Preeclampsia

Pre-eclampsia is a form of late toxicosis( gestosis) and a precursor to the development of its most severe, terminal, stage - eclampsia. Pre-eclampsia in pregnancy is regarded by specialists as a result of the growing symptoms of late toxicosis( edema, oppression of kidney function and hypertension), which are subsequently joined by "classic" signs of disruption of the central parts of the nervous system.

Pre-eclampsia, in comparison with other, previous, stages of gestosis, is accompanied by more severe disorders of the kidneys, heart, vessels and brain structures, therefore the female body is unable to compensate for such serious violations for too long. Without appropriate external intervention, in a short time, preeclampsia is transformed into the most formidable form of late toxicosis - eclampsia. Eclampsia develops rapidly when, against the backdrop of a growing clinic of preeclampsia, convulsions, frustration of consciousness and coma suddenly arise. Often everything happens so quickly, and between preeclampsia and eclampsia, the time span is so small that it is simply impossible to prevent serious consequences.

The diagnosis of preeclampsia, unfortunately, has become more frequent in recent years in the history of the disease. The frequency of the disease is in a very wide range( from 7% to 20%), but more often it is registered among women with pathological conditions of the cardiovascular system( hypertension, blood diseases) and kidneys( glomerulonephritis, pyelonephritis).

Pre-eclampsia diagnosis does not require complex diagnostic measures, as its leading clinical symptoms are specific. The main diagnostic criteria are high blood pressure figures, presence of protein( proteinuria) in the urine, general, generalized edema, blood coagulation disorders and neurological symptoms( change in hearing, vision, headache).All these symptoms are not always expressed in the same way, but their presence is mandatory. Depending on how much the clinic is expressed, classify the mild, moderate and severe degree of preeclampsia. Classification of pre-eclampsia is used to assess the condition of a pregnant woman in order to choose the right therapy tactics.

Therapeutic measures for pre-eclampsia correspond to those for gestosis therapy. As a rule, the treatment of pre-eclampsia begins long before its appearance, when late toxicosis begins during pregnancy. The earlier the gestosis is diagnosed and treated, the less likely it is that it will "reach" pre-eclampsia.

Emergency care for pre-eclampsia is always necessary, as the condition develops rapidly, does not last long, and treatment should have the desired effect as soon as possible.

It should be noted that in the prevention of gestosis and preeclampsia in particular, the behavior of the pregnant woman and her attitude to the recommendations of specialists play an important role. If the pregnant woman closely follows changes in her condition, fulfills the prescribed appointments and follows the regime of visits to the doctor, it becomes easier to detect the first signs of trouble.

The most terrible consequence of preeclampsia is eclampsia - a series of convulsive seizures, with a high probability of leading to the death of a pregnant woman. Complications of pre-eclampsia concern not only the pregnant woman, but she also threatens the developing fetus.

Despite the poorly high prevalence of preeclampsia, eclampsia has been registered much more rarely in recent years( no more than 1.5%), as modern medicine has learned to diagnose gestosis, treat it and prevent the development of the most threatening complications.

Symptoms of preeclampsia more often( 82%) are recorded in the last trimester( after the 26th week), but there are cases of their appearance at an earlier time, during childbirth and even in the postpartum period. This article will tell you about pre-eclampsia of pregnant women.

What is preeclampsia of pregnant

Preeclampsia is a late toxicosis, that's why it is etiologically and pathogenetically related to gestosis - dropsy of pregnant women and nephropathy, which, in fact, are stages of one pathological process.

Dropsy( swelling) is considered the first sign of trouble, and also indicates that the kidneys of a pregnant woman are under severe stress. Edemas are a consequence of the disturbance of water-salt metabolism, when the vascular system, together with the kidneys, instead of taking out excess fluid, begins to accumulate it. Contrary to the erroneous opinion, edema is not always "visible", since initially the fluid is retained in the spaces between the cells, and then begins to "come out" under the skin and be visualized. Hidden edema is also dangerous, as well as obvious, but it is more difficult to diagnose them. More often on them indirectly indicates an excessive increase in body weight over the past week: if it exceeds 500 g, its appearance is correlated with excess fluid in the body.

