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GESTOSIS

Gestosis (from lat. gestattio - Pregnancy) occurs, usually after 20 weeks of


pregnancy. As the progression of clinically gestosis may manifest in the
form of three symptoms: edema, hypertension, proteinuria, that diminished
after delivery and most women disappear completely. The term "gestosis"
combines a number of pathological condition characterized by multiple
organ failure with impaired renal function and live, vascular and nerve
system, one and fetoplacental complex.

What gestosis terminology used in the International Classification


of Diseases (ICD-10) and English literature?
The MKB-10 (010-016) gestosis indicated as follows:
• pregnancy-induced edema and proteinuria without hypertension;
• pregnancy-induced hypertension without significant proteinuria;
• pregnancy-induced hypertension with significant proteinuria;
• eclampsia.
In English literature, except the term “gestosis ", we use the following
terms: "preeclampsia" and "eclampsia", "hypertonia, induced pregnancy"
and "EPN-gestosis (EPN - Edema, proteinuria, hypertension), and” toxemia”.

For practical use of ICD-10 is inconvenient, so for clinical use (for writing the
history of childbirth), we recommends adapted Russian Society of
Obstetricians and Gynecologists classification match ICD-10 (Prof., Acad.
RAMS GM Saveleva, prof. L . E. Murashko, prof. Radzinsky VE).

Table 13-2.Differeces in ICD-10 and Classification of Russian Society of


Obstetricians and Gynecology

Classification of
Russian Society of
ICD
Obstetricians and
Gynecology
O11 Existing previously hypertension with Combined/Associated
acceding proteinuria gestosis*
O12.2 Induced pregnant edema with proteinuria Gestosis*
O13 Induced pregnant hypertension without Mild degree of
significant proteinuria. Mild pre-ecclampsia (Mild gestosis*
stages of nephropathy)
O14 Pregnancy-induced hypertension with Gestosis*
significant proteinuria
O14.0 Pre-ecclampsia (nephropathy) of medium Medium degree of
severity Gestosis
O14.1 Severe Pre-ecclampsia Severe degree of
gestosis
O14.9 Pre-ecclampsia (nephropathy) unspecified
Pre-ecclampsia
O15 Eclampsia (Same)
O15.0 Eclampsia during pregnancy (Same)
O15.1 Eclampsia during birth (Same)
O15.2 Eclampsia during post-partum period (Same)
O15.9 Eclampsia with unspecified period (Same)
O16 Hypertension of mother is not unspecified (Same)
O16 Transient Hypertension during pregnancy (Same)
Note. *Degree of severity of gestosis is divided in point scale

sWhat gestosis classification is adopted in Russia?


In Russia, we adopted a classification that includes four clinical forms of
gestosis: dropsy, nephropathy (three degrees), pre-eclampsia and
eclampsia. Transferring forms can be considered as a single stage process,
where the hydrocephalus - initial, or light, stage, and the Eclampsia - the
ultimate, or most difficult, stage of gestosis. Widely-used terms form the
division of gestosis in the "clean" that developed in previously somatic
healthy woman, and "combine" that developed against the background of
illness of the kidneys, cardiovascular system, etc.

What underlies the pathogenesis of gestosis?


In the pathogenesis of gestosis leading recognize generalized spasm of
vessels , hypovolemia, change their rheological and coagulation; leaf blood,
disorder of microcirculation and water-salt metabolism. These changes
cause hypoperfusion tissues and develop in them Dystrophy up to necrosis.

What is dropsy pregnancy pregnant?


Dropsy pregnant - the initial stage of development of gestosis. In this case,
general state of patients remains satisfactory. Only sometimes they
complain of hard breathing and fatigue. The main symptoms of this disease
are - Edema and oliguria (Fig. 13-1).

Three degrees of edema: I - lower leg edema, II –


Swelling of waist and the anterior abdominal wall III
– general edema (anasarca). Absence of visible
edema does not always indicate the well. There are
so-called hidden edema. At their appearance
indicates a rapid increase in body weight of patient.
Development of edema accompanied by oliguria,
however, on urine analysis absent of pathological
changes. Edema seen as dropsy only if they do not
disappear after a night's sleep, with pathological weight gain of more than
500 grams per week and more than 2 kg per month.

