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Methodical recommendations for the student’s of stomatological faculty




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Vinnitsa Nathional Medical University named after N.I. Pyrogov


Head of Obstetrics and Gynaecology department № 2 MD, prof. Bulavenkо О.V.__________

the «____» ____________of 20___ year


METHODICAL RECOMMENDATIONS

FOR THE STUDENT’S OF STOMATOLOGICAL FACULTY

FOR PREPARING TO PRACTICAL LESSON



Subject

Obstetrics

Module 1.

Physiological and pathological course of pregnancy, childbirth and the postpartum period. Perinatal complications.



Semantic module 1.

Physiological and pathological course of pregnancy, childbirth and the postpartum period. Perinatal complications.


Subject lessons

Hypertensive disorders in pregnancy. Pre-eclampsia, eclampsia.

(first and second sessions)

Year of study

4

Faculty

Stomatological

Author

Assistаnt, Goncharenko O.M.



Vinnitsa 2013

1. Topicality. This topic is relevant for future physicians as family medicine and obstetrician-gynecologists and for dentists because patients in these categories doctors quite often pregnant women. But early diagnosis and prevention of gestosis pregnant reduces maternal mortality and perinatal morbidity. Knowledge of algorithm acts doctor in the cases of eclampsia saves the patient's life.


^ 2. Specific objectives:


Analyze the causes complications gestosis pregnant.

Explain the theory of gestosis pregnant.

Consider risk factors gestosis pregnant and identify women at risk for the occurrence of gestosis

Gestosis classify the degree of severity. Interpret data of laboratory and instrumental methods of analysis.

Draw up a treatment regimen gestosis depending on the severity.

Analyze the causes of perinatal morbidity of this pathology.

To make the algorithm acts of the doctor in case of an attack of eclampsia, tactics for selecting the method of delivery depending on the obstetric situation.


^ 3. Basic knowledges, skills necessary for studying the topic (interdisciplinary integration).


The names of the preceding disciplines

The skills

  1. Propaedeutics.




  1. Pharmacology.




  1. Laboratory diagnosis




  1. Obstetrics




Describe syndromes and symptoms of this nosology.
Calculate the required dose of the drug required per day in the treatment of this disease, to determine the side effects and contraindications of drugs.
Apply the necessary laboratory methods for the diagnosis of pathological abnormalities in the body of this pathology, have the ability to interpret the results of laboratory tests.

Classify the types of gestosis, depending on gestational age, identify this pathology among other diseases, compare types of delivery, depending on the obstetric situation, display case of pregnant women.




^ 4. Tasks for independent work in preparation for employment.
List of key terms that students must master in preparation for the Session:


Term

Definition

1. Gestoses


2. Preeclampsia


3. Triad of Tsanhemeyster


4. Еclampsia


5. Ststus of eclampsia


6. Coma


7. НЕLLP- syndrome


8. Hypertensive disorders in pregnancy


9. Chronic hypertension


10. Gestational hypertension


11. Proteinuria


12. Combined preeclampsia


13.Transient (transient) gestational hypertension


14. Chronic gestational hypertension

15. Hypertension unspecified

- these are states pregnant women arise with the development of the ovum or its individual elements, characterized by a variety of symptoms, most of which are permanent and severe dysfunction of the central nervous system, cardiovascular disorders and metabolic disorders. When you remove the ovum or its elements disease usually stops.


- hypertension that emerged after the 20th week of pregnancy in combination with proteinuria.

- is a set of symptoms that poyenuye presence in pregnant edema, proteinuria and hypertensionї.

- convulsions (seizures) in patients with preeclampsia


- seizures, which follow each other in a patient with preeclampsia.

- development of brain edema due to eclampsia, unconsciousness central origin.

-this is one of the clinical forms of late preeclampsia, which is characterized by the development of hemolysis of red blood cells (hemolysis (H) - microangiopathic hemolytic anemia), elevated liver fermehts (EL) - increased concentrations of liver enzymes in the blood plasma; low platelet quantity (LP) - a reduction in platelet

- chronic hypertension, gestational hypertension, transient (transient) gestational hypertension, chronic gestational hypertension, pre-eclampsia, preeclampsia combined.

- hypertension observed before pregnancy or there (was first detected) until the 20th week of pregnancy.


- hypertension, which appeared for the first time after the 20th week of pregnancy and is not accompanied by proteinuria until delivery.


- presence of protein at a concentration of 0.3 g / l in midstream urine collected twice with an interval of 4 hours. or more, or the number of protein excretion 0.3 g per day.

-of proteinuria after the 20th week of pregnancy on a background of chronic hypertension.

-normalization of blood pressure in patients who have had gestational hypertension for 12 weeks. after childbirth (retrospective diagnosis).

-hypertension arising after 20 weeks of pregnancy and stored for 12 weeks. after birth.

-hypertension, found after 20 weeks of pregnancy, in the absence of information on the AT to the 20th week of pregnancy.



Theoretical question for the class:


1. What is gestosis of pregnancy?
2. Classification of gestosis of pregnant.
3. Clinic of rare forms of gestosis.
4. Treatment of early gestosis ..
5. Diagnostics of late gestosis of pregnant.
7. Treatment of gestosis of pregnant.
8. Methods of delivery during gestosis of pregnant.
9. Indications for cesarean section during gestosis.