In 88 - 90%, the diagnosed edema is transformed into gestosis, as the vascular system "overloaded" with excessive fluid causes a malfunction, and the kidneys lose the ability to compensate for the increased load. The first sign of renal dysfunction( nephropathy) is the appearance in the urine of protein, its concentration is directly proportional to the degree of severity of the process.

Arterial pressure in gestosis also changes. Overloaded with excess fluid and "harmful" neevakuirovannymi exchange products, the bloodstream inevitably begins to increase the pressure in the system.

On the background of nephropathy, there is a short( several hours) period when a characteristic symptom complex, which points to circulatory dysfunction in the structures of the brain, joins the existing pathological disorders. This period is classified as pre-eclampsia.

Reasons for pre-eclampsia

The only immediate cause of preeclampsia is one - severe gestosis. However, the question remains as to why the preeclampsia does not develop at all in the presence of preeclampsia clinic, or develops, but it manifests itself unequally hard. In addition, in a small number of pregnant women, preeclampsia occurs suddenly on the background of absolute health, bypassing the phase of severe gestosis. Apparently, in the development of pathological processes preceding the emergence of pre-eclampsia, a great role is played by a combination of provoking factors, and not by any one reason.

Pre-eclampsia in pregnancy has the same roots as the preceding late toxicosis. The greatest risk of gestosis is pregnant with hypertension, chronic kidney disease, heart disease and blood diseases( especially the coagulation system).

Often gestoses, and eclampsia, respectively, accompany a multiple pregnancy. In addition to the excessive burden on the vessels and kidneys, the multiparticle creates mechanical prerequisites for disrupting the circulation of the pelvic cavity, when the overgrown uterus literally squeezes large blood vessels.

Participates in the creation of prerequisites for the development of preeclampsia and the placenta( a child's place).Up to 80% of cases of severe gestosis are accompanied by circulatory disorders in the area of ​​attachment of the placenta to the uterine wall( uteroplacental blood flow).If the anatomic connection of the uterus and the child's place is broken, the placenta "requires" more blood from the circulatory system to provide the fetus with oxygen and the substances necessary for development.

Among all survivors of the pre-eclampsia episode pregnant women are more often present giving birth for the first time, as well as women over 35 years old.

Sometimes pre-eclampsia during pregnancy is diagnosed in members of the same family, suggesting a possible genetic predisposition.

Symptoms and signs of pre-eclampsia

Regardless of the severity of symptoms, pre-eclampsia is characterized by "classic" symptoms. As a rule, the disease is preceded by severe nephropathy, which is the basis and at the same time a harbinger of pre-eclampsia. If timely diagnosed and treated nephropathy, the development of pre-eclampsia can be prevented.

Nephropathy is manifested by edema, hypertension and proteinuria. Expression of edema indirectly indicates the severity of the process. Ocular syndrome is not always the same, so it is customary to classify it into four stages:

- I degree is manifested by visible edema on the legs( zone of feet and ankles);

- II degree "adds" swelling to the anterior abdominal wall;

- III degree is diagnosed if the hands and face swell;

- IV degree is associated with generalized, general edema.

A dropsy, even pronounced, feels like a pregnant woman slightly. More often it provokes thirst, fatigue and a feeling of heaviness in the legs. The absence of considerable discomfort is often misleading the pregnant woman, who does not consider edemas as a serious cause for alarm.

If the edematous syndrome is not corrected in a timely manner, nephropathy joins the dropsy when arterial pressure rises against the background of edema, and a urine test reveals the presence of protein( proteinuria).

When pronounced hydrocephalus, an unmotivated increase in body weight occurs when it rises too fast because of the accumulation of fluid in the tissues. At the same time, swelling can not be visualized.

The presence of protein in the urine of a healthy pregnant woman is excluded, so its occurrence often indicates renal dysfunction and the likelihood of severe gestosis. Often at the initial stages of the development of pathology, the protein in the urine is present not consistently, but occasionally, so it is advisable to determine its presence in the urine collected per day.

In preeclampsia, proteinuria often occurs after the onset of hypertension, so the diagnosis of pre-eclampsia relies on the dynamics of changes in blood pressure. The following signs are taken into account:

- Hypertension more than 140/90 mm Hg;

- In a dynamic observation for 6 hours between episodes of hypertension, systolic pressure increases twice by 30 mm Hg or diastolic( also twice) by 15 mm Hg.

- A steady increase in diastolic pressure to a mark of 90 mm Hg.