What are the methods of diagnosing dropsy pregnant?


For diagnostics of hidden edema produce regular weighing of women.
Weight gain per week more than 300 g and for all the pregnancies of more
than 8-9 kg indicates the presence of the disease. Expose the hidden edema
also helps test Мак Клура - Олдриджа: pregnant women with dropsy
blister formed by subcutaneous injection of 0.2 ml of saline in the area of
the forearm, dissolves in less than 35 minutes.
In order to assess diuresis to calculate the water balance: the amount of
fluid consumed by a woman, and daily urine output. Revealed thus confirms
the diagnosis of oliguria in dropsy pregnancy.

What methods can be used pregnant self-monitoring of hidden


edema?
For self-monitoring of pregnancy can be used weekly weighing, measuring
drunk and exudation, assessed as a <symptom of the ring.>

What are the treatments for dropsy pregnant?


Treatments of dropsy pregnancy begin on an outpatient basis, and with the
ineffectiveness of exercise therapy in obstetrics hospital. Therapy of dropsy
is the appointment of a protein salt-free diet without limitation the use of
the liquid. In addition, be appointed start discharge day once in 7-10 days.
During the discharge of the day the patient receives any form of 1,5 kg of
apples or 1,5 kg of low-fat cottage cheese fractional portions. In the
treatment of dropsy pregnancy conditions are prescribed sedatives
fetopreparations (root of valerian, motherwort, etc.), herbal diuretics
(hydrated tea, diuretic collection), and use of diuretics is contraindicated.
In order correction of metabolic disorders using total tocopherols (vitamin
E), ascorbic acid (vitamin C), rutozid, phospholipids. Apply tools that
improve the rheological properties of blood and microcirculation
(pentoxifylline, Dypiridamol, xanthine nicotinate), preparations of
magnesium. With increasing edema on the background of the therapy of
pregnant women is hospitalized in pathology department, where they spend
more intensive therapy, including infusible preparations (onco-
osmotherapy), as when nephropathy stage I severity. In order to designate
desensitization, must start diphenhydramine of 0.05 g 1-2 times a day, and
to create an emotional rest - tranquilizers: diazepam at a dose of 0,001 g, 3-
4 times a day.

Treatment is performed under strict supervision of the dynamic supervision


on present pregnant woman: carefully monitor body weight and diuresis.
Hospital discharge is possible only after the complete disappearance of
edema, normalization of body weight and diuresis. If pregnant woman does
not recover, or the therapy has no effect, gestosis progresses to a more
severe stage -nephropathy.

What is Nephropathy?
Nephropathy - the next stage of development of dropsy state of gestosis,
which lead to a pronounced pathological change in the body of a pregnant
woman. Leading role in the pathogenesis of nephropathy is disorder of
vascular system, disruption microcirculation, hypovolemia (decrease in
volume of circulating plasma) with involvement in the process of all vital
organs and fetoplacental system.

How to distinguish the severity of nephropathy?


Distinguish 3 severity of nephropathy: I degree - mild, II - moderate and III –
severe nephropathy.

What are the clinical manifestations of nephropathy?


The main symptoms - edema and oliguria, hypertension and proteinuria.
Three leading symptom in nephropathy - edema, proteinuria and
hypertension - are known as triads Tsangemeystera. In dependences of
symptoms and severity of distinguish three degrees of severity nephropathy
(Table 13.3). In addition, the severity of nephropathy was assessed using
tables of Vittlingera and Goeka in modification by GM Saveleva (Table 13-4,
13-5).

Clinical Stages of nephropathy


feature
I II III
Arterial 130 and 90 – 140 and 90 More than 160
pressure, 135 and 95 -160 and 100 and 100
mmHg
Proteinuria, <1 1 -3 >3
g/day
Diuresis,ml/day >1000 400 – 1000 <400
Deficit Until 25% Until 25% 25% and more
excretion of
protein

SCALE OF VITTLINGERA

Symptoms Stages of Mark / Ballov


protienuria
Absent 0
Edema Local 2
Generalize 4
Until 12 0
Addition of weight, From 13 - 15 2
kg
16 and more 4
Absent 0
Proteinuria, g/ day Until 1 2
From 2 to 3 4
From 4 and more 6
120 and 80 0
BP, mm Hg 140 and 90 2
160 and 100 4
180 and 110 8
>1000 0
Daily dieresis, ml 900 – 600 4
<500 6
Anuria >6h 8
Subjective Absent 0
symptoms
Present 4

Total from 2 to 10 ballov – mild stage of nephropathy, from 11 to 20 ballov –


moderate nephropathy, more than 21 ballov – severe nephropathy.

