Eclampsia emergency care. Preeclampsia and eclampsia

Today, no problem in obstetrics attracts as much attention as the problem of preeclampsia and eclampsia. In the general population of pregnant women, the incidence of preeclampsia is 5-10%, and eclampsia - 0.05%.

In the global structure of maternal mortality, the share of preeclampsia is 12%, and in developing countries this figure reaches 30%. Preeclampsia is currently a leading cause of perinatal morbidity and mortality in developing countries. Up to 18% of cases of antenatal fetal death are associated with hypertensive complications of pregnancy. In Russia, the share of preeclampsia and eclampsia in the structure of maternal mortality is 10% (2011).

In developed countries, rates of maternal and perinatal mortality associated with preeclampsia are an order of magnitude lower than in developing countries, which indicates the manageability of complicated forms of preeclampsia and the possibility of effectively influencing the outcome with a systematic approach to this problem.

The concept of “preeclampsia” is also interpreted differently by domestic and foreign authors, which greatly complicates the comparability of treatment effectiveness. In Russia, the terms “mild, moderate and severe gestosis” continue to be used, the criteria of which are extremely vague and this situation gives rise to a large number of errors.

In Russia, there is no unified approach to providing emergency care for preeclampsia and eclampsia, HELLP syndrome; many treatment methods do not meet the criteria accepted in medicine, based on evidence.

All of the above determines the undoubted relevance of implementing clinical recommendations, providing emergency care for severe preeclampsia and its complications: eclampsia, HELLP syndrome, since it is these forms that determine maternal and perinatal mortality.

Preeclampsia. Basic provisions

Classification and the assessment of the severity of preeclampsia and eclampsia is carried out in accordance with the ICD X revision.

• O13 Pregnancy-induced hypertension without significant proteinuria
• O14 Pregnancy-induced hypertension with significant proteinuria
• O14.0 Moderate preeclampsia [nephropathy]
• O14.1 Severe preeclampsia
• O14.9 Preeclampsia [nephropathy] unspecified
• O15 Eclampsia
• O15.0 Eclampsia during pregnancy
• O15.1 Eclampsia during childbirth
• O15.2 Eclampsia in the puerperium
• O15.9 Eclampsia, unspecified
• O16 Maternal hypertension, unspecified

Mandatory criteria for diagnosing Preeclampsia are: gestational age, arterial hypertension and proteinuria. Edema is not taken into account as a diagnostic criterion for preeclampsia.

Criteria for diagnosing preeclampsia:

• Pregnancy period is more than 20 weeks;
• Arterial hypertension;
• Proteinuria (protein in urine more than 0.3 g/l in a daily urine sample).

Forms of arterial hypertension during pregnancy

• Chronic arterial hypertension - an increase in systolic blood pressure above 140 mm Hg. Art., diastolic blood pressure above 90 mm Hg. Art. Blood pressure detected before pregnancy or registered before 20 weeks of pregnancy and persisting for 42 days after birth or more;
• Preeclampsia and eclampsia;
• Chronic arterial hypertension complicated by preeclampsia;
• Pregnancy-related arterial hypertension is arterial hypertension first registered during pregnancy without proteinuria and other signs of preeclampsia (in 15-45% of pregnant women it later develops into preeclampsia).

Criteria for arterial hypertension during pregnancy

• Registration of systolic blood pressure above 140 mm Hg. Art., diastolic blood pressure above 90 mm Hg. Art. is sufficient to meet the criteria for arterial hypertension;
• Increase in systolic blood pressure by 30 mm Hg. Art. compared with its average value recorded before the 20th week of pregnancy;
• Increase in diastolic blood pressure by 15 mm Hg. compared with its average value recorded before the 20th week of pregnancy.

Among all forms of arterial hypertension during pregnancy with preeclampsia, it is important to timely assess its severity, which determines the indications for delivery at any stage of pregnancy (within 24 hours).

Severity of arterial hypertension

• Normal (for normotensive patients): systolic pressure less than or equal to 140 mm Hg, diastolic pressure less than or equal to 90 mm Hg.
• Moderate hypertension: systolic pressure 140-159 mm Hg, diastolic pressure 90-109 mm Hg.
• Severe hypertension: systolic pressure greater than or equal to 160 mmHg, diastolic pressure greater than or equal to 110 mmHg.

The multiorgan nature of the lesion in preeclampsia determines the variety of clinical manifestations and complications. Any clinical symptoms in a pregnant woman should always be considered from the point of view of preeclampsia, and only then from the point of view of extragenital pathology.

Clinical manifestations of preeclampsia

Symptoms and symptom complexes

• From the central nervous system: headache, photopsia, paresthesia, fibrillation, convulsions
• From the outside cardiovascular systems s: arterial hypertension, heart failure, hypovolemia
• From the urinary system: oliguria, anuria, proteinuria
• From the gastrointestinal tract: pain in the epigastric region, heartburn, nausea, vomiting
• From the blood system: thrombocytopenia, hemostasis disorders, hemolytic anemia
• From the fetus: delayed fetal development, intrauterine hypoxia fetus, antenatal fetal death.

Clinical options for the implementation of severe preeclampsia that determine the maximum adverse outcome

• CNS dysfunction resulting from cerebral hemorrhage
• Respiratory dysfunction due to ARDS, pulmonary edema, pneumonia
• Liver dysfunction: HELLP syndrome, necrosis, subcapsular hematoma
• All forms of DIC syndrome (explicit or implicit)
• Acute renal failure
• Placental abruption, hemorrhagic shock

Symptoms and symptom complexes, the appearance of which indicates the development of a critical situation:

• chest pain;
• dyspnea; pulmonary edema;
• thrombocytopenia;
• increased levels of liver transaminases;
• HELLP syndrome;
• creatinine level more than 90 µmol/l;
• diastolic blood pressure more than 110 mm Hg;
• vaginal bleeding (any amount).

To confirm the diagnosis and objectively assess the severity of preeclampsia, a comprehensive clinical, laboratory, functional and instrumental examination of the mother and fetus is necessary.

The diagnosis of “eclampsia” is made when a convulsive attack or a series of convulsive attacks develops in a pregnant woman with clinical preeclampsia in the absence of other causes (tumor, epilepsy, stroke, etc.).

