Gestosis 2nd half of pregnancy 1st help. Preeclampsia in pregnant women: symptoms, treatment and degree of danger for the fetus and mother. Classification by period of occurrence

The consequences of gestosis during pregnancy can be very serious: up to placental abruption and fetal death. Therefore, women carrying a baby so often have to undergo tests. The purpose of these research procedures is to identify signs of a serious condition in the early stages for timely correction of the situation, while pathological changes have not yet had time to harm the health of the mother and child.

Preeclampsia during pregnancy is a complication that significantly increases the risk of perinatal death, threatening the life and health of a woman and practically guaranteeing problems during childbirth. Recently, this diagnosis has been made to approximately 30% of expectant mothers.

The period of bearing a child is a kind of test of the state of the body. At this time, hereditary characteristics and chronic diseases that the woman had not previously known about may become aggravated and appear. Due to the presence of certain defects and “weak points,” the body cannot cope with the load, and disorders develop in vital organs and systems.

Preeclampsia is usually diagnosed in the third trimester of pregnancy. However, the process of pathological changes in the body begins earlier - at the 17-18th week.

Experts distinguish 2 types of gestosis:

• clean. Develops in expectant mothers who do not have a history of serious illnesses;
• combined. Diagnosed in women suffering from hypertension, kidney and liver diseases, various pathologies of the endocrine system and other chronic ailments.

Early gestosis during pregnancy, or so-called early toxicosis, is considered the norm, a kind of adaptation of the body to a new state, but still requires special control from the woman herself and doctors. If the pathology develops after the 20th week, they already speak of gestosis of the 2nd half of pregnancy. This is what causes the greatest concern.

Causes of gestosis

There are several opinions explaining the causes of the disease. There is no single explanation yet. Most likely, in each specific case one of the theories or a combination of several versions turns out to be correct:

• the cortico-visceral version connects disturbances in the circulatory system that provoke gestosis with problems in the regulation between the cortex and subcortex of the brain that arise as a result of the body becoming accustomed to pregnancy;
• the hormonal theory blames the occurrence of the condition on disturbances in the functioning of the adrenal glands, abnormal estrogen production or hormonal insufficiency of the placenta;
• The immunogenetic theory suggests that gestosis in late pregnancy is nothing more than an inadequate reaction of the mother’s immune system to foreign fetal proteins, as a result of which the body tries in every possible way to reject the foreign body. There is another immunogenetic version, the supporters of which believe that, on the contrary, the maternal body, in response to antigens coming from the placenta into the blood vessels, produces antibodies in insufficient quantities, as a result, defective complexes circulate in the bloodstream, which have a negative effect, first of all, on kidneys;
• theory of inheritance: if a woman’s mother and grandmother suffered from a serious condition, then she is unlikely to escape this fate, and therefore special attention should be paid to the prevention of the disease.

If experts have not yet come to a common opinion about the causes of gestosis during pregnancy, they are unanimous about the risk factors.

Conditions that significantly increase your chances of getting a diagnosis include:

• obesity;
• endocrine pathologies;
• liver and kidney diseases;
• diseases of the cardiovascular system;
• allergic reactions.

There are special categories of women who are at risk. The occurrence of gestosis is most likely in:

• pregnant women under 17-18 and over 33 years old;
• women carrying more than one child;
• women whose nervous system is exhausted by frequent stress;
• women who suffered from gestosis during previous pregnancies;
• pregnant women who abuse alcohol, smoking and drugs;
• pregnant women from a social risk group who are undernourished and living in unfavorable conditions;
• women with at least 2 years between pregnancies;
• women who frequently have abortions or have a history of miscarriages prior to conception.

If the expectant mother did not suffer from gestosis while carrying her first child, then the chances that it will manifest itself in the existing pregnancy are low. If a pregnant woman has a history of serious illnesses or belongs to a risk group, specialists should pay increased attention to her condition.

Preeclampsia: what happens in the body?

The basis for the occurrence of gestosis during pregnancy is vascular spasm. As a result, the total volume of blood circulating in the blood vessels decreases, and the nutrition of organs and cells is disrupted. This leads to them not being able to do their job well.

First of all, brain cells, as well as kidneys and liver, suffer from insufficient blood supply. This situation also turns into a disaster for the placenta. It cannot function normally, which threatens the fetus with hypoxia and, accordingly, developmental delay.

Symptoms and stages of gestosis

It is worth keeping in mind that signs of gestosis during pregnancy can have varying degrees of severity. It happens that a woman feels great, but tests indicate that a condition is developing in her body that threatens her health and the life of the fetus.

The following stages of development of gestosis are distinguished:

• dropsy (or swelling);
• nephropathy;
• preeclampsia;
• eclampsia.

Swelling during gestosis can also be hidden - the specialist’s suspicion in this case is caused by the patient’s excessive weight gain. And sometimes the woman herself suddenly begins to notice that the wedding ring is difficult to put on, and the elastic bands of the socks leave quite deep grooves on the ankles.

There is a simple method for detecting swelling - you need to press your thumb on the skin. If a light mark remains in this place for a long time, it means that swelling is present.

The ankles are usually the first to swell. Then the dropsy spreads upward. Sometimes swelling even reaches the face, changing its features beyond recognition.

Dropsy, depending on its prevalence, is classified into stages:

• Stage 1 – only the feet and legs swell;
• Stage 2 – swelling of the anterior abdominal wall is added;
• Stage 3 – legs, stomach, face and arms swell;
• Stage 4 – generalized edema (over the entire body).

The second stage of gestosis, nephropathy, is manifested by such symptoms as:

• swelling;
• protein in urine;
• increase in blood pressure to 130\80 and above.

A rise, and especially sharp fluctuations in blood pressure, is an alarming symptom of gestosis during pregnancy, indicating insufficient blood supply to the placenta, which leads to oxygen starvation of the fetus and threatens its death, premature detachment, and bleeding.

The appearance of protein in the urine indicates the progression of nephropathy. The kidneys can no longer cope with the load, and diuresis decreases. The longer the period of nephropathy, the lower the chances of a successful pregnancy outcome.

In the absence of proper treatment, nephropathy flows into the next stage of gestosis, characterized by a generalized disorder of the blood supply to the central nervous system - preeclampsia.

Symptoms of this condition are:

• floaters or fog before the eyes;
• diarrhea;
• vomit;
• pain in the head and stomach;
• heaviness in the back of the head;
• sleep and memory disorders;
• lethargy and apathy or, conversely, irritability and aggression.

Along with this, blood pressure continues to rise (up to 155/120 and higher), the amount of protein in the urine increases, diuresis decreases, the proportion of platelets in the blood decreases, and its coagulation indicators decrease.

The fourth and most dangerous stage of late gestosis during pregnancy is eclampsia. Most often, this condition manifests itself as convulsions - they can be provoked by any irritant: a loud sound, light, awkward movement.

It all starts with twitching of the eyelid and facial muscles. Then the seizure gains momentum and reaches its climax, when the patient literally convulses and loses consciousness. The nonconvulsive form of eclampsia is considered even more dangerous, when a pregnant woman suddenly falls into a coma due to pathological processes occurring in the body and high blood pressure.

Eclampsia threatens with such serious consequences as:

• stroke;
• retinal disinsertion;
• fetal strangulation;
• hemorrhages in internal organs (primarily in the liver and kidneys);
• pulmonary and cerebral edema;
• coma and death.

Diagnosis of gestosis

If a woman registers in a timely manner and does not miss scheduled visits to the doctor, gestosis will not go unnoticed. Modern medical practice involves regular testing and examination of patients. Based on the results of these research procedures, signs indicating the development of a dangerous condition are identified.

So, suspicions may arise when deviations from the norm are detected during such medical measures as:

• weighing a pregnant woman (an increase of more than 400 grams per week raises concerns, although everything here is individual: you need to take into account both the gestational age and the woman’s weight when registering);
• urine analysis (even traces of protein are a reason for a more detailed examination);
• fundus examination;
• blood pressure measurement;
• analysis of the ratio “volume of liquid drunk: urine excreted”;
• blood clotting test;
• general blood analysis.

If an accurate diagnosis is made, monitoring of the fetal condition is necessary, carried out using the ultrasound + Doppler method. After 29-30 weeks - CTG. In this case, the woman is additionally observed by specialized specialists: nephrologist, neurologist, ophthalmologist.

Treatment of gestosis

Timely treatment of gestosis during pregnancy increases the chances of a successful outcome and natural delivery. Patients with nephropathy of any severity, preeclampsia and eclampsia are placed in a hospital setting.

Therapeutic measures are aimed at normalizing the water-salt balance of the pregnant woman, as well as harmonizing metabolic processes, the activity of the cardiovascular and central nervous systems.

The range of medical procedures includes:

• bed and semi-bed rest;
• exclusion of stressful situations;
• vitamin-enriched nutrition;
• physiotherapy, which has a calming effect;
• drug treatment carried out with the aim of normalizing the functions of the organs and systems of the pregnant woman and supporting the fetus suffering from hypoxia.

If there is no improvement during treatment or, moreover, progression of a dangerous condition, we are talking about early delivery. In this case, being a child in the womb becomes more dangerous than being born prematurely.

As for mild gestosis during pregnancy, accompanied only by swelling and mild symptoms, it is treated on an outpatient basis. In other cases, the patient needs round-the-clock supervision by specialists, because at any moment the disease can begin to progress rapidly.

Prevention of gestosis

Women at risk need to pay special attention to the prevention of gestosis during pregnancy. And you need to start acting at the stage of planning a child, that is, before conception: get examined to identify and eliminate pathologies, give up bad habits, take special vitamin complexes, etc.

If you become pregnant, you must register as soon as possible. When a pregnant woman’s condition is under the control of specialists, many problems can be identified and eliminated in the initial stages. Patients often have to undergo tests and visit antenatal clinics, where they are weighed and blood pressure measured every time.

An excellent prevention of gestosis are the following simple measures:

• limiting the amount of fluid you drink and salt consumed (especially in the second half of pregnancy);
• adequate sleep lasting at least 8 hours;
• adequate physical activity;
• walks in the open air;
• avoiding stress;
• nutritious food rich in vitamins and proper diet (preferably little by little, but often).
• Fatty, salty and spicy foods should be excluded from the diet - this is an additional and completely unnecessary load on the liver.

According to individual indications, drug prophylaxis may be prescribed.

Preeclampsia is a condition that threatens the life and health of the mother and fetus. The dangerous thing is that there may be no visible signs of the disease. The woman feels great, but at this time pathological changes occur in her body.

Fortunately, a timely visit to the doctor leading the pregnancy is a guarantee of recognizing the disease at an early stage. With a competent approach, pregnancy after treatment of gestosis and further childbirth proceed without complications.

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Late toxicosis is a complication of the second half of pregnancy, characterized by disruption of the normal functioning of organs and manifested by a triad of main symptoms (edema, proteinuria - detection of protein in the urine, hypertension - increased blood pressure).

