Creating a protective regimen for late toxemia in pregnant women

The patient should be placed in a separate room, where conditions are created that maximally protect her from various irritants (sound, light, olfactory, etc.). To do this, the room is darkened, a rubber carpet is laid on the floor, conversations are excluded (only whispered speech is allowed), etc. There should be a separate nurse's station in the room, at the station - everything necessary to prevent attacks of eclampsia and to care for the patient (medications, cardiac monitor, intubator, artificial lung ventilation apparatus, etc.).

In the presence of preeclampsia symptoms, the patient is put under short-term nitrous oxide-aeote-fluorothane anesthesia. Strict bed rest is mandatory, preferably on the side to exclude inferior vena cava syndrome and improve uteroplacental circulation. It is especially important to maintain a horizontal position in the presence of hypotension; with normal and elevated blood pressure, the head of the bed is raised by 20-30, which reduces temporal pressure by 10-15 mm Hg (1.3-2 kPa) and creates more physiological conditions for spontaneous breathing. Bed rest promotes faster stabilization of blood pressure, improves uteroplacental circulation and organ blood flow, and reduces and increases urinary excretion of sodium.

All manipulations should be reduced to a minimum and performed only under anesthesia (fluorothane and trichloroethylene). To prevent biting of the tongue during an attack, a mouth gag and tongue depressor are used. If the patient is in a coma or deep drug-induced sleep, a tight rubber airway is inserted into her mouth and fixed with a ribbon to prevent biting and retraction of the tongue. It is advisable to conduct oxygen therapy (inhalation of 100% oxygen, short-term, 10-15 minutes to increase the oxygen tension in the blood, the disappearance of bradycardia in the fetus after an eclamptic attack in the mother). If bradycardia is not eliminated by this, then there is probably either compression of the umbilical cord or premature detachment of a normally located placenta.

Oral hygiene and mucus suction are important. Eclamptic coma itself is not an indication for artificial ventilation, but if the breathing rhythm is disturbed, hypoxemia, Mendelson syndrome or respiratory distress syndrome develop, artificial ventilation is indicated.

In eclampsia, glucose tolerance decreases and insulin metabolism (in the kidneys) decreases, so its dosage should be reduced. To prevent asphyxia of the newborn, it is advisable to administer etimeol - 0.5% solution 1 mg/kg of the mother's body weight 5-7 minutes before the birth of the child.

In the treatment of severe toxicoses, a limited number of drugs should be used, prescribed in minimal doses, taking into account the possibility of potentiation of action and undesirable side effects. Treatment should be individualized depending on the characteristics of the body, its growth and mass indicators, the course of the disease and the effect of drugs.

A very effective method of pain relief during labor in cases of severe toxicosis of pregnancy is epidural analgesia.

Drug treatment of late toxicosis

Scheme 1. The leading drug treatment for severe forms of late toxicosis is a combination of magnesium therapy with sedative, antihypertensive and osmo-oncotherapy.

1. Magnesium sulfate is administered intravenously, slowly (over 5 minutes) - 12 ml of a 25% solution. At the same time, 4.5-6 g of magnesium sulfate is administered intramuscularly, depending on the patient's weight, on average 0.1 g / kg, and then the same dose is repeated every 6 hours intramuscularly. In total, the patient receives from 21 to 27 g per day (depending on body weight). Magnesium sulfate can be administered after the initial administration of 3 g intravenously and 4 g intramuscularly - every 4 hours, 4.5-6 g, depending on the patient's weight (at the rate of 0.1 g / kg, but not more than 24 g per day; after a 12-hour break, the course can be repeated).

Before the introduction of magnesium sulfate, it is necessary to check the knee reflexes (presence of live reflexes), respiratory rate of at least 14 per 1 min and diuresis of at least 30 ml per hour, as well as an intramuscular injection of 2-3 ml of 0.5% novocaine solution. On the 2nd and 3rd days of treatment, intramuscular administration of magnesium sulfate can be reduced to 2-3 injections.

2. In eclampsia, oncoosmotherapy is prescribed simultaneously with magnesium sulfate (no more than 1-1.5 l). The following sequence of alternating administered solutions is desirable: rheopolyglucin 400 ml, concentrated plasma 200 ml, 20% albumin solution 100-200 ml, polyamine 100 ml (polyamine is administered with 10% glucose solution and insulin - 1 U per 4 g of dry glucose matter), vitamin B6 (1 ml of 5% solution) and vitamin C (5 ml of 5% solution).

To inhibit the aggregation of red blood cells and platelets, improve microcirculation, reduce blood pressure and improve cerebral and coronary blood flow, curantil is prescribed (0.05 g 3-4 times a day orally).

