, methyldopa is taken throughout pregnancy until delivery.

If a sharp attack of hypertension occurs, the pressure is normalized with Nifedipine or Sodium nitroprusside, after which the woman is again transferred to methyldopa.

After childbirth, magnesium therapy should be carried out during the day, consisting of loading and maintenance dosages. Antihypertensive drugs after childbirth are used individually, canceling gradually.

Rules for delivery in eclampsia and preeclampsia

With eclampsia, regardless of the gestational age, delivery is performed within 3 to 12 hours after the relief of seizures.

With mild preeclampsia, delivery is carried out at 37 weeks of gestation.

In severe preeclampsia, regardless of the gestational age, delivery is performed within 12 to 24 hours.

Neither eclampsia nor preeclampsia are absolute indications for caesarean section, moreover, vaginal delivery is preferable. Delivery by caesarean section is performed only with placental abruption or with unsuccessful attempts to induce labor. In all other cases, women with preeclampsia or eclampsia have vaginal delivery. At the same time, they do not wait for the natural onset of childbirth, but carry out their induction (induction). Childbirth with eclampsia or preeclampsia is necessarily carried out with the use of epidural anesthesia and against the background of careful monitoring of the fetal heart rate using CTG.

Complications of eclampsia

An attack of eclampsia can provoke the following complications:

Pulmonary edema;
aspiration pneumonia;
Cerebral hemorrhage (stroke) followed by hemiplegia or paralysis;
Retinal detachment followed by temporary blindness. Usually vision is restored within a week;
Psychosis, lasting from 2 weeks to 2 - 3 months;
Coma;
swelling of the brain;
Sudden death due to infringement of the brain against the background of its edema.

Prevention of eclampsia and preeclampsia

Currently, the effectiveness of the following drugs for the prevention of eclampsia and preeclampsia has been proven:

Taking small doses of Aspirin (75 - 120 mg per day) from the beginning to the 20th week of pregnancy;
Taking calcium preparations (for example, calcium gluconate, calcium glycerophosphate, etc.) at a dosage of 1 g per day throughout pregnancy.

Aspirin and calcium for the prevention of eclampsia and preeclampsia should be taken by women who have risk factors for the development of these pathological conditions. Women who are not at risk of developing eclampsia and preeclampsia can also take aspirin and calcium as a preventive measure.

Preeclampsia is a condition that occurs in pregnant women and is characterized by increased, as well as the presence of protein in the urine. In most cases, preeclampsia appears in the second half of pregnancy, closer to the third trimester. Therefore, preeclampsia is referred to as late toxicosis of pregnant women. In exceptional cases, the manifestation of preeclampsia at an earlier date is possible.

After preeclampsia, the most severe form of late toxicosis () follows - eclampsia. Eclampsia is accompanied by convulsions and loss of consciousness. Convulsions begin suddenly and cover the whole body. The danger is that eclampsia can cause coma and even death for both the mother and her unborn child. What can develop eclampsia before, during, and after childbirth.

Causes of Preeclampsia in Pregnancy

Despite the fact that eclampsia was described in ancient medical treatises, what exactly causes it is not known. In the same way, it is quite difficult to say what exactly led to the development of preeclampsia preceding it, since the exact cause of this condition has also not been completely established. Some experts cite malnutrition, high levels of body fat, or insufficient blood flow to the uterus among the causes of preeclampsia.

Main features

Signs of preeclampsia include:

main:, protein in the urine, arterial hypertension;
additional: rapid weight gain, dizziness, severe headaches, severe nausea and vomiting, abdominal pain, reflex changes, decreased urine volume, visual disturbances, pain in the epigastric region.

But do not be afraid when reading these lines, since swelling during pregnancy does not mean the presence of preeclampsia at all. Pregnancy is characterized by some swelling. But, if the edema remains even after a long rest and, moreover, is combined with the described symptoms and is accompanied by high blood pressure, this is an alarming bell.

Who can develop preeclampsia?