The incidence of gestosis ranges from 2 to 14%. There is a more frequent occurrence of this pathology in women suffering from various somatic diseases, as well as in women with their first birth, especially in young women (under 18 years of age), and in pregnant women and women in labor over 30 years of age. There is evidence of an increase in the likelihood of gestosis among the following groups of women:

1) with Rh conflict between mother and fetus (when the Rh factor is negative in the mother and positive in the fetus);

2) with the presence of antiphospholipid syndrome;

3) with arterial hypotension, hydatidiform mole;

4) obese, etc.

The occurrence of gestosis in the second half of pregnancy is often noted in women with a hereditary predisposition, in whom the development of this pathology during pregnancy occurred in the family (mother, sister, daughter).

For their convenience, obstetricians-gynecologists distinguish between pure and mixed forms of gestosis. Most often, mixed (complicated) forms develop against the background of somatic pathology - hypertension, kidney, liver, heart diseases, diencephalic neurometabolic endocrine syndrome.

Pure gestosis is divided into four stages:

1) edema of pregnant women;

2) nephropathy – mild, moderate, severe;

3) preeclampsia;

4) eclampsia.

The WHO classification, in turn, is slightly different:

1) arterial hypertension in pregnant women without proteinuria;

2) proteinuria in pregnant women;

3) preeclampsia – a combination of arterial hypertension in pregnancy with proteinuria;

4) eclampsia;

5) latent arterial hypertension, latent kidney disease and other diseases that appear only during pregnancy;

6) previously known diseases accompanied by arterial hypertension;

7) preeclampsia and eclampsia, complicating previously known:

a) arterial hypertension;

b) kidney disease.

Based on this classification, each type, depending on the time of occurrence, can be divided into the following:

a) during pregnancy;

b) during childbirth;

c) in the first 48 hours of the postpartum period.

Etiology and pathogenesis

There are many theories put forward by various authors about the cause of gestosis in the second half of pregnancy, but to this day there is a lot of uncertainty about the causes and ways of occurrence of this process. There is no doubt about the main point - the connection of this disease with pregnancy. The occurrence of gestosis is possible only during pregnancy, and if this process does not have time to lead to serious complications, then all signs of its manifestation disappear without a trace after the end of pregnancy.

With the development of medicine and science, the prevailing theories from the total number of theories of the occurrence of preeclampsia changed periodically. So, in the 19th century. the infectious theory prevailed, and in the 20s. XX century The most popular was the toxic theory associated with intoxication of the mother’s body with substances coming from the fertilized egg. However, both of these theories have not been scientifically proven. Also, today there are a number of theories that have their supporters and opponents.

The cortico-visceral theory considers gestosis as a violation of the physiological interaction between the cerebral cortex and subcortical formations.

The endocrine theory connects the appearance of gestosis with disturbances in adaptation reactions and the occurrence of stress in connection with this (based on the teachings of G. Selye).

The immunological theory is based on the position that trophoblast tissue is an antigen, as a result of which the maternal body begins to produce anti-placental antibodies, which can in turn disrupt the normal functioning of the mother’s organs, in particular the kidneys and liver, which causes symptoms of gestosis.

The genetic theory has the right to exist due to the observation that in the daughters of women who suffered gestosis during pregnancy, the incidence of this pathology is an order of magnitude higher than in all others. An autosomal recessive mode of inheritance of this pathology is assumed, as well as the presence of “preeclampsia genes” and the active role of fetal genes in the pathogenesis of the disease.

The placental theory is based on the fact that the symptoms of the disease are eliminated only after the birth of the placenta.

Researchers, together with obstetricians and gynecologists, currently agree that the etiology of gestosis is multifactorial - the presence of several components of disorders to varying degrees of severity is observed.

Considering the mechanisms of pathogenesis, it should be noted that the foundations of the disease are laid in the early stages of gestation (in the first trimester of pregnancy). Already at the time of implantation, insufficient invasion of the fertilized egg is observed due to the immunological and genetic characteristics of the woman. There is also a lack of transformation (dielastosis) of the muscular layer of the spiral arteries of the myometrium. This results in the spiral arteries retaining non-pregnant morphology, which predisposes them to spasm and reduced intervillous blood flow. As a consequence, hypoxia occurs in the tissues of the uteroplacental complex, and this in turn causes damage to the endothelium with a violation of its thromboresistant and vasoconstrictive properties and the release of mediators (serotonin, thromboxane, endothelin, circulating eclampsia factor), which play a major role in the regulation of hemostasis and vascular tone.

Together with the above processes, disturbances in the synthesis and imbalance of prostaglandins of maternal and fetal origin (prostaglandins of class E and F, prostacyclin, thromboxane, etc.) occur. It is noted that prostanoids provide dynamic balance in the homeostasis system, and also cause the necessary changes in a woman’s body during pregnancy. Insufficient production of prostacyclin and prostaglandins E or overproduction of prostaglandins F and thromboxane is accompanied by generalized vascular spasm.

At the present stage, a special place is given to nitric oxide (NO) in the pathogenesis of preeclampsia. It is a regulator of vascular tone and an inhibitor of platelet aggregation. It is synthesized by epithelial cells, and during a normal pregnancy its level gradually increases. In turn, in the presence of gestosis, a pronounced decrease in the synthesis of nitric oxide was noted, which leads to arteriolospasm and impaired microcirculation. Also, research in recent years has proven the importance of reducing phospholipid levels with increasing cholesterol levels. And the resulting depletion of phospholipids in the body causes a disruption in the structure of platelets and red blood cells.

The result of all of the above pathological disorders is systemic vascular spasm, leading to an increase in total peripheral vascular resistance, a decrease in cardiac output, a decrease in blood flow and glomerular filtration of the kidneys. All this determines the clinical picture of gestosis.

It should be noted that the characteristic triad of symptoms of gestosis (described in 1913 by the German obstetrician Zangemeister), i.e. edema, proteinuria, hypertension, is due to the interrelation of a number of pathological changes in all internal organs.

One of the first to occur is vascular spasm (mainly in the arterial circulation), which leads to an increase in intravascular pressure, blood stasis in the capillaries, and increased permeability of small vessels. This results in an increase in general peripheral vascular resistance, and as a consequence of this, arterial hypertension and circulatory disorders occur in vital organs (such as the brain, liver, kidneys, heart, etc.). The extent of this process directly depends on the severity of gestosis. Further disturbances are associated with prolonged vascular spasm, which leads to disturbances in the activity of the myocardium (ischemic myocardiopathy), ischemia of the renal cortex (often leading to an even greater increase in blood pressure), spasm of cerebral vessels, spasm of the uterine and spiral arteries (disorders of the uteroplacental and fetal-placental blood flow). Violations of macro- and microcirculation contribute to the loss of fibrin into the lumen of blood vessels, aggregation of erythrocytes and platelets. At the same time, the blood supply to vital organs and the supply of oxygen and nutrients to them are further deteriorated. All this leads to a decrease in detoxification activity and protein-forming function of the liver. This is manifested by the accumulation of fluid in the interstitial space (swelling and pastiness occur); this occurs against the background of hypovolemia, hemoconcentration and fluid retention.

A number of researchers have conducted extensive studies, which have revealed that with gestosis, despite a decrease in volumetric parameters of central hemodynamics and systemic vascular spasm, compensatory and adaptive mechanisms are formed, aimed primarily at the normal functioning of the mother-placenta-fetus system. And already with pronounced depletion of these mechanisms and the body as a whole, fetoplacental insufficiency and intrauterine growth retardation develop.

Clinic

The symptoms of gestosis in the second half are quite clear (an atypical course of this disease is very rare), represented by various combinations of the above three symptoms - edema, proteinuria (determination of protein in the urine), hypertension. This triad was described for the first time by Zangemeister. Nevertheless, the clinical variations of the course are much wider. We can say that there are as many clinical variants of gestosis as there are pregnant women with this complication.

Not always, especially in the initial stages of the disease, a woman feels unwell, swelling may be insignificant, and pressure increases may not be felt or are interpreted by the woman as fatigue or headache. However, modern doctors also distinguish the so-called preclinical stage of gestosis, in which the clinical picture of the disease is still absent, and laboratory data are changed in the direction of gestosis (these changes in laboratory data are often noted already in the first and early second trimester of pregnancy). Signs of the preclinical stage of gestosis are expressed in a progressive decrease in the number of platelets as it develops, the presence of hypercoagulation in the cellular and plasma levels of homeostasis, a decrease in the level of anticoagulants, and lymphopenia. Also, at the preclinical stage, there may already be disturbances in the uteroplacental blood flow, which is established on the basis of data from a Doppler study. You can perform a special test to establish this stage of gestosis: blood pressure is measured three times with an interval of 5 minutes in the position of the woman on her side, on her back and again on her side. The test is considered positive if the diastolic pressure changes by more than 20 mmHg. Art.

As a rule, the initial manifestations of gestosis in the second half of pregnancy are detected in the antenatal clinic, since they constantly monitor body weight gain, measure blood pressure in both arms, conduct a urine test and assess the condition of the fetus (counting the heart rate).

The consultation also takes into account all the woman’s characteristics when assessing the amount of body weight gain, since there are factors that influence this process, namely age, initial body weight before pregnancy, diet, work and rest. It is currently accepted that, starting from approximately 32 weeks of pregnancy, a woman’s weight should increase by 50 g per day and, therefore, by 350–400 g per week or 1 kg 600 g (but not more than 2 kg) per month, and beyond throughout pregnancy – no more than 10–12 kg. Of course, all these data are averaged. It is possible to calculate the rate of weight gain individually for each woman, taking into account the ratio of body weight to height. We can assume that weekly weight gain should not exceed 22 g for every 10 cm of height and 55 g for every 10 kg of the initial weight of the pregnant woman. For example, if a pregnant woman’s height is 160 cm, then her weekly gain should be 350 g, and if her body weight before pregnancy is 60 kg, then her weekly gain should be 330 g. A pronounced increase in body weight is primarily associated with fluid retention in the interstitial space, the manifestation of which is edema.

The severity of edema can vary; there are three degrees of severity.

I degree – localization of edema only in the lower extremities.

II degree – their spread to the abdominal wall.

III degree – generalization of edema up to edema of internal organs.

Diagnosis of edema, as a rule, does not cause difficulties. When diagnosing hidden edema, nocturia, a decrease in diuresis of less than 1000 ml with a water load of 1500 ml, pathological and uneven weight gain, and a positive “ring” symptom are taken into account. For early detection of hidden edema, you can use the McClure-Aldrich tissue hydrophilicity test: after intradermal injection of 0.1–0.2 ml of isotonic sodium chloride solution, the blister resolves in less than 35 minutes.

Arterial hypertension often occurs together with edema and proteinuria, but sometimes an isolated form of gestosis with hypertension alone occurs. According to severity, arterial hypertension is divided into three degrees:

I degree – blood pressure not higher than 150/90 mm Hg. Art.;

II degree – blood pressure from 150/90 to 170/100 mm Hg. Art.;

III degree – blood pressure above 170/100 mm Hg. Art.

The next point is impaired renal function (nephropathy). This is one of the most common forms of late gestosis (it accounts for 60% of all other forms). This form of gestosis is also divided according to the severity of changes in the kidneys.

