Dangerous changes: gestosis of pregnant women. Indications for early delivery and caesarean section with preeclampsia Will late preeclampsia pass after childbirth

Preeclampsia is a pathology of pregnancy, which is one of the most threatening complications for both the mother and the fetus. Preeclampsia is characterized by a deep disorder of the functions of vital organs and systems. According to various authors, the incidence of preeclampsia in pregnant women in our country ranges from 7 to 16%.

In the structure of mortality of pregnant women, women in childbirth and puerperas, severe forms of gestosis occupy one of the first places.

Childbirth, eliminating the cause of the disease, does not prevent the preservation and progression of changes in the organs and systems of a woman after pregnancy. This increases the risk of complications in the postpartum period, the occurrence of preeclampsia during repeated pregnancy, the formation of extragenital pathology.

Currently, gestosis in 70% of cases develops in pregnant women with extragenital pathology.

Preeclampsia is a syndrome of multiple organ functional failure that occurs or worsens in connection with pregnancy. It is based on a violation of the mechanisms of adaptation of a woman's body to pregnancy.

In our opinion, speaking about the development of gestosis, one should agree with the conclusion of the majority of scientists about the combined effect of a number of factors on the body of a pregnant woman: neurogenic, hormonal, immunological, placental, genetic.

Human placenta, liver and kidneys are known to contain common antigens. The emergence of antibodies to the placenta, liver and kidneys of the fetus due to cross-reactions leads to immunological alteration of these organs of the mother's body and disruption of their function, which is observed in late gestosis.

The genetic theory of gestosis suggests an autosomal recessive way of inheritance of the disease. It has been noted that among the daughters of women with preeclampsia, the number of gestosis diseases is 8 times higher than in the normal population.

As a trigger for gestosis, supporters of the placental theory mention humoral factors of placental origin. In the early stages of gestation, trophoblast migration into the arteries is inhibited. At the same time, no transformation of the muscle layer is observed in the tortuous uterine arteries. These morphological features of spiral vessels, as gestation progresses, predispose them to spasm, decreased intervillous blood flow, and hypoxia. Hypoxia, which develops in the tissues of the uteroplacental complex against the background of impaired blood flow, causes local damage to the endothelium, which later becomes generalized. Damage to the endothelium in the development of preeclampsia is currently accepted to take one of the significant places.

The main markers of endothelial dysfunction in late gestosis are thromboxane A2, prostacyclin, von Willebrand factor, fibronectin, tissue plasminogen activator and its inhibitor, endothelial relaxing factor, endothelial cells circulating in the blood. The authors came to the conclusion that with an increase in the gestation period, an increase in the severity of late gestosis, the number of endotheliocytes circulating in the blood increases.

When conducting electron microscopy in blood smears in patients with eclampsia, a large number of endothelial cells were found, their swelling against the background of increased plasmolemma permeability and signs of cell damage in the form of cytoplasm vacuolization, swelling and clarification of the mitochondrial matrix, and chromatin condensation were noted.

Damage to the endothelium contributes to the development of changes underlying gestosis - an increase in vascular permeability and their sensitivity to vasoactive substances, the loss of their thrombotic properties with the formation of hypercoagulation, with the creation of conditions for generalized vasospasm. Generalized vasospasm leads to ischemic and hypoxic changes in vital organs and disruption of their function.

Against the background of spasm of the microcirculation vessels, the rheological and coagulation properties of the blood change, and a chronic form of the syndrome of disseminated intravascular coagulation (DIC) of the blood develops. One of the reasons for the development of DIC is the deficiency of anticoagulants - endogenous heparin and antithrombin III, the decrease of which, according to a number of authors, corresponds to the severity of preeclampsia. The basis of the chronic course of DIC in preeclampsia is widespread intravascular coagulation with impaired microcirculation in the organs.

Along with vasospasm, impaired rheological and coagulative properties of blood, hypovolemia plays an important role in the development of organ hypoperfusion, mainly due to low circulating plasma volume (CVV). Low values of VCP in preeclampsia are due to generalized vasoconstriction and a decrease in the vascular bed, increased permeability of the vascular wall with the release of part of the blood into the tissues. Vascular and extravascular changes lead to a decrease in tissue perfusion and the development of hypoxic changes in tissues, as evidenced by a decrease in tissue partial oxygen tension in tissues by 1.5-2 times, depending on the severity of the disease.

The authors of some works suggest that the trigger for the development of multiple organ failure in preeclampsia (as in sepsis, toxic-allergic dermatitis, postoperative syndrome, etc.) is a systemic inflammatory response syndrome, in the development of which there are three stages. The first stage, in response to a damaging factor (immune or non-immune agent), is characterized by local production of cytokines by activated cells, which are numerous mediators (lymphokines, monokines, thymosins, etc.), which are mediators of intercellular interactions and regulators of hematopoiesis, immune response. The second stage is characterized by activation of macrophages and platelets by cytokines, an increase in the production of growth hormone. At the same time, an acute phase reaction develops, which is controlled by anti-inflammatory mediators and their endogenous antagonists.

In case of insufficient function of the systems regulating homeostasis of the body, the damaging effect of cytokines and other mediators increases. This entails a violation of the permeability and function of endothelial capillaries, the formation of distant foci of systemic inflammation and the development of organ dysfunction, which is typical for the third stage of the systemic inflammatory response syndrome.

According to the latest data (I. S. Sidorova et al., 2005), neurospecific proteins of the fetal brain play a leading role in the development of preeclampsia and acute endotheliosis. This is due to the fact that in the mother's body there is no tolerance to these proteins, which have the properties of autoantigens and, when they enter the mother's bloodstream, cause the formation of antibodies. The appearance of antigens of neurospecific proteins in the mother's blood is due to a violation of the permeability of the blood-brain barrier. One of the most important pathogenetic links leading to impaired permeability of the blood-brain barrier is autoimmune brain damage, which leads to the development of severe forms of the disease during pregnancy and childbirth, and also causes the development of complications during the three-year postpartum period.

Without denying the significance of damage to the central nervous system, kidneys, uterus and other organs that develops with gestosis, I would like to emphasize the role of liver changes that occur in connection with the development of hepatosis or HELLP syndrome. The relevance of the study of these pathological conditions is due to the fact that there are still no definitively developed criteria for their diagnosis and therapy, and in 50-70% they lead to death.