10. The algorithm action of doctors in a fit of eclampsia.
11. Treatment eclampsia attack.
12. Complications of gestosis.
13. Complications of eclampsia.
14. Prevention gestosis of pregnant.
15. Rehabilitation of women who had preeclampsia later.

Practical work (tasks) to be performed in class:


1. To determine the degree of predicted risk of preeclampsia during pregnancy.
2. To chart early prevention gestosis pregnant women in particular.
3. Work out on a mannequin: tactics of physician in a fit of eclampsia.
4. Make a table of methods of delivery during gestosis depending on obstetric situation.
5. Scheme of therapy in preeclampsia moderate and severe stages.
6. Develop a scheme of rehabilitation of women who had preeclampsia later.


Content topics:


Gestoses is a syndrome defined as violated adaptation of women to pregnancy. Gestosis arises only in connection with pregnancy, is etiologically linked to fetal egg development, is characterized by various symptoms, complicates the course of pregnancy and usually disappears right after the end of pregnancy.

Many theories have been offered to explain gestosis reasons: toxemic, allergic, corticovisceral, endocrine, neurogenic, psychogenic, immune, genetic and others, around 40 theories.

For instance, the genetic theory developed after it was found that in women having a family history of preeclampsia or eclampsia these complications are met 4 times more often. Besides, the genes transferring inclination to preeclampsia (mitochondrial genes) were identified.

The immune theory represents the fetoplacental complex as an allograft and preeclampsia development is a reaction akin to allograft regection reaction.

Multiple theory of preeclampsia pathogenesis suggest that none of them describes it completely.

The clinical presentation of gestosis is conditioned by activation or dysfunction of endoteliocytes of vessels (first of all of spiral arterioles) and is accompanied by trombocytes activation. In the plasma there is considerably increased concentration of the markers of the affection of endoteliocytes (endotelin, fibronectin), activation of trombocytes (tromboxane-prostacyclin, cytoadherence molecules, von Willebrand factor), trombocytes degranulation products.

An important role in gestoses origin belongs to:

  1. insufficiency of the uterine spiral arterioles, which causes placental circulation violation;

  2. vessel endothelium dysfunction connected with autoimmune violations caused by pregnancy.

Risk factors of gestoses onset include:

  1. Extragenital pathology:

  • arterial hypertension before pregnancy;

  • renal dysfunction;

  • metabolic disorder (obesity);

  • cardiovalcular system diseases (diabetic angiopathy, autoimmune vasculitis);

  • sicklemia.

  1. Obstetric- gynecologic risk factors:

  • conditions accompanied by the formation of the placenta of big size (multiple pregnancy, diabetes mellitus, gestational edema);

  • presence of hypertonic disorders in hereditary anamnesis;

  • presence of preeclampsia during previous pregnancy;

  • the age of the pregnant (less than 19, more than 30 years);

  • isosensitization by Rh- factor and ABO system.

3. Social and living factors:

  • bad habits;

  • occupational hazards;

  • unbalanced diet.

The knowledge of the risk factor of preeclampsia development and their detection allow timely formation of risk groups concerning preeclampsia onset.


^ EARLY GESTOSES


There is no single gestoses classification. The MPH of Ukraine and the Association of Obstetricians-Gynecologists of Ukraine recommend the classification of early and late gestoses (Table 1).

In many countries early gestoses are viewed as pregnancy complications or unpleasant symptoms of pregnancy. We consider vomiting and salivation to be early manifestations of organism dysadaptation to pregnancy and therefore view these conditions as gestoses, early by the term of onset.

The diagnostics of the severity of vomiting of pregnant is based on clinical and laboratory data. The latter include: hematocrit, the quantity of protein and its fractions, blood electrolytes, bilirubin, urea, common urine analysis, diuresis.

Moderate and severe vomiting should be treated in the in-patient department.


The main principles of vomiting treatment are:


1.Normalization of the violations of correlation between the excitative and inhibitory processes in the CNS — psychotheraру, electrical sleep, acupuncture, laser reflexotherapy, sedatives and/or tranquilizers (diazepam, seduxen).

2.Antiemetic agents - droperidol, aminazine, etapirazin, cerukal.

3. Water-electrolytic balance correction, metabolism correction: Ringer's, Dissol, Trisol solutions, physiologic saline. The solutions of hydroxyethylstarch — refortan, stabisol — are also used.

Unfavorable prognostic symptoms are also icteric discolor of the skin, body temperature more than 38 °C, tachycardia over 120 bpm, albuminuria, comatose state, delusion.

Indications to abortion are disease progression against the background of treatment.

Usually early gestoses of pregnant stop during the 13th—14th week of pregnancy.

Table 1 . ^ Early Gestoses Classification


Classification

Definition

1. Vomiting of pregnant (emesis gravidarum):

Vomiting connected to pregnancy

— mild vomiting

—vomiting up to 3—5 times a day on an empty stomach or after meals

—reduced appetite

— moderate vomiting

—vomiting up to 10 times a day irrespective of food intake

—weight loss, weakness, apathy

—electrolyte imbalance

— severe vomiting (hy-peremesis gravidarum)

—vomiting more than 10 times a day, no food is hold

—weight loss

—low grade fever

—icteric discolor of the skin and sclerae

—acetonuria with oliguria

—tachycardia, hypotension

—hyperbilirubinemia, hypokalemia, hypernatremia, hypoproteinemia

—hematocrit increase

2. Salivation (ptyalis-mus gravidarum)

—hypersalivation

^ LATE GESTOSES

Under the recommendation of the WHO (1989) and on demand of the ICD of the 10th revision (1995), the Association of Obstetri­cians-Gynecologists of Ukraine recommended and the MPH of Ukraine approved such classification of late gestoses (Tables 2, 3).