Actually, pre-eclampsia is characterized by the appearance of "new" symptoms - headache( more often in the frontal lobes), visual function disorders( flickering, flare), epigastric pain in combination with nausea and vomiting. Severe form is often accompanied by "precursors" of eclampsia - fibrillar( tendinous) twitching of small muscles, including the face. The volume of excreted urine decreases( oliguria), signs of damage to the structures of the central nervous system appear: apathy, memory loss, lethargy, irritability and the like.

Pre-eclampsia is characterized by changes in blood composition, namely, a decrease in the number of platelets - blood elements that control the timely coagulation of blood. Thrombocytopenia threatens the development of bleeding.

A distinctive feature of headaches in pre-eclampsia is the inability to stop them with conventional means.

In the treatment of preeclampsia, the time factor is extremely important. This condition continues for a few hours, if not diagnosed in time, even the "best" treatment can not prevent the sad consequences:

- hypertensive crisis against hypertension;

- acute renal and hepatic impairment up to necrosis;

- excessive accumulation of fluid by the brain tissue and its swelling;

- pulmonary edema as a consequence of "overload" of the small circle of blood circulation;

- acute placental insufficiency, leading to placental abruption and acute fetal hypoxia;

- retardation of fetal development due to nutritional deficiency and blood supply;

is eclampsia and, as a result, a fatal outcome for a woman and a fetus.

Pre-eclampsia rates

The classification of pre-eclampsia is based on the severity of the main clinical and laboratory signs when assessing the degree of arterial hypertension, the concentration of protein in the urine, the presence of edema and the degree of dropsy.

The mild degree is equivalent in essence to the preclinical stage, when there are predisposing factors for the formation of pathology in the absence of obvious clinical signs. It is diagnosed at a level of hypertension no higher than 150/90 mm Hg. St, protein concentration no more than 1 g / l and visualization of edema only on the feet and ankles.

The average degree of pre-eclampsia is diagnosed in the presence of a full-fledged clinical picture, when against the background of pronounced violations of the state( complaints) of the pregnant woman there are laboratory deviations. This degree differs increased to 170/110 mm Hg. Art. Hypertension, an increase in the protein concentration to 5 g / L, an increase in creatinine( 100-300 μmol / L), and dropsy of II-III degree.

The last, severe, degree of ailment is extremely dangerous in the prognostic plan. Severe degree of preeclampsia essentially means the initial stage of eclampsia, when the first neurological symptoms appear and single faint seizures are convulsive. This condition lasts very briefly, since the compensatory capabilities of the body are completely exhausted. Arterial hypertension exceeds 170/110 mm Hg, the protein in the urine exceeds the concentration of 5 g / l, the level of creatinine continues to grow.

The degree of pre-eclampsia is not identical to the stages of development of the pathological process, so severe gestosis can immediately be transformed into severe preeclampsia, bypassing other degrees - mild and moderate.

Easy preeclampsia

The diagnosis of mild pre-eclampsia is in fact just a statement of the appearance of negative signs - precursors, which are likely to lead to the development of a full-fledged pre-eclampsia clinic, so their availability requires timely medication.

A clinic of mild degree of pre-eclampsia can be weakly expressed when the pregnant woman does not fix them, and all the occurring negative changes can be diagnosed exclusively by laboratory methods.

The diagnosis of preeclampsia in this situation is based on the main signs:

- arterial hypertension within 150 / 90mm Hg. P.

- swelling of the ankles and / or feet( may not be);

- proteinuria not higher than 1 g / l;

- laboratory abnormalities in blood tests: creatinine up to 100 μmol / l and platelets not lower than 180х109 / l.

Such an indicator as the level of cretinin is very important in diagnosis. Creatinine is a metabolite that is formed during the metabolism of many tissues, but mostly in muscle structures. In fact, it is a toxin that is eliminated with the kidneys. If the kidney function is disrupted, metabolites, instead of being neutralized, accumulate and "poison" the body. The higher the level of creatinine, the stronger the damage to the excretory function.

Unfortunately, not every pregnant woman is reasonable about the recommendations of specialists. If you have good health, regular check-ups and taking tests seem somewhat superfluous, so they neglect the established mode of visiting a women's consultation. Meanwhile, it is the early diagnosis of gestosis and pre-eclampsia that can help to avoid the most negative scenario.