Women at risk for developing preeclampsia include:

pregnant for the first time;
pregnant at a very young age (before 16) or over 40 years of age;
with the presence of arterial hypertension before pregnancy;
with a strong stage of obesity;
with diseases: diabetes mellitus, lupus erythematosus, rheumatoid arthritis;
with kidney disease;
with multiple pregnancy;
who have experienced preeclampsia in previous pregnancies;
whose mother or sister also had preeclampsia.

Does preeclampsia in pregnancy put the baby in the womb at risk?

Unfortunately yes. With preeclampsia, placental blood flow is disturbed, which leads to the birth of an underdeveloped baby. Moreover, pregnancy complicated by preeclampsia in most cases ends in premature birth. There is also a high risk of having a baby with a variety of pathologies. For example, epilepsy, cerebral palsy, impaired vision and hearing.

How to treat preeclampsia in pregnancy?

There is no specific treatment for preeclampsia. But, in connection with the threat of the transition of this condition into eclampsia, the pregnant woman needs urgent hospitalization. In a hospital, a woman, in order to prevent the occurrence of seizures and lower blood pressure, may be prescribed magnesium sulfate preparations (). The use of magnesium sulfate has been found to halve the risk of developing eclampsia in women with symptoms of preeclampsia. Hydralazine or similar drugs may be used to lower blood pressure. It is also possible to prescribe drugs with anticonvulsant and sedative effects. Especially carefully during this period, the consumption of fluid by a pregnant woman and the volume of urine she excretes are monitored. Also, a pregnant woman is advised to rest as much as possible. During rest, you need to be either lying on your left side, or sitting straight.

Women with mild preeclampsia need gentle care and significant activity restriction.

If there is a risk of preterm birth, doctors will do everything possible to prolong the pregnancy and ensure that the baby is born alive. If the gestational age is already approaching the expected date of birth, childbirth is induced artificially. In the case of a very severe form of preeclampsia, immediate delivery is carried out, despite the gestational age, since the slightest delay in this case is fraught with death.

Fortunately, not every case of preeclampsia ends badly. According to statistics, today there is only one in two hundred cases, which turns out to be tragic.

Prevention of occurrence

There is no 100% reliable way to prevent preeclampsia in pregnancy. However, in order to prevent its development, doctors advise during the period of bearing a baby (especially if a woman is at risk) to be as attentive as possible to her body: rest more, not overstrain, eat right and undergo medical examinations on time. It is necessary to regularly take all tests, even such, at first glance, simple as blood and urine tests. Constant monitoring of the level of protein in the urine, as well as blood pressure, will help determine preeclampsia in its early stages. And this, in turn, will ensure the most favorable outcome.

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Increase in blood pressure.
Detection of protein in urine.
Edema of the face and limbs.
Rapid weight gain associated with fluid retention in the body.
Violation of vision (flickering flies before the eyes, weakening of vision).
Headache that cannot be controlled with analgesics (painkillers).
Pain in the upper abdomen.
Nausea, vomiting.
Symptoms of damage to the central nervous system: lethargy, irritability, memory loss, apathy (indifference), drowsiness or insomnia.
Oliguria (decreased urine output).
Jaundice, which is manifested by a change in skin color (yellowing) and dark urine. Associated with impaired liver function.
Thrombocytopenia (decrease in the content of platelets (blood cells responsible for coagulation and the formation of blood clots (clots) in the blood).

Forms

There are three degrees of severity of preeclampsia.

Light degree: pressure rises to 150/90 mm Hg. Art., the level of protein in the urine - no more than 1 g / l; there is swelling of the legs.
Average degree: blood pressure up to 170/110 mm Hg. Art., the level of protein in the urine up to 5 g / l, blood creatinine (the end product of protein metabolism) 100-300 µmol / l. (an increase in blood creatinine indicates an increased breakdown of protein and insufficiency of kidney function); edema extends to the anterior abdominal wall, arms.
Severe degree: pressure above 170/110 mm Hg. Art., urine protein - above 5 g / l, blood creatinine - more than 300 μmol / l. There are visual disturbances, abdominal pain, headache, swelling (including the face and nasal mucosa).

Causes

The cause of preeclampsia is not fully understood.
Currently, the disease is considered as a genetically determined pathology, in which the adaptation (adaptation) of a woman's body to the conditions of functioning during pregnancy is disrupted.
In the development of the disease, vasospasm plays a decisive role. It occurs due to a violation of the production of hormones that regulate vascular tone (angiotensin, protacycline, thromboxane), or due to an abnormal sensitivity to them. In addition, the viscosity and clotting of blood increases.