Table 2 . ^ Late Gestoses Classification


Classification

Definition

1. Gestational hyper­tension, or hypertension during pregnancy:

Hypertension which appeared after 20 weeks of preg­nancy and is not accompanied by proteinuria up to delivery:

—transient gestational hypertension

—normalization of arterial blood pressure in the woman, who has been having gestational hypertension during 12 weeks after delivery

—chronic gestational hypertension

—hypertension, which appeared after 20 weeks of pregnancy and continues during 12 weeks after delivery

2. Proteinuria during pregnancy

Protein content of 0.3 g/L in an average portion of urine collected twice with an interval of 4 h or more, or protein excretion of 0.3 g a day

3. Edema during preg­nancy

Liquid holdup, local or generalized edema. Diuretic-resistant edema, pathologic weight gain

Preeclampsia

Hypertension, which appeared after 20 weeks of pregnancy in combination with proteinuria, with/without edemata ("pure" gestosis)

4. Mild preeclampsia

—arterial blood pressure (ABP) systolic and diastolic 140-159 per 90-99 mm Hg

—proteinuria < 0.3 g/day

5. Moderate pre­eclampsia

—ABP 160-179 per 100-109 mm Hg

—proteinuria 0.3—5.0 g/day

—edemata on the face, hands

—sometimes headache

6. Severe preeclampsia

—ABP > 180 per > 110 mm Hg

—proteinuria > 5.0 g/day

—generalized, considerable edemata

—headache, visual impairment

—hyperreflexia

—pain in the epigastrium and/or right hypochondrium

—oliguria (< 500 ml/day)

—thrombocytopenia

7. Eclampsia (during pregnancy, in the pro­cess of delivery, in the puerperal period, un­specified by the term)

—convulsive attack (one or more) in the pregnant with preeclampsia

Note: The presence of at least one criterion of more severe preeclampsia gives grounds for corresponding diagnosis.

^ Rare Form of Gestoses-HELLP syndrome

HELLP syndrome - is hemolysis (H) - microangiopathic hemolytic anemia, elevated liver fermehts (EL) - increased concentration of liver enzymes in the blood plasma; low platelet quantity (LP) - decrease in platelets.

The frequency of the disease in perinatal centers is 1 case per 150-300 births. Thus the maternal mortality rate reaches 3.5%, and perinatal -79 ‰.

Pathophysiological changes in NELLP-syndrome occurring mainly in the liver. Segment vasospasm leads to disruption of blood flow in the liver and stretching hlisonovoyi capsule (pain in the upper abdomen). Hepatocellular necrosis leads transaminase elevations. Thrombocytopenia and hemolysis resulting from endothelial damage in obstructive altered vessels. If this vicious circle, consisting of endothelial damage and intravascular activation of clotting system is not interrupted, then a few hours developing DIC - syndrome with fatal bleeding.

The disease most often (59%) occurs during pregnancy and in term of 35 weeks. In 10% of cases in a period less than 27 weeks., And 31% - during the first week after birth.

The clinical course of HELLP-syndrome is unpredictable and manifested by headache, nausea, vomiting, diffuse or localized in the right upper quadrant or epigastric pain in the abdomen. Typical jaundice, hematemesis, hemorrhage at the injection, progressive liver failure, seizures and coma. Occur in isolated cases return of symptoms with conservative treatment. However, most patients developed rapidly worsening disease resistant to treatment and leads to severe complications: premature detachment of the placenta (15-22%), acute renal failure (8%), pulmonary edema (4.5%), intracerebral hemorrhage (5%), rupture of the liver (1.5%), DIC (38%).

Suspicion of HELLP-syndrome need immediate laboratory research. The syndrome is characterized by the appearance of these signs, especially pronounced growth activity of lactate dehydrogenase, thrombocytopenia erased the background often vague symptoms of preeclampsia. Characterized by pain in the epigastric region, tension and tenderness in the right upper quadrant abdominal discomfort, nausea, and vomiting. The liver can be increased in consistency as soft and extremely dense, often with subcapsular hemorrhages. Sharply to 500 units instead of 35 units increased aminotransferase (ALT, AST) and 3-10 times the activity of lactate dehydrogenase, the number of platelets decreased to 100h109 15 / L, hemoglobin concentration falls to 90 g / l and lower hematocrit decreases to 0, 25-0,3 g / l, increased levels of bilirubin, a possible hemolysis. Violated parameters of hemostasis: decreased levels of antithrombin III increases protytrombinovyy time and partial thromboplastin time, fibrinogen level is lower than desired during pregnancy. Simultaneously noted mild hypertension (150/100 mm Hg. Cent.), The increase in plasma uric acid, nitrogen compounds, lowering blood sugar to hypoglycemia in severe cases.

Treatment consists of correction of coagulation, transfusion of plasma enriched with platelets or platelet levels in platelets less 40h109 / l, stabilize cardiovascular system and quick delivery practices.

Method of delivery practices depends on obstetric situations: when mature cervix and no contraindications to independent childbirth emergency delivery practices carried out through the natural birth canal, the unavailability of a generic ways spend cesarean section.