The liver is an organ in which numerous metabolic reactions take place. It occupies a central place not only in the processes of intermediate metabolism of carbohydrates, proteins, nitrogen, etc., but also in the synthesis of proteins, redox reactions, and the neutralization of foreign substances and compounds.

The dynamic development of the gestational process, leading to an increase in the load on the organ, exposes the liver to functional stress, which does not lead to any special changes in it. However, it must be borne in mind that the liver, depleting its reserve capacity as pregnancy progresses, becomes vulnerable.

During this period, it is advisable to pay special attention to the functional state of the hepatobiliary system, which plays a significant role in the pathogenesis of severe forms of preeclampsia. At the same time, a change in most parameters can be recorded even at the preclinical stage, which makes it possible to predict the development of liver failure. In addition, when observing a physiologically proceeding pregnancy, one should take into account the effect of progesterone on the tone and motility of the biliary tract, which contributes to the occurrence of cholelithiasis and cholestasis even in healthy women.

During a physiologically proceeding pregnancy, as the authors point out, certain changes are observed in the liver, which are purely functional in nature and do not cause disturbances in the general condition of pregnant women.

Pregnant women with a physiological course of gestation are characterized by an increase in the activity of alkaline phosphatase due to additional synthesis of the enzyme by the placenta, an increased content of cholesterol, triglycerides. On the 6th day of the postpartum period in healthy puerperas, regardless of the method of delivery, all indicators of the functional state of the liver return to normal.

In pregnant women with gestosis, there is a violation of the functional activity of the liver, manifested by hyperenzymemia, changes in pigment, lipid, protein, carbohydrate metabolism and thrombocytopenia, immunodeficiency phenomena, the severity of which corresponds to the severity of the disease. Changes in indicators of the state of the liver in most pregnant women with preeclampsia are not accompanied by clinical signs of her disease.

The data available in the literature indicate that the violation of the functional state of the liver in severe forms of preeclampsia reaches a maximum and persists for 24-48 hours after delivery.

With gestosis in the liver, as in an organ with a developed capillary system, to one degree or another, a deep violation of microcirculation and chronic tissue hypoxia always develop. At the same time, according to the author, her condition, according to clinical and biological indicators, is characterized by a syndrome of hepatocellular insufficiency.

In patients with mild forms of gestosis, no significant changes in the liver are found in the study of biopsy material. In severe forms of gestosis, small droplet fatty degeneration of hepatocytes develops in the absence of necrosis, swelling of the cytoplasm, and changes in the hepatic parenchyma. However, even in the mildest cases, there are signs of a violation of the functional state of the liver. First of all, there is a regular change in the protein-forming and detoxifying functions of the liver. According to a number of studies, with an increase in the severity of preeclampsia, hypoproteinemia increases, expressed in a decrease in albumin fractions and an increase in globulin (IgG, IgA, IgE), an increase in the level of circulating immune complexes.

It has been established that with gestosis, the antitoxic function of the liver, cellular and humoral immunity are sharply suppressed. Pigment and carbohydrate functions are disturbed least of all. An increase in bilirubin is noted only with preeclampsia - mainly due to the fraction of indirect bilirubin. In severe forms of gestosis, hypercholesterolemia and an increase in transaminase activity are found.

Studies show that the activity of indicator liver enzymes in preeclampsia can both increase and significantly decrease. At the same time, according to the author, various systems of hepatocytes are damaged to varying degrees, some can continue to function even with a very severe course of preeclampsia. Apparently, it depends on the initial state of the body.

According to most authors, clinically, liver damage is asymptomatic or develops only with a developed picture of severe preeclampsia (acute fatty hepatosis or HELLP syndrome), while milder degrees go unnoticed.

The poverty of the clinical manifestations of liver pathology in preeclampsia, according to M. A. Repina, dictates the need to develop reliable laboratory criteria for assessing the severity of its damage.

The question of whether the transferred preeclampsia really increases the likelihood of developing various diseases in the future is of interest to many researchers. However, the results of clinical and epidemiological studies are very contradictory (G. M. Savelyeva, 2003; V. L. Pecherina et al., 2000).

Thus, at present there is no consensus on the long-term consequences of preeclampsia and the occurrence or progression of any extragenital diseases in the future. Nevertheless, it can be assumed that profound changes in organs and systems (multiple organ failure), arising as a result of the pathogenesis of preeclampsia, do not stop after delivery and may cause the development of extragenital complications in the future.

Diagnosis of liver diseases in pregnant women presents certain difficulties. This is due to the fact that the clinical picture of the disease in pregnant women with preeclampsia often changes, the disease can proceed atypically. In the second half of pregnancy, the definition of the boundaries of the liver and its palpation are difficult due to the filling of the abdominal cavity with a growing uterus; during pregnancy, biochemical blood parameters also change, as a result of which the interpretation of liver function tests in pregnant women requires some correction. The most modern research methods (radionuclide liver scan, splenoportography, laparoscopy, puncture liver biopsy) are unsafe for pregnant women, and we can perform them only after delivery.

Based on the above pathogenetic features of gestosis, the algorithm for diagnosing liver disorders consists of determining its morphological and functional changes.

Until now, blood serum indicators have been the main criteria for the clinical diagnosis of hepatocellular insufficiency. In this regard, it is necessary to study the biochemical parameters of blood serum. The criterion for assessing the permeability of the plasma membrane and damage to hepatocytes is the determination of the level of enzymatic activity of alanine aminotransferase, a cytosolic enzyme of hepatocytes, as well as enzymes associated with various cell structures: aspartate aminotransferase, alkaline phosphatase, lactate dehydrogenase. It is also necessary to determine indicators of cellular (subpopulations of T-lymphocytes, B-lymphocytes) and humoral immunity (IgG, IgA, IgM, IgE) to assess the severity of immunodeficiency.

The study of morphological changes is an assessment of the results of ultrasound examination of the liver and gallbladder; at the same time, the density of the wall of the gallbladder, liver, gallbladder bile is determined, the volume and thickness of the walls of the gallbladder are measured. Ultrasonic diagnosis of fatty hepatosis is carried out by recording the ultrasonic density of various sections of the hepatic parenchyma by echodensitometry, which, based on a pathological change in a specially introduced attenuation coefficient, makes it possible to diagnose fatty hepatosis.