SCALE OF GOEKA
Points
Symptoms
0 1 2 3
Edema No On leg or On leg, Generalized
pathological anterior
increase abdominal
weight cavity
Proteinuria, g/day No 0.033 – 0.132 0.132 – 1.0 1 or more
Systolic arterial Less 130 - 150 150 - 170 170 and
pressure, mmHg than more
130
Diastolic arterial Until 85 - 95 90 - 110 More than
pressure, mmHg 85 110
Duration of No 36 – 40 or 35 - 30 24 – 30 or
manifestation of during labour earlier
gestosis
ЗРП, weeks No – Gap from 1 Gap from 3
-2 -4 and more
Background of No Manifestation Manifestation Manifestation
disease of disease of disease of disease
before during before and
pregnancy pregnancy during
pregnancy

Mild stage of gestosis – less 7 ballov, moderate stage – 8 – 11 ballov, severe


stage – 12 ballov

What are the methods of diagnosis of nephropathy?


The diagnosis of nephropathy is set on the basis of medical history, clinical
picture and the results of laboratory studies. Putting history pregnant, you
need to know the total weight gain during pregnancy. If it is higher than
8.10 kg, with absence of other reasons (e.g., violations of fat metabolism)
should think about the appearance of hidden edema.

In the presence of hypertension, attention should be paid, in what stage of


pregnancy for the first time increased blood pressure, whether it was there
in earlier disease accompanied by hypertension or not. Increased blood
pressure in early pregnancy indicates beginning of somatic diseases
(hypertension, chronic nephritis, vegetative vascular dystonia by hypertonic
type). If gestosis develops on the background of these diseases, it is
combined gestosis. Combined gestosis always more severe.

All pregnant women need to produce dynamic control of BP level, which is


measured on both hands. Identification asymmetry indications of 10 mmHg
and more than level of normal BP shows initial forms of nephropathy.
Assessment of BP production lead to the initial level. Increased systolic
blood pressure by 15-20%, and diastolic - by 10% in comparison with the
outcome should be regarded as an expression of hypertension. Unfavorable
prognostic sign is the increase diastolic pressure even at relatively low level
of systolic blood pressure (e.g., 135 and 105 mm Hg). It is generally
accepted to consider not only systolic and diastolic blood pressure, but
average blood pressure (ABP). ABD is calculated by adding the systolic
pressure and two diastolics. The resulting amount is divided by 3, the ABD
should increase during pregnancy 100 mmHg (ABP = AD + 2DD / 3).

Vascular changes are reflected in the picture fundus. In the study of eye
fundus noted phenomenon hypertonic angiopathy: a spasm of retinal
arteries and veins with precapillary edema, hemorrhages in the retina and
swelling.
To identify proteinuria in pregnancy after 32 weeks is to produce a urine
sample daily. In the presence of proteinuria in the early stages of urine
sample is repeated every 3-4 days. When collection protein in the urine, the
appearance of the cylinders to divide the blood content to residual nitrogen,
urea, to produce a sample of Zomnitski, analysis of blood electrolytes.
Increase number of units of residual nitrogen in the blood, even if his
figures are within the physiological, is an unfavorable sign, is evidence of
the disorder of nitrogen excretory kidney function.

What liver function abnormalities develop during gestosis?


Disorders of the liver develop in severe course of gestosis and expressed
changes of protein and lipid metabolism, homeostasis system, which
manifests itself in the form of chronic DIC (disseminated intravascular
coagulation).

Disorders of the protein function of the liver characterized by reduced


protein content in the blood to 60 g /L and below, a shift albumin-globulin
coefficient in the direction of globulins (less than 1). Disorders whether
pidnogo exchange expressed reduced high density lipoprotein and
increased low-density lipoproteins. Reduced functional activity of the liver
leads to change general and toxic (not associated with glucoronic acid), an
indirect bilirubin. Disorders of protein, lipid metabolism, affects
microcirculation, hypertension and other pathophysiological changes in
gestosis contribute to disorder in fetoplacental system which is manifested
by hypoxia and fetal hypotrophy. Particularly difficult during gestosis gets
when there are situation HELLP syndrome and acute liver steatosis in
pregnancy.