Moderate preeclampsia

At the stage of moderate pre-eclampsia, typical clinical signs already appear, clearly indicating the full development of a dangerous condition. The criteria for moderate pre-eclampsia are:

- persistent increase in blood pressure within 150-170/110 mm Hg. P.

- pronounced renal dysfunction, manifested by high numbers( over 5 g / l) of proteinuria and accumulation of metabolites( creatinine 100-300 μmol / l);

- further changes in the coagulating system( platelets from 150 to 180x109 / l);

- edema that spreads from the lower limbs to the hands and stomach.

At this stage, the compensatory capabilities of all systems are reduced, and the pregnant woman feels the first negative symptoms: fatigue, fatigue, heaviness in the legs, dizziness, a decrease in the amount of daily urine.

In addition to the most pregnant, the developing fetus also feels badly, it begins to suffer from lack of oxygen( intrauterine hypoxia), and also experiences toxic effects of metabolic products that are not eliminated by the placenta properly. Oxygen deficiency and excess toxins also lead to a slowing of the normal development of the fetus.

With moderate eclampsia, pregnant women often observe changes in the motor activity( stirring) of the fetus.

Emergency care for pre-eclampsia should be given at its first manifestations - preferably at an early stage. More often pre-eclampsia is preceded by nephropathy, and the pregnant woman is already under observation and receives treatment. In this situation, it is easier to suspect the progression of the process.

Unfortunately, due to the meager symptomatology of early preeclampsia without previous severe gestosis, treatment is often "delayed", it is started in the mild phase, however, a qualified medication correction still helps to prevent a negative scenario.

Severe preeclampsia

In fact, a severe degree indicates the onset of the most serious complication of preeclampsia - actually eclampsia.

Arterial pressure is steadily increased and sometimes exceeds 170/110 mm Hg. The proteinuria is determined in an amount exceeding 5 g / l, the creatinine concentration continues to increase( more than 300 μmol / l).Swelling of the extremities and abdomen spread to the face and nasal sinuses.

The state of health of a pregnant woman worsens significantly. Poor detoxification of the kidneys and liver lead to accumulation of toxins in the blood. The first signs of central hypoxia appear when brain tissue begins to suffer from a lack of oxygen and toxic effects. Abdominal pains begin, eyesight deteriorates.

first harbinger of the beginning of eclampsia are small convulsive muscle contractions( fibrillar twitching), more often - on the face.

Severe eclampsia is extremely difficult to "stop", more often it leads to very dangerous consequences. Rapidly growing symptoms of severe pre-eclampsia are more likely to provoke a dangerous complication of both of HELLP - syndrome:

- H - hemolysis( destruction) of red blood cells when they become deformed and wrinkled. When red blood cells are destroyed, substances that stimulate intravascular coagulation( microscopic thrombi) enter the bloodstream.

- ELL - an increase in the number of hepatic enzymes. Blood flow in the vessels of the liver is blocked, so enzymes synthesized by the liver can not leave the body and accumulate and damage the hepatic tissue. Increased pressure in the hepatic vessels leads to hemorrhage and dystrophy.

- LP - low number of platelets. Their number is reduced because of the formation of multiple microthrombi.

This syndrome always proceeds with a bright, aggressive clinic, its symptoms are increasing rapidly. First there are nonspecific symptoms: head and abdominal pain, malaise, nausea( sometimes with vomiting).Then there is jaundice, bloody vomiting, hemorrhages in the places of injections, convulsions and coma.

Another severe consequence of severe preeclampsia is eclampsia. About her appearance herald cramps. Seizure seizures are layered not existing manifestations of preeclampsia and / or nephropathy.

The onset of each convulsive episode initially provokes an increased headache, increased blood pressure, and reduced vision.

eclamptic seizure lasts no longer than 2 minutes, and has a well-defined Phase:

- preconvulsive period( 20-30 seconds).Expressed twitching of facial muscles.

- Tonic convulsions( 20-30 sec).The large muscles of the whole body contract. The torso is tightened, the breath stops, the face becomes cyanotic. The most dangerous moment for the pregnant and fetus.

- Clonic convulsions( 20-30 sec).Convulsive twitching of the muscular structures of the face, limbs. After their weakening, there is a hoarse independent breath, foam from the mouth( often with blood due to damage to the tongue).