Hepatobiliary scintigraphy is a comprehensive study of the functional and organic state of the hepatobiliary system, including the assessment of bilisynthetic and biliary excretory functions of the liver, concentration and motor functions of the gallbladder, biliary tract patency. The study is highly informative in patients with inflammatory and metabolic diseases of the liver, gallbladder, cholelithiasis, biliary tract dyskinesia, diseases of the gastrointestinal tract, abdominal syndrome of unclear etiology, etc. .

Undoubtedly, the state of the phagocytic system of the liver attracts great attention of scientists, since a serious influence of the function of the reticuloendothelial system on the course of various diseases has been noted.

Thus, the data available in the literature on the functional state of the liver in women who have undergone preeclampsia are contradictory, since they were obtained from the analysis of a small and heterogeneous number of clinical observations and, in addition, are often limited to the characteristics of one of the liver functions.

Based on a comprehensive analysis of the morphological and functional changes in qualitative and quantitative indicators identified using modern research methods, it is possible to most accurately diagnose morphological and functional changes in the liver in women who have undergone nephropathy, which will allow solving some controversial issues of practical obstetrics in the management of women with this pathology in the postpartum period.

From our point of view, the study of liver function indicators will allow diagnosing liver damage in the early stages before clinical symptoms, monitoring ongoing therapy, restoring the functional state of the liver in the postpartum period, predicting the course of preeclampsia, as well as possible complications in repeated pregnancies.

In this regard, it is necessary to correct treatment regimens in the postpartum period with the inclusion of pathogenetically substantiated simple and safe efferent methods.

In order to correct the immune status in women who have undergone preeclampsia, therapy is carried out with the immunomodulatory drug polyoxidonium (Immafarma), which has immunocorrective, detoxifying, membrane-stabilizing activity and promotes physiological and reparative regeneration of the liver. It is used at a dose of 6 mg in saline, one injection per day for 8 days, then at a maintenance dose of 6 mg once a week for 1 month (depending on the severity of the pathological process).

The most promising direction in the treatment of metabolic disorders of the liver can be considered long-term lipid-correcting therapy with vaseline-pectic emulsion Fishant S (PentaMed) once a week for 2-12 months, with the obligatory use of combined herbal hepatotropic drugs: hepabene (Ratiopharm), at a dose of 1 capsule

3 times a day - and restoration of colon microbiocenosis with probiotics: hilak forte (Ratiopharm) at a dose of 40-60 drops per day, polybacterin (Alpharm) - 2 tablets 3 times a day for 10 days.

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V. A. Kakhramanova
A. M. Torchinov, doctor of medical sciences, professor
V. K. Shishlo, Candidate of Medical Sciences, Associate Professor
MGMSU, RMAPO, Moscow

Table of contents of the subject "Treatment of a preeclampsia. Treatment of an eclampsia. Premature birth.":
1. Treatment of preeclampsia. Prevention of attacks of eclampsia. Relief of attacks of eclampsia.
2. Treatment of eclampsia. Relief of attacks of eclampsia.
3. Indications for caesarean section with preeclampsia. Tactics of conducting childbirth in women with preeclampsia. Postpartum period with gestosis.
4. Premature birth. Definition, classification of preterm birth.
5. Frequency (epidemiology) of preterm birth. Causes (etiology) of premature birth.
6. Pathogenesis (development) of preterm labor. The mechanism of action of bacteria in inducing preterm labor.
7. Clinical picture (clinic) of premature birth. Threatening premature birth. Beginning, beginning premature birth. course of preterm birth.
8. Diagnosis of threatening and incipient preterm labor. Tocolysis index according to Baumgarten.
9. Transvaginal ultrasound in preterm labor. biochemical markers of infection. Fruit fibronectin.
10. Management of preterm labor. Conservative-waiting tactics. Indications for caesarean section with preeclampsia. Tactics of conducting childbirth in women with preeclampsia. Postpartum period with gestosis.

Indication for caesarean section with gestosis is:
1) eclampsia during pregnancy and childbirth in the absence of conditions for delivery through the natural birth canal;
2)severe complications of preeclampsia(suspicion or presence of hemorrhages in the brain, detachment or hemorrhage in the retina, coma, acute renal and hepatic failure, premature detachment of the placenta);
3) no effect of treatment severe forms of nephropathy and preeclampsia with unprepared birth canals;
4) no effect from labor induction or rhodostimulation;
5) combination of preeclampsia with obstetric pathology(breech presentation, large fetus, etc.);
6) fetal weight less than 1500 g and an immature cervix;
7) worsening condition of the mother(increase in blood pressure, tachycardia, shortness of breath, the appearance of neurological symptoms) or the fetus during childbirth in the absence of conditions for rapid delivery through the natural birth canal.

Of considerable interest is practice of childbirth in women with preeclampsia. Complex intensive care in childbirth with gestosis has a number of features. The main task of treatment during childbirth is adequate pain relief and effective antihypertensive therapy. Anesthesia during childbirth is carried out due to long-term phased analgesia, the combined use of neurotropic drugs for various purposes. It is based on acid-oxygen analgesia (2:1 ratio), promedol (20 mg) intravenously. In the absence of effect on the background of antihypertensive therapy, prolonged superficial anesthesia is used using intravenous administration of sodium oxybutyrate at a rate of 40-50 mg/kg against the background of preliminary intramuscular administration of seduxen (sibazon) at a dose of 0.1 mg/kg under the control of blood pressure.

Effective potentiation of oxygen-oxygen analgesia intramuscular or intravenous administration of 5-10 mg (2-4 ml) of droperidol or 5-10 mg (1-2 ml) of seduxen in combination with antihypstaminic drugs (suprastin, diphenhydramine, tavegil, diprazine intramuscularly).

Very effective in childbirth epidural anesthesia lidocaine, which, in addition to analgesic action, has a hypotensive effect.

In the first stage of childbirth should be conducted in a noise-isolated room. In the opening period, an early opening of the fetal bladder is shown (with the opening of the cervix by 3-4 cm) in order to reduce intrauterine pressure and stimulate labor, as well as the widespread use of antispasmodic drugs (no-shpa, etc.).