I degree of severity

It is characterized by the presence of edema only in the lower extremities, the appearance of traces of protein in the urine and an increase in blood pressure to 150/90 mm Hg. Art.

II degree of severity

The spread of edema reaches the upper extremities and the anterior abdominal wall, the protein content in the urine at this severity level is from 1 to 3 g/l, and the increase in pressure occurs by more than 150/90 mm Hg. Art., however, not higher than 170/100 mm Hg. Art.

III degree of severity

It is characterized by severe edema with puffiness of the face, protein content in the urine more than 3 g/l, blood pressure above 170/100 mm Hg. Art.

An ophthalmologist's examination of the woman's fundus, which reflects the real picture of the severity of hypertension, is very helpful in assessing the severity of gestosis.

In addition to this research, many additional research methods help to establish the severity and form of gestosis itself. Repeated examination of urine makes it possible to trace the course of the disease, since an increase in protein in the urine will indicate a worsening of the woman’s condition. A blood test is carried out; the quantitative composition of electrolytes and blood protein is important, which changes with the development of gestosis in the second half of pregnancy. It must be remembered that in the process of examination and treatment it is necessary to monitor the condition of the fetus, and if there are changes (increase or decrease) in the fetal heart rate, one can judge the severity of the gestosis process itself.

Objective criteria for the severity of severe nephropathy are as follows:

1) systolic blood pressure 150 mm Hg. Art. and higher, diastolic blood pressure 100 mm Hg. Art. and higher;

2) oliguria (daily diuresis less than 400 ml);

3) proteinuria up to 5 g/l or more;

4) hypoxic type of central maternal hemodynamics with increased general peripheral vascular resistance;

5) severe disturbances of blood flow in the uterine arteries, as well as in the arteries of the kidneys;

6) severe disturbances of cerebral blood flow;

7) lack of normalization or deterioration of systemic maternal hemodynamics against the background of complex intensive therapy for preeclampsia;

8) thrombocytopenia, hypocoagulation, increased activity of liver enzymes, hyperbilirubinemia.

Treatment of gestosis

It must be remembered that if there are symptoms of gestosis, you should always carry out a full range of studies and treatment. For any form of gestosis in the second half of pregnancy, it is advisable to carry out treatment in a specialized hospital. In severe forms, such as preeclampsia and eclampsia, in addition to intensive therapy for gestosis, resuscitation measures are necessary.

Therapy for gestosis should be comprehensive and aimed at:

1) quick and gentle delivery;

2) creation of a medical and protective regime;

3) restoration of the function of vital organs.

The creation of a protective treatment regime involves the use of sedative and psychotropic therapy in the hospital. For patients in this category, preference is given to sedatives of plant origin (valerian, motherwort extract), sometimes in combination with tranquilizers (diazepam, elenium). The next point in treatment is infusion-transfusion therapy, which makes it possible to normalize the volume of circulating blood, colloid-osmotic pressure of plasma, rheological and coagulation properties of blood, etc. For this purpose, hydroxyethyl starch (refortan, infucol), as well as magnesium sulfate, sometimes blood transfusions. In the presence of arterial hypertension, drugs that normalize blood pressure are used. In addition to generally accepted drugs (dibazole, papaverine, aminophylline), calcium antagonists, blockers and stimulators of adrenergic receptors, vasodilators, and ganglion blockers are currently recommended. For mild cases, monotherapy is quite effective; moderate severity often requires a comprehensive selection of drugs. To normalize the rheological and coagulation properties of blood, disaggregants are used - trental, chimes, fraxiparin, aspirin. Doses of drugs and method of administration depend on the severity of the process. With gestosis, it is also necessary to restore the structural and functional properties of cell membranes and cellular metabolism, which is achieved by the use of antioxidants: vitamin E, actovegin, vitamin C, glutamic acid, lipostabil, essentiale, etc.

Today, there are also efferent methods of treating gestosis, including the use of extracorporeal methods of detoxification and dehydration - plasmapheresis and ultrafiltration.

In non-severe forms of gestosis (the presence of a positive effect from therapy, the absence of significant disturbances in uteroplacental blood flow) and the absence of other indications, a woman can give birth on her own. To prepare the birth canal, in particular the cervix, hormonal therapy is carried out, and prostaglandins are also used, preferably topically. With the cervix prepared, amniotomy is performed followed by induction of labor. The use of adequate pain relief and antispasmodic drugs is also mandatory.

Gestosis of the second half will be an indication for cesarean section only if there is a severe form of this process that cannot be treated, and also if complications of this disease develop (cerebral hemorrhage due to increased pressure, retinal detachment, acute renal and hepatic failure). When organs do not cope with their work, as a result of which metabolic products accumulate in the body, coma (unconsciousness) or premature abruption of a normally located placenta may develop.

• The condition is the main danger of the second half of pregnancy and poses a serious threat to the life of the expectant mother.

What it is? Preeclampsia during pregnancy is a pathological condition of the body in which the functions of vital organs are disrupted and which is extremely difficult to control if it has entered an advanced stage.

The disease occurs mainly in the third trimester and has another name - late toxicosis. However, it differs from the classic ailment in the form of nausea and vomiting in that it entails dysfunction of the cardiovascular and endocrine systems, damage to the central nervous system as a result of spasm of blood vessels.

The prevalence reaches 30%; the situation is further complicated by the fact that gestosis in the first half of pregnancy is very difficult to detect in the initial stages of development. For example, late toxicosis, which began at 20 weeks, is detected only by 27–28 weeks.

What is the danger of gestosis?

Until now, despite the development of medicine, gestosis remains one of the main causes of maternal and infant mortality in the prenatal and postpartum period. It does not kill instantly, but contributes to the rapid decline of the body over several days.

The patient may lose vision, the ability to move independently, and one by one important organs stop functioning: liver, kidneys, heart, brain. The more serious the stage of gestosis, the less chance doctors have to save the patient and (or) her child.

Only close attention to the deterioration of your health and timely examination will help identify late toxicosis in the early stages of its development and avoid the fatal risk.

Causes of gestosis

Scientists have not yet reliably found out what exactly is the cause of the development of late gestosis. There are only some assumptions about this:

• Pathological changes in the central nervous system. The relationship between the cerebral cortex and subcortical structures is disrupted, which leads to pathology. The trigger is the psychological stress that a woman may have been exposed to while carrying a child.
• Immune disorders, in particular, failures in the recognition of maternal tissue and fetal tissue. This process involves special T cells, which are regulators of the immune response.
• Disruptions in the endocrine system. Pregnancy involves dramatic changes in hormonal status, which can result in disruptions in the functioning of a woman’s entire body.
• Lack of folic acid. This provokes an increase in the level of non-proteinogenic amino acids, which are extremely toxic to the body.

Preeclampsia, a complication of pregnancy, involves spasm of all blood vessels - this is what causes the failure of vital organs.

Symptoms of gestosis during pregnancy by stage

There are several classifications of late gestosis, but doctors in Russia distinguish 4 main stages in the development of the disease, each of which is characterized by certain clinical manifestations.

Dropsy

It is characterized by insufficient removal of fluid from the body, resulting in swelling. This stage is divided into 4 stages, which are characterized by the ascending direction of localization of edema:

1. The feet swell, and there is slight swelling of the legs.
2. The legs swell completely, the lower third of the abdomen swells.
3. The swelling rises higher and affects the face, in addition to the legs and body.
4. Edema affects the entire body and is observed in internal organs.

Characteristic signs of edema

• When you press your finger on the surface of the skin, a dent remains. The longer it takes to disappear, the more severe the swelling becomes.
• There is tingling and numbness in the swollen limb.
• Severe swelling causes a feeling of fatigue in a pregnant woman.

These are the earliest symptoms of gestosis during pregnancy - if doctors prescribe the woman the necessary therapy, then late toxicosis will not develop further.

Nephropathy

If no therapeutic measures were taken when edema appeared, then the disease progresses and enters the stage of nephropathy. In addition to fluid retention, hypertension appears in the body, and urine tests indicate an increase in protein.

All these symptoms of gestosis will be noticeable to the doctor if the patient visits the antenatal clinic at least once every 2 weeks and regularly passes the necessary tests. Nephropathy has several degrees, which have certain symptoms:

1. I degree - the pressure does not exceed 150/90, and the distance from the upper to the lower limit should be normal. A urine test reveals protein of no more than 1 g/l. There is swelling of the lower extremities.
2. II degree - pressure does not exceed 170/100, protein in the urine increases and begins to reach 3 g/l. Edema spreads not only to the lower extremities, but also to the lower third of the abdominal wall.
3. III degree – pressure is above 170/110, protein in the urine exceeds 3 g/l, swelling spreads throughout the body, swelling of the internal organs is detected.

Nephropathy, especially its severe degree, cannot go unnoticed, and the pregnant woman will be forced to go to the hospital due to the deterioration of her condition.

Preeclampsia

In some cases, stage III nephropathy, despite treatment, develops into preeclampsia. The main difference between this condition and nephropathy is that the pregnant woman has a circulatory disorder in the brain.

There is a real threat to the life of the mother and fetus, which requires immediate hospitalization. Among the signs of severe gestosis during pregnancy are the following:

• Confusion
• Headache
• Loss of vision and/or hearing
• Feeling of heaviness in the back of the head
• Manifestations of sclerosis
• Hemorrhages in the walls of vital organs
• Vomit

If a woman in this condition is left without medical care, she will die. Preeclampsia involves placing the patient in an intensive care unit, since her well-being must be monitored around the clock.

Eclampsia

It is considered the most severe degree of gestosis of pregnancy, in which even emergency and highly qualified care does not guarantee that the woman will survive. Some doctors are inclined to consider preeclampsia the initial stage of eclampsia.

Eclampsia involves worsening the manifestations of nephropathy and a rather weak response of the body to the measures taken to save the patient’s life.

Characteristic signs of eclampsia

• Loss of consciousness
• Tonic convulsions
• Clonus
• Severe weakness
• Strong headache
• Extensive swelling of internal organs (most often the brain)
• Blood pressure above 170/110

Eclampsia does not occur suddenly, so if you respond promptly to worsening health and test results, you can successfully prevent this condition.

Treatment of gestosis in stages - drugs, regimens

For each stage of gestosis in the third trimester of pregnancy, the doctor selects appropriate therapy. For diagnosis, the results of urine and blood tests, blood pressure indicators, body weight indicators (over several weeks), and fundus examinations are used.

Treatment of stage I (edema)

The main reason for the appearance of edema is the delay in the removal of fluid from the body. Traditionally, Russian obstetricians and gynecologists practice strict control over fluid intake and significant limitation of its volume.

• The results of such a “diet” are not always noticeable: the pregnant woman is constantly thirsty, and existing swelling goes away too slowly. However, no new ones are formed.

Gradually, our doctors began to adopt the experience of Western specialists: a pregnant woman is allowed to drink as much as she wants, but with one condition - all the liquid consumed must have a pronounced diuretic effect. This could be cranberry juice or brewed lingonberry leaves. This method of treating gestosis is much easier to tolerate, and it gets rid of edema much faster.