Eclampsia develops against the background of preeclampsia of any severity, and is not a manifestation of the maximum severity of preeclampsia. In 30% of cases, eclampsia develops suddenly without warning. The main precursors of eclampsia are headache, arterial hypertension and convulsive readiness.

Considering the many reasons that can cause convulsions during pregnancy in addition to eclampsia, it is necessary to assess the patient’s neurological status as early as possible - in the first hours after delivery.

To assess the neurological status of a patient undergoing mechanical ventilation, muscle relaxants, narcotic and sedatives are discontinued from the first hours after delivery, and the time to restore consciousness is assessed. The anticonvulsant effect is provided under these conditions by magnesium sulfate. Planning is not allowed extended mechanical ventilation for several days under conditions of deep sedation, since in these conditions the assessment of the state of the central nervous system without additional methods research is extremely difficult.

Therapeutic measures

Since the etiology and pathogenesis of preeclampsia are not fully understood, there is currently no effective methods prevention and treatment. The main etiopathogenetic method of treating severe preeclampsia and eclampsia remains timely delivery

In a patient with a clinical picture of severe preeclampsia, before delivery the main task is to stabilize the condition, prevent the development of complications (eclampsia, placental abruption, HELLP syndrome, DIC syndrome, etc.), and prepare for delivery. The patient should be in the intensive care unit, supervised by an obstetrician-gynecologist and an anesthesiologist-resuscitator jointly.

Basic therapy for preeclampsia/eclampsia should be aimed at solving the following problems:

• prevention of seizures (magnesium sulfate)
• antihypertensive therapy (dopegit, nifedipine)
• optimization of the timing and method of delivery
• infusion therapy (crystalloids)

Anticonvulsant therapy

Magnesium sulfate(group A according to the FDA) is the main drug for the treatment of severe preeclampsia and the prevention of the development of eclampsia: the risk of developing eclampsia while taking magnesium sulfate is reduced by 58%.

Magnesium sulfate is an anticonvulsant drug and its administration should not be interrupted solely on the basis of a decrease in blood pressure. Magnesium sulfate is an emergency drug and its planned use during pregnancy does not prevent the development and progression of preeclampsia.

Application scheme: 5 g intravenously for 10-15 minutes, then 2 g/hour micro-jet. Therapy with magnesium sulfate in women with severe preeclampsia and eclampsia should continue for at least 48 hours after delivery.

Drugs that are of secondary importance for achieving an anticonvulsant effect in eclampsia should be used only as adjuncts for a short period of time.

Benzodiazepines: diazepam, midazolam (FDA group D).

Barbiturates: The use of sodium thiopental should be considered only as sedation and anticonvulsant therapy in mechanical ventilation.

Dexmedetomidine: patients who have already been intubated and who are in a state of sedation are given an initial IV infusion rate of 0.7 mcg/kg/h, which can be gradually adjusted within the range of - 0.2-1.4 mcg/kg/h to achieve the desired level of sedation.

It should be noted that dexmedetomidine is a potent drug, hence the infusion rate is indicated at one hour. Typically, a saturation loading dose is not required. For patients requiring rapid onset of sedation, a loading infusion of 0.5–1.0 mcg/kg body weight over 20 minutes is first administered, i.e., an initial infusion of 1.5–3 mcg/kg/h over 20 minutes. The initial infusion rate after loading is 0.4 mcg/kg/h, which can be adjusted later.

Antihypertensive therapy

Active antihypertensive therapy using intravenous drugs is carried out only when the blood pressure level is more than 160/110 mmHg. In other cases, only tableted antihypertensive drugs (methyldopa and calcium antagonists) are used.

Methyldopa(dopegyt): 500-2000 mg/day enterally (FDA group B). The main antihypertensive drug for any form of arterial hypertension during pregnancy. Contraindicated in hepatitis, liver failure, pheochromocytoma.

Clonidine(clonidine): up to 300 mcg/day IM or enterally (FDA group C). Use only for stable arterial hypertension and to relieve a hypertensive crisis. The use of clonidine has no advantages over the use of methyldopa or beta-blockers. In early pregnancy, the use of clonidine is unacceptable, as it is believed to be capable of causing embryopathy. Contraindicated in sick sinus syndrome, AV block, fetal bradycardia.

Nifedipine 30-60 mg/day enterally (FDA group C). The safety of using this calcium channel blocker during pregnancy has now been proven.

Nimodipine 240 mg/day (FDA group C). It is used only to relieve spasm of cerebral vessels during ischemic injury and eclampsia. Contraindicated in cases of cerebral edema, intracranial hypertension, and liver dysfunction. To use it, verification of cerebral vasospasm (Doppler ultrasound) is necessary, especially when administered intravenously.

Atenolol 25-100 mg/day enterally (FDA group C). In some situations, a β-blocker can be used. During pregnancy, it is used only in a short course for arterial hypertension in combination with tachycardia - heart rate more than 100 per minute. Contraindicated in case of sinus bradycardia, fetal bradycardia, AV block, heart failure, obstructive pulmonary diseases, diabetes mellitus.

If severe hypertension develops (systolic pressure greater than or equal to 160 mm Hg, diastolic pressure greater than or equal to 110 mm Hg), the following drugs are currently recommended.

Urapidil(ebrantil): α-blocker. The drug is contraindicated during pregnancy and is used effectively immediately after delivery. Directions for use: 25 mg of urapidil is diluted to 20 ml with 0.9% saline and administered at a rate of 2 mg/min for the effect of lowering blood pressure.

After administration of 25 mg of urapidil, it is necessary to evaluate the effect of the drug and its duration. A maintenance dose of 100 mg of urapidil is diluted with 0.9% saline to 50.0 ml and administered at a rate of 4.5 ml/hour according to the effect of maintaining blood pressure at a safe level.

For any outcome, the level of blood pressure should decrease smoothly within 2-4 hours. If, against the background of ongoing antihypertensive therapy, an increase in blood pressure is again observed, this may be a reason to review the severity of preeclampsia and even decide on the issue of delivery.

Infusion therapy

When conducting infusion therapy before birth, the volume of intravenous fluid administered should be limited to 40-45 ml/h (maximum 80 ml/h) and preference should be given to balanced crystalloids (Ringer, Sterofundin, Ionosteril).

