Creation of a protective regime for late toxicosis of pregnant women

The patient should be placed in a separate room, where conditions are created that maximally protect her from various stimuli (sound, light, olfactory, etc.). For this purpose, a darkening is created in the room, a rubber carpet is placed on the floor, conversations are excluded (only whispering is permissible), etc. There should be a separate nurse post in the ward, everything necessary to prevent eclampsia attacks and to care for the patient medicines, a cardiomonitor, an intubator, an apparatus for artificial ventilation of the lungs, etc.).

In the presence of symptoms of pre-eclampsia, the patient is injected into short-term nitrous-aeotine-fluorotane anesthesia. Strict bed rest is mandatory, mainly on the side for the exclusion of the syndrome of the inferior vena cava, improvement of the utero-placental circulation. It is especially important to observe a horizontal position in the presence of hypotension; at normal and elevated arterial pressure, the head end of the bed is raised by 20-30, which reduces the temporal pressure by 10-15 mm Hg. Art. (1.3-2 kPa) and creates more physiological conditions for spontaneous breathing. Bed rest promotes faster stabilization of arterial pressure, improvement of uteroplacental blood circulation and organ blood flow, and reduction and enhancement of urinary sodium excretion.

All manipulations should be reduced to a minimum and be made only under anesthesia (Fgorotan and trichlorethylene). To prevent biting of the tongue during the seizure use a rotator and a tongue holder. If the patient is in a coma or a deep medical dream, a dense rubber air duct is inserted into her mouth and fixed with a ribbon to prevent biting and twisting of the tongue. It is advisable to carry out oxygen therapy (inhalation of 100% oxygen, short-term, 10-15 min to increase the oxygen tension in the blood, disappearance of bradycardia in the fetus after an eclampsic fit in the mother). If the bradycardia does not eliminate this, then, probably, there is either compression of the umbilical cord, or premature detachment of the normally located placenta.

Important is the toilet of the mouth, suction of mucus. The eclampsic coma itself is not an indication for artificial ventilation, but if the rhythm of breathing is disturbed, hypoxemia develops, Mendelssohn syndrome or respiratory distress syndrome, and artificial lung ventilation (IVL) is indicated.

With eclampsia, glucose tolerance decreases, and the metabolism of insulin (in the kidneys) decreases, so the dosage should be reduced. To prevent asphyxia of a newborn for 5-7 minutes before the birth of a child, it is advisable to introduce these etioles - a 0.5% solution of 1 mg / kg of the mass of the mother giving birth.

In the treatment of severe toxicosis, a limited number of medicines should be used, and they should be prescribed in minimal doses, taking into account the potential for potentiation of the action and undesirable side effects. Treatment should be individualized depending on the characteristics of the organism, its growth-mass indicators, the course of the disease and the action of medications.

A very effective method of anesthetizing labor in severe toxicosis of pregnant women is peridural analgesia.

Medicamentous treatment of late toxicosis

Scheme 1. The leading in the drug treatment of severe forms of late toxicosis is the combination of magnesia therapy with sedative, antihypertensive and osmorecopy.

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

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

2. With eclampsia concurrently with magnesium sulfate prescribe onco-osmotherapy (not more than 1-1.5 liters). The following sequence of alternation of the 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 ED per 4 g glucose dry matter), vitamin B6 (1 ml of 5% solution) and vitamin C (5 ml of 5% solution).

To inhibit the aggregation of erythrocytes and platelets, improve microcirculation, reduce blood pressure and improve the cerebral and coronary blood flow appoint a quarantil (0,05 g 3-4 times a day inside).

Infusion therapy in the amount of no more than 20-30% of BCC is carried out only in severe toxicoses, in the presence of the following conditions (without them, carrying it out is strictly forbidden!):

• positive diuresis, when the volume of the withdrawn liquid is not less than 600 ml per day exceeds the volume of the injected liquid;
• eliminated arterial hypertension;
• there is a normal venous pressure, there are no symptoms of threatening pulmonary edema or cerebral hemorrhage.

3. In case of insufficient effectiveness of magnesium sulfate for the management of eclampsia seizures, intravenous injection of seduksen (10 mg - 2 ml of 0.5% solution intravenously slowly in 20 ml of 5% glucose solution) is applied.
4. To increase the sedative effect of the therapy, if it is required by clinical data, and reduce the elevated diastolic pressure, you can appoint droperidol intravenously or intramuscularly 5-10 mg 2-3 times a day (0.25% solution - 1-2 ml).
5. To lower blood pressure - at a systolic pressure above 160-180 mm Hg. Art. (21.3-24 kPa) and diastolic 100-110 mm Hg. Art. And above (13.3-14.7 kPa), if the effectiveness of magnesium sulfate is inadequate, pentamine (5% in a dose of 50-150 mg) in a 5% glucose solution is used. Enter slowly, under the control of blood pressure, without reducing the latter below 20% of the original. Pentamine can be administered and intramuscularly 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 antihypertensive effect is provided by intravenous injection of eufillin (2.4% solution - 10 ml) every 3-4 hours (alternating with papaverine 2% solution - 2 ml or no-shdy 2% solution - 2-4 ml intravenously).
7. Heparin therapy is indicated only in laboratory-confirmed coagulopathy of consumption. It is best to use rheopolyglucin-heparin mixture at the rate of 5-6 ml of reopolyglucin and 340 units of heparin per 1 kg of the patient's mass (for example, 300 ml of reopolyglucin and 21,000 units of heparin are administered at 60 kg of body weight). Half of the calculated amount of heparin is intravenously dripped (20 drops / min) with a full dose of rheopolyglucin. The remaining amount of heparin is administered every 4-6 hours (within a day) subcutaneously, in equal doses. The next day, these activities are repeated. When the clinical effect is achieved, they switch to daily subcutaneous administration of heparin every 4 to 6 hours; Reopoliglyukin is not administered every day, but after 1-3 days. After the normalization of the parameters, the dose of heparin should be reduced gradually, with the same intervals between the administrations. When using rheopolyglucin-heparin mixture, it is necessary to control the content of hematocrit, fibrinogen and the parameters of the blood coagulation system. With the introduction of this mixture, the reduction in blood clotting is not more than 2 times as high as normal.