In addition to natural remedies, the doctor may prescribe diuretics:

• Canephron is available in the form of drops, as well as in the form of dragees. Dilates renal vessels, prevents excess fluid absorption. Reduces protein excretion in urine.
• Cyston - increases blood supply to the epithelial tissue of the urinary system, has an antibacterial and diuretic effect. Available in tablet form.
• Phytolysin – promotes relaxation of smooth muscles, has an anti-inflammatory and diuretic effect. It is produced in the form of a special paste from which a suspension must be made.

In case of severe edema, hospitalization and treatment in a hospital setting are indicated for a pregnant woman.

Treatment of stage II (nephropathy)

Nephropathy involves a combination of edema and increased blood pressure. Consequently, therapy that helps normalize blood pressure is added to the treatment of fluid retention in the body.

Since a surge in pressure can occur repeatedly and within a short period of time, the pregnant woman should be admitted to the hospital to monitor her blood pressure around the clock, as well as monitor her kidney function. To stabilize the condition, the following will be prescribed:

• Complete peace. Physical effort provokes a rise in blood pressure, so the woman needs to remain in bed for several days.
• Taking sedatives. They help lower blood pressure, however, during pregnancy, some of them can have an abortifacient effect, so you should not choose a sedative yourself.
• A diet whose goal is to reduce salt and fluid intake, as well as normalize the ratio of proteins, fats and carbohydrates in the diet.
• Taking antispasmodics. Since late toxicosis is based on vasospasm, it is important to prevent it. Otherwise, the symptoms of placental gestosis will worsen. During pregnancy, drugs such as No-shpa and papaverine are allowed.
• Taking protein drugs. Nephropathy involves increased leaching of protein from the body, so the doctor’s task is to increase its levels.

Comprehensive timely treatment of gestosis during pregnancy at the stage of nephropathy, in most cases, gives a positive effect and stops further progression of late toxicosis.

Treatment of stages III and IV (preeclampsia and eclampsia)

Both of these diseases involve serious dysfunction of the kidneys, liver, heart, brain, as well as large blood vessels of the placenta, so this stage of gestosis most often has consequences for the child.

If the pregnancy has reached the period at which the fetus can be born viable, then the mother undergoes an emergency caesarean section.

To stabilize the patient's condition, the following measures are taken:

• Intravenous drip administration of magnesium, rheopolyglucin, glucose and diuretics, which should relieve the woman of edema.
• Complete rest and strict bed rest. As a rule, with eclampsia the patient feels so weak that she is unable to get out of bed on her own.
• Administration of anticonvulsants if the patient experiences tonic seizures.
• Hourly monitoring of protein levels in urine. Since the woman is not able to take the test herself, a catheter is inserted into the urethra.
• Connection to the artificial lung ventilation system.
• Taking strong sedatives to normalize blood pressure and prevent new seizures.

Emergency delivery should be carried out only when convulsive contractions have been stopped and relative stabilization of blood pressure has been achieved.

Pregnancy after mild forms of gestosis should proceed under close medical supervision. Since the exact causes of late toxicosis are unknown, it is difficult to determine specific preventive measures that would protect a pregnant woman from developing this disease.

• The surest way to protect yourself from preeclampsia and eclampsia is timely therapy in the early stages of gestosis.

20. Early and late gestosis. Etiology. Pathogenesis. Clinical picture and diagnosis. Treatment. Methods of delivery, features of labor management. Prevention of severe forms of gestosis.

Preeclampsia– a number of diseases that occur only during pregnancy, complicate its course and disappear with the end or termination of pregnancy.

Preeclampsia- syndrome of multiple organ functional failure, caused by a discrepancy between the capabilities of the adaptive systems of the mother’s body to adequately meet the needs of the developing fetus.

Classification: a) early gestosis - occurs in the first half of pregnancy (in the first 3-4 months), b) late gestosis - develops in the second half of pregnancy (in the last 2-3 months).

Early gestosis.

Early gestosis includes vomiting, salivation, dermatoses, jaundice, acute yellow liver atrophy, bronchial asthma, tetany, and osteomalacia of pregnant women.

Etiopathogenesis: The main cause of early gestosis is considered to be a violation of the relationship between the function of the central nervous system and the activity of internal organs. With prolonged disturbance of impulses, overstimulation of the vegetative centers of the subcortex occurs (in the vomiting and salivary centers) and a decrease in the function of nervous processes in the cerebral cortex. This leads to disruption of the physiological processes of adaptation of the body to pregnancy. Changes in metabolism, activity of the endocrine system, digestive and other systems often become pathological.

1. Vomiting during pregnancy- vomiting, which is repeated several times a day, is accompanied by nausea, decreased appetite, and changes in taste and olfactory sensations.

Forms/stages of vomiting during pregnancy

A) light- repeats 3-5 times a day, usually after meals, does not affect the general condition of the pregnant woman, is easy to treat and goes away on its own upon reaching 10-12 weeks of pregnancy

b) moderate– increased vomiting, occurring regardless of food intake, up to 10-12 times a day and is accompanied by a decrease in body weight, general weakness, tachycardia, dry skin, and decreased diuresis. With proper treatment, disorders of the nervous, endocrine and other systems gradually disappear. After the signs of gestosis disappear, pregnancy develops normally.

V) excessive- vomiting repeats up to 20 or more times a day and causes a serious condition for the patient. All types of metabolism are disrupted. Fasting and dehydration of the body lead to exhaustion, loss of body weight, and disappearance of the subcutaneous fat layer. The skin becomes dry and flabby. Sometimes a icteric discoloration of the sclera and skin occurs. The tongue is coated, the mucous membrane of the lips is dry, and the smell of acetone is noted from the mouth. Body temperature is subfebrile. The pulse is increased, in severe cases it reaches 120 beats per minute or more. Hypotension is common. Daily diuresis is reduced, acetone is found in the urine, and protein and casts often appear. The content of residual nitrogen in the blood increases, the amount of chlorides decreases, and the concentration of bilirubin often increases. Hemoglobin levels may increase, which is associated with dehydration.

Vomiting in pregnant women must be differentiated from urinary tract infection, gastrointestinal diseases, brain tumor, uterine strangulation in the pelvis, polyhydramnios, and hiatal hernia.

2. Drooling. It may be accompanied by vomiting or occur as an independent early gestosis. Daily salivation varies, sometimes reaching 1 liter or more. Drooling depresses the patient’s psyche and causes maceration of the skin and mucous membrane of the lips. With significant saliva production, symptoms of dehydration appear.

Treatment of vomiting and drooling carried out on an outpatient basis. If it is ineffective, patients are hospitalized, thoroughly examined and treated:

1. normalization of the disturbed relationship between the processes of excitation and inhibition in the central nervous system;

2. fight against starvation, dehydration and intoxication of the body;

3. use of antihistamines, antiemetics, vitamins;

4. treatment of concomitant diseases;

5. restoration of metabolism and functions of the most important organs.

6. creating conditions of emotional and physical peace, which often leads to the cessation of vomiting and drooling without additional treatment. Two patients whose pregnancy is accompanied by vomiting should not be placed in the same room. To normalize the function of the central nervous system, psychotherapy, acupuncture, and electrosleep are used.

7. To suppress the excitability of the vomiting center, etaparazine, torecan, droperidol, and cerucal are used.

8. vitamin therapy.

9. fight against hypoproteinemia and dehydration: plasma, albumin, protein, 5 % glucose solution, Ringer's solution, isotonic sodium chloride solution. To eliminate metabolic acidosis, it is recommended to administer 100-150 mg of 5% sodium bicarbonate solution intravenously. The patient should receive at least 2-2.5 liters of fluid per day.

10. To reduce salivation, a 0.1% atropine solution is prescribed intramuscularly, 1 ml.

If treatment is unsuccessful, termination of pregnancy is indicated for health reasons.

3. Dermatoses of pregnant women – a group of skin diseases that occur during pregnancy and disappear after its end. The most common form of dermatosis is itching of pregnancy. It can be limited to the area of ​​the external genitalia or spread throughout the body, causing insomnia and irritability. Less common is eczema of pregnant women, which affects the skin of the mammary glands or abdomen, thighs, and arms.

It should be differentiated from diabetes mellitus, allergies to drugs and foods, and helminthic infestation.

Treatment: agents that regulate the functions of the nervous system, reduce sensitization of the body, and provide a general strengthening effect.

4. Jaundicepregnant women. It is rare, manifested by icteric discoloration and itching of the skin, liver damage. It can also occur in the second half of pregnancy.

Differentiate with symptomatic jaundice that occurs with infectious hepatitis, Vasiliev-Weil disease, cholelithiasis, and intoxication.

Pregnant women with jaundice are urgently hospitalized to determine its cause. If jaundice in pregnant women is diagnosed as gestosis, termination of pregnancy is indicated.

5. Yellow liver dystrophy It is rare and occurs independently or with excessive vomiting during pregnancy. It is severe and often leads to death. Characterized by fatty and protein degeneration of the liver, a decrease in its size, an increase in jaundice, itchy skin, the appearance of convulsions and a coma. Immediate termination of pregnancy is indicated.

6. Bronchial asthma in pregnant women observed very rarely. The causes of its occurrence are hypofunction of the parathyroid glands and calcium metabolism disorders.

Treatment. Pregnancy can be prolonged, as the disease is highly treatable. Calcium supplements, sedatives, and vitamins are usually prescribed.

7. Tetany of pregnant women occurs when the function of the parathyroid glands decreases or disappears, resulting in impaired calcium metabolism. Clinically, the disease is manifested by muscle cramps, most often of the upper extremities (“obstetrician’s hand”), less often of the lower (“ballerina’s leg”), sometimes of the facial muscles (“fish mouth” or lockjaw pattern), torso and, quite rarely, of the larynx and stomach.

Treatment. Parathyroidin, calcium supplements, and vitamin D are used. If treatment is ineffective, as well as in severe forms of the disease, termination of pregnancy is indicated.

8. Osteomalacia. It is characterized by decalcification of bones and their softening as a result of disturbances in phosphorus-calcium metabolism. Most often, the bones of the pelvis and spine are affected, with pain in the bones and deformation may occur, in particular beak-like protrusion of the symphysis, significant displacement of the promontory into the pelvic cavity, and a decrease in the intertrochanteric size.

Treatment: vitamins D and E, progesterone, ultraviolet irradiation, if unsuccessful, termination of pregnancy is indicated.

During pregnancy 12-14 weeks, the manifestations of early gestosis usually gradually disappear. Patients who have suffered gestosis in the first half of pregnancy should be registered at a dispensary in a high-risk group, since they may have relapses.

Late gestosis.

Late gestosis- syndrome of multiple organ and multisystem functional failure that develops during pregnancy. It is characterized by a classic “triad” of symptoms: O - edema, P - proteinuria, G - hypertension - OPG-preeclampsia.

Classification.