In the first and second stages of childbirth are carried out under cardiomonitoring control over the condition of the fetus and the nature of the contractile activity of the uterus. Prevention of intrauterine fetal hypoxia is shown. It is necessary to limit infusion therapy to 500-800 ml.

Antihypertensive therapy during delivery is carried out under the control of blood pressure. High blood pressure and the threat of transition of nephropathy to preeclampsia and eclampsia may be an indication for an anesthetist to conduct controlled relative normotension with gangliolytic drugs, which is usually carried out in the second and third stages of labor. If it is impossible to use this method in severe nephropathy, it is necessary to turn off the attempts by applying obstetric forceps (with cephalic presentation) or removing the fetus by the pelvic end (with breech presentation). The operation of vacuum extraction of the fetus with preeclampsia is contraindicated. A child born to a woman with preeclampsia is at risk and needs special monitoring.

In the third stage of labor in order to prevent bleeding, drip intravenous administration of methylergometrine or oxytocin is indicated. Pathological blood loss in puerperas with gestosis should be completely replenished. Immediately after delivery, adequate infusion therapy is indicated. As the main symptoms of gestosis regress, the volume of therapy is gradually reduced.

Used in caesarean section combined endotracheal anesthesia, which allows to control the patient's respiratory function, exclude hypoxia and minimize the amount of anesthetics used. Patients with eclampsia in the presence of inadequate breathing in the initial state or with often following one after another eclamptic seizures, endotracheal anesthesia may also be necessary for "small" obstetric operations (imposition of forceps, etc.), since mask and intravenous anesthesia does not allow adequate breathing. ALV is used in this case not only as a component of anesthesia, but also as a therapeutic and resuscitation aid. You should not rush to extubate the trachea, spontaneous breathing is carried out through an endotracheal tube for 30 minutes - 1 hour. After extubation of the trachea, a therapeutic and protective regimen is created with the introduction of sedative, ataractic and other drugs in reduced doses. In the early postoperative period, complex therapy is continued until the function of vital organs is restored.

In the postpartum period, continue gestosis therapy until the disappearance of edema, normalization of blood pressure, the disappearance of protein in the urine. Women in childbirth who have undergone severe forms of gestosis, complex therapy in a hospital is carried out for 2 weeks. After discharge from the hospital, women in this group are observed not only by an obstetrician-gynecologist; they should be registered with the therapist, nephrologist and, according to indications, with other specialists.

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Indications for early delivery are:

moderate preeclampsia in the absence of the effect of therapy for 5-6 days;
severe preeclampsia and preeclampsia with ineffective therapy within 3-12 hours;
eclampsia, HELLP syndrome, AFLD;
preeclampsia, accompanied by severe feto-placental insufficiency and fetal hypotrophy.

It is fundamentally important to treat the intensive care of critical forms of preeclampsia as a preoperative preparation, since spontaneous childbirth poses a danger to the life of the mother and fetus. According to the instructions of obstetrician-gynecologists, severe preeclampsia is treated within 1 day, preeclampsia - up to 8 hours, with the development of eclampsia, immediate delivery is recommended. Depending on the conditions and the obstetric situation, a caesarean section or obstetric forceps is selected. With severe hypertension syndrome, even with the use of controlled normotonia, it is not possible to keep blood pressure at a safe level for a long time. At the same time, there is a significant risk of developing complications such as premature detachment of a normally located placenta, intrapartum fetal death, cerebrovascular accident, retinal detachment, and pulmonary edema. With the development of a convulsive syndrome, it is advisable to conduct intensive therapy for 1-2 hours to stop cerebral edema and multiple organ failure, and only then proceed to operative delivery.

Absolute indications for caesarean section are:

eclampsia and its complications;
complications of preeclampsia - coma, cerebral hemorrhage, HELLP syndrome, acute fatty hepatosis of pregnant women, premature detachment of a normally located placenta, retinal detachment and hemorrhage into it, anuria (oliguria), etc .;
severe form of preeclampsia and lack of conditions for rapid delivery;
a combination of preeclampsia with another obstetric pathology.

Caesarean section in severe forms of preeclampsia is performed only under endotracheal anesthesia. In less severe forms, it is possible to perform the operation under epidural anesthesia. After fetal extraction, for the prevention of bleeding, it is advisable to give an intravenous bolus injection of 20,000 IU of contrykal followed by the administration of 5 IU of oxytocin. Intraoperative blood loss is compensated with fresh frozen plasma, infucol solution (HES 6% or 10%) and crystalloids.

An indication for blood transfusion is a decrease in Hb below 80 g/l, Ht below 0.25. Given the high risk of developing clinically pronounced DIC and respiratory distress syndrome in severe forms of gestosis, red blood cells are used to compensate for blood loss for no more than 3 days of storage. When delivering through the natural birth canal, childbirth is carried out with maximum anesthesia - phased long-term analgesia using fentanyl, stadol. It is effective to conduct sacral, epidural anesthesia, which also has a hypotensive effect.

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Now there are many clinics in the country that can provide such services.

In order for a caesarean section to be successful, it must be properly prepared for it. In this article, we will talk about preparing for a caesarean section.

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Gestosis after childbirth

Preeclampsia after delivery: how to deal with it

Preeclampsia after pregnancy and during it has symptoms known to doctors: increased blood pressure, swelling, and in connection with them a quick and large weight gain, as well as protein in the urine. In severe preeclampsia, a woman experiences nausea and vomiting, a severe headache. Since pathology can cause a lot of problems, more than one doctor decides how to treat preeclampsia after childbirth. It all depends on which organs of the mother he hit.

Preeclampsia (late toxicosis) is one of the most severe pathologies in expectant mothers. It is directly related to pregnancy. It begins in the second, and more often the third trimester, and is the main cause of maternal and child mortality. It is not treated with medication, only by delivery. All that doctors can do is to help prepare the child as much as possible for life outside the womb (with the rapid early progression of the pathology, the child is born prematurely) and prevent (though not in all cases) eclampsia, a formidable complication of preeclampsia in the mother.

Preeclampsia that occurs in the mother for a period of weeks, as a rule, leads to an emergency caesarean section due to her serious condition and the child in order to save them. If late toxicosis occurs after weeks, there is a chance that preeclampsia will not have time to harm the body of the mother and child too much. Mild preeclampsia rarely has consequences. Usually, all its symptoms go away in the first 1-2 days after the baby is born.