Risk factors.

Age over 35-40 years old, teenage girls.
First birth.
(the number of fetuses in the uterus is two or more).
Dropsy of the fetus (edema of the tissues of the fetus and accumulation of fluid in its cavities).
(a disease characterized by a lack of insulin (a hormone produced in the pancreas) or decreased sensitivity to it).
(disease, the main symptom of which is an increase in blood pressure).
Kidney diseases: glomerulonephritis (damage to the capillaries responsible for filtering (purifying) the blood), (pathology of the immune system, in which, among other things, kidney tissue is affected), etc.
(increased volume of amniotic fluid).
Some hereditary conditions (for example, cystinosis, a rare hereditary disease characterized by a primary lesion of the kidneys and eyes).
(overgrowth of placental tissues).

Diagnostics

Analysis of complaints and anamnesis of the disease - when did headaches, swelling appear, were they accompanied by visual impairment, was there an increase in blood pressure during pregnancy, from what time, to what numbers, what was the weight gain from the beginning of pregnancy.
Life history analysis - age, surgical interventions, injuries, chronic kidney disease, cardiovascular system, infectious diseases.
Analysis of obstetric and gynecological history: gynecological diseases, sexually transmitted infections, pregnancies, their course, childbirth.
Inspection data: the presence of edema of the limbs and face, the color of the skin, the presence of lethargy, lethargy.
Observation of the dynamics of weight.
Blood pressure measurement - is carried out to detect high blood pressure, which is one of the signs of preeclampsia.
Urinalysis - is performed to detect protein, sugar, leukocytes (white blood cells) in the urine. Protein in the urine is one of the signs of preeclampsia; sugar in the urine can be a symptom of diabetes mellitus (insufficiency of insulin (a hormone produced by the pancreas)); an elevated white blood cell count in the urine may be a sign of an inflammatory process in the kidneys, which increases the risk of developing preeclampsia.
Analysis of urine collected per day - the amount of protein excreted by the kidneys per day (an indicator of the severity of kidney damage) is examined, as well as the total amount of urine, which decreases with preeclampsia.
A complete blood count is performed to detect anemia (a decrease in the content of red blood cells and hemoglobin responsible for transporting oxygen to cells), signs of inflammatory diseases in the body.
Coagulogram (analysis of the blood coagulation system) - is carried out to detect thrombocytopenia (decrease in the content of platelets (blood cells responsible for clotting and the formation of blood clots (clots)).
A biochemical blood test is carried out to determine the filtering ability of the kidneys and the condition of the liver (the level of AsAT - aspartate aminotransferase, which characterizes the breakdown of liver cells).
Ultrasound examination (ultrasound) of the fetus and internal organs - is carried out to monitor the condition of the fetus and pathological processes in the organs of a woman).
Consultation with an ophthalmologist (examination of the fundus).

Treatment of preeclampsia

Treatment is usually carried out in a hospital. In the event of preeclampsia, the issue of early delivery can be resolved, which is caused by a high risk of development (the most severe complication of pregnancy with damage to the central nervous system), which is fraught with serious complications.

Compliance with bed rest.
Diet with restriction of salt, fat and liquid. Nutrition should include a sufficient amount of protein, important minerals (calcium, potassium, magnesium, etc.) and vitamins.
Correction of the level of arterial pressure.
Maintaining the work of the heart, lungs, liver, kidneys - for this, oxygen is used, vasodilators are prescribed.
Treatment aimed at increasing fetal survival if early delivery is necessary: oxygen, hormonal agents.
Improving uteroplacental blood flow: using vasodilators, using oxygen.
Prevention of seizures: anticonvulsants.
To normalize the work of the central nervous system, psychotropic drugs can be prescribed.