1. According to clinical forms: dropsy, nephropathy, preeclampsia, eclampsia.

2. Symptomatic classification: monosymptomatic OPG-gestosis, polysymptomatic OPG-gestosis, threatening eclampsia and convulsive eclampsia.

3. Pathogenetic classification: OPG-preeclampsia against the background of other diseases; transient OPG-gestosis; unclassified OPG-preeclampsia; concomitant diseases with OPG symptoms, but without gestosis, the same diseases in combination with OPG - gestosis, etc.

4. 4 forms of gestosis:

a) Monosymptomatic gestosis: dropsy, proteinuria and hypertension in pregnant women.

b) Polysymptomatic gestosis - characterized by the presence of 2 or 3 cardinal symptoms (OP-, OG-, PG-, OPG-gestosis).

c) Preeclampsia.

d) Eclampsia.

5. According to the form of development: a) pure (with an uncomplicated somatic history) and combined (against the background of extragenital pathology); b) typical (triad of symptoms) and atypical (mono- and bisymptomatic course, nonconvulsive eclampsia).

Etiopathogenesis. The ovum is an etiological factor in the development of gestosis. The pathogenesis of the disease has not been fully elucidated. There are about 30 theories trying to explain the mechanism of development of this symptom complex. The leading links in pathogenesis are: generalized vasoconstriction, hypovolemia, disturbance of the rheological properties of blood, damage to the vascular endothelium, development of disseminated intravascular coagulation syndrome. Currently, it is generally accepted that immunological factors associated with the development of the ovum, genetic predisposition, and poor nutrition play a role in the development of gestosis. Due to a violation of the immunological adaptation of the fetal egg, sufficient dilation of blood vessels does not occur, their high sensitivity to vasoconstrictive effects remains, which predisposes to a decrease in maternal blood flow and the development of hypoxia. This causes endothelial damage, initially local, and then in target organs: kidneys, brain, liver. Due to an increase in the aggregation properties of erythrocytes and platelets, hypercoagulation and hyperviscosity of blood, disseminated intravascular coagulation, and the progression of vasospasm, a complex of microcirculatory disorders is formed. Against the background of developing hypoxic changes in tissues, the central nervous system is affected with dysfunction, and the enzymatic function of the liver is disrupted. Renal and placental failure may occur, which leads to a deterioration in the delivery of oxygen and other metabolites to the fetus.

1. O-gestosis - swelling or dropsy of pregnancy - characterized by the occurrence of swelling that is persistent.

Pathogenesis: The occurrence of edema is associated with impaired water-salt metabolism and increased vascular permeability of the microvasculature. An increase in extracellular extravascular fluid volume is accompanied by a decrease in plasma volume, resulting in an increase in hemoglobin and hematocrit, which leads to a decrease in uteroplacental circulation and leads to chronic fetal hypoxia.

The disease begins in the second half of pregnancy, closer to childbirth. Swelling is initially localized to the legs and feet, then can spread to the thighs, external genitalia, abdominal wall, face, upper limbs and, finally, to the entire body (anasarca). Their severity varies. Significant swelling of the legs and puffiness of the face without visible swelling of the abdominal wall are often observed. Fluid effusion into the serous cavities (abdominal, pleural) usually does not occur; it accumulates in the tissues, mainly in the subcutaneous tissue. Accumulation of fluid in serous cavities (hydropericardium, hydrothorax, ascites) occurs in severe forms of late gestosis. Typically, swelling develops gradually, but there are cases when it reaches large sizes within a very short time.

The general condition of patients usually does not suffer. Sometimes mild fatigue occurs, and with severe edema, shortness of breath, thirst, and slight tachycardia may appear.

Diagnostics.

1. Ultrasound - determine the presence of free fluid in the abdominal cavity.

2. Blood test - increased chloride content, hypoproteinemia.

3. Determination of body weight gain - an increase in body weight throughout pregnancy, exceeding physiological weight by 5 kg (12 kg), as well as an increase in body weight after 20 weeks of pregnancy by more than 300-400 g per week, may indicate the development of gestosis.

4. Comparison of the daily amount of urine excreted with the amount of fluid drunk and the weight gain of the pregnant woman.

5. McClure-Aldrich test - performed to identify hidden edema. 0.2 ml of isotonic sodium chloride solution is injected intradermally into the forearm area, and the time during which the resulting blister completely resolves is noted. Normally, this period of time averages 45-60 minutes; in the presence of edema, the blister disappears in 5-25 minutes.

6. Breakdown with a ring - if swelling occurs, the selected ring will be difficult to put on or it will be impossible to put it on at all.

7. An increase in the circumference of the ankle joint by more than 1 cm within a week or an increase in the circumference of the lower leg by 8-10 % to the original value.

Differential diagnosis is carried out with edema of cardiac and renal origin.

Treatment. Treatment is carried out on an outpatient basis; if there is no effect, hospitalization is indicated. A complete cessation of smoking and drinking alcohol is necessary.

1. Dietary regimen: limiting fluid to 800-1000 ml per day and table salt to 3-5 g, including complete proteins (meat, fish, cottage cheese, etc.) in the diet, eating fruits and vegetables, fasting days (apple, cottage cheese) ) once a week.

It is important to eliminate adverse factors that affect the pregnant woman’s body at work and at home.

2. Sedative, antispasmodic, desensitizing therapy.

2. P-gestosis - proteinuria in pregnant women. In the normal morphofunctional state of the kidneys, up to 50-60 mg of protein is lost per day, which is not determined by conventional research methods. During a physiological pregnancy, protein loss is 200-300 mg per day. A higher loss (2 g/day) indicates impaired renal function, and the protein begins to be detected in the urine. As gestosis develops, proteinuria increases. An increase in protein to 1 g/l or more gives reason to consider this condition a sign of gestosis.

Pathogenesis: proteinuria can be:

a) renal - associated with increased permeability to the protein of the vessels of the renal glomeruli and the walls of the renal tubules with simultaneous impairment of protein reabsorption, which serves as a manifestation of general changes occurring in the vascular system of pregnant women

b) extrarenal - increased content of low molecular weight proteins in the blood, which are freely filtered by the renal glomeruli.

Diagnostics.

1. Urinalysis: an increase in protein in the urine of 1 g/l, increased hyaline and granular casts, constant isosthenuria according to the Zimnitsky test (1010-1012), persistent hyposthenuria (1002-1008), a decrease in daily diuresis to 1000 ml.

2. Blood test: decrease in total protein content to 60 g/l or more, albumin-globulin ratio below one, decrease in increase in urea level (normally 3.8-5.8 mmol/l).

3. Calculation of endogenous creatinine clearance - multiply the value of daily diuresis by the concentration of creatinine in the urine, the resulting result is divided by the value of the concentration of creatinine in the blood plasma.

4. Appearance in urine, along with.

3. G-gestosis - hypertension in pregnant women- increase in systolic blood pressure by more than 30 mm Hg. Art. and diastolic - more than 15 mm Hg. Art. compared with baseline values ​​(relative to blood pressure before pregnancy or in the first trimester of pregnancy). Hypertension in pregnant women is diagnosed when systolic blood pressure increases more than 140 mm Hg. and/or diastolic blood pressure more than 90 mm Hg.

Complications: fetal death, developmental delay, hypoxia, premature birth, premature abruption of a normally located placenta.

Diagnostics.

1. Blood pressure monitoring

2. Determination of average blood pressure - the sum of one systolic and two diastolic divided by 3 (the norm is 900-100 mm Hg). If the resulting figure is 105 mm Hg. and more, we can talk about hypertension, in which an increase in diastolic pressure predominates.

3. Functional tests - measuring blood pressure at different body positions of the pregnant woman. Blood pressure is measured with the pregnant woman lying on her left side every 5 minutes until a stable level of diastolic pressure is established. Then the pregnant woman is turned on her back and blood pressure is measured immediately after changing body position and after 5 minutes. The test is considered positive if diastolic pressure increases in the supine position by more than 20 mm Hg, which allows the woman to be classified as at risk for developing preeclampsia or to diagnose its initial manifestation.

4. Change in pressure in the temporal vessels. Normally, blood pressure in the temporal arteries does not exceed half the maximum pressure in the brachial artery, which is expressed in the temporobrachial coefficient, which is on average 0.5. An increase in the coefficient to 0.7-0.8 indicates an increase in blood pressure in the vessels of the brain, which can be considered a manifestation of late gestosis.

5. Fundus examination in the second half of pregnancy. Changes in the fundus of the eye begin with a moderate narrowing of the arteries and a slight dilation of the veins of the retina. The severity of changes in the vessels of the fundus depends on the severity and duration of gestosis.

4. OPG-preeclampsia – polysymptomatic - characterized by a triad of symptoms: edema, proteinuria and hypertension.

There are three degrees of severity of the disease.

a) in grade 1 there is swelling of the legs. Blood pressure is increased by 25-30% (about 150/90 mm Hg), moderate proteinuria is noted (up to 1 g/l); the platelet content in the blood is 180x10 9 /l or more, the pulse pressure is at least 50 mm Hg, the hematocrit value corresponds to 0.36-0.38;

b) in degree II, pronounced swelling of the legs and abdominal wall is detected, blood pressure increases by 40% compared to the initial level (up to 170/100 mm Hg), proteinuria is more pronounced (from 1 to 3 g/l); platelet count - 150-180 x 10 9 /l, pulse pressure - at least 40 mm Hg, hematocrit value - 0.39-0.42;

c) with the third degree of gestosis, pronounced swelling of the legs, abdominal wall, and face is detected; increase in blood pressure by more than 40 % (above 170/100 mmHg) and severe proteinuria (protein content in urine more than 3 g/l); platelet count - 120-150x10 9 /l, pulse pressure - less than 40 mm Hg, hematocrit value - more than 0.42.

To assess the severity of gestosis, the Wittlinger scale is also used, which makes it possible to objectify some clinical signs. The severity of gestosis is assessed in points. The total score gives an idea of ​​the severity of gestosis. A score from 2 to 10 indicates a mild degree of gestosis, from 10 to 20 indicates a moderate degree, and more than 20 indicates a particularly severe degree of gestosis.

To assess the severity of gestosis that has arisen against the background of extragenital pathology, a scale developed by G.M. is used. Savelyeva, according to which, along with clinical symptoms, the duration of the disease, the presence of extragenital pathology, as well as the condition of the fetus are taken into account. By background diseases we mean kidney diseases, hypertension, endocrinopathies, chronic nonspecific diseases of the lungs and bronchi, obesity, chronic liver diseases, heart defects of various origins. The scale characterizes the condition of pregnant women at the time of examination. A mild degree of gestosis in combination with extragenital pathology corresponds to 7 or less points, moderate severity - 8-11 points and a severe form of gestosis - 12 or more points.

5. Preeclampsia - characterized by the fact that the clinical picture of late gestosis is accompanied by symptoms indicating a dysfunction of the central and autonomic nervous system. The symptomatology of preeclampsia is caused by the occurrence of cerebrovascular accidents, resulting in cerebral edema and increased intracranial pressure.