Childbirth with gestosis can be natural or operative, it depends on many factors. However, this situation is always under the control of doctors and anesthesiologists. Approximately half of the cases of eclampsia (severe convulsive seizures) occur in the postpartum period, in the first 28 days after birth. And more often eclampsia is diagnosed in women who gave birth at term.

With a period of less than 32 weeks and severe preeclampsia (severe preeclampsia), a woman is given a caesarean section. After 34 weeks, natural childbirth is possible if the baby does not show any health problems and is in the correct position in the uterus.

During childbirth, as a prevention of eclampsia, a woman receives epidural anesthesia, that is, she gives birth only with anesthesia, as well as drugs that reduce blood pressure.

Doctors are required to prevent prolonged labor and severe uterine bleeding after them. Therefore, a uterine contracting drug is used - "Oxytocin".

On the first day after childbirth, a woman suffering from severe preeclampsia is in the intensive care unit, where her condition is closely monitored by resuscitators. At this time, she receives anticonvulsant therapy in the form of "magnesia" familiar to many women. This drug not only relieves the tone of the uterus, but is also a good prophylactic against eclampsia. The condition of the woman is closely monitored. They take urine and blood samples from her, and often measure her blood pressure.

In the first days after childbirth, women physiologically increase the volume of circulating blood, and for those who suffer from preeclampsia, this is an additional risk factor for arterial hypertension. Depending on the level of blood pressure and the severity of preeclampsia, the puerperal is prescribed drugs for pressure. If possible, compatible with lactation. For example, Dopegit, Nifedipine. Treatment of postpartum preeclampsia continues after discharge from the hospital. The increase in pressure can last up to about two months, but normally the condition should gradually return to normal. Withdrawal of the drug occurs by slowly reducing the frequency of administration and dosage.

Edema after childbirth is a common occurrence. And not only in those suffering from gestosis. A sign of preeclampsia is considered a rapid increase in swelling of the hands and face. If the ankles are swollen - it's not so scary. It will pass within a few days or weeks. At the same time, breastfeeding women should not use diuretic (diuretic) drugs, as this will lead to a decrease in lactation - a lack of breast milk.

What to do if preeclampsia does not go away after childbirth

You need to know the symptoms that require urgent medical attention:

headache;
blurred vision, flies in the eyes;
pain between the ribs or in the right hypochondrium (liver);
infrequent urination;
increase in pressure.

If the protein in the urine remains after 6-8 weeks after childbirth, a consultation with a urologist or nephrologist is required.

If there was eclampsia, it is necessary to do a CT scan of the brain. In addition, donate blood for antiphospholipid antibodies, lupus anticoagulant, undergo a test for thrombophilia.

Supervision at least of the gynecologist and the therapist is required.

Consequences of gestosis for the child and mother

The woman is explained that she is at risk for developing arterial hypertension, kidney and liver failure, and diabetes in the future. Preeclampsia after cesarean and childbirth can eventually turn into coronary heart disease, cause a stroke.

As for the new pregnancy, there is a risk of repeating the scenario of the previous one. For prevention, a woman is prescribed aspirin in small doses from 12 weeks of pregnancy until its end. Sometimes together with calcium preparations.

The interval between pregnancies should not be more than 10 years, as this is also a risk factor for the development of eclampsia when carrying a child.

Preeclampsia in pregnant women also has a negative effect on the child's body - after childbirth, preeclampsia in mothers disappears, but problems in the baby may remain. Most often, with the nervous system. Children whose mothers have suffered severe preeclampsia are almost always born small, with signs of intrauterine growth retardation and chronic hypoxia.

Toxicosis during pregnancy (gestosis)

In pregnant women, edema often appears on the body. This occurs against the background of a violation of the removal of excess fluid from the body and may not be a serious pathology. But in some cases, edema indicates a serious illness called gestosis of pregnant women. If the patient or the doctor does not sound the alarm in time, preeclampsia can be complicated by conditions that end in death.

Gestosis and its varieties

Preeclampsia (late toxicosis) is a disease that develops only during pregnancy and is characterized by the appearance of serious organic and functional disorders in many body systems, but most often in the cardiovascular system. Usually, in pregnant women, late toxicosis occurs after the 20th week of gestation, but is clinically detected after the 26th week. Up to a third of all pregnancies are accompanied by gestosis of one degree or another, and the woman's condition returns to normal only after childbirth has occurred. The most severe preeclampsia is observed in women suffering from endocrine pathologies, diseases of the kidneys, liver, heart, blood vessels.

The classification of preeclampsia is primarily based on the forms of its course:

All forms of late toxicosis can sequentially flow into one another, ending in the most severe of them - eclampsia. Preeclampsia can be concomitant (in women with a history of severe pathologies) and pure (in healthy pregnant women). Foreign classification divides gestosis into 3 forms:

arterial hypertension of pregnant women;
preeclampsia;
eclampsia.

This classification in separate lines puts transient hypertension in pregnant women and preeclampsia, layered on existing hypertension. Another classification is based on the differentiation of preemplaxia by degrees (mild, moderate, severe).

Why do pregnant women develop preeclampsia

Late toxicosis is a syndrome of multiple organ failure, which is caused by a violation of the mechanisms of adaptation of the body to pregnancy. It is believed that the immediate causes of gestosis are associated with an autoimmune reaction of the body to the release of certain substances by the placenta and fetus. These substances, reacting with their own cells of the immune system, form complex complexes of antibodies. They damage the walls of blood vessels, making them permeable. In addition, these causes lead to generalized vasospasm, which disrupts the blood supply to internal organs. Due to angiospasm, blood pressure rises and the total volume of circulating blood decreases. The viscosity of the blood increases, blood clots appear, hypoxia of the tissues of the kidneys, brain, and liver is detected.

Presumably, the above processes in the body of a pregnant woman can be combined with a change in the hormonal regulation of the functioning of vital organs. There is also a genetic predisposition to gestosis. The causes of preeclampsia are also associated with a failure of the nervous regulation of the activity of organs and systems.