Complications and consequences

, characterized by convulsions, a critical increase in blood pressure, acute renal dysfunction. It poses a serious threat to the life of the woman and the fetus. With eclampsia, there is a high risk of circulatory disorders of the vital organs of the woman and the fetus, and this can lead to death.
- a critical increase in blood pressure.
, characterized by the accumulation of fluid in the tissues of the lungs. Pulmonary edema causes hypoxia (oxygen starvation) and is dangerous for the woman and the fetus.
Fetal death.
Lethal outcome for a woman.

Prevention of preeclampsia

Pregnancy planning (exclusion of unwanted pregnancy).
Timely preparation for pregnancy (detection and treatment of chronic and gynecological diseases before pregnancy).
Examination and treatment of concomitant diseases before pregnancy.
Timely registration of a pregnant woman in a antenatal clinic (up to 12 weeks of pregnancy).
Regular visits (1 time per month in the 1st trimester, 1 time in 2-3 weeks in the 2nd trimester, 1 time in 7-10 days in the 3rd trimester).
Fulfillment of all doctor's prescriptions (analysis, research, treatment).

- this is a complication of pregnancy, characterized by the occurrence of arterial hypertension and proteinuria (detection of protein in the urine test) after pregnancy. In some cases, preeclampsia causes dysfunction of the liver, kidneys, lungs, and brain.

In medicine, preeclampsia is called late or arterial hypertension of pregnant women.

Who is at risk

Women who have at least one of the following characteristics are at increased risk of developing preeclampsia:

first pregnancy (without miscarriages and abortions);
chronic arterial hypertension, kidney disease, lupus erythematosus or diabetes before pregnancy;
multiple pregnancy (for example, twins or triplets);
family history of preeclampsia;
the presence of preeclampsia in the history of the disease;
age up to 20 years, or over 35 years;
obesity.

Causes of preeclampsia during pregnancy

Anomalies in the development of the blood vessels of the uterus and placenta that occur in the early stages of pregnancy activate processes that ultimately lead to preeclampsia. The cause of the symptoms of the disease are changes inside the small arteries, which reduce blood flow to the kidneys, liver, brain and to the placenta itself. What is the trigger mechanism for such violations for physicians remains a mystery.

Maternal preeclampsia

Most pregnant women with preeclampsia have slightly elevated blood pressure and a small amount of excess protein in their urine. Otherwise, the clinical picture of the disease is stable and does not cause concern. However, there are cases when the signs of preeclampsia signal the seriousness of the situation:

strong;
vision problems (blurred or double vision, blind spots, light flashes, loss of vision);
shortness of breath due to the presence of fluid in the lungs;
pain in the epigastric region (like heartburn);
blood pressure >160/110 mmHg st;
poor renal function tests (eg, serum creatinine >1.1 mg/dL);
platelets<100 000/мм3;
abnormal liver function (according to the results of a blood test);
pulmonary edema.

Fetal Preeclampsia

This disease can adversely affect the ability of the placenta to provide the baby with adequate nutrition and oxygen, which can have certain consequences:

unsatisfactory results of the non-stress test and the biophysical profile of the fetus;
slow growth of the child (usually noted with help);
a decrease in the amount of amniotic fluid around the child;
decrease in the intensity of blood flow in the vessels of the umbilical cord (determined using dopplerometry).

Can preeclampsia be prevented during pregnancy?

There are no tests that predict with certainty when to expect complications of this kind, and there are no ways to prevent them. For expectant mothers who are at risk, doctors may recommend low-dose aspirin. You can start taking the drug from the end of the first trimester until the end of the pregnancy.

Treatment of preeclampsia during pregnancy

the only preeclampsia treatment is the birth of a child and a placenta. Bed rest and medications can lower blood pressure and consequently reduce the risk of stroke, but these procedures will not affect the underlying vascular abnormalities in the mother, and thus will not stop the progression of the disease.

Pregnancy management program, complicated by preeclampsia, is formed taking into account the gestational age of the fetus and the presence of severe signs of the disease. Method of delivery, whether vaginal or C-section, depends on a number of factors such as the position of the fetus, the opening and thinning of the cervix, as well as the general condition of the child. In most cases, the baby is born vaginally.

To stimulate the uterus, obstetricians use oxytocin, which is administered intravenously. If labor activity is weak or accompanied by any abnormalities that require a quick extraction of the child, a caesarean section is performed.