More patients requiring intensive therapy, which consists of the introduction of glucocorticoid drugs (at least 1 g of prednisolone per day), the introduction of immunoglobulins, hepatoprotective substances. Appropriate use of alternative therapies (eg,plasmapheresis).

In the CNS: brain edema, intracranial hemorrhage.

Pathophysiological changes at HELLP-syndrome generally takes place in the liver. Segmented vasoconstriction leads to' hepatic blood flow disturbance and gleason capsule stretch (pains in the upper part of the abdomen). Hepatocelular necrosis conditions transaminases increase.

Thrombocytopenia and hemolysis are caused by endothelium damage in the obstructively altered vessels. If this vicious circle, consisting of endothelium damage and intravascular activation of the coagulation system, is not broken, within a couple of hours there de­velops thrombohemorragic syndrome (THS) with fatal hemorrhage.

Pregnancy Hypertension Management

^ Monitoring of the condition of pregnant women with hypertension:

  1. Examination in the antenatal clinic with taking ABP till 20 weeks of pregnancy twice per three weeks, from "20 to 28 weeks — once a fortnight, after 28 weeks — every week.

  2. Detecting daily proteinuria on the first visit to the antenatal clinic, from 20 to 28 weeks — once a fortnight, after 28 weeks — weekly.

  3. Daily domiciliary self-checking of ABP.

  4. Examination of the oculist on the first visit to the antenatal clinic, at 28 and 36 weeks of pregnancy.

  5. ECG on the first visit to the antenatal clinic, at 26—30 weeks and after 36 weeks of pregnancy.

  6. Ultrasonography of the fetus and placenta in the period of 9— 11 weeks, 18—22 weeks, 30—32 weeks.

  7. Actography (fetal movements test) — daily after 28 weeks of pregnancy.

  8. Biochemical blood analysis: whole protein, urea, creatinine, glucose, potassium, sodium, fibrinogen, fibrin, fibrinogen B, pro­thrombin index, bilirubin, coagulogram, hematocrit, hemoglobin.

If necessary, examination may be extended, conducted earlier and in other terms.

Contraindications to carrying of a pregnancy to 12 weeks:

  1. Severe arterial hypertension (the 3rd degree).

  2. Severe damages of target organs caused by arterial hyperten­sion:

  • of the heart (myocardial infarction, cardiac insufficiency);

  • of the brain (stroke, transient ischemic attack, hypertensive en­cephalopathy);

  • of the retina (hemorrhages and exudates, edema of the disk of optic nerve);

  • of the kidneys (renal insufficiency);

  • of the vessels (dissecting aneurysm of the aorta);

  • malignant course of hypertension (diastolic pressure > 130 mm Hg, eye ground changes by the type of neuroretinopathy).

Indications to abortion at late term:

  1. Malignant course of arterial hypertension.

  2. Dissecting aneurysm of the aorta.

  3. Acute disturbance of cerebral or coronary circulation (only after the stabilization of the patient's condition).

  4. Early addition of preeclampsia, which resists intensive therapy.

Abortion technique — abdominal cesarean section.

Indications to hospitalization:

  • addition of preeclampsia to pregnancy hypertension;

  • uncontrollable severe hypertension, hypertensive crisis;

  • appearance or progression of changes on the eye grounds;

  • stroke;

  • coronary pathology;

  • cardiac insufficiency;

  • renal dysfunction;

  • fetal growth inhibition at hypertension during pregnancy;

  • appearance of at least one sign of moderate preeclampsia;

  • fetal condition violation.

Arterial hypertension treatment.

Indications to the administra­tion of constant antihypertensive therapy during pregnancy to the patient with chronic arterial hypertension:

  • diastolic pressure >100 mm Hg, the aim is to keep diastolic pressure at the level of 80—90 mm Hg;

  • a rise of predominantly systolic arterial pressure to > 150 mm Hg, the aim is to stabilize the level at 120—140 mm Hg (not lower than HOmmHg);

  • if the woman had been taking hypertensive preparations before pregnancy, one selects preparations permissible to use during preg­nancy (Table 3).

p-adrenoceptor antagonists (pindolol, oxprenolol, atenolol, meto-prolol) do not have teratogenic action, but may cause uterine growth inhibition and giving birth to underweight children. Calcium antago­nists, dihydropyridines (nifedipine), especially at simultaneous use p-adrenoceptor antagonists (pindolol, oxprenolol, atenolol, meto-prolol) do not have teratogenic action, but may cause uterine growth inhibition and giving birth to underweight children. Calcium antago­nists, dihydropyridines (nifedipine), especially at simultaneous use with magnesium sulfate, may lead to uncontrollable hypotension, dangerous inhibition of the neuromuscular function, fetal distress. Myotropic vasodilators (hydralizin) inay cause thrombocytopenia in newborns as they are not effective as a monotherapy. Diuretics are not used during pregnancy, especially the potassium-sparing ones. Furasemide may have embryotoxic action during early pregnancy. Thiazide-type diuretics may only be used in case of cardiac insuffi­ciency or renal pathology in the pregnant woman.

Table 3 . Medicaments Used to Treat Arterial Hypertension During Pregnancy



Pharmacologic group,subgroup

Drug

Regimen of use

Max daily dos







Basal therapy

Quick reduction




Central a-adrenoagonists

Methyldopa

250-500 mg 3—4 times



4,000




Clonidine

0.075-0.2 mg 2—4 times

0.15—0.2 under the tongue or 0.5-1 mlof0.01%i.v. or i.m.