Infusion therapy in a volume of no more than 20-30% of the BCC is carried out only in cases of severe toxicosis, in the presence of the following conditions (without them, its implementation is strictly contraindicated!):

• positive diuresis, when the volume of fluid excreted is at least 600 ml per day greater than the volume of fluid introduced;
• arterial hypertension has been eliminated;
• there is normal venous pressure, there are no symptoms of threatening pulmonary edema or cerebral hemorrhage.

3. If magnesium sulfate is not effective enough to stop eclamptic attacks, intravenous administration of seduxen (10 mg - 2 ml of a 0.5% solution intravenously slowly in 20 ml of a 5% glucose solution) is used in addition to it.
4. To enhance the sedative effect of the therapy, if required by clinical data, and to reduce elevated diastolic pressure, droperidol can be prescribed intravenously or intramuscularly at 5-10 mg 2-3 times a day (0.25% solution - 1-2 ml).
5. To reduce blood pressure - with systolic pressure above 160-180 mm Hg (21.3-24 kPa) and diastolic pressure of 100-110 mm Hg and above (13.3-14.7 kPa), if the effectiveness of magnesium sulfate is insufficient, use pentamine (5% at a dose of 50-150 mg) in 5% glucose solution. Administer slowly, under the control of blood pressure, without reducing the latter below 20% of the initial. Pentamine can also be administered intramuscularly at 1 ml of a 5% solution every 4-6 hours.
6. Against the background of droperidol, seduxen and promedol (2% solution - 1 ml), a good hypotensive effect is provided by intravenous administration of euphyllin (2.4% solution - 10 ml) every 3-4 hours (can be alternated with the administration of papaverine 2% solution - 2 ml or no-shpa 2% solution - 2-4 ml intravenously).
7. Heparin therapy is indicated only in case of laboratory-confirmed consumption coagulopathy. It is best to use a rheopolyglucin-heparin mixture at the rate of 5-6 ml of rheopolyglucin and 340 U of heparin per 1 kg of the patient's weight (thus, for a weight of 60 kg, 300 ml of rheopolyglucin and 21,000 U of heparin are administered). Half of the calculated amount of heparin is administered intravenously by drip (20 drops/min) with a full dose of rheopolyglucin. The remaining amount of heparin is administered subcutaneously every 4-6 hours (during the day), in equal doses. The following day, these measures are repeated. Upon achieving a clinical effect, switch to daily subcutaneous administration of heparin every 4-6 hours; rheopolyglucin is administered not every day, but every 1-3 days. After normalization of the indices, the dose of heparin should be reduced gradually, with the same intervals between administrations. When using a rheopolyglucin-heparin mixture, it is necessary to monitor the content of hematocrit, fibrinogen and indicators of the blood coagulation system. When introducing this mixture, a decrease in blood coagulation by no more than 2 times compared to the norm is permissible.

In case of obvious symptoms of disseminated intravascular coagulation, i.e. when there is a low concentration of fibrinogen - below 2 g/l, platelets - below 150,000, the rheopolyglucin-heparin mixture should be administered with plasma that contains antithrombin III, which is necessary for the anticoagulant properties of heparin to manifest (with DIC, antithrombin III in the patient's plasma is suppressed).

8. In case of laboratory-confirmed decompensated metabolic acidosis, an S% solution of sodium bicarbonate (tris buffer, trisamine, lactasol) is administered - 100-200 ml under the control of the acid-base balance.
9. Dehydration therapy is prescribed only after normalization of osmotic and oncotic pressure and microcirculation to eliminate water intoxication, intracranial hypertension and cerebral edema. Diuretics are contraindicated in case of impaired renal filtration capacity, anuria and high blood pressure (over 150 mm Hg or over 20 kPa). A single dose of lasix 0.04 g intravenously at one time, can be repeated (if necessary) after 4-6 hours; the total amount of lasix is no more than 0.1-0.12 g.

The introduction of mannitol is not recommended due to the phenomenon of "rebound". When prescribing a rheopolyglucin-heparin mixture, 0.04 g of lasix is sufficient to restore diuresis.

Infusion, dehydration and diuretic therapy can be carried out under the control of hematocrit and diuresis. A decrease in hematocrit below 30% indicates excessive dilution of the blood, its depletion of oxygen and anemia. An increase in hematocrit above 45% indicates hemoconcentration - increased viscosity, deterioration of microcirculation, increased peripheral resistance and blood pressure. Excessive diuresis leads to hypovolemia and spasm of peripheral vessels. With sufficient diuresis, the amount of fluid administered should not exceed 80 ml (maximum 1 l) per day.