Clinic: headache localized in the frontal or occipital region, severe constant or throbbing headaches, which can occur simultaneously with visual disturbances; visual impairment (periodically appearing flickering of bright and dark spots in front of the eyes, “fog” in the eyes, flickering of “spots” in front of the eyes, less often temporary loss of vision); pain in the epigastric region or in the right upper quadrant of the abdomen, sometimes nausea and vomiting, pain throughout the abdomen, urge to defecate; general excited state, anxiety, euphoria, insomnia, tinnitus or, conversely, lethargy, lethargy, drowsiness; cyanosis or a peculiar coloring of the face (against the background of a normal complexion, a bluish tint in the area of ​​the wings of the nose and lips, caused by impaired blood circulation in the capillaries); increase in individual or leading symptoms of gestosis (edema, proteinuria, oliguria, hypertension).

Preeclampsia most often occurs during the first pregnancy, before the age of 25 and after 35 years, against the background of any form of late gestosis; sometimes preeclampsia develops against the background of a relatively favorable course of the disease, but more often with a more severe form of gestosis. Dangerous signs are a rapid rise in blood pressure with a simultaneous decrease in pulse pressure, severe pathological changes in the eyes (severe vasospasm, hemorrhages, edema, retinal detachment).

The appearance of central nervous system dysfunction of varying forms and severity against the background of gestosis indicates the presence of convulsive readiness. The action of some more intense irritant (pain, loud sound, bright light) is enough for an attack of eclampsia to develop.

In all forms of late gestosis, uteroplacental insufficiency is detected. In mild forms, the effectiveness of uterine blood flow is supported by increased cardiac activity and increased blood pressure. Severe forms of gestosis are accompanied by impaired blood supply to the uterus and diffusion processes in the placenta. A decrease in blood flow in the uterus and placenta is a manifestation of generalized vascular disorders and occurs mainly due to a decrease in pulse blood pressure and worsening venous outflow of blood, which leads to intrauterine hypoxia and fetal death.

Treatment. Carrying out intensive complex treatment, aimed primarily at correcting hypovolemia and arterial hypertension, regulating protein and water-salt metabolism, as well as improving microcirculation, uteroplacental circulation and renal blood flow.

6. Eclampsia- a clinically pronounced syndrome of multiple organ failure, against the background of which one or more convulsive seizures develop, etiologically unrelated to other pathological conditions in pregnant women, parturient women and postpartum women with gestosis.

Clinic. Eclampsia is preceded by symptoms that are harbingers and are characterized by signs of significant irritation of the central nervous system: increased reflex excitability of the sensory organs. Harsh light, noise, painful stimuli and other factors can serve as factors that provoke a seizure. Each seizure of eclampsia lasts 1-2 minutes and consists of four periods: preconvulsant, tonic seizures, clonic seizures and resolution of the seizure.

Pre-convulsant period. Small fibrillary twitching of the eyelids appears, quickly spreading to the muscles of the face and upper limbs; the gaze becomes frozen, motionless; the eyes are fixed in one direction, only slightly deviating upward or to the side. The duration of the period is about 20-30 s.

The period of tonic convulsions. Following the twitching of the upper limbs, the patient's head leans back or to the side, the body stretches and tenses, the spine bends, the face turns pale, the jaw clenches tightly. The pupils dilate and go under the upper eyelid, as a result of which only the whites of the eyeballs remain visible. The patient is not breathing, the pulse is not palpable. The duration of the period is 20-30 s.

Period of clonic convulsions. Clonic convulsions begin, continuously following each other, spreading from top to bottom to all the muscles of the body, breathing is difficult or absent, the pulse is imperceptible, the face becomes purple-blue, the jugular veins tense. Gradually the convulsions become less frequent, weaker and finally stop. This period, like the previous one, is the most dangerous for the mother and fetus. Its duration is from 20-30 s to 1 min, and sometimes more.

Period of seizure resolution. Following a noisy deep breath, often accompanied by snoring, breathing is restored: the patient begins to breathe slowly and deeply, foamy saliva is released from the mouth, sometimes mixed with blood (due to biting the tongue), the lip becomes less cyanotic and gradually turns pink. The pupils narrow. The pulse begins to be felt, and at first it is very frequent and thread-like, then gradually slows down and its filling improves.

After a seizure, the patient is in a comatose state, but usually soon regains consciousness. The patient does not remember what happened; she complains of headache, general weakness, and weakness. The number of seizures varies among different pregnant women: from one to several dozen, in most cases 1-2.

The severity of eclampsia is judged by the number of seizures, their duration and the duration of unconsciousness. The more convulsive paroxysms, the longer the comatose state after them, the more serious the prognosis. Sometimes the patient does not have time to come out of the coma before the next seizure begins. This series of seizures is usually called eclamptic status. A special form of gestosis can also be observed - eclampsia without convulsions, when a pregnant woman with severe gestosis without a single seizure falls into an unconscious state, very often ending in death.

Complications: eclamptic coma (develops against the background of diffuse cerebral edema of post-hypoxic origin, as well as against the background of ischemia and hemorrhage in the brain); cerebral hemorrhage; poor circulation and hemorrhages in the liver, kidneys, placenta, gastrointestinal tract and other organs; partial placental abruption.

Differential diagnosis should be carried out with hypertensive encephalopathy, epilepsy and other diseases of the central nervous system, diabetic, uremic and hepatic coma.

Urgent Care.

1. The patient must be laid on a flat surface and her head turned to the side, clear the airways by carefully opening the mouth with a spatula or spoon, stretch the tongue forward and, if possible, aspirate the contents of the oral cavity and upper respiratory tract.

2. With the rapid restoration of spontaneous breathing - oxygen. In case of prolonged apnea, artificial ventilation of the lungs is resorted to using a mask.

3. When cardiac activity stops, closed cardiac massage and other cardiovascular resuscitation techniques are performed.

4. The patient must be put under anesthesia with fluorotane to prevent recurrence of seizures during obstetric examination and catheterization of the main vein.

5. To eliminate convulsive syndrome, various anticonvulsant and sedative drugs are used - diazepam, magnesium sulfate solution. To stop seizures, 0.02 g of diazepam is administered intravenously at the same time and the administration of 0.01 g is repeated after 10 minutes. Also, 20 ml of a 25% solution of magnesium sulfate is administered intravenously.

6. Treatment of cerebral insufficiency. Aimed at improving cerebral blood flow - the use of antispasmodics, antiplatelet agents, anticoagulants, and dextran preparations.

7. Normalization of blood volume, maintaining blood pressure at a moderate hypertensive level.

8. During the rehabilitation period, HBO is used, which accelerates the restoration of the functions of the central nervous system and parenchymal organs.

Treatment A patient with eclampsia should be examined simultaneously by an obstetrician-gynecologist and an anesthesiologist-resuscitator, if possible, in a specialized institution.

Regardless of the clinical form, all pregnant women with gestosis are hospitalized in the department of pathology of pregnant women of the obstetric hospital. Early hospitalization ensures more rational treatment and improves its effectiveness.

Treatment of late gestosis.

1.Creation of therapeutic and protective measures: includes a regimen of rest, sleep, prescription of medications: trioxazine, diphenhydramine, pipolfen. In severe cases of gestosis, short-term oxide-oxygen anesthesia in combination with fluorotane is used before starting examination and treatment. Seduxen, droperidol, promedol are administered intravenously.

2. Rational and balanced diet. A regimen of four meals a day at three-hour intervals and fasting days are recommended.

3. Normalization of macro- and microhemodynamics - prescription of antihypertensive drugs that eliminate vasospasm: antispasmodics, adrenergic blockers, peripheral vasodilators. inhibitors of vasoactive amines, magnesium sulfate (has a hypotensive, sedative, diuretic effect, has an anticonvulsant, antispasmodic effect and reduces intracranial pressure), magnesium sulfate (intramuscular injection of 20 ml of a 25% solution (5 g) after 4 hours, 4 injections per course; 2-3 courses of treatment with a 12-hour break between courses).

4. Pathogenetic therapy: combating hypovolemia, hypoproteinemia, intoxication of the body, correction of rheological properties of blood, CBS and electrolyte balance. For this purpose, solutions of glucose, Ringer, albumin, protein, fresh frozen plasma, 6% hydroxyethyl starch, reopolyglucin, reogluman, hemodez, acesol, disol, sodium bicarbonate, glucose-novocaine mixture are used.

Infusion therapy is carried out evenly throughout the day at an optimal rate of 200 ml/hour. The total volume of infused fluid should not exceed 800-1200 ml for severe gestosis and preeclampsia and no more than 2000-2500 ml for eclampsia.

Therapy is carried out with colloid and crystalloid solutions in a ratio of 2: 1.

6. Normalization of rheological and coagulation properties of blood: disaggregants (dextran preparations, trental, chimes, sermion, aspirin), heparin for a long course of moderate and severe gestosis.

7. Normalization of metabolism: panangin, methionine, folic acid, essentiale, vitamin complex, syrup and infusion of rose hips, chokeberry berries.

8. Prevention of placental insufficiency: oxygen therapy, cocarboxylase, chimes, korglykon.

9. With increasing oliguria, azotemic intoxication and hyperhydration syndrome - hemodialysis, therapeutic plasmapheresis.

Labor management tactics.

The choice of delivery date depends on the severity of late gestosis. Severe forms of gestosis include eclampsia, preeclampsia, HELLP syndrome, and semi-symptomatic third-degree gestosis; to moderate severity - OPG-gestosis of the second degree and to mild - OPG-gestosis of the first degree. The severity of gestosis is determined not only by the severity of its clinical manifestations, but also by the duration of its course. Choosing the due date:

1. In case of eclampsia, severe complications of gestosis (eclamptic coma, acute renal failure, cerebral hemorrhage, retinal detachment) - urgent delivery. It is also indicated in the absence of effect from intensive therapy for preeclampsia within 4-6 hours and severe gestosis within 24 hours.

2. For moderate gestosis:

a) if the pregnancy is 36 weeks or more, they resort to urgent or planned delivery

b) if the gestational age is less than 36 weeks, urgent delivery if, regardless of the intensive care provided, clinical or laboratory data indicate a deterioration in the pregnant woman’s condition or it remains unchanged

3. For mild forms of gestosis:

a) if the pregnancy is 36 weeks or more - planned termination of pregnancy

b) if the gestational age is less than 36 weeks, the patient is included in a long-term treatment and observation program, which makes it possible to wait the time necessary to achieve sufficient fetal maturity and a favorable pregnancy outcome. Pregnant long-term observation groups remain in the maternity hospital until the birth of the child.

Delivery.

1. Through the natural birth canal - with mild to moderate severity of gestosis, when planned delivery is expected and there is time to prepare for it. It is carried out with a prepared cervix by induction of labor with opening of the amniotic sac. In the absence of labor within 2-3 hours after amniotomy, induction of labor should be started by intravenous drip administration of oxytocin, prostaglandin, or a combination thereof.

With an “immature” cervix, to prepare it for childbirth, depending on the urgency, an estrogen-vitamin background is prescribed for 3-5 days or accelerated treatment with prostaglandins in combination with estrogen drugs. In case of premature pregnancy, fetal distress syndrome is prevented. To induce labor in such situations, it is advisable to use prostaglandins.