The use of synthetic (solutions of HES and modified gelatin) and natural (albumin) colloids has no advantages over crystalloids in terms of maternal and perinatal outcomes in preeclampsia/eclampsia and should be based only on absolute indications (hypovolemia, shock, blood loss).

For all synthetic colloids, the instructions for use include the following instruction: during pregnancy, the drug can be used only when the risk of use is lower than the expected benefit.

A restrictive regimen of infusion therapy is also used after delivery (excluding HELLP syndrome). In any case of development of a critical condition with preeclampsia/eclampsia, it is necessary to switch to enteral nutrition as soon as possible.

Transfusion therapy

The use of blood components is regulated by Order M3 of the Russian Federation No. 363 of 2002. It must be taken into account that preeclampsia and its complicated forms are at the highest risk of massive bleeding in obstetrics. When providing emergency care to patients in this category, it is necessary to be prepared to provide surgical, local and conservative hemostasis, intensive therapy for massive blood loss (blood components, blood coagulation factors, the possibility of hardware blood reinfusion).

Indications for prolonged mechanical ventilation in severe preeclampsia and eclampsia

• Impaired consciousness of any etiology (drugs, cerebral edema, circulatory disorders, volumetric process, hypoxia).
• Brain hemorrhage.
• Manifestations of coagulopathic bleeding.
• Combination with shock (hemorrhagic, septic, anaphylactic, etc.).
• Picture of acute lung injury (ALI) or acute respiratory distress syndrome (ARDS), alveolar pulmonary edema.
• Unstable hemodynamics (uncorrectable arterial hypertension more than 160/110 mm Hg, or vice versa, arterial hypotension requiring the use of vasopressors).
• Progressive multiple organ failure (cerebral, ARDS, DIC, renal, liver failure).

With prolonged mechanical ventilation, it is necessary to ensure a normal ventilation regime and determine the degree of neurological impairment already in the first hours after delivery. For this purpose, the first step is to cancel muscle relaxants and evaluate convulsive readiness. If possible, this is best done using an EEG.

In its absence, the next step is to cancel all sedatives with the exception of magnesium sulfate, which provides an anticonvulsant effect under these conditions. After the end of the effect of sedatives, the level of consciousness is determined: in uncomplicated eclampsia, elements of consciousness should appear within 24 hours.

If this does not happen when sedatives are completely withdrawn within 24 hours, then computed tomography and magnetic resonance imaging of the brain are necessary. In this situation, mechanical ventilation is continued until the diagnosis is clarified.

Limitations of drug therapy

Before delivery in women with severe preeclampsia/eclampsia, the use of the following drugs is undesirable or even contraindicated (see instructions):

• neuroleptics (droperidol), GHB;
• fresh frozen plasma, albumin;
• synthetic colloids (HES, gelatin);
• extracorporeal methods (plasmapheresis, hemosorption, ultrafiltration);
• disaggregants;
• glucose-novocaine mixture;
• diuretics (furosemide, mannitol);
• narcotic analgesics (morphine, promedol);
• heparin.

At the stage of intensive therapy and preparation for delivery, the following are contraindicated due to the high risk of developing hemorrhagic complications:

• antiplatelet agents (aspirin) and anticoagulants (heparin, LMWH);
• After delivery, methylergometrine is contraindicated.

Patients with severe preeclampsia and its complicated forms should be transferred and delivered in level III obstetric facilities. The question of the admissibility of transportation is decided individually; an absolute contraindication to transportation is any bleeding.

When deciding whether to transfer a patient to another hospital, it is necessary to exclude placental abruption (ultrasound), as one of the potentially fatal complications of preeclampsia.

Indications for emergency delivery

Only if bleeding from the birth canal is detected (if placental abruption is suspected or diagnosed), delivery is carried out immediately (within 30 minutes after the decision is made). The same indication may be acute fetal hypoxia.

In other cases, it is necessary to prepare magnesium sulfate and antihypertensive drugs and clarify the severity of preeclampsia. The duration of preparation is determined by the effectiveness of the therapy, the condition of the patient and the fetus.

In a pregnant woman with clinical preeclampsia of any severity, deterioration of the condition determines the indication for emergency delivery.

Emergency (minutes) readings for delivery:

• bleeding from the birth canal, suspected placental abruption
• acute fetal hypoxia, in pregnancy more than 28 weeks

Urgent (hours) delivery:

• syndrome of delayed fetal growth II-III degree
• severe oligohydramnios
• violation of the fetal condition, recorded according to CTG, ultrasound
• platelet count less than 100 - 10-9/l and its progressive decrease
• progressive deterioration of liver and/or kidney function
• persistent headache and visual disturbances
• persistent epigastric pain, nausea or vomiting
• eclampsia
• arterial hypertension that cannot be corrected

If the pregnancy is less than 34 weeks, prophylaxis of fetal RDS with glucocorticoids (dexamethasone, betamethasone) should be provided. However, the fact of lack of prophylaxis for fetal RDS cannot be decisive in the presence of emergency indications for delivery.

Delivery through the natural birth canal is possible in the absence of emergency indications, the appropriate state of the birth canal (“mature” cervix), the compensated condition of the fetus, the possibility of full observation and the provision of adequate anesthesia. During conservative delivery, pain relief using epidural analgesia is mandatory.

In all cases, prenatal (preoperative) preparation is required for 2-6-24 hours based on the basic treatment of preeclampsia.

During cesarean section in women with preeclampsia, the method of choice is regional (spinal, epidural) anesthesia in the absence of contraindications. For eclampsia, the method of choice is general anesthesia with mechanical ventilation (sodium thiopental, fentanyl, inhalational anesthetics).

The organization of the work of an anesthesiologist-resuscitator and the equipment of operating rooms and intensive care wards is carried out in accordance with the Procedure for the provision of medical care for the adult population in the field of anesthesiology and resuscitation, approved by order of the Ministry of Health Russian Federation dated November 15, 2012 N 919n and the Procedure for the provision of medical care in the field of “obstetrics and gynecology (except for the use of assisted reproductive technologies)”, approved by order of the Ministry of Health of the Russian Federation dated November 1, 2012 No. 572n.