1.2

P-adrenoceptor antagonists with qualities of thea-blocker

Labetolol

100-400 mg 2—3 times

10—20 mg i.v. painfully every 10 min (up to 300 mg) or i.v. drop-by-drop 1—2 mg/min

2,400

Calcium

antagonists,

dihydropyridines

Nifedipine

10-20 mg 3—4 times

5—10 mg under the tongue or i.v. drop-by-drop every 2—3 h

100

a-adrenoceptor

antagonists,

aj-blockers

Prasosin

0.5—4 mg 3—4 times




20

Delivery. If hypertension is controllable and there are no other complications, delivery is conducted through the natural maternal passages.

Cesarean section is carried out routinely at:

  • uncontrollable severe hypertension;

  • target organs affection;

  • severe uterine fetal growth delay.

The third stage of delivery is conducted actively. The usage of er-gometrine and its derivatives in patients with arterial hypertension is contraindicated. In the puerperal period there is provided thorough follow-up of the therapeutist, daily control of ABP, examination of the eye grounds, proteinuria and blood creatinine detection.

Contraindications to lactation include malignant hypertension, severe affections of target organs. Temporary contraindications — un­controllable hypertension.

Preeclampsia Management

Preeclampsia development prevention:

  1. Acetylsalicylic acid 60—100 mg/day, beginning from 20 weeks of pregnancy.

  2. Calcium drugs 2 g/day (in terms of elementary calcium), be­ginning from 16 weeks of pregnancy.

  3. Including marine products with a high content of polyunsatu­rated fatty acids into the food ration.

Preeclampsia Diagnostics

Preeclampsia diagnosis is rightful at the term bigger than 20 weeks of gestation, ABP more than 140/190 mm Hg, or in case of dia­stolic arterial pressure rise by 15 % from the initial in the 1st trimester of pregnancy with proteinuria present (protein in daily urine more than 0.3 g/L) and generalized edemata (body weight increase by more than 900 g per week or 3 kg per month).

Only the value of diastolic ABP is used as a criterion of hyperten­sion severity in pregnant women, indications to the beginning of anti­hypertensive treatment and the criterion of its effectiveness.

Table 4. Additional Preeclampsia Clinicolaboratory Criteria



Signs

^ Mild preeclampsia

Moderate preeclampsia

Severe preeclampsia

Uric acid, millimole/L

<0.35

0.35-0.45

>0.45

Urea, millimole/L

<4.5

4.5-8.0

>8

Creatinine, micromole/L

<75

75-120

> 120 or oliguria

Thrombocytes • 109/L

> 150

80-150

<80

Screening tests are to be conducted in order to monitor the state of pregnant women from the risk group of preeclampsia development (body weight control, ABP control, thrombocytes quantity investiga­tion, testing urine for protein content, bacterioscopic urine analysis) once in three weeks in the first half of pregnancy, once a fortnight from the 20Lh till the 28th week, and weekly after the 28th week of pregnancy.

When taking ABP one must follow some rules: the patient must be in the state of rest during at least 10 min, the arm freely lies on a hard surface, the cuff is located at the heart level and is wrapped around the shoulder not less than thrice. To detect diastolic pressure the 5th Korotkoff s tone is used, taking the point of the complete disappearance of arterial murmur.

Medical Approach to Preeclampsia

^ MILD PREECLAMPSIA

Aid provision depends on the condition of the pregnant woman, pa­rameters of ABP and proteinuria. If the pregnant woman's condition corresponds to mild preeclampsia criteria at the term of pregnancy up to 37 weeks, day hospital follow-up is possible. The patient is taught independent monitoring of the main signs of preeclampsia develop­ment: taking ABP, controlling liquid and edemata balance, registering fetal movements.

^ Laboratory investigation is conducted: common urine analysis, daily proteinuria, creatinine and urea of the blood plasma, hemoglo­bin, hematocrit, thrombocytes quantity, coagulogram, AST and AAT, detecting fetal condition (non-stress test if possible). Medicamental therapy is not administered. Consumption of liquid and dietary salt is not limited.

^ Indications to hospitalization: appearance of at least one sign of moderate preeclampsia; fetal condition disorder.

If the woman's condition is stable within the criteria of mild pre­eclampsia, pregnancy management is waiting. Delivery is conducted in accordance with obstetric situation.

^ MODERATE PREECLAMPSIA

Scheduled hospitalization of the pregnant to the in-patient de­partment.

Primary laboratory examination: complete blood count, hemato­crit, thrombocytes quantity, coagulogram, AST and AAT, blood group and rhesus-factor (if exact information is not available), com­mon urine analysis, daily proteinuria, creatinine and uric acid of the blood plasma, electrolytes (sodium and potassium), fetal condition assessment.

^ Preservation regimen: half-bed, limitation of physical and psychic load.

Rational nutrition: food with a high content of proteins, without limiting salt and water consumption, consumption of products not causing thirst.

A complex of vitamins and microelements for pregnant women, iron preparations if necessary. At diastolic ABP > 100—109 mm Hg administration of hypotension drugs (methyldopa — 0.25—0.5 g 3—4 times a day, maximum dose — 3 g a day; if it is necessary, nifedipine is added — 10 mg 2—3 times a day, maximum daily dose — 100 mg).