What is HELLP syndrome?


HELLP syndrome: (H –hemolysis) - hemolytic anemia, (EL – elevated live
enzymes) - increase the concentration of liver enzymes in the blood, (LP –
low platelet count) – reduce number of platelets in 1ml of blood to 150
thousand or less. In the lab analysis of anemia, thrombocytopenia,
increased transferase activity 10 times or more shows rapid early delivery.

What is acute steatosis pregnant?


During the acute fatty liver, which usually develops in first pregnancy,
distinguish two periods. First, anicteric, can last from 2 to 6 weeks. For him,
character s: reduction or loss of appetite, weakness, heartburn, nausea,
vomiting, pain and feeling of heaviness in the epigastric region, itchy skin,
and decrease body weight. Second, yellow, final period of disease
characterized by stormy clinical picture is characterized by hepatic-renal
insufficiency: jaundice, oligoanuria, peripheral edema, accumulation of fluid
in serous cavities, uterine bleeding, and antenatal death of fetus. For
biochemical analysis of blood revealed: hyperbilirubinemia due to direct
fraction hypoproteinemia (<60 g / L),hypofibrinoemia (<2 g /L), not
expressed thrombocytopenia, a slight increase in transaminases. In vivo
acute fatty liver pregnant often develop hepatic coma with dysfunction of
the brain from minor disorders of consciousness to his deep loss of
inhibition of reflexes.

What are the principles of modern treatment of gestosis?


Treatment of pregnant women with nephropathy conducted only under
conditions of hospitalization. Therapy of gestosis, based on the known
impact of the pathogenesis of disease is complex. It aims to:
• normalization of osmotic and oncotic pressure;
• elimination of vascular spasm and reduction in blood-pressure;
• Establishment of medical protective regime;
• elimination of hypoxia and metabolic disorders;
• improving the rheological properties of blood and normalization of a
system of homeostasis;
• maintaining the function of vital organs;
• prevention and treatment of hypoxia and malnutrition of the fetus.
In the treatment of severe forms of nephropathy apply extra corporal
methods of detoxification and dehydration: plasmapheresis and ultra
filtration.

What is the basic therapy of gestosis?


In modern conditions the basic therapy of gestosis is onco - osmotherapy,
which occupies a special place of magnesium sulfate, provides, good
therapeutic antihypertensive effects. It contributes to eliminate brain
edema, decrease intracranial pressure, hold dehydration and sedative
action, normalizes osmotic pressure.
A solution of magnesium sulfate (25%) injected internal stream via infusion
pump or, at a small number (up to 200 ml) solution of 5% glucose at a
speed of 1 g per hour. Dose determines the degree of severity of gestosis
(Table 13-6).

Table 13-6. Basic therapy for gestosis. (onco-osmotherapy)

Nephropathy I degree - Up to 12 g
Nephropathy II degree - Up to 18 g
Nephropathy III degree - Up to 25 g
Preeclampsia – Up to 25g
Eclampsia - Up to 50 g

Of these, 4 g in the first hour, the rest - for 23 hours in equal shares. With
intravenous drip of magnesium sulfate is necessary to monitor urine output,
tendon reflexes and frequency of respiration, which must not be less than
14 per minute.
To normalize oncotic pressure and treatment of hypoproteinemia use
intravenous drip 400 ml Hydroxyethylstarch, 200-250 ml one group of fresh
frozen plasma or 10-20% albumin solution. Also use the solution dextran
(reopoliglukin). At the present time to deal with hypovolemia and impaired
microcirculation preference to give preparation of Hydroxyethylstarch,
which is able to bind and retain water in the intravascular space in internal
vessels.

What drugs are used additionally for hypertension?