10. In case of oliguria, euphyllin, cardiac glycosides and glucose-novocaine mixture are administered first to enhance glomerular filtration and relieve spasm of small peripheral vessels. After that, 0.02 g of lasix is administered. Upon obtaining sufficient diuresis in 2 hours - at least 700-800 ml - mannitol administration (30 g) can be continued. If diuresis is less than 100 ml in 2 hours, then euphyllin, cardiac glycosides and glucose-novocaine mixture should be administered again; mannitol should be administered only after sufficient diuresis has been established. Infusion therapy for oliguria should not be performed (or prescribed with extreme caution under control of diuresis, pulse and arterial pressure).

Calculation of electrolytes during infusion therapy. Cation (anion) deficit = (A1 - A2) • M - 0.2, where A is the normal anion (cation) content in the patient; M is the patient's weight; 0.2 is the correction factor (the amount of extracellular fluid that constitutes 20% of the patient's weight). The norm for potassium is 5 mmol/l, sodium - 145 mmol/l, chloride - 105 mmol/l, calcium - 2.5 mmol/l, HCO3 - 25 mmol/l.

11. According to indications, intensive therapy for late toxicosis of pregnancy can be supplemented by the introduction of cocarboxylase (increase in the rate of oxygen consumption, normalization of acid-base balance), cytochrome C (enhancement of oxidation-reduction processes), glutamic acid (stimulation of metabolic processes), tocopherol acetate (synthesis of the precursor of prostaglandins - arachidonic acid), antioxidant vitamins (A, E, P).
12. Hyperbaric oxygen therapy can be used only in cases of moderate late toxicosis of pregnancy and the absence of contraindications. The latter include high blood pressure, chronic processes in the ear, throat, nose, increased sensitivity to oxygen, the presence of a cavity in the internal organs (in the lungs, etc.), fear of confined spaces. A mandatory condition for the use of hyperbaric oxygenation is laboratory evidence of hypoxia in the body. If there is no hypoxia, then HBO can only cause harm (toxic and non-specific inhibitory effect).
13. Cardiac therapy is prescribed according to indications. For tachycardia - intravenous strophanthin (0.5-1 ml of 0.05% solution), corglycon (1 ml of 0.06% solution), cocarboxylase (0.05-0.1 g), panangin (10 ml), potassium chloride (1% solution in 10% glucose solution).

Scheme II.

1. Creation of neurolepsy (droperidol intravenously - 5-10 mg (2-4 ml of 0.25% solution) for nephropathy, 4-5 ml - for eclampsia plus seduxen - 10-12.5 mg (2 ml of 0.5% solution) - background for the action of hypotensive diuretics. Can be administered repeatedly (within 24 hours), reducing the dose of droperidol for up to 3 days.
2. Neurolepsy can be intensified and the effect prolonged by introducing 0.01-0.02 g of promedol (at the same time, diphenhydramine or suprastin, or pipolfen can be introduced - up to 0.02-0.03 g). If droperidol is not tolerated (tremors, anxiety, depression), it is replaced by magnesium sulfate (25% solution - 10 ml intramuscularly every 4 hours), but in combination with seduxen (2 ml intravenously). As the patient's condition improves, the intervals between injections are increased and the doses are reduced.
3. See point 6 of diagram 1.
4. See point 5 of diagram 1.
5. If hypotensive therapy (items 3 and 4) is insufficient to achieve an effect, it is enhanced either with rauwolfia preparations (depression - 0.02-0.04 g orally or 10-15 mg intramuscularly), which begin to act no earlier than after 3-6 hours, or with beta-blockers (obzidan, anaprilin) and beta-adrenergic agonists (partusisten, etc.).

Instead, chlormethiazole (antihypertensive, anticonvulsant and sedative action) can be used at 2 g per day intravenously.

6. See points 2, 7, 8, 10, 12, 14 from diagram 1.

Indications for cesarean section. In addition to those mentioned above:

• persistent seizures that are not controlled by therapy;
• amaurosis;
• retinal detachment;
• anuria;
• risk of cerebral hemorrhage;
• prolonged comatose state;
• severe toxicosis that does not respond to conservative treatment (if the birth canal is unprepared);
• eclampsia in the presence of obstetric (breech presentation, narrow pelvis, large fetus, acute yellow atrophy of the liver, complications during childbirth, signs of DIC, complicated obstetric history) or extragenital pathology.

In case of cesarean section, curettage is recommended to remove tissue - the source of spasmogenic substances. Full compensation of blood loss is mandatory, which in case of cesarean section is not less than 1 liter.

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