At pregnancy term till 34 weeks corticosteroids are administered for the prevention of respiratory distress syndrome (RDS) — dexa-methasone by 6 mg in 12 h 4 times during 2 days.

Investigation is conducted with the fixed order of case monitoring of indices:

  • ABP control — every 6 h of the first day, further — twice a day;

  • fetal heartbeats auscultation every 8 h;

  • urine analysis — every day;

  • daily proteinuria — every day;

  • hemoglobin, hematocrit, coagulogram, thrombocytes quantity, AST and AAT, creatinine, urea — every three days;

  • daily monitoring of fetal condition.

If preeclampsia progresses, preparation to delivery is begun.


Delivery. The method of delivery at any term of gestation is de­fined by the readiness of the maternal passages and fetal condition. If . preparation of the maternal passages with prostaglandins appears in­effective, cesarean section is carried out. If the uterine neck is mature enough, delivery is stimulated and conducted through the natural maternal passages.

Transition to the management of the pregnant woman by the al­gorithm of severe preeclampsia is resorted to in cases of increasing of at least one of the following signs:

  • diastolic ABP > 110 mm Hg;

  • headache;

  • visual impairment;




  • pain in the epigastric area or the right hypochondrium; - — signs of liver impairment;

  • oliguria (< 25 ml/h);

  • thrombocytopenia (< 100 • 109/L);

  • signs of THS;

  • AST and AAT activity increase.

^ SEVERE PREECLAMPSIA

Hospitalization. The pregnant woman is hospitalized to the de­partment of anesthesiology and intensive therapy of the inpatient de­partment of the 3rd level to assess the degree of pregnancy risk for the mother and fetus and choice of delivery method during 24 h. An indi­vidual ward with intensive twenty-four-hour surveillance of medical staff is given.

A peripheral vein is catheterized for long-term fluid maintenance, if CVT is to be controlled — a central vein, to control hourly diure­sis — the urinary bladder. By indications — transnasal catheteriza­tion of the stomach.

^ Primary laboratory examination: complete blood count, hemato­crit, thrombocytes quantity, coagulogram, AST and AAT, blood group and rhesus-factor (if exact information is not available), com­mon urine analysis, detecting proteinuria, creatinine, urea, whole pro­tein, bilirubin and its fractions, electrolytes.

Thorough case monitoring:

    • ABP control — every hour;

    • urine analysis — every 4 h;

    • hourly diuresis control (urinary bladder catheterization with the Foley catheter);

    • hemoglobin, hematocrit, thrombocytes quantity, liver function tests, plasma creatinine — every hour;

    • fetal condition monitoring.

Treatment. Preservation regimen (absolute bed rest). At the term of pregnancy till 34 weeks — corticosteroids for the prophylaxis of RDS — dexamethasone, 6 mg in 12 h 4 times during 2 days.

Management policy is active with delivery in the nearest 24 h from the moment of putting diagnosis irrespective of pregnancy term.

^ ANTIHYPERTENSIVE THERAPY

Arterial hypertension treatment is not pathogenetic, but is necessary for the mother and fetus. ABP decrease aims at preventing hyperten­sive encephalopathy and cerebral hemorrhages. One should try to bring ABP to the safe level (150/90-160/100 mm Hg, not lower!), which provides preservation of adequate cerebral and placental blood flow. Rapid and sharp decrease of ABP level may cause aggravation of the mother and fetus. Antihypertensive therapy is carried out at dia­stolic pressure rise > 110 mm Hg. It has been proved that medicamen-tous antihypertensive therapy should not be begun if ABP < 150/100 mm Hg. Constant antihypertensive therapy can reduce the frequency of hypertension progress (severe hypertension development) and in­crease of the severity of preeclampsia, which has developed, but can not prevent preeclampsia. Constant antihypertensive therapy does not improve consequences of pregnancy for the fetus and even leads to the increased birth rate of low-weight infants and of infants with the weight low for their gestational age. In whole, ABP reduction due to medicamentous therapy may improve consequences of pregnancy for the mother, but not for the fetus. Among antihypertensive drugs dur­ing pregnancy there are used: methyldopa 1.0—3.0 g a day (drug of choice), nifedipine 5—10 mg under the tongue, labetalol i.v. 10 mg, ad­renoceptor antagonists, clonidine 0.5—1.0 ml of 0.01 % solution i.v. or i.m. or 0.15—0.2 mg under the tongue 4—6 times a day, hydralizine 20 mg (1 ml) i.v. If it is possible to research the type of hemodynamics, antihypertensive therapy is conducted taking it into account. If the type is hyperkinetic, it is expedient to use a combination of labetalol with nifedipine, hypokinetic - clonidine + nifedipine against the back­ground of blood volume renewal, eukinetic - methyldopa + nifedipine.

Diuretics usage should be avoided, especially in cases of pre­eclampsia (except for pulmonary edema or renal insufficiency). An-giotensin-converting enzyme inhibitors and angiotensin II receptor blockers are categorically contraindicated.

Magnesium sulfate is used as an anticonvulsant with simultaneous antihypertensive action; it is a drug of choice for the prophylaxis and treatment of convulsions, which arise in hospitalized women as a re­sult of insufficient treatment of severe preeclampsia.