After delivery, magnesium sulfate infusion should be administered for 48 hours to prevent early postpartum eclampsia.

In women with severe preeclampsia and eclampsia, methylergometrine is contraindicated. The main uterotonic is oxytocin. In women with chronic arterial hypertension in the postpartum period, the blood pressure level is maintained at no more than 140/90 mm Hg. In the postpartum period, thromboprophylaxis is mandatory.

HELLP syndrome

After delivery, women with severe preeclampsia may experience deterioration in liver function, development of HELLP syndrome, intracerebral hemorrhage and late eclampsia. Personnel must be prepared to diagnose and treat postpartum complications of preeclampsia.

The diagnosis of HELLP syndrome is made based on the following signs:

• Hemolysis - free hemoglobin in serum and urine,
• Elevated Liverenzimes - increasing the level of AST, ALT,
• Low Platelets - thrombocytopenia.

It is a potentially fatal complication of preeclampsia (coagulopathy, necrosis and rupture of the liver, intracerebral hematoma). Depending on the set of symptoms, complete HELLP syndrome and its partial forms are distinguished: in the absence of hemolytic anemia, the developed symptom complex is designated as ELLP syndrome, and in the absence or slight severity of thrombocytopenia - HEL syndrome. Thrombocytopenia is a prerequisite for the diagnosis of HELLP syndrome.

To diagnose hemolysis, in addition to the visual picture of the blood serum, it is necessary to detect fragments of red blood cells - schizocytes in the blood smear.

Only timely delivery can prevent the progression of HELLP syndrome, but its development is possible in the immediate postpartum period. As a rule, the manifestation of the clinical picture (hemolysis, liver failure, thrombocytopenia) occurs already in the first hours after delivery.

Surgical delivery of women with HELLP syndrome is carried out under general anesthesia due to severe thrombocytopenia.

The use of corticosteroids does not prevent the development and progression of HELLP syndrome, but may affect the degree of thrombocytopenia and the preparation of the fetal lungs. Drugs are prescribed when the platelet count is less than 50 - 10-9/l: betamethasone: 12 mg every 24 hours, dexamethasone: 6 mg every 12 hours, or a high-dose dexamethasone regimen - 10 mg every 12 hours.

Treatment of massive intravascular hemolysis

When a diagnosis of massive intravascular hemolysis (free hemoglobin in the blood and urine) is made and immediate hemodialysis is not possible, conservative tactics can ensure the preservation of kidney function. Depending on the clinical picture, several options for such treatment are possible.

With preserved diuresis (more than 0.5 ml/kg/h):

• immediately begin the administration of 4% sodium bicarbonate 200 ml to relieve metabolic acidosis and prevent the formation of hematin hydrochloride in the lumen of the renal tubules
• intravenous administration of balanced crystalloids (sodium chloride 0.9%, Ringer's solution, Sterofundin, Ionosteril) at the rate of 60-80 ml/kg body weight with an administration rate of up to 1000 ml/h
• in parallel, diuresis is stimulated with saluretics - furosemide 20-40 mg divided intravenously to maintain the diuresis rate to 150-200 ml/h

An indicator of the effectiveness of the therapy is a decrease in the level of free hemoglobin in the blood and urine. Against the background of volumetric infusion therapy, the course of preeclampsia may worsen, but this tactic will avoid the formation of acute tubular necrosis and acute renal failure.

In case of oliguria, it is necessary to limit the volume of administered fluid to 600 ml/day and begin renal replacement therapy (hemofiltration, hemodialysis) when renal failure is confirmed, namely:

• diuresis rate less than 0.5 ml/kg/h within 6 hours after the start of infusion therapy, stabilization of blood pressure and stimulation of diuresis with 100 mg of furosemide;
• an increase in serum creatinine level by 1.5 times, or: a decrease in glomerular filtration >25%, or: the development of renal dysfunction and failure of stage “I” or “F” according to the RIFLE classification or stages 2-3 according to the AKIN classification.

A.V. Kulikov, E.M. Shifman, S.R. Belomestnov, A.L. Leviticus

Fortunately, most happy mothers do not know about eclampsia in pregnant women, since this condition occurs only in 0.05% of women. However, among the problems of modern obstetrics, the question of diagnosis and treatment of this disease is more acute than ever and requires further study, because domestic and foreign gynecology interprets it differently.

This dangerous condition is preceded by a variant called preeclampsia. Such pathological changes in the body are recorded in 5-10% of pregnant women. From our article you will learn why these dangerous ailments occur, how to recognize and eliminate them.

Specifics of definitions

Eclampsia and preeclampsia are conditions of pathological disorders in the body of a pregnant woman. Neither the first nor the second ailment can be called an independent disease, since they are a consequence of insufficient functionality of systems and diseases internal organs. Moreover, their symptomatic manifestations are always accompanied by disturbances of the central nervous system of varying severity.

Note!

Eclampsia and preeclampsia are conditions that occur only in pregnant women, in women during childbirth and in the first days after delivery.

The condition occurs as a consequence of disruptions in the relationship in the mother-placenta-fetus chain during pregnancy. The causes and symptoms of the pathology vary, so in world medical practice there is still no uniform approach to its classification. Thus, in obstetrics in America, Europe and Japan, such syndromes are associated with manifestations of arterial hypertension during pregnancy. Russian doctors believe that such manifestations are gestosis, or rather, their forms complicated by convulsions.

Preeclampsia is a syndrome that develops in the second trimester of pregnancy, with characteristic features persistent disorders, which are accompanied by swelling and the appearance of protein in the urine.

Eclampsia is a clearly manifested symptom of a dysfunction of the brain, the main symptom of which is an attack of convulsions that quickly progress. Seizures and coma are the result of a malfunction of the central nervous system due to excessive blood pressure.

Features of classification manifestations

The World Health Organization considers pathological disorders in the following sequence:

• Chronic course of arterial hypertension, recorded before conception;
• Hypertension that arose as a reaction of the body to the appearance and development of the fetus during pregnancy;
• Mild stage of preeclampsia;
• Severe stage of preeclampsia;
• Eclampsia.

Note!

The development of eclampsia does not always occur according to the scheme considered: it can also occur after a mild degree of preeclampsia.