In the first stage, childbirth should be carried out in a room isolated from noise. During the dilatation period, early opening of the amniotic sac is indicated (when the cervix is ​​dilated by 3-4 cm) in order to reduce intrauterine pressure and stimulate labor.

During childbirth, it is necessary to carefully monitor the state of hemodynamics, respiration, renal function, liver and biochemical parameters, labor and the condition of the fetus. Intensive therapy continues. Part of the pathogenetic therapy is labor pain relief - a 2% solution of promedol, administered 1 ml intramuscularly, in some cases intravenously.

The appearance of neurological symptoms (headache, nausea, vomiting), insensitivity of the woman in labor to drug therapy, signs of threatening fetal hypoxia are indications for termination of labor using obstetric forceps or extraction of the fetus by the pelvic end under anesthesia. In case of a dead fetus, a fruit-destroying operation is performed.

2. Caesarean section. Indications: eclampsia, preeclampsia and severe form of OPG-gestosis with intensive unsuccessful therapy within a few hours; comatose state; anuria; amaurosis; retinal hemorrhage or detachment; suspicion or presence of cerebral hemorrhage; lack of effect from labor induction when the birth canal is unprepared; unprepared birth canal in pregnant women, even with sufficient effect from complex intensive therapy; development of fetal hypoxia when it is impossible to quickly complete labor through the natural birth canal; complicated course of labor (anomalies of labor) and a combination of gestosis with other obstetric pathology (breech presentation, large fetus, etc.). It is performed under general endotracheal or epidural anesthesia.

In the third stage of labor, drip intravenous infusion of methylergometrine or oxytocin is indicated to prevent bleeding.

In the postpartum period, the principles of treatment remain the same as during pregnancy. Women who have suffered late gestosis can be discharged home no earlier than 2-3 weeks after birth. They are transferred under the supervision of an obstetrician-gynecologist and a therapist. When a child born with preeclampsia is discharged, the children's clinic is notified of the need for careful patronage.

Prevention of late gestosis: proper monitoring of pregnant women in antenatal clinics and providing them with the necessary timely medical care; special registration of women who constitute a group at increased risk of developing late gestosis; timely identification and treatment of early signs of late gestosis in order to prevent the transition of the initial stages of the disease to more severe forms.

The site provides reference information for informational purposes only. Diagnosis and treatment of diseases must be carried out under the supervision of a specialist. All drugs have contraindications. Consultation with a specialist is required!

What is gestosis during pregnancy?

Preeclampsia is a consequence of a disruption in the process of adaptation of the mother's body to a developing pregnancy. Preeclampsia is fraught with complications for both the mother and the fetus.

Preeclampsia develops only during pregnancy and disappears after childbirth or termination of pregnancy. Rarely, gestosis causes pathology that remains after the end of pregnancy.

Preeclampsia is a fairly common pathology during pregnancy; it develops in 25-30% of expectant mothers. This terrible disease has been the cause of maternal mortality for many years (ranks 2nd among the causes of death of pregnant women in Russia).

Preeclampsia leads to dysfunction of vital organs, especially the vascular system and blood flow.

If gestosis develops in a practically healthy woman, in the absence of diseases, it is called pure gestosis. Preeclampsia, which develops against the background of chronic diseases in a woman (kidney disease, liver disease, hypertension, lipid metabolism disorder or endocrine pathology), is called combined preeclampsia.

Preeclampsia can begin both in the first and second half of pregnancy, but most often develops in the third trimester, from 28 weeks of pregnancy.

Causes of gestosis during pregnancy

Predisposing factors for the development of gestosis may be: insufficiency of adaptive reactions of neuroendocrine regulation; pathology of the cardiovascular system; endocrine diseases; kidney diseases; diseases of the liver and biliary tract; obesity; frequent stressful situations; intoxication (drinking alcohol, drugs, smoking); immunological and allergic reactions.

TO risk group The development of gestosis during pregnancy includes:

• women with overwork, chronic stress (this indicates a weak adaptive ability of the nervous system);
• pregnant women under 18 and over 35 years of age;
• pregnant women who suffered gestosis during a previous pregnancy;
• women with a hereditary predisposition to gestosis;
• women who gave birth often with short intervals between births or often had abortions;
• pregnant women with chronic infections or intoxications;
• socially vulnerable women (poor nutrition in pregnant women, poor environmental conditions);
• women with genital infantilism (delayed sexual development or underdevelopment of the genital organs and their functions);
• women with their first pregnancy;
• women with multiple pregnancies;
• women with bad habits.

The risk of developing preeclampsia is 8 times higher in women whose mothers had preeclampsia compared to other women whose mothers did not have preeclampsia. Studies have shown that daughters develop eclampsia in 48.9% of cases (the eldest daughter more often than the youngest), and sisters develop it in 58% of cases.

Even manifestations of early gestosis or toxicosis, according to the observations of gynecologists, develop in those women whose mothers suffered from toxicosis. If the mother did not show it, then the daughter may only experience slight motion sickness in transport, or her sense of smell may become somewhat heightened.

Most scientists are inclined to believe that when gestosis occurs, a combination of several of these reasons is important.

The metabolic products of the embryo are not neutralized in the first trimester by the placenta (it is formed from 9 to 16 weeks of pregnancy), enter the blood of the pregnant woman and cause nausea and vomiting in response.

Due to changes in a woman’s body (including hormonal ones), the permeability of the vascular wall increases, and as a result, the liquid part of the blood “leaves” the bloodstream and accumulates in the tissues - this is how edema occurs. Both the uterus and placenta swell, which impairs blood supply and oxygen supply to the fetus.

Due to blood thickening, its ability to form blood clots increases. In order to “push” this thickened blood through the vessels, the body has to increase blood pressure - another manifestation of gestosis.

Increased permeability of the vascular wall in the kidneys leads to protein entering the urine and being released from the body - proteinuria is also a symptom of gestosis.

What are the dangers of gestosis during pregnancy (consequences of gestosis)?

Uncontrollable vomiting during gestosis can cause dehydration of a woman’s body. Preeclampsia can lead to premature placental abruption, premature birth, and fetal asphyxia. With gestosis of mild and moderate severity, premature birth is observed in 8-9%, and with severe gestosis - in 19-20% of cases. If gestosis progresses to the stage of eclampsia, then 32% of children are born prematurely.

The consequences of late gestosis in any form are extremely unfavorable for the child. An acute form of gestosis with premature placental abruption can even cause the death of the child. Perinatal mortality with gestosis reaches 32%.

Sluggish gestosis leads to fetal hypoxia (insufficient oxygen supply), which, in turn, is likely to cause intrauterine growth retardation. 30-35% of children born to mothers with manifestations of gestosis have low body weight. Fetal hypoxia subsequently leads to delayed physical and mental development of the child. Many children get sick often.

In the most severe form of gestosis - eclampsia - urgent delivery (or termination of pregnancy) is the only way to save the life of the woman and child. Delivery before the due date is not always a favorable outcome for a premature immature baby. Although in some cases the baby has a better chance of surviving outside the womb.

Ptyalism, or drooling, can occur independently or accompany vomiting. Drooling can reach a volume of 1 liter or more per day. At the same time, general health worsens, appetite decreases, there may be a loss of body weight, and sleep disturbances. With severe ptyalism, signs of dehydration may appear.

Typically, early gestosis rarely exhibits an aggressive course. Regardless of the severity of early gestosis, its manifestations should disappear by 12-13 weeks of pregnancy. If manifestations of toxicosis continue, it is necessary to conduct an examination of the pregnant woman to exclude an exacerbation of any chronic disease of the internal organs.

Gestosis of the second half of pregnancy (late gestosis)

Characteristic triad of symptoms ( swelling, protein in urine, increased blood pressure) may not occur in all women. One of them may indicate the development of gestosis. The only visible manifestation of gestosis for a woman is swelling. And increased blood pressure and protein in the urine can only be detected by a doctor. Therefore, it is so important for a pregnant woman to register for pregnancy in a timely manner and regularly attend doctor’s appointments.

The combination of symptoms for gestosis can be different. Currently, all 3 signs of late gestosis are observed only in 15% of cases, edema with increased pressure - in 32% of cases, protein in the urine and increased pressure - in 12% of cases, edema and protein in the urine - in 3% of cases. Moreover, obvious edema is observed in 25%, and hidden edema (indicated by pathological weight gain) - in 13% of cases.

The first stage of late gestosis – swelling, or dropsy during pregnancy. A woman can notice the appearance of edema by feeling a slight numbness in her fingers. With swelling, it becomes difficult to straighten your fingers and put rings on your fingers.

Swelling does not always mean the development of gestosis. Swelling may be the result of increased production of progesterone (the so-called pregnancy hormone). Edema can also appear as a result of exacerbation of a chronic disease (varicose veins, heart disease, kidney disease). But only a doctor can figure out whether edema is a common manifestation of pregnancy, a symptom of a chronic disease, or a symptom of gestosis.

If there is excessive weight gain in a pregnant woman, but there is no visible edema, then to check the woman can undergo a Maclure-Aldrich test: a saline solution is injected subcutaneously and the time taken for the “button” to dissolve is observed. If it does not disappear in less than 35 minutes, it means there is hidden swelling.

If swelling becomes visible, it means that 3 liters of excess fluid are retained in the body. First, the feet swell, then the swelling spreads upward, involving the legs, thighs, abdomen, neck and face. Even if a woman does not experience any unpleasant sensations, it is necessary to take urgent measures to prevent gestosis from worsening. It is dangerous to self-medicate and take diuretics, because... this will make the situation even worse. The condition can deteriorate sharply at any time.

Second stage of gestosis – nephropathy– usually develops against the background of dropsy. Its first symptom is increased blood pressure. For a pregnant woman, not only an increase in pressure is important, but also sharp fluctuations in it, which can cause placental abruption and fetal death or sudden bleeding.

Third stage of gestosis – preeclampsia– characterized by the fact that in addition to swelling and high blood pressure, there is also protein in urine. At this stage, severe disturbances in the blood supply to the brain may develop, which is manifested by the appearance of severe headaches, a feeling of heaviness in the back of the head, flashing spots before the eyes, nausea and vomiting, visual impairment, memory impairment, and sometimes even mental disorders. Irritability, insomnia, lethargy, pain in the abdomen and right hypochondrium are also noted. Blood pressure is increased - 160/110 mm Hg. Art. and higher.

The fourth, most severe stage of gestosis – eclampsia. Sometimes it, bypassing preeclampsia, develops very quickly after nephropathy. With eclampsia, the function of many organs is impaired, and convulsions may occur. Seizure attacks can be provoked by various factors: a sharp sound, bright light, a stressful situation, pain. The attack of convulsions continues for 1-2 minutes. There may be tonic ("pulling" spasms) and clonic (small muscle twitches). The convulsive attack ends with loss of consciousness. But there is also a non-convulsive form of eclampsia, in which, against the background of high blood pressure, a woman suddenly falls into a coma (loses consciousness).