It has been absolutely proved that magnesium sulfate prevents the development of eclampsia and is the drug of choice for its treatment. All women with eclampsia must get magnesium sulfate in the course of delivery and during 24 h after delivery. Magnesium therapy is pain­ful introduction of 4 g of dry matter of magnesium sulfate with fur­ther continuous i.v. infusion with the speed detected according to the patient's condition. Magnesium therapy is begun from the moment of hospitalization if diastolic ABP > 130 mm Hg. The therapy aims at keeping magnesium ions in the blood of the pregnant woman at the level necessary for convulsions prevention.

Sufficiency of the magnesium sulfate dose is detected by its level in the blood serum during the first 4—6 h. If it is impossible to control the level of serum magnesium, the presence/absence of clinical symptoms of magnesium sulfate toxicity is conducted thoroughly and hourly.

Magnesium intoxication signs are even possible against the back­ground of therapeutic concentrations of magnesium in the blood plas­ma provided it is combined with other preparations, especially with blockers of calcium channels. When signs of magnesium sulfate toxici­ty appear, 1 g of calcium gluconate is administered i.v. (10 ml of 10 % solution), which should always be by the patient's bed.

Monitoring of the pregnant woman's condition during antihyper­tensive and magnesium therapy includes taking ABP every 20 min; heart rate calculation; observation over respiratory rate and character (respiratory rate must be not less than 14 per min); detecting O2 satu­ration (not lower than 95 %); cardiomonitoring control; ECG; knee reflexes check every 2 h; hourly diuresis control (must be not less than 50 ml/h). Besides, one controls symptoms of preeclampsia severity in­crease: headache, visual impairment (image splitting, "flies flicker" in the eyes), pain in the epigastrium; symptoms of possible pulmonary edema: heaviness in the chest, cough with/without sputum, dyspnea, CVT in­crease, appearance of crepitation or bubbling rales at lungs auscultation, increase of heart rate and hypoxia signs, consciousness level decrease; fetal condition (hourly heart rate auscultation, fetal monitoring).

^ Infusion therapy. Strict control of introduced and drunk liquid and diuresis is a condition of adequate infusion therapy. Diuresis must be not less than 50 ml/h. The total volume of introduced liquid must cor­respond to the daily physiological need of the woman (30—35 ml/kg on average), adding the volume of nonphysiological losses (hemor­rhage, etc.). The speed of liquid introduction should not exceed 85 ml/ h or the hourly diuresis + 30 ml/h. the drugs of choice of infusion ther­apy till the moment of delivery are isotonic saline solutions (Ringer's, NaCl 0.9 %). If blood volume is to be renewed, optimal preparations are 6 % or 10 % hydroxyethylstarch solutions (stabisol, refortan). Hy-droxyethylstarches or dextrans should be introduced together with crystalloids in the ratio 2:1. It is expedient to include fresh frozen do­nor plasma into the infusion-transfusion program for the liquidation of hypoproteinemia (plasma protein indices < 55 g/L), normalization of the correlation anticoagulants/procoagulants, which is a prophylaxis of hemorrhages during delivery and in the puerperal period.

Hyposmolar solutions — 5 % and 10 % glucose — and their mix­tures with electrolytes ("polarizing mixtures") are not used as they often cause hypoglycemia in the fetus, increase lactate accumulation in the brain, thus worsening neurological prognosis in case of eclamp­sia. Glucose solutions introduction into a patient with severe pre­eclampsia is resorted to only at absolute indications — hypoglycemia, hypernatremia, and hypertensive dehydration, sometimes — in pa­tients with diabetes mellitus for hypoglycemia prophylaxis.

Delivery. Delivery is conducted taking into account the obstetric-situation. Delivery through the natural maternal passages with ade­quate anesthesia (epidural anesthesia or nitrous oxide inhalation) is preferred.

If the maternal passages are ready, amniotomy is conducted with further labor induction by oxytocin.

If the uterine neck is not ready and there is no effect from prepa­ration with prostaglandins, or in case of hypertension progressing, convulsive attack threat, or fetal condition aggravation, delivery is conducted by means of cesarean section.

Indications to scheduled cesarean section in case of severe pre­eclampsia are progressing preeclampsia or fetal condition aggravation in the pregnant woman with immature maternal passages.

If the condition of the pregnant woman or fetus worsens at the second stage of labor, obstetrical forceps are applied or vacuum ex­traction of the fetus is conducted against the background of adequate anesthesia.At the third stage of labor uterotonic therapy is conducted with the purpose of hemorrhage prophylaxis (oxytocin i.v. drop-by-drop).

After delivery preeclampsia treatment is continued depending on the condition of the woman, clinical symptomatology, and laboratory indices. ABP monitoring and antihypertensive therapy are necessary. Doses of antihypertensive drugs are gradually reduced, but not earlier than after 48 h after delivery. Magnesium therapy lasts not less than 24 h after delivery.

^ PREECLAMPSIA IN THE PUERPERAL PERIOD

Preservation regimen, ABP control, and balanced diet are admin­istered.

Laboratory investigation: complete blood count (hemoglobin, he­matocrit, thrombocytes quantity), urine analysis, biochemical blood analysis (AST and AAT, bilirubin, creatinine, urea, whole protein), coagulogram.