Domestic obstetrics adheres to a different classification of pathology. Unlike foreign colleagues, Russian doctors assume that preeclampsia lasts a short period of time, followed by eclampsia. In Europe and America, preeclampsia is diagnosed if blood pressure exceeds 140/90 mm. rt. Art., swelling is clearly visible on the woman’s body, and the amount of protein in the daily dose of urine is more than 0.3 g/l.

Russian experts classify these same signs as nephropathy, the severity of which is determined by the severity of symptoms. The stage of preeclampsia is diagnosed if the following symptoms are added to the 3 signs described above:

• Decreased vision clarity;
• , accompanied by ;
• A sharp decrease in the amount of urine excreted.

That is, foreign experts consider nephropathy an emergency condition requiring immediate hospitalization.

The development of nephropathy and the degree of its manifestation are presented in the table.

Severe degree refers to complicated forms of pathology, when proteinuria is accompanied by the following symptoms:

• Impaired quality of vision;
• Severe attacks of headache;
• Pain syndrome in the stomach;
• Nausea accompanied by vomiting;
• Readiness for seizures;
• Massive swelling throughout the body;
• A sharp decrease in urine output per day;
• Pain on palpation of the liver;
• Changes in laboratory blood parameters.

The more severe the form of pathological changes, the greater the likelihood that the growing embryo will not withstand drug therapy, and the development of the fetus will be stopped.

There are also forms of the disease, the course of which depends on the time of their occurrence:

1. Manifestations during pregnancy. The most common form of pathology. Threatens the life of mother and baby. There is a danger of termination of pregnancy when the fetus cannot withstand the effects of medications used for treatment.
2. During the period of childbirth in women. Occurs in 20% of all recorded cases. It poses a danger to the life of the baby and mother. The attack is provoked by childbirth.
3. Pathology that develops after the birth of a child. Appears very rarely in the first days after birth.

Note!

All forms of eclampsia develop according to the same pattern, therefore, their symptoms and treatment will be identical.

It is worth dwelling on the classification, which is based on dysfunction of any organ. In this case, the clinical picture of the disease will be different.

1. Typical form. It manifests itself as severe swelling of the entire body, high blood pressure, intracranial pressure, and proteinuria.
2. Atypical shape. Occurs as a result of prolonged labor activity in women giving birth with a weak nervous system. It manifests itself as cerebral edema without pronounced symptoms of swelling of the subcutaneous tissue. In this case, slightly elevated blood pressure and moderate proteinuria are observed.
3. The conditions in which eclampsia manifests itself differ from the previous 2. Swelling and elevated blood pressure levels are insignificant. It is characterized by a large accumulation of fluid in the peritoneal cavity and amniotic sac.

Characteristic symptoms

In patients with a convulsive form of gestosis, the manifestations of pathology can be combined into a system of general symptoms that should be familiarized with before providing emergency care for eclampsia. These include the following manifestations:

• Persistent increase in blood pressure;
• Swelling, which most often affects the upper parts of the body;
• Frequent attacks of convulsions, the duration of which is 1-2 minutes, have small intervals between each other. Possible loss of consciousness for a short time.
• Eclamptic status. Frequent seizures occur when a woman is in a coma and does not regain consciousness.

Convulsive symptom is a clear consequence of eclampsia. The stages of its development and the characteristic symptoms of each stage are presented in the table.

Note!

After the stage of clinical convulsions, a woman may not recover. In this case, a state of coma occurs, which develops under the influence of cerebral edema. The duration of the coma depends on the time the swelling is eliminated. The longer it lasts, the less chance of a favorable outcome.

Any of the symptoms described above requires emergency care, be it eclampsia or preeclampsia. The patient should be immediately sent to the gynecological department, having previously provided emergency eclamptic care during an attack.

Specifics of first aid

Considering that the serious condition of gestosis is based on, it is impossible to do without qualified assistance from medical personnel. Treatment methods will also be prescribed by the doctor, and the emergency care algorithm for eclampsia will be as follows:

• Call an emergency medical team, informing the dispatcher about the extremely serious condition of the pregnant woman;
• It is necessary to place the patient on her left side;
• Cover the woman with soft things: blankets, pillows, rugs. This way you can prevent injury during a seizure;
• If necessary, fix the tongue so that it does not stick;
• Between attacks of convulsions, carefully remove accumulated vomit from the mouth.

To eliminate the recurrence of serial seizures, you can administer a magnesium solution intravenously.

The possibilities are determined by the arriving doctors, and assistance to the expectant mother should be carried out in an ambulance, since it may be necessary to restore breathing. They also carry out emergency measures to reduce blood pressure.

Therapeutic measures

At the initial stage of treatment for pregnant women and women in labor, it is advisable to use drugs that relieve seizures and reduce blood pressure. At the same time, swelling is relieved, which worsens the woman’s general condition.

Note!

The use of any one direction of therapy will only worsen the patient’s condition: the use of anticonvulsants without normalizing blood pressure is pointless.

Carrying out sulfate infusion therapy includes the use of such drugs.

• Medicines that relieve seizures:

1. Emergency (Droperidol, Magnesia);
2. Supporters (Fulsed, Andakin);
3. Strengthening the sedative effect (Glycine, Diphenhydramine).

• Drugs that lower blood pressure:

1. Emergency (Nifediline);
2. Supportive (Methyldopa).

Note!

You need to control your blood pressure by taking medications throughout your pregnancy. All medications are used intravenously or intramuscularly.

If the attacks are severe and difficult to treat, emergency delivery is indicated. Indications for its implementation include the following symptoms:

• from the birth canal;
• Placental abruption;
• Fetal hypoxia.

At the same time, they begin to stimulate labor after stopping the attack of convulsions, choosing a natural method of delivery, since anesthesia for caesarean section can provoke another attack.

In all other cases, therapy is carried out with magnesium and prescribed medicines until the severity of the pathology is clarified and general condition health of mother and baby.

From the very early dates During pregnancy, a special system of interaction between the mother’s body and the fetus is formed. In gynecology, it is called the “mother-placenta-fetus system.” Thanks to it, the woman’s body does not reject the embryo, but on the contrary: it contributes to its preservation and development.