- Permission period. The fit ends, but the pregnant woman is in a coma, from which it leaves very long( hours) and slowly. When she "returns", she does not remember what happened. Sometimes, if eclampsia is most severe, seizures resume during this period.

Eclampsia is able to immediately develop into a coma, bypassing the convulsive period, this variant of the current is most dangerous.

Complications of severe preeclampsia are not always inevitable. More often they develop in having extragenital "dangerous" pathologies of pregnant women.

Treatment of pre-eclampsia

Pre-eclampsia always requires emergency resuscitation in appropriate settings. The pregnant woman is housed in the intensive care ward, where she is constantly monitored for her condition. Due to deep damage to the structures of the central nervous system, the patient's excitability from external influences of the environment sharply increases, when loud sounds, bright light or sudden movements can provoke another attack of seizures. Therefore, the premises are organized sparing conditions: eliminated unnecessary noise( if possible, silence should be maximum), creates a twilight. To avoid unnecessary emotional outbursts and to limit excessive motor activity, the patient is "loaded" - one of the drugs depressing the nervous system is drip-introduced to avoid the following convulsions.

In order to monitor the change in the state and effect of the therapy, the pregnant woman is under compulsory continuous hardware control. The registration of blood pressure, heart rate, ECG is removed. Laboratory control includes the determination of blood composition( electrolytes, hemoglobin, platelets, blood gases and others).To monitor the function of the kidneys and control the level of proteinuria, the hourly diuresis is measured( put a urinary catheter).

Since preeclampsia and eclampsia are considered as stages in a single pathological process, the principles of their treatment are symmetrical.

The main goal of all activities is to prevent the appearance of a convulsive syndrome and to eliminate the consequences if it has already happened.

The etiology of gestosis, and preeclampsia in particular, is based on the phenomenon of generalized vascular spasm, which provokes arterial hypertension. Therefore, elimination of spasm of blood vessels is rightfully considered the "gold standard" of therapy. Magnesium sulfate, euphyllin, papaverine and the like are used.

Evacuation of excess fluid from tissues( lasix, furosemide) helps to relieve the vasculature and "help" the kidneys, and also prevents swelling of the brain tissue.

Protein preparations are injected intravenously( albumin, protein and the like) and detoxification solutions( gemodez, rheopolyglucin).

The plan of therapy always includes activities aimed at helping the intrauterine fetus. After a thorough diagnosis of the fetus, the most important question is whether it is possible to leave the baby in the womb without affecting the life of the mother( or both).In this situation, the gestational age is taken into account - the closer it is to childbirth, the greater the chances of success. After 34 weeks, the fetus is able to live outside the uterus, so the pregnant one can be delivered( caesarean section).

Until that time, fetal lungs are not yet ready to breathe independently outside the amnion, since they have not yet been smashed and can not be filled with oxygen. In such a situation, infusion of drugs that accelerate the "maturation" of the fetal lungs is performed.

If preeclampsia is severe, or there are already signs of eclampsia, caesarean section is performed immediately, since it is necessary to save a woman. In parallel, all resuscitation measures are carried out.

After successful treatment and delivery, it is necessary to continue therapy and follow-up in order to diagnose and exclude the relapse of the seizure in time.

Prevention of pre-eclampsia

Preventing severe gestosis is very realistic, so its prevention in its importance is rightfully equated with the treatment of preeclampsia. Sudden development of severe gestosis with a successful, but complicated, pregnancy is rarely observed. More often gestoses appear at having risk factors of pregnant women, therefore preventive measures start already on early terms.

There are no specific preventive measures for pre-eclampsia, they are carried out according to an individual plan, however in all situations the following are taken into account:

- the presence of extragenital( hypertension, renal pathology and others) chronic pathology that can aggravate the course of pregnancy;

- presence of preeclampsia during previous pregnancies;

- gestosis in female relatives( genetic factor).

If the probability of pre-eclampsia is high after the examination, preventive maintenance starts from 8 to 9 weeks. The list of medications depends on the specific situation, however, any chosen scheme always includes drugs that improve the blood flow in the placenta, leading to clotting indices to the established rate, unloading the kidneys.

Participates in preventive measures and the pregnant woman herself, when she complies with the proposed visit plan, undergoes timely laboratory tests, eats and rests correctly.