Hypertension used antihypertensive preparations:
• aminophylline - intravenously 10 ml of 2.4% solution; aminophylline
vasorelaxant, spasmolytic improves renal blood flow and reduces tubular
reabsorption, reapplied aminophylline after 6 h, does not recommend the
drug for severe tachycardia;
• dibasol - 4-6 ml 0,5-1% solution injected intramuscularly 2-3 times per
day;
• methyldopa reduces blood pressure, slows heart rate, decrease
peripheral vascular resistance; contraindicated in acute liver disease;
designate from 0,25 g to 1 g per day in 2-3 doses;
• Clonidine - lowers blood pressure, reduces peripheral vascular resistance,
has sedative effect; appoint 0,075 mg 2-4 times a day sublingually, should
not be combined with other hypotensive drugs, with severe gestosis
injected IV slowly from 0,9% sodium chloride to 1 ml 0.01% solution;
•Nifedipine – blocker of slow calcium channel, lowers arterial blood
pressure, increases peripheral artery pressure; used by 10-20 mg 3 times
per day sublingual ; not apply when tachycardia; shown at threat for
premature birth;
• Prazosin – selective alpha adrenoblocker decreases blood pressure,
decreases total peripheral vascular resistance, improves renal and brain
blood supply; to be taken by 0.5 mg 2-3 times a day;
• Nitroprusside sodium (and other drugs of nitric oxide) reduces blood
pressure, prescribed by 50-100 mg / day;
• nebivolol - highly selective beta-blocker, modulate synthesis of nitric
oxide, appointed by 2.5 mg, 2 times a day;
• azamethonium bromide, 5% solution, referred to as ganglioblocker,
injected with 0.9% sodium chloride in the amount of 1,0 ml.
Ganglioblockers apply in case of insufficient effect of other antihypertensive
therapy. Using ganglia blockers must carefully control arterial blood
pressure. Repeat introduction of the preparation within 1-2 hours.

In avoidance of orthostatic collapse within 2 h after the introduction of


ganglinoblockers pregnant women should stay in horizontal position. In the
first stage of labor used azamethonium bromide of 50 mg of IM or IV.
Intravenous azamethonium under the control of blood pressure in the
second stage of labor is called "controlled normotonii" or "controlled
hypotension".

By what methods and means we can achieve the elimination of


hypoxia, intoxication, metabolic disorders and increased blood
volume?
To eliminate hypoxia and metabolic disorders using a solution phospholipid
(Essentiale), 2-5 ml of ascorbic acid in a 5% solution (injected), total
tocopherols, or a-tocopherol acetate (vitamin E), but 200-300 mg per day.
The latter has antioxidant activity and normalizes the activity of platelets.

Increased Blood volume, improve microcirculation, removal of intoxication,


correction of metabolic disorders produced using infusion therapy.
Indication for infusion therapy are severe forms of dropsy pregnancy,
nephropathy, preeclampsia, and eclampsia.

What means are used to improve the rheological properties of


blood and normalization of homeostasis?
• To improve rheological properties of blood and normalization of the
homeostasis system used pentoxiphylline, which improves microcirculation
and reduces viscosity of blood. Assign the drug in pill form, but 0.2 g, 2-3
times daily or 5 ml, diluted in 200 ml 5% glucose solution or dextran.
• Acetylsalicylic acid normalizes platelet aggregation, reduces permeability
of capillaries. Applied by low dose, 100 mg per day.
• Heparin or Nadroparin calcium - anticoagulant direct action, apply a dose
of 2,5-5 thousands ME (heparin)or 0,2-0,3 ml (nadroparin calcium) 1-2
times a day. Drugs injected into the subcutaneous space of abdomen.
Therapy straight anticoagulant absent only under the supervision of the
homeostasis system.
• Solution Hydroxyethylstarch normalizes microcirculation and improves the
rheological properties of blood, it is injected by intravenous drip (200-400
ml).

What are the principles of fluid therapy?


The duration of therapy is determined by its efficiency. When severe
nephropathy, infusion therapy is carried out daily. The composition of it
changes depending on the clinical and laboratory data. Infusion therapy in
pregnant women with gestosis need to be done in caution under the control
of urine output and hematocrit, which is lower than 27% said on
hemodilution, and increased more than 45% - about hemoconcentration,
also requires monitoring of acid-base status of blood, its biochemical
composition and homeostasis. total fluid intake of pregnant woman with
gestosis should more than 1200-1400 ml per day, in condition of normal
diuresis. Infusion therapy is done until a persistent improvement in the
overall condition, decrease blood pressure, restoration of diuresis. At birth
and during the heavy nephropathy number of input of liquid is limited to
300-500 ml.