However, some pregnant women may experience a disruption in the functioning of this system, which leads to eclampsia, a condition in which there is dysfunction of the mother’s vital organs, which poses a direct threat to both the life of the woman and the life of the fetus.

To date, there is no consensus on why this disease begins, but it is reliably known that its appearance is typical only for pregnant women, women in labor and postpartum women. In obstetric practice, two conditions of late gestosis are distinguished: preeclampsia and eclampsia, but what is it in simple terms?

Preeclampsia– this is a condition in which damage to the nervous system, liver, kidneys occurs, and arterial hypertension develops.

is a condition that requires emergency hospitalization; it can develop in patients with preeclampsia, and also exist as an independent form of a serious disease.

Causes of eclampsia in pregnant women

Since eclampsia is a dysfunction of the “mother-placenta-fetus” system, the causes are diseases that the woman already had before conceiving the child. During pregnancy, these pathologies can be a trigger for the onset of severe gestosis. Among the causes of eclampsia are the following:

1. Fetoplacental insufficiency (FPI) is a condition in which the blood flow of the placenta begins to function poorly. Only a doctor can assess the condition of the arteries using a Doppler examination.
2. Thrombophilia is a genetic disease that involves a special mutation of genes that provoke thrombus formation. During pregnancy, thrombophilia becomes active and later is the cause of the development of FPN.
3. Mutations of the eNOS gene affect the functioning of blood vessels. If there is a genetic defect, a woman’s body may perceive the fetus as a foreign body and try to get rid of it.
4. Defects in the attachment of the placenta to the walls of the uterus cause deterioration in fetal nutrition and provoke the appearance of FPN. With this pathology, blood flow disturbances can develop either gradually or suddenly.

In addition to the causes, there are risk factors for eclampsia and preeclampsia. At the very beginning of pregnancy, when registering, the gynecologist should pay attention to their presence and prescribe the patient appropriate therapy so that risk factors do not provoke the onset of severe gestosis.

• Chronic hypertension;
• Multiple pregnancy;
• Presence of eclampsia or preeclampsia in obstetric history;
• The presence of eclampsia or preeclampsia in the obstetric history of the mother, grandmother, aunt or sister;
• Old-time women (over 40 years of age at the time of pregnancy).

Particularly close attention to the patient’s condition should be paid if one or more risk factors for the development of gestosis are combined with the fact that the woman is carrying her first pregnancy.

Types of disease

In general, eclampsia can be divided into two types: according to the severity of the disease and the time of its onset. Depending on this, the treatment regimen will be determined and the risk to the health of the mother and fetus will be assessed.

The Russian classification of the stages of development of gestosis is somewhat different from that adopted in European countries. According to domestic experts, preeclampsia is the initial stage of eclampsia.

Severity of the disease

• Mild preeclampsia – involves blood pressure in the range of 140 – 170/90 – 110 mmHg. Art. In this case, proteinuria (more than 0.3 g/l) will be determined in a urine test.
• Severe preeclampsia - involves blood pressure above the limit of 170/110 mm Hg. Art. Proteinuria is pronounced.

Time of onset of illness

• Eclampsia during pregnancy is the most common and poses a threat to the life of mother and child. Treatment is complicated by the fact that the fetus may not tolerate certain drugs to relieve attacks.
• Eclampsia during childbirth - occurs in approximately 20% of all cases and poses a threat to the life of the woman and child. In this case, the provocateur of the attacks is labor.
• Eclampsia after childbirth occurs very rarely and develops within 24 hours after the baby is born.

Signs of eclampsia and symptoms

Despite the variety of species, the signs of eclampsia have a certain similarity, so they can be divided into a general list:

• Increased blood pressure - depending on the level to which it has increased, the doctor will determine the severity of the disease.
• Edema - the more severe the patient’s condition, the stronger the fluid retention in her body. The swelling is mainly in the upper body (face, arms).
• A series of convulsive seizures are numerous, lasting 1-2 minutes. The intervals between seizures are small. Loss of consciousness is short-term.
• Eclamptic status is a series of convulsive seizures in which the patient is in a coma and does not regain consciousness.

Characteristics of a seizure

The attack begins with involuntary contractions of the facial muscles. After a short period of time, the entire musculature of the body is involved in the process. The woman loses consciousness and limb clonus appears. After a series of clonus, coma occurs.

Diagnostics

Making a diagnosis is complicated by the fact that eclampsia does not have specific symptoms that would correspond only to it. Cramps, edema and proteinuria may be symptoms of other diseases that have nothing to do with gestosis.

Currently, the problem of determining eclampsia is being actively studied, and to make a diagnosis, doctors use special examinations and tests that reveal initial stage diseases - preeclampsia:

• Systematic blood pressure measurement. Moreover, to confirm eclampsia, it is necessary to monitor the state of blood pressure over time.
• Urine analysis to determine the amount of protein. The daily test () is important here.

If the indicators indicate the presence of preeclampsia, then subsequent convulsive seizures will indicate that the pathological processes in the woman’s body have entered the most severe stage of their development - eclampsia.

Since severe degrees of gestosis suggest the presence of convulsive seizures, self-medication must be completely avoided. First aid for eclampsia will be reduced to the following actions:

1. Call an ambulance (most likely they will send an ambulance).
2. Lay the woman on her left side and build rolls of blankets around her. This precaution will help the patient avoid injury until doctors arrive. In addition, this position will ensure the free flow of foam released during an attack.
3. Fix the tongue to prevent it from falling into the pharyngeal cavity.
4. In between attacks, remove vomit and foam from the mouth.

A repeated series of seizures can be stopped by intravenous administration of magnesium (20 ml of a 25% solution over 30 minutes).

It is important to remember - in emergency cases, you can call 03 and ask the doctor on duty to give you instructions on the actions that need to be taken while the ambulance team is on the way.

Treatment of eclampsia in pregnant women

Therapy for severe gestosis consists of two stages. First you need to stop the seizures, and then lower your blood pressure. At the same time, it is necessary to eliminate swelling in order to alleviate the woman’s condition.

However, this is only an auxiliary measure in the treatment of eclampsia. The main actions should be normalization of blood pressure and anticonvulsant therapy. It is important to adhere to a certain sequence in prescribing treatment.