Treatment. If hypotension drugs were used before delivery, their introduction is continued after delivery. If the therapy is not effective enough, thiazide diuretics are added. If hypertension appears for the first time after delivery, treatment begins with thiazide diuretics. Magnesium sulfate is administered by indications if there is a risk of eclampsia appearance. Uterus involution is thoroughly controlled. Hemorrhage is prevented by oxytocin introduction.

The parturient woman is discharged from the maternity depart­ment after her condition is normalized; the woman is to be followed up by a doctor of the maternity welfare clinic and necessary specialists.

Eclampsia Management

A high risk of eclampsia development is testified to by severe head­ache, high hypertension (diastolic ABP > 120 mm Hg), nausea, vom­iting, visual impairment, pain in the right hypochondrium and/or epigastric area.

The main aims of emergency care:

  • convulsions cessation;

  • airways patency renewal.

The tasks of intensive therapy after convulsions elimination:

  • prevention of recurrent convulsive attacks;

  • elimination of hypoxia and acidosis (respiratory and metabolic);

  • prevention of aspiration syndrome;

  • emergency delivery.

First aid at eclampsia attack development. The treatment in case of convulsions attack is begun on the site. Intensive therapy is resorted to or the pregnant woman is hospitalized to the department of anes­thesiology and intensive therapy. The patient is put down onto even surface in the position on the left side, the airways are quickly released by means of opening the mouth and protruding the lower jaw, simulta­neously the contents of the mouth cavity are evacuated. If it is possi­ble, if spontaneous breathing is preserved, an artificial airway is intro­duced and oxygen inhalation is conducted. In case of continuous apnea development immediate forced ventilation with a nasofacial mask with 100 % oxygen supply in the regimen of positive pressure is conducted in the end of expiration. If convulsions repeat or the patient remains in coma, muscle relaxants are introduced and the patient is on artificial pulmonary ventilation (APV) in the regimen of moderate hyperventi­lation. APV is not the main method of eclampsia treatment; still, hy­poxia elimination (the main pathogenetic factor of multiple organ fail­ure development) is the principal condition of taking other measures.

At complete recovery of consciousness, absence of convulsions and convulsive readiness without using antispasmodic preparations, hemodynamics stabilization, hemostasis system condition stability, renewed oxygen capacity of blood (hemoglobin not less than 80 g/L) APV stoppage should be planned, winch must be accompanied by complete cessation of sedative therapy. This condition is to be achieved during the first day.

In case of cerebral hemorrhage and coma of the pregnant woman the question of APV cessation is discussed not earlier than in two days. Intensive therapy is continued in full volume.

Simultaneously with the measures aimed at renewing the adequate gas exchange a peripheral vein is catheterized and antispasmodic drugs introduction is begun (magnesium sulfate — bolus 4 g during 5 min i.v., then supporting therapy 1—2 g/h) with thorough control of ABP and heart rate. The urinary bladder is catheterized. All the manipulations (catheterization of the veins, urinary bladder, obstetric manipulations) are conducted under general anesthesia. After convul­sions elimination correction of metabolic disorders, water-electrolytic balance, acid-base balance, and protein metabolism is carried out.

Laboratory analyses: complete blood count (thrombocytes, hema­tocrit, hemoglobin, coagulation time), whole protein, the level of al­bumin, glucose, urea, creatinine, transaminases, electrolytes, the level of calcium, magnesium, fibrinogen and products of its degradation, prothrombin and prothrombin time, urine analysis, daily proteinuria. The woman, who has had eclampsia, is observed in conditions of the resuscitation and intensive therapy ward or an individual post.

Delivery is conducted urgently. If obstetric situation does not al­low immediate delivery through the natural maternal passages (eclamptic attack took place at the second stage of delivery), cesarean section is conducted. Delivery is conducted right after the elimina­tion of convulsions attack against the background of-constant intro­duction of magnesium sulfate and antihypertensive therapy. If con­vulsions attack continues, urgent delivery is conducted after the pa­tient is transferred to APV. After operative intervention is over, APV is continued till the stabilization of the patient's condition. After de­livery treatment is continued according to the condition of the partu­rient woman. Magnesium therapy is to last not less than 48 h.

Observation over the woman, who has had preeclampsia/ec­lampsia after discharge from the maternity department. The wom­an, who has had moderate or severe preeclampsia/eclampsia, is fol­lowed up in the conditions of the maternity welfare clinic with the participation of a therapeutist. The follow-up includes:

  • home nursing;

  • consultation of specialists (if it is necessary);

  • complex examination in 6 weeks after delivery.

The women in need of hypotension drugs treatment are examined every week after discharge from the maternity department with obligatory laboratory control of the level of proteinuria and creati­nine concentration in the blood plasma.

If hypertension is kept during 3 weeks after delivery, the woman is hospitalized to the medical hospital. The duration of inpatient fol­low-up after moderate or severe preeclampsia/eclampsia is 1 year.

The volume and terms of follow-up:

  • common urine analysis — in 1, 3, 6, 9, and 12 months after de­livery;

  • complete blood count — in 1 and 3 months;

  • ophthalmoscopy — in 1, 3, and 12 months;

  • ECG — in 1 month, then — by therapeutist administration;

  • daily ABP control in the course of one year after delivery.

Therefore such parturient women are to observed by a therapeu­tist and be regularly examined (detecting the content of cholesterol and glucose annually).

Of great importance for the women, who have had eclampsia, and for their husbands is psychiatrist's help, as severe complications of pregnancy often lead to posttraumatic stress disturbance.

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