What is medical protective regime for V.V. Stroganov?


Medical protective mode based on the decrease of excitability of the brain,
stabilization neurovegetative reaction. At the present time to reach with
help neurotropic preparations - neuroleptics (droperidol), tranquilizer
(diazepam) and narcotics (trimeperidin). For progressive state neurolepsy
combine IV diazepam and droperidol.

What is the tactics of labor with nephropathy?


In addition to stated above therapy in childbirth, shown early and thorough
anesthesia. The best method of anesthesia for in nephropathy is epidural
anesthesia, which, exclude pain relief effect, provoke arterial hypotension.
All activities and manipulations in patients with nephropathy II and III stage
conducted after the introduction of tranquilizers or neuroleptics (vaginal
examination, IV infusion and opening of amniotic sac, etc.). To make early
amiotomy must have opening of the amniotic sac in latent phase of labor,
up to 3-4 cm opening cervix of the uterus. This helps reduce the intrauterine
pressure and acceleration of labour.
In the second stage of labor with high blood pressure showed permission
with help of obstetrician forceps to a quick end the birth. It is allowed to
avoid operations of imposition of obstetrical forceps, if the arterial pressure
is lowered with the help of normotonic (hypotonia) ganglionblockers.

Deliveries are constant monitoring mother, fetus and activity of the uterus,
requiring a partogramm. Non rational management of pregnancy and
childbirth, absent treatment or its inefficiency can lead to the development
of the next phase of gestosis - preeclampsia.

What is pre-eclampsia and what are its clinical manifestations?


Pre-eclampsia - an intermediate stage between nephropathy and eclampsia.
In the development pre-eclampsia to clinical manifestation of nephropathy,
there are symptoms indicating dysfunction of the central nervous system -
symptoms of hypertensive encephalopathy. Patients complain of headache,
pain in the epigastric region, blurred vision, nausea and vomiting.

There is a rise of all symptoms: blood pressure increased to 180 and 110
mmHg and more, increased proteinuria, and increased edema. Blood
pressure is characterized by rapid rise with a simultaneous decrease in its
amplitude. When examining eyeball, there is a sharp angiospasm of
arterioles, hemorrhage, and edema and detachment of retina. Azotemia
increases, hypoxia develops until severe acidosis, deteriorating function of
all critically important organs, reduces utero-placental blood flow,
progresses to chronic DIC. Any stimulus can lead to the development of
convulsive seizure - eclampsia.

What therapy and tactics for symptoms of pre-eclampsia?


When pre-eclampsia symptoms appears (headache, amblyopia, pain in the
epigastric region), patients is immediately anesthetized and begin intensive
therapy, as such in nephropathy III degree/stage. Ineffective treatment or
deterioration of the pregnant woman in labor or no conditions for natural
delivery, deliver via caesarean section. If this condition happens in the
second stage of labor, immediate elective delivery with help of obstetric
forceps must be done. All manipulations and operations are performed
under anesthesia, as pre-eclampsia can quickly developed into next stage of
gestosis - eclampsia.

What is eclampsia?
Eclampsia - the most dangerous stage of gestosis, characterized by rapid
growth of cerebral symptoms and the appearance of seizures. The danger of
an attack of eclampsia is the fact that during the attack, bleeding may occur
in the retina of the eye and the brain or other vital organs, and therefore the
possibility of loss of vision and a fatal outcome. The fetus may die from
hypoxia due to disturbance of utero-placental circulation, which can be
acute (premature placenta abruptio) or chronic (and worsening angiospasm
and progressive DIC syndrome).

What are the clinical symptoms of eclampsia?


Development of eclampsia is preceded by symptoms that indicate a
significant stimulation of the central nervous system. Note that increase
reflex irritability (hypereflexia), hyperesthesia. Bright light, noise, pain
stimuli can provoke seizures.