Thus, reducing blood pressure without eliminating seizures will not give the expected effect and will generally be difficult, since a pregnant woman will not be able to take pills or medicine due to the high muscle tone that occurs during seizures.

Anticonvulsant therapy

All medications intended to relieve seizures can be divided into three categories:

1. Drugs intended for emergency use: 25% magnesia solution, Droperidol, Diazepam.
2. Drugs intended for maintenance therapy: 25% magnesium solution at a dosage of 2 g per hour, Fulsed, Seduxen, Andaxin.
3. Drugs that enhance the sedative effect: Diphenhydramine, Glycine.

The dosage must be prescribed by a doctor. All anticonvulsants tend to significantly relax muscles and cause excessive drowsiness. If attacks of eclampsia were stopped and delivery did not take place, then therapy should be repeated throughout the entire pregnancy to avoid new manifestations of gestosis.

Antihypertensive therapy

It is carried out after the seizures have stopped. It is important not just to reduce high blood pressure one-time, but also to keep it within normal limits - this can be difficult if, with eclampsia, a decision was made not to do an emergency delivery.

• Drugs intended for emergency use: Nifediline, Sodium nitroprusside (intravenously, maximum - 5 mcg per 1 kg of body weight per minute.)
• Drugs intended for maintenance therapy: Methyldopa.

Remedies against high pressure should be taken until the end of pregnancy to prevent attacks from recurring. Antihypertensive therapy should be carried out primarily only if the patient is at risk of cerebral hemorrhage.

In severe cases of eclampsia, delivery is indicated as treatment, regardless of the gestational age and condition of the fetus. In this case, the mother’s life is at stake, so all possible measures must be taken to save her. However, when organizing childbirth, the following conditions must be met:

• Convulsions must be stopped. Delivery procedures should begin only a few hours after the attack has stopped.
• If possible, childbirth should be done through natural means. C-section assumes general anesthesia, which can provoke new wave convulsions after recovery from anesthesia.
• Labor must be stimulated artificially. It is important to meet the period when the attack has subsided - when it resumes, the muscles of the whole body will become toned again and the birth of a child will become difficult.

Prevention

Preventive measures to prevent eclampsia are prescribed either to those patients who have a history of this condition during previous pregnancies, or to those who have already had attacks and there is a need to prevent new ones.

The gynecologist may prescribe calcium supplements or aspirin. Depending on the condition of the woman and the fetus, these drugs are prescribed for the entire term, or for a certain period of time, until the doctor is convinced that the patient is out of danger.

Treatment of eclampsia in a pregnant woman requires the immediate intervention of a specialist, so all actions of her relatives should be limited to providing first aid until the medical team arrives.

Immediate action - first aid for eclampsia - must be carried out clearly and consistently to prevent irreversible consequences of the pathology. Eclampsia - a complication last months pregnancy with severe toxic manifestations. Health problems manifest themselves in the form of increased blood pressure, convulsive seizures, and coma. It can occur before, during and in the first days after childbirth. First aid is based on symptom relief.

Causes and symptoms of pathology

The main causes of eclampsia include existing pathologies of the cardiovascular system associated with increased blood pressure and kidney disease.

Risk factors that increase the possibility of complications:

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• age of the first pregnant woman before 20 and after 35 years; general diseases: arterial hypertension, diabetes
• , systemic lupus erythematosus, rheumatoid arthritis, colitis, gastritis;
• conditions of preeclampsia and eclampsia in close relatives;

multiple pregnancy; The course of pregnancy is influenced by a woman’s compliance with medical prescriptions. Basic rules - developing the correct daily routine, balanced nutrition, staying on fresh air , maintaining a stable psycho-emotional background and refusing bad habits

. Violation of norms increases the risk of complications of toxicosis.

• Before an attack of eclampsia, preeclampsia occurs. appear:
• nausea, vomiting, stomach pain;
• headaches;
• the appearance of swelling of the body;
• beginning visual disturbances;
• coordination disorders;

increased excitability.

At the first symptoms of eclampsia, you need to consult a doctor, as this threatens the life of the child and mother.

• An attack of eclampsia is accompanied by:
• increased blood pressure;
• dizziness;
• increase in temperature;
• spasms of the facial muscles;
• increased coordination and visual impairment;
• convulsions, cramps, numbness of the limbs;
• increased nausea, vomiting and foaming at the mouth;

loss of consciousness. With pathology, disorders of the entire body occur. Central characterized by increased excitability, which can provoke seizures. To remove possible irritants, it is necessary to avoid bright light, pain, sharp and loud sounds, and nervous shock.

Stages and forms of eclampsia

In the development of an attack of eclampsia in pregnant women, four stages are distinguished, which are characterized by a gradual increase in symptoms and manifestations, followed by their decrease and restoration of the body’s vital functions. A description of the development of eclampsia is presented in the table:

Stage	Duration	Characteristic
Preconvulsant	20-30 seconds	Small contractions of the facial muscles, drooping of the corners of the mouth, rolling of the eyes.
				Tonic convulsions	10-30 seconds	Tension, contraction, spasm of body muscles. Difficulty, cessation of breathing. Bluishness of the face.
Clonic seizures	20-90 seconds	Severe cramps of the whole body. Lack of breathing, pulse.
				Seizure resolution	–	The appearance of hoarse breathing, pulse, foam mixed with blood from the mouth. The face returns to its normal color. Gaining consciousness or falling into a coma.

Forms of manifestation and clinical signs are presented in the table:

Severe eclampsia can be fatal.

The severity of seizures is determined by their duration, number, time intervals between them and the patient’s well-being. If a woman does not regain consciousness for a long time, damage to vital organs, especially the brain, is possible, followed by death for the pregnant woman and the fetus.

Complications of the pathology are manifested by the following disorders:

• pneumonia, pulmonary edema;
• deterioration of brain activity;
• renal failure;
• suffocation;
• premature placental abruption;
• hypoxia, fetal death;
• cerebral hemorrhage, cerebral edema.

Algorithm of actions for symptoms of pathology

Emergency care must be provided strictly in a certain order. Since the pathology gives serious complications and poses a threat to the mother and fetus, and at the first signs of onset seizures, call ambulance. Before doctors arrive, you must:

1. Place the patient on a pillow with her left side and cover her with blankets.
2. Open your mouth and fix the position of your tongue, preventing it from swallowing and choking.
3. Wipe your mouth to remove vomit, foam and mucus.
4. If necessary, perform a heart massage.