There are a number of factors, the impact of which is considered predisposing to the development of preeclampsia during pregnancy. Among them:

diseases of pregnant women in history, including pathologies of the heart, liver, nervous system, metabolism, gallbladder, kidneys;
the presence of autoimmune diseases and allergic reactions at the time of pregnancy;
bad habits;
severe stress;
excess body weight;
violations of the structure of the genital organs, their underdevelopment;
poisoning, intoxication;
polyhydramnios, hydatidiform drift.

According to statistics, the symptoms of preeclampsia often occur in women over the age of 35 and under 18, in socially unprotected women who have poor living conditions and nutrition. Preeclampsia can develop after abortions performed at short intervals or during multiple pregnancies.

Gestosis in the first half of pregnancy

Preeclampsia in pregnant women can occur even in the initial stages of gestation. Early toxicosis (preeclampsia) is more often detected from the first weeks and has a variety of symptoms. The woman notes nausea, vomiting, changes in taste and smell, nervousness, tearfulness. Early mild toxicosis can cause vomiting up to 3-5 times a day. The average severity of toxicosis has more severe symptoms: vomiting is observed up to 7-10 times a day, there is a pronounced weight loss. After the development of a severe degree of toxicosis, a woman urgently needs hospitalization, since indomitable vomiting is combined with an increase in body temperature, a drop in pressure, pulse, a sharp weight loss, the appearance of acetone and protein in the urine. If early preeclampsia has not disappeared by the end of the 1st trimester, a comprehensive examination of the woman for pathology of the internal organs should be carried out.

Gestosis in the second half of pregnancy

If early preeclampsia is dangerous due to dehydration and impaired fetal development, then late toxicosis is an even more serious condition. Already by the presence of rapid weight gain, the appearance of edema and protein in the urine, the doctor may suspect preeclampsia in pregnant women. Later, as a complication, an increase in blood pressure is added, which occurs in about 30% of women with preeclampsia. The danger of toxicosis in the second half of pregnancy is that its signs can quickly turn into a serious condition - eclampsia, which is very dangerous for the life of the mother and child. Late toxicosis often develops during the first pregnancy, and its symptoms can increase hourly and have a very aggressive course. Sometimes only an emergency birth can save the life of an expectant mother.

Gestosis during the second pregnancy

Women who have experienced severe preeclampsia during pregnancy have a high risk of developing pathology during repeated gestation. If the interval between pregnancies is small, then the risk of preeclampsia is even higher. Usually, expectant mothers from the risk group are placed in a hospital in advance, or their health status is monitored on an outpatient basis from the first weeks of pregnancy.

Clinical picture of preeclampsia

As a rule, in late pregnancy, signs of preeclampsia are associated with the appearance of edema (dropsy). They can be implicit and are detected by rapid weight gain (more than 400 grams per week). As the pathology develops, edema becomes noticeable on the legs, feet, abdomen, face, hands. Edema is especially visible in the second half of the day.

Preeclampsia in pregnant women at the stage of dropsy is due to a decrease in urine output and a violation of the outflow of fluid. At the same time, other signs of pathology are often absent, and the woman may feel well. Later, thirst, severe fatigue, heaviness in the legs join.

At the stage of nephropathy during pregnancy, proteinuria (the presence of protein) is detected in the urine, blood pressure increases (from 135/85 mm Hg). An uneven, spasmodic fluctuation of pressure during the day is diagnosed. The amount of urine excreted by a woman falls sharply, despite the consumption of a large volume of fluid. If at this stage there is no necessary treatment, the symptoms of gestosis increase rapidly and can develop into pathologies such as eclampsia and preeclampsia.

Preeclampsia is a complication of nephropathy in pregnant women, accompanied by severe circulatory disorders and damage to the nervous system. In addition, the patient has small hemorrhages in the retina, liver, stomach. Preeclampsia has the following clinical features:

heaviness in the head, pain, dizziness;
nausea, vomiting;
pain in the abdomen, stomach, ribs;
sleep disorders;
visual dysfunction due to damage to the retina.

Treatment for preeclampsia must be urgent and most often includes induced labor and intravenous medication. Otherwise, there is a high probability of developing a pathology such as eclampsia. Signs of this condition:

severe pain in the body without a clear localization;
headache;
convulsive seizures;
loss of consciousness;
coma.

Eclampsia is often expressed in convulsions that last for several minutes and cause severe tension in the body, face. Foam with blood may come out of the mouth, breathing becomes intermittent, hoarse. During this period, a pregnant woman can quickly die from a massive cerebral hemorrhage. After consciousness has returned, the woman may again fall into a state of seizure due to exposure to any stimulus (sound, light). If the state of eclampsia was diagnosed in late pregnancy, even with successful delivery and saving the life of a woman, internal organs and systems are damaged. Their treatment in the future will depend on the complexity, magnitude and severity of the course.

Consequences and complications of preeclampsia

Preeclampsia is always a serious test for both mother and child. Retinal detachment in preeclampsia leads to irreversible blindness or permanent visual impairment. The functioning of the nervous system, kidneys, liver worsens, blood clots form, heart failure develops. Preeclampsia and eclampsia can cause complications that threaten a woman's life - severe dehydration, stroke, hemorrhages in internal organs, dropsy of the brain, pulmonary edema, acute liver dystrophy. The baby can also die due to placental abruption and hypoxia and suffocation developing in connection with this. The overall rate of perinatal mortality against the background of preeclampsia reaches 30%. Even a mild form of gestosis causes disturbances in the physical development of the fetus due to hypoxia, as well as the appearance of mental abnormalities after childbirth. Due to the very serious consequences, the prevention of preeclampsia and its early detection are of high relevance.

Gestosis after childbirth

As a rule, childbirth quickly alleviates the condition of the pregnant woman. Preeclampsia most often improves symptoms within 48 hours after delivery, but eclampsia may develop within the same period. In this regard, after childbirth, drug prevention of further complications is carried out. If the signs of preeclampsia do not disappear 14 days after delivery, this means the presence of damage to the internal organs and systems. Such patients need long-term, sometimes life-long treatment of emerging pathologies.

Diagnosis of preeclampsia

If there is a rapid weight gain (from 400 grams per week), the specialist should conduct an examination of the pregnant woman in order to identify signs of preeclampsia. It includes:

general analysis of urine, blood;
blood biochemistry;
urinalysis according to Zimnitsky;
regular weighing and pressure measurements;
fundus examination;
fetal ultrasound;
Ultrasound of internal organs.