Clinically, eclampsia can be divided into four stages:


• 1st stage - short. Pregnant appear small fibrillating muscle, twitching of
eyelids, extension of muscles of the face and upper limbs. Staring look.
Breathing is normal. This period lasts about 20-30sec.
• 2nd stage is characterized by tonic convulsions. Pale face, clenched, jaw
dilated eyes. Unconsciousness. Breathing stops, the pulse not presence.
The period lasts about 20-30s.
• 3rd stage is characterized by clonic convulsions, following each other and
spread downward. Unconsciousness. Breathing difficulties or none at all,
the pulse is not identified, the person becomes a purplish-blue. Gradually
the spasms stopped. The period lasts from 30 sec to 1 min or more.
• 4th stage - Resolution of attack. Restored the breath of his mouth stands
ieiistaya saliva mixed with blood as a result of the biting tongue. Face is
pink in color, narrowed eyes, pulse is at first frequent and thready. After
the attack, the patient is in coma, and then slowly becomes conscious.
On the fit, patient did not remember complaining of headache, weakness,
broken. Eclampsia causes progression of severe multiple organ failure
that can lead to death of women.

What are the complications encountered in severe gestosis and


eclampsia?
Outcome of severe forms of gestosis and eclampsia may be:
• heart failure accompanied by pulmonary edema;
• brain hemorrhage, thrombosis, cerebral edema, coma;
• DIC with circulatory disturbance of the vital organs, and bleeding;
• hepatic insufficiency;
• renal failure;
• acute syndrome of respiratory disorders- ASRD
• bleeding in the retina and its detachment;
• premature placenta abruptio;
• Hypoxia, malnutrition, the death of the fetus.

What is the tactics physician in eclampsia?


Tactics of doctor is to provide emergency and intensive care. At the time of
seizure, to avoid biting of the tongue, impose gag and glossotilt. Pregnant
women must immediately anesthetize, better to use halothene. With
anesthesia comes a comprehensive intensive care. All manipulation and
intervention is performed under general anesthesia. One of the stages of
emergency relief is immediate delivery. If there are no conditions for
delivery through the vaginal with obstetric forceps, then do caesarean
section under endotracheal anesthesia, followed by mechanical ventilation.

Indications of doing cesarean section in gestosis are:


• deterioration despite ongoing therapy;
• eclampsia (if there are no conditions for labor with obstetric
forceps);
• cerebrovascular disturbance;
• coma;
• acute renal failure;
• premature placenta abruptio;
• Deterioration of a viable fetus.

In the second period, labor ends with the operation with obstetric forceps.
Intensive therapy is continued until there is a persistent improvement
(achievement of stable hemodynamics, normalization of liver function and
kidney).

Which obstetric pathology may lead to gestosis?


Gestosis is a serious danger to the health of mother and newborn. High
blood pressure, dysfunction of critically important organs and hemostasis,
morphological changes in the placenta caused by gestosis, can lead to
premature detachment of the placenta. With disorder of tissue metabolism
in myometrium from women giving birth in the first and second stage of
labor may develop weakness of the clan's activities and in the postpartum
period - hypotonic bleeding. In pregnant women with gestosis, circulating
blood volume – CBV (Объем Циркулирующей Крови - ОЦК) reduced, so
even a small amount of blood loss but can cause decompensation. In
expected mothers with gestosis, it is necessary to prevent bleeding by
intravenous oxytocin at the end of the second period, in the third stage of
labor and early postpartum period.

In the presence of blood loss during delivery, blood must be adequately


filled with time and volume. In gestosis, physiological blood loss may
amount to 0.3% of body weight (in healthy birth up to 0.5%). Blood loss is
one of the most frequent causes of terminal states in patients with gestosis.
The terminal condition can also be a consequence of disorders of cerebral
circulation with brain hemorrhage or severe injury of parenchymal organs -
hepatic-renal insufficiency.

This pathology, as gestosis can not affect the condition of the fetus. As a
result of disturbance of utero-placental blood circulation and gas exchange
in the fetus, chronic hypoxia may developed and, as a consequence -
placental insufficiency. Chronic hypoxia has often become the cause of
asphyxia in the birth of children. Therefore, during childbirth is necessary to
prevent fetal hypoxia, and after the birth, to be ready to provide newborn
with intensive care benefits.

What are the risk factors for development of gestosis?


Risk factors for the development of gestosis are extragenital pathology, the
presence of gestosis in amnesis, young age and late pregnancy, multiple
pregnancies.