The main focus in treating the disease is to eliminate seizures.

Next, the patient is transported to the intensive care unit. The room should be soundproof, with darkened windows and dim lighting. Diagnostic measures are carried out under anesthesia to eliminate additional irritating factors. Ensuring the vital functions of the body during convulsive seizures is ensured by the following resuscitation measures:

• artificial ventilation to maintain breathing;
• administration of intravenous diuretics;
• catheterization Bladder to ensure the excretory functions of the body;
• intravenous administration of glucose to lower intracranial pressure and stabilize cardiac activity;
• drip or intravenous administration medicines to improve the activity of the hematopoietic system;
• the use of sedatives to relieve stimulation of the central nervous system.

Urgent Care in case of pathology, it is aimed at maintaining the functioning of all organs and systems of the body, especially the kidneys, liver, heart and brain. When providing first aid, the following indicators are constantly monitored:

• blood pressure;
• heart rate;
• completeness of breathing;
• functioning of the urinary system.

Preeclampsia and eclampsia are severe forms of gestosis. Preeclampsia is a symptom complex that includes:

Heaviness in the back of the head and/or headache;

Visual impairment (weakness, appearance of a “veil” or “fog” before the eyes, flickering of “flies” or “sparks”);

Nausea, vomiting, pain in the epigastric region or in the right hypochondrium.

Eclampsia is characterized by attacks of cramps in the striated muscles of the entire body.

Pre-hospital assistance.

Emergency care at the prehospital stage includes the prescription of sedatives, antipsychotics, narcotics and antihypertensive drugs. The effect on the central nervous system ensures the creation of a therapeutic and protective regime on site and during subsequent transportation of the patient, and prevents the development of eclamptic attacks. Antihypertensive drugs increase the patient's resistance to transportation and ensure the start of treatment even before the pregnant woman is admitted to the hospital. In case of severe gestosis (blood pressure 150/100 mm Hg or higher, proteinuria more than 0.5-1 g/l, edema), urgent hospitalization in an obstetric hospital is necessary. Immediately upon the doctor’s arrival, before transportation, intramuscular administration of 10 mg of seduxen and intramuscular administration of 6 g (in terms of dry matter) of magnesium sulfate are required.

With preeclampsia (against the background of the same symptoms as with severe gestosis, subjective symptoms appear - complaints about headache, blurred vision, pain in the epigastric region, etc.) the doctor’s tactics are similar to those described. If the ambulance is equipped with anesthesia equipment, then during transportation it is advisable to use mask anesthesia with nitrous oxide and oxygen in a 2:1 ratio to ensure the analgesic stage of anesthesia and prevent the development of an eclamptic attack during transportation.

For eclampsia and coma, the medical tactics are the same, but the scope of treatment measures is wider. Upon arrival to the patient, quick and reliable access to the vein should be ensured. The infusion solution can be 5-10% glucose solution, isotonic sodium chloride solution. In this case, antispasmodics and antipsychotics are urgently administered intravenously: seduxen (10 mg) and no-shpu. You can apply 2-3 drops of nitroglycerin to the tongue. If there is an attack of eclampsia, it is necessary to insert a mouth dilator (a spoon wrapped in gauze or cotton wool). Immediately after the end of the attack, mask anesthesia should be provided with nitrous oxide and oxygen in a ratio of 1:1 or 2:1.

The patient is transported to the hospital only under narcotic sleep conditions.

Treatment at the hospital stage.

Treatment of preeclampsia and eclampsia should be carried out jointly with resuscitators in the intensive care unit with monitoring of the condition of vital organs.

Principles of treatment for pregnant women, postpartum women and women in labor with preeclampsia and eclampsia:

Relief and prevention of attacks of eclampsia;

Restoring the function of vital organs (primarily cardiopulmonary, central nervous system, excretory).

At the time of an attack of eclampsia, magnesium sulfate is administered intravenously (4-6 g in a stream, daily dose of 50 g of dry matter), the uterus is shifted to the left (a cushion under the right buttock), pressure is applied to the cricoid cartilage, oxygenation is carried out with oxygen. All of these activities are carried out simultaneously.

Then magnesium sulfate is administered at a rate of 2 g/h (maintenance dose). If the convulsive syndrome could not be stopped, then an additional 2 to 4 g of magnesium sulfate is administered over 3 minutes, as well as 20 mg of diazepam intravenously, and if there is no effect, general anesthetics and muscle relaxants are administered with the patient transferred to mechanical ventilation.

Transfer to mechanical ventilation is also carried out in case of respiratory failure and lack of consciousness after an attack of eclampsia. Delivery is carried out under general anesthesia.

In addition, complications of gestosis such as cerebral hemorrhage, bleeding, aspiration of gastric contents, pulmonary edema, as well as multiple organ failure (MOF) are indications for mechanical ventilation.

With normal function of the respiratory and cardiovascular systems, after an attack of eclampsia, delivery is possible under regional anesthesia, which, in severe gestosis, also acts as a method of treatment, helping, in particular, to lower blood pressure.

Antihypertensive and infusion therapy is carried out according to the same principles as for gestosis. In severe forms of gestosis, infusion therapy should be controlled and carried out taking into account data from monitoring central and peripheral hemodynamics, diuresis, and blood protein. Preference is given to crystalloids (Ringer's solution at 40-80 ml/h), high-molecular dextrans, the introduction of which should eliminate hypovolemia and prevent tissue overhydration. Albumin is administered when its content in the blood is less than 25 g/l. Treatment of pregnant women with eclampsia should be carried out taking into account rapid preparation for delivery, after which a delivery operation is performed. In the postpartum period, antihypertensive, infusion and magnesium sulfate therapy is continued (at least 24 hours), as well as therapy aimed at restoring the functions of vital organs. According to indications, prevention of thrombotic complications and antibacterial therapy are carried out. If there is no effect from this therapy after delivery, extracorporeal methods of detoxification and dehydration are indicated: plasma ultrafiltration, hemosorption, hemodiafiltration. Indications for ultrafiltration.