Eclampsia is fraught with serious complications: placental abruption, premature birth, bleeding, fetal hypoxia and even fetal death. At this stage, it is possible that a heart attack, pulmonary edema, stroke, or renal failure may occur.

Eclampsia most often develops in women with their first pregnancy. When predicting the risk of developing eclampsia, genetic factors should also be taken into account. With hydatidiform mole and multiple pregnancy, the risk of developing eclampsia increases significantly.

In some cases, an asymptomatic or low-symptomatic course of gestosis is possible. But rapid development of this pregnancy complication is also possible. Therefore, at the slightest suspicion that a pregnant woman has gestosis, delay in examination and treatment is dangerous for the life of the mother and child.

Late gestosis can have an unpredictable development. It can progress sharply, and the deterioration of the woman’s condition will rapidly increase with each passing hour. The earlier gestosis develops, the more aggressive its course, and the more severe consequences it will have, especially if treatment is not timely.

Rare forms of gestosis

• Jaundice of pregnant women: it occurs more often in the second trimester, is accompanied by itching, and is usually progressive in nature; may cause miscarriage, impaired fetal development, bleeding. It recurs during the next pregnancy and is an indication for termination of pregnancy. The cause of its occurrence may be viral hepatitis suffered in the past.
• Dermatoses: eczema, urticaria, herpetic rashes; there may only be painful skin itching (local or total), causing irritability and insomnia. Occurs more often in people with allergic manifestations and liver pathology.
• Acute fatty liver degeneration (fatty liver disease): characterized by bleeding, bruising, vomiting, swelling, decreased urine output and convulsions. The cause is unclear; may be the outcome of other types of gestosis. May be combined with fatty kidney disease. Characterized by a gradual decrease in kidney and liver function.
• Tetany of pregnant women: frequent occurrence of muscle cramps, mainly in the extremities. Occurs when there is a lack of calcium due to its consumption by the fetus, when the function of the parathyroid gland is impaired, when calcium absorption in the intestines is impaired and when there is a lack of vitamin D.
• Osteomalacia(softening of skeletal bones) and arthropathy(disorders of the articulations of the pelvic bones and joints): also associated with disturbances of calcium and phosphorus metabolism and decreased function of the parathyroid gland. A lack of vitamin D contributes to the occurrence of this type of gestosis.
• Chorea of ​​pregnancy: uncoordinated and involuntary movements, emotional instability, mental disorders, some difficulty swallowing and speaking. Occurs with organic brain lesions. In mild cases, pregnancy continues and ends in childbirth. In severe cases, termination of pregnancy. After pregnancy, symptoms of chorea gradually disappear.

Preeclampsia during second pregnancy

Women who have experienced gestosis during pregnancy are at risk for developing gestosis. The risk increases if there is a short interval between pregnancies. Such women should monitor the course of pregnancy and health status from the first weeks of pregnancy, regularly and carefully.

There are, however, known cases when during the second pregnancy gestosis did not develop at all or occurred in a milder form.

Management of pregnancy during gestosis

• bed or semi-bed rest;
• control blood pressure 5-6 times a day;
• body weight control (once every 4 days);
• daily monitoring of fluid received (drunk and administered intravenously) and excreted;
• control of protein content in urine (in a single portion every 2-3 days and in the daily amount of urine every 5 days);
• general blood and urine test every 5 days;
• eye examinations;
• monitoring the condition of the fetus daily.

In severe cases of gestosis, more active pregnancy management tactics are currently being used. Indications for early delivery are not only eclampsia (convulsive or non-convulsive) and complications of eclampsia, but also preeclampsia if there is no effect of treatment within 3-12 hours, and moderate gestosis if there is no effect of treatment within 5-6 days. A rapid increase in the severity of a woman's condition or progression of placental insufficiency is also an indication for early delivery.

The severity of gestosis and the condition of the woman and fetus determine the choice of method and time of delivery. Vaginal delivery is preferred. But for this, the following conditions are necessary: ​​cephalic presentation of the fetus, proportionality of the fetal head and the mother’s pelvis, maturity of the cervix, the age of the pregnant woman is not older than 30 years, etc.

With gestosis, the anti-stress resistance of both the mother and the fetus decreases. Childbirth with gestosis is stressful for both of them. And at any moment (with fatigue during childbirth, painful sensations, etc.) a woman can suffer from pressure that has sharply increased to critical levels. This can lead to the development of eclampsia during childbirth and to cerebrovascular accident. Therefore, with gestosis, childbirth is often carried out by cesarean section (although eclampsia can develop in this case).

Indications for delivery by cesarean section with gestosis are currently expanded:

• eclampsia and complications of eclampsia;
• various complications of gestosis: acute renal failure, coma, retinal detachment or retinal hemorrhage, cerebral hemorrhage, premature placental abruption, acute fatty liver disease in pregnant women, HELLP syndrome (combined liver damage and hemolytic anemia in nephropathy), etc.;
• preeclampsia, severe gestosis with an immature cervix;
• gestosis in combination with other obstetric pathology;
• gestosis for a long time (more than 3 weeks).

Treatment of gestosis during pregnancy

Treatment of early gestosis

If nausea constantly bothers you, and vomiting occurs occasionally, then you can try to reduce nausea with tea (with mint, lemon balm or lemon), fruit drinks and juices. In the morning it is better to eat cottage cheese or fermented milk products, cheese - every woman will be able to choose acceptable ways to combat nausea. You can rinse your mouth with infusion of chamomile and sage.

If you have severe salivation, rinsing with oak bark infusion and taking yarrow infusion 10 minutes before meals and 2 hours after meals will also help.

If vomiting is uncontrollable and constant, then you should definitely consult a doctor, as this can threaten the health of both the woman and the fetus. Vomiting occurs in 50-60% of pregnant women, and only 8-10% of them require treatment. Don't forget to drink enough to replace fluid lost through vomiting.

Medicinal treatment, including homeopathic remedies, can only be used as prescribed by a doctor and under the supervision of a doctor.

In the case of a severe general condition of a woman (development of acute renal failure or acute yellow dystrophy of the liver) with gestosis in the first half of pregnancy and in the absence of effect from treatment within 6-12 hours, termination of pregnancy is indicated. And since most often early gestosis develops in 6-12 weeks of pregnancy, the pregnancy is terminated through an induced abortion.

Treatment of late gestosis

• Creation of a therapeutic and protective regime. Depending on the severity of gestosis, bed or semi-bed rest and sufficient sleep are prescribed. Loud sounds and emotional experiences are excluded. Psychotherapeutic work with women is recommended as a mandatory component of treatment. If necessary, the doctor prescribes sedatives (valerian, motherwort for mild gestosis, or more potent drugs for severe gestosis).
• Proper diet for a pregnant woman: varied, fortified, easily digestible food; limiting carbohydrates and sufficient amounts of protein in foods; eating enough fruits and vegetables, juices and fruit drinks. Sometimes it is recommended to eat food while lying in bed, in small portions, chilled. Fasting days are not recommended. You should not limit fluid, even with severe edema (contrary to many recommendations on the Internet) - after all, on the contrary, it is necessary to replenish the volume of the bloodstream.
• Drug treatment is prescribed for the purpose of normalizing the functions of organs and systems of a pregnant woman and preventing or treating fetal hypoxia. Diuretics are practically not used, because their use further reduces the volume of blood flow, thereby disrupting (or further exacerbating existing disturbances) placental circulation. The only indications for their use are pulmonary edema and heart failure, but after replenishment of the circulating blood volume. Vitamins of group B, C, E are prescribed; drugs that improve uteroplacental blood circulation and reduce the permeability of the vascular wall, lower blood pressure and others.
• Early delivery. Indications for early delivery and methods are described in the section “Management of pregnancy during gestosis.”

The main condition for successful treatment is timeliness and professionalism.

Prevention of gestosis during pregnancy

During pregnancy, the following measures will serve to prevent gestosis:

• Sufficient sleep (8-9 hours a day), proper rest, limitation of physical activity, exclusion of stressful situations and a positive psycho-emotional climate in the family are the most important conditions for the prevention of gestosis.
• Breathing exercises, special physical therapy for pregnant women, massage of the cervical-collar region and head will balance the processes of inhibition and excitation in the centers of the brain and improve blood oxygen saturation. Swimming, Pilates, yoga, and long walks (hiking) in the fresh air will help prevent gestosis (toxicosis).
• It is important that the family understands the condition of the pregnant woman and tries to alleviate it. For example, if a woman is irritated by strong odors during this period (husband’s eau de toilette, coffee, garlic, onions, etc.), then she should stop using them.
• You should wake up slowly, without making sudden movements. While still lying down (even if there is no nausea yet), you can eat a piece of black bread or a cracker, kiwi or a slice of lemon, or drink a chamomile decoction.
• Nutrition should be complete, but this does not mean that you can eat everything and in unlimited quantities. During the day, food should be consumed often, but in small portions. Food should not be very hot and not very cold.

It is useful to eat porridge (buckwheat, oatmeal).

A growing fetus needs proteins, so a pregnant woman should eat protein-rich foods: lean meats (beef, chicken, veal), eggs, fish, cottage cheese. And if gestosis has already appeared, then the need for proteins is even higher, because proteins are lost in urine.

Fruits and berries, decoctions of dried fruits and rose hips, and cranberry juice will provide the body with vitamins. We should not forget about fiber - it will both cause a feeling of fullness and serve as a preventive measure for constipation. The most fiber is found in vegetables (carrots, beets), fruits and dried fruits, mushrooms, bran, seaweed, and herbs.

• The recommended volume of fluid per day is at least 2 liters. This volume also includes milk, soups, and juicy fruits. You can drink alkaline mineral waters without carbon, tea with lemon balm or mint.
• It is necessary to constantly monitor your weight and keep records. After 28 weeks of pregnancy, weekly weight gain should average 350 g, and no more than 500 g. During the entire pregnancy, a woman should gain no more than 12 kg in weight. Excessive or too rapid weight gain may indicate the development of edema.
• Difficulties in the outflow of urine contribute to the occurrence of edema and the development of gestosis. The uterus in a standing position puts pressure on the ureters and thereby disrupts the outflow of urine. Therefore, doctors recommend that pregnant women stand in the knee-elbow position 3-4 times a day for 10 minutes. You can place a pillow under your chest for comfort. This improves urine flow.
• To prevent edema, it is recommended to drink kidney tea, a decoction of lingonberry, rosehip, and bearberry leaves. You can take herbal preparations such as Cyston, Canephron, Cystenal.
• Sometimes doctors prescribe magnesium preparations (Magnerot, Magne-B6), lipoic acid, vitamin E, Chophytol (promotes inactivation of substances that destroy blood vessels in the liver), Curantil (improves blood supply to the placenta and is a preventive agent for the development of gestosis) to prevent gestosis.

Preeclampsia: causes, symptoms, consequences, treatment, prevention - video

Pregnancy after gestosis

A woman in this situation is at risk for gestosis and needs careful medical supervision from the very first weeks of a new pregnancy.

But the occurrence of gestosis in subsequent pregnancies is not inevitable.