A woman must consult a nephrologist, ophthalmologist, neuropathologist, and, if necessary, a cardiologist. If latent edema is detected due to excessive weight gain, an MCO test is performed (subcutaneous injection of saline and fixing the time during which it resolves).

Mild Preeclampsia in Pregnancy

Preeclampsia in late pregnancy can present with varying degrees of severity. With a mild degree, a woman has the following indicators:

arterial pressure periodically rises to 150/90 mm Hg;
the concentration of protein in the urine is not higher than 1 g / l;
visualized swelling on the legs (lower leg, foot);
the platelet count reaches 180 * 109 l;
creatinine in the blood is not more than 100 μmol / l.

At this stage, the pregnant woman is placed in a hospital, her movement is strictly limited, and drug treatment is performed. When the condition worsens, an operation is performed - childbirth by caesarean section.

Preeclampsia of moderate severity in pregnant women

Moderate preeclampsia is characterized by the following indicators:

blood pressure rises to 170/110 mm Hg;
proteinuria not higher than 5 g/l;
edema is found on the legs, on the anterior part of the peritoneum;
creatinine in the blood - mk.mol / l.

At this stage, urgent delivery by caesarean section is indicated.

Severe preeclampsia

Severe preeclampsia occurs with severe symptoms (vomiting, headache, etc.). At any moment, this condition turns into eclampsia, but sometimes the last degree of preeclampsia develops atypically, when there are no visible causes and signs of it. Therefore, if moderate edema does not disappear after treatment within 3 weeks, the disease qualifies as severe preeclampsia. Her diagnostic criteria are:

blood pressure over 170/110 mm Hg;
proteinuria - from 5 g / l;
edema is found on the legs, anterior part of the peritoneum, on the face, hands;
platelet count - * 109 l;
creatinine - from 300 micromol / l.

Features of pregnancy management with preeclampsia

If the treatment of preeclampsia or observational tactics do not lead to an improvement in the woman's condition, delivery is planned, regardless of the duration of pregnancy. On the contrary, if laboratory parameters and clinical signs have improved, then the pregnant woman continues to remain in the hospital under close supervision. Be sure to appoint a special diet, bed rest, pressure control up to 6 times a day. A woman is weighed twice a week, the drinking regimen and the amount of urine excreted are monitored. Urine and blood tests are also regularly performed, examinations are carried out by narrow specialists. Thus, the treatment and prevention of preeclampsia often help to bring the pregnancy to a week and safely carry out delivery. Childbirth by caesarean section is planned in the absence of the effect of therapy.

Nutrition of the expectant mother with gestosis

The diet of a pregnant woman should provide her and the baby with all the necessary nutrients, but the amount of food should be limited. In other words, you should not exceed the norms for the caloric content of the diet established for pregnant women. The diet for preeclampsia must necessarily include animal protein (fish, meat, dairy products, eggs), which is lost in the urine. We must not forget about vegetable fiber, but it is better to exclude sweets and salty, refined, fatty foods. Treatment of preeclampsia necessarily includes limiting salt and fluid intake (up to a liter per day). Instead of water, it is better for a future mother to drink diuretic teas, a decoction of lingonberry leaves, bearberry. The pregnant diet excludes the consumption of pickles, marinades, salted fish, etc.

Treatment of preeclampsia

In addition to dietary nutrition, fluid restriction and bed rest, a pregnant woman is often prescribed medication:

sedative preparations of plant origin (valerian, motherwort);
herbal diuretics (canephron, cystone), synthetic diuretics (lasix);
magnesium preparations for removing excess fluid from the body (magne B6, magnesium sulfate intravenously);
vitamin and mineral complexes;
drugs to improve placental circulation (actovegin, chimes);
drugs of the latest generation that lower blood pressure (valz, physiotens, etc.);
preparations to improve the functioning of the liver (chophytol, Essentiale).

Outpatient treatment is carried out only in the initial degree of preeclampsia - dropsy. All other stages of the pathology require the placement of a pregnant woman in a hospital. In severe cases, a woman is prescribed emergency therapy with drugs that reduce blood pressure, anticonvulsants, and after stabilization of the condition, immediate delivery is performed.

The influence of preeclampsia on the methods and timing of delivery

Independent childbirth is allowed if the treatment of preeclampsia was successful, the condition of the fetus and the pregnant woman herself is not satisfactory, and there are no prerequisites for the development of acute preeclampsia during childbirth. In other cases, operative delivery is indicated. Indications for preterm birth are:

persistent nephropathy of moderate, severe degree;
failure of gestosis therapy;
preeclampsia, eclampsia (including complications of eclampsia).

Childbirth in severe cases of late toxicosis is carried out within 2-12 hours, which depends on the period of normalization of the woman's condition after the start of drug therapy. Childbirth with moderate preeclampsia is planned in 2-5 days from the start of treatment in the absence of its effectiveness.

How to prevent gestosis

Prevention of preeclampsia should be carried out in every pregnant woman after the end of the first trimester. Particular attention should be paid to women with multiple pregnancies, women over 35 years of age and with a history of chronic diseases of the internal organs. To prevent gestosis, the following measures are taken:

organization of the daily routine and proper nutrition;
regular but moderate physical activity;
frequent exposure to the open air;
limiting salt intake;
observation by an obstetrician-gynecologist during the entire period of pregnancy;
treatment, correction of chronic pathologies;
rejection of bad habits.

At the first sign of fluid retention in the body, you need to notify the doctor about this, who will do everything necessary to maintain the health of the mother and the birth of a strong baby!

constant general fatigue;
drowsiness;
malaise;
periodic causeless pain in the internal organs;
depression

The presented materials are general information and cannot replace the advice of a doctor.

GESTOSIS: correction in the postpartum period

In the structure of mortality of pregnant women, women in childbirth and puerperas, severe forms of gestosis occupy one of the first places.

Currently, gestosis in 70% of cases develops in pregnant women with extragenital pathology.

Damage to the endothelium contributes to the development of changes underlying gestosis - an increase in vascular permeability and their sensitivity to vasoactive substances, the loss of their thrombotic properties with the formation of hypercoagulability, with the creation of conditions for generalized vasospasm. Generalized vasospasm leads to ischemic and hypoxic changes in vital organs and disruption of their function.