With a full-term pregnancy, the appearance of preeclampsia at term no longer poses a threat to the health of a woman or her child. Babies born at term are not at high risk for complications from preterm birth and usually do not need an extra stay in an incubator.

If preeclampsia develops at an earlier date and there are no serious signs of the disease, the possibility of postponing childbirth is allowed. This gives the baby extra time to gain the right weight and complete fetal development. With more serious symptoms of the disease, entailing a threat to the health of the woman in labor and the baby, a delivery operation is performed.

Preeclampsia of pregnant women with delayed delivery

In delayed delivery, the mother and baby are closely monitored, which includes the following:

Help with childbirth

To prevent an attack of eclampsia (a more severe form of preeclampsia), an intravenous injection of a solution of magnesia is given during childbirth and within 24 hours after childbirth. To prevent a stroke in the mother, drugs are administered to relieve high blood pressure.

Preeclampsia is a well-known toxicosis in the last trimester. It can give complications and then preeclampsia develops. For the expectant mother, you should find out in advance the problems associated with this pathology. How terrible are the consequences directly for the woman and the child.

What is preeclampsia in pregnancy

So, what is preeclampsia in pregnancy? This is a kind of late toxicosis, manifested by the presence.

In rare cases, these symptoms can disturb the expectant mother in the early stages.

The disease can worsen and go into a more serious stage of eclampsia. The disease is dangerous for the life of the mother and child.

Its symptoms develop rapidly both before childbirth, during and after them. Seizures begin throughout the body, which can turn into a coma and lead to death.

For a short period of time, relapses of typical muscle contractions are possible.

Causes

The exact reasons why this disease develops have not been established, however, there are some reasonable versions:

rejection of the fetus due to immunological changes in the woman's body;
abnormal in uterus with enlargement of spiral arteries
violation ;
tendency to form in the blood in a latent form. The process develops with a large amount of the hormone thromboxane 2;
imbalance between the cerebral cortex and subcortical structures, which contributes to poor blood flow through the vessels;
in the last stages of pregnancy, edema is often formed, which is associated with a lack of folic acid and B vitamins;
genetics in the female line.

There are experts who note preeclampsia that develops in women due to insufficient.

Symptoms

In the mild stage, the symptoms of preeclampsia may not manifest themselves, and the pregnant woman will feel fine.

But a severe disease has the following symptoms:

Having such symptoms, we can say that the prognosis is not comforting for both the mother and the unborn child.

Subsequently, complications may develop that are close to irreversible consequences.

Why is preeclampsia dangerous?

Any serious illness is fraught with consequences, especially if a woman is pregnant. Accordingly, the fetus suffers. Can happen , the child and even him .

For the mother, the disease can turn into:

All these manifestations are individual. They can occur either collectively or singly.

Classification

The classification of preeclampsia is conditionally divided into three types: mild, moderate and severe stage of the disease.

Light form

This degree is characterized by a slight increase in blood pressure, mild malaise and weakness of the whole organism. Visible swelling of the extremities plus weight gain.

Medium

Along with the disease, symptoms increase. Arterial pressure becomes higher than 160, and diastolic 100-109. The head hurts constantly, and the weight does not stop increasing. Swelling of the face, legs and arms.

severe stage

In addition to the feet and lower legs, the face and upper limbs swell significantly, and fluid begins to accumulate inside the natural cavities.

The pressure of the upper and lower indicators reaches the critical norm. They appear, feel sick, dizzy and have a headache.

The organs of vision suffer.

Therapy

Treatment of preeclampsia in pregnant women depends on the stage of development of the disease and the duration of pregnancy.

At an easy stage, a woman does not need to be under observation. It is enough to take the necessary amount of protein in the urine a couple of times a week, in particular. This is the most accurate indicator of the development of the disease.

In this case, it is necessary to monitor the pressure and record it daily.

Also, the expectant mother should monitor her physical health, not overwork, reduce the activity of movements.

Hospitalization is indicated for moderate severity. The pregnant woman may need bed rest. At this stage, the main thing is not to allow high pressure. For this, special medicines are used.

Severe preeclampsia involves surgery only after relief of seizures or other symptoms.

If placental abruption occurs, perform.