Along with vasospasm, impaired rheological and coagulation properties of blood, hypovolemia plays an important role in the development of organ hypoperfusion, mainly due to low circulating plasma volume (VCV). Low values of VCP in preeclampsia are due to generalized vasoconstriction and a decrease in the vascular bed, increased permeability of the vascular wall with the release of part of the blood into the tissues. Vascular and extravascular changes lead to a decrease in tissue perfusion and the development of hypoxic changes in tissues, as evidenced by a decrease in tissue partial oxygen tension in tissues by 1.5–2 times, depending on the severity of the disease.

The data available in the literature indicate that the violation of the functional state of the liver in severe forms of preeclampsia reaches a maximum and persists for 24–48 hours after childbirth.

Studies show that the activity of indicator liver enzymes in preeclampsia can both increase and significantly decrease. At the same time, according to the author, various systems of hepatocytes are damaged to varying degrees, some can continue to function even with a very severe course of preeclampsia. Apparently, it depends on the initial state of the body.

Based on the above pathogenetic features of gestosis, the algorithm for diagnosing liver disorders consists of determining its morphological and functional changes.

Hepatobiliary scintigraphy is a comprehensive study of the functional and organic state of the hepatobiliary system, including an assessment of bilisynthetic and biliary excretory functions of the liver, concentration and motor functions of the gallbladder, biliary tract patency. The study is highly informative in patients with inflammatory and metabolic diseases of the liver, gallbladder, cholelithiasis, biliary tract dyskinesia, diseases of the gastrointestinal tract, abdominal syndrome of unclear etiology, etc. .

In this regard, it is necessary to correct treatment regimens in the postpartum period with the inclusion of pathogenetically substantiated simple and safe efferent methods.

The most promising direction in the treatment of metabolic disorders of the liver can be considered long-term lipid-correcting therapy with vaseline-pectic emulsion Fishant S (PentaMed) once a week for 2–12 months, with the obligatory use of combined herbal hepatotropic drugs: hepabene (Ratiopharm), at a dose of 1 capsule

3 times a day - and restoration of colon microbiocenosis with probiotics: hilak forte (Ratiopharm) at a dose of 40–60 drops per day, polybacterin (Alpharm) - 2 tablets 3 times a day for 10 days.

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A. M. Torchinov, Doctor of Medical Sciences, Professor

V. K. Shishlo, Candidate of Medical Sciences, Associate Professor

MGMSU, RMAPO, Moscow

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Usually, early gestosis is called toxicosis of pregnant women, these are its classic signs with nausea and vomiting, intolerance to strong odors, weakness and severe drowsiness. However, doctors consider toxicosis not as dangerous for the fetus as the development of so-called late gestosis.

Gestoses of pregnancy or toxicosis are painful changes during pregnancy caused by hormonal fluctuations, various pathologies and diseases. According to the time when a problem may arise, early gestosis during pregnancy and late are distinguished.

Causes of gestosis in pregnant women

Although the manifestations of gestosis have been studied for a long time, but until today it has not been possible to identify the exact causes of this pathology. Often, pregnant women with disorders of the nervous system and brain, with problems with the heart and pressure suffer from gestosis. Relationships with kidney pathologies and the development of preeclampsia, with the presence of allergies, endocrine and metabolic failures, as well as the presence of bad habits before conception, were revealed.

Very young future mothers or age-related ones often suffer from gestosis - this is explained either by immaturity or age-related changes in the body, as well as those who carry twins, who are overweight and pressure, or who also had gestosis in the female line.

According to the severity of manifestations and the severity of the course, it is customary to distinguish three degrees in late gestosis.

Preeclampsia 1 degree during pregnancy

Usually, mild gestosis during pregnancy is called dropsy of pregnant women. These are the initial, relatively mild manifestations. At the same time, pronounced, rather serious edemas are formed throughout the body; they give a large increase in body weight. Edema is visible on the limbs, on the body and even on the face, they increase in the evening, progress and are difficult to correct. Against the background of dropsy, the phenomena of nephropathy can join - kidney damage when they do not cope with their tasks.

Preeclampsia of the 2nd degree during pregnancy

It is the development of nephropathy (kidney damage) with the progression of edema and increased blood pressure, the manifestation of protein in the urine that is already referred to as severe preeclampsia. Such changes indicate that the body cannot cope with the loads that pregnancy imposes on it, and it malfunctions. Gradually, with the progression of the process, extremely severe manifestations of gestosis can occur - preeclampsia and eclampsia. These are serious lesions of the nervous system against the background of all the ongoing changes - swelling, pressure, loss of protein by the kidneys. These changes give the most severe and life-threatening consequences of preeclampsia during pregnancy.

What is dangerous gestosis in late pregnancy

Gestoses develop exclusively in pregnant women - they are directly related to the bearing of the fetus. After childbirth, gestosis usually disappears, but often, in severe cases, the consequences of gestosis remain even after childbirth. However, gestosis is dangerous during pregnancy, especially in the third trimester. They can lead to eclampsia, severe seizures that are life-threatening. With them, the pressure goes off scale, the kidneys fail, the whole body swells. This condition requires immediate resuscitation and the birth of a baby to save both lives.

The consequences of preeclampsia for the mother

But often, even after delivery, as a result of severe complications of pregnancy, there are serious consequences of preeclampsia for the mother after childbirth. These can be severe postpartum hemorrhage leading to anemia, as well as complications such as the development of strokes or brain damage due to seizures, irreversible kidney damage with the development of their failure, visual impairment, persistent headaches due to high blood pressure, and much more.

The consequences of gestosis for a child

Naturally, in a difficult condition of the mother, the developing baby will suffer along with her. The development of preeclampsia during pregnancy is no less dangerous and the consequences for the child. Naturally, the most dangerous complication will be intrauterine death of the fetus as a result of hypoxia and nutritional deficiency. This is due to severe placental edema or placental abruption, bleeding and premature birth.

The influence of preeclampsia in the mother on the development of the fetus is expressed. Such children are weakened, they suffer from chronic hypoxia, lag behind in growth and development, and can often and for a long time get sick after birth.

Given the need for the development of pathology to give birth ahead of time, you can add another answer here - what is the danger of gestosis for the fetus. When a child is born much earlier than the due date, he is completely unprepared for an independent life and requires special care, may have deviations in health and developmental delay.