With obvious symptoms of disseminated intravascular coagulation, ie, when there is a small concentration of fibrinogen - below 2 g / l, platelets - below 150,000, the reopolyglucin-heparin mixture must be administered with a plasma that contains antithrombin III, which is necessary for anti- properties of heparin (in the ICE antithrombin III in the patient's plasma is depressed).

8. In laboratory-confirmed decompensated metabolic acidosis, an S% solution of sodium hydrogencarbonate (tris-buffer, trisamine, lactasol) is administered - 100-200 ml under the control of the acid-base state.
9. Dehydration therapy is prescribed only after the normalization of osmotic and oncotic pressure and microcirculation to eliminate water intoxication, intracranial hypertension and cerebral edema. Diuretics are contraindicated in violation of the filtration capacity of the kidneys, anuria and high blood pressure (above 150 mm Hg or above 20 kPa). A single dose of lasix 0.04 g intravenously 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 because of the phenomenon of "recoil". When prescribing rheopolyglucin-heparin mixture, 0,04 g of lasix is sufficient to restore diuresis.

Infusion, dehydration and diuretic therapy can be performed under the control of hematocrit and diuresis. A decrease in hematocrit below 30% indicates excessive blood dilution, oxygen depletion and anemia. A rise in hematocrit above 45% indicates a hemoconcentration - increased viscosity, worsening microcirculation, increased peripheral resistance, and blood pressure. Excessive diuresis leads to hypovolemia and spasm of peripheral vessels. With sufficient diuresis, the amount of liquid administered should not be more than 80 ml (maximum 1 l) per day.

10. In oliguria, pre-injected with euphyllin, cardiac glycosides and glucose-novocaine mixture to enhance glomerular filtration and to relieve spasm of small peripheral vessels. After this, 0.02 g of lasix is introduced. When sufficient diuresis is obtained in 2 hours - at least 700-800 ml - mannitol (30 g) can be continued. If diuresis is less than 100 ml for 2 hours, then repeat the introduction of euphyllin, cardiac glycosides and glucose-novocaine mixture, mannitol is administered only after sufficient diuresis has been established. Infusion therapy with oliguria should not be performed (or prescribed with extreme caution under the control of diuresis, pulse and blood pressure).

Calculation of electrolytes during infusion therapy. Deficiency of the cation (annona) = (A1 - A2) • M - 0,2, where A, - the normal content of the anion (cation) in the patient; M is the patient's mass; 0.2 - correction factor (amount of extracellular fluid, which is 20% of the patient's weight). The norm of 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 the indications, intensive therapy of late toxicosis of pregnant women can be supplemented with the introduction of cocarboxylase (an increase in the rate of oxygen consumption, the normalization of acid-base equilibrium), 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. Therapy with hyperbaric oxygenation can be carried out only with late toxicosis of pregnant women of moderate severity and no contraindications. The latter include high blood pressure, chronic processes in the ear, throat, nose, hypersensitivity to oxygen, the presence of cavities in the internal organs (in the lungs, etc.), the fear of enclosed space. An obligatory condition for the use of hyperbaric oxygenation is the laboratory evidence of the presence of hypoxia in the body. If there is no hypoxia, HBO can only bring harm (toxic and nonspecific inhibitory action).
13. Cardiac therapy is prescribed according to the indications. For tachycardia, intravenous strophanthin (0.5-1 ml 0.05% solution), korglikon (1 ml 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) with nephropathy, 4-5 ml - with eclampsia plus seduxen - 10-12.5 mg (2 ml of 0.5% solution) - background for the action of antihypertensive diuretics.It can be administered repeatedly (within days), reducing the dose of droperidol for up to 3 days.
2. Deepening of neurolepsy and lengthening of action is achieved by the introduction of 0.01-0.02 g of promedol (simultaneously it is possible to administer dimedrol or suprastin, or pipolphene to 0.02-0.03 g). With intolerance to droperidol (trembling, anxiety, depression), it is replaced with magnesium sulfate (25% solution - 10 ml intramuscularly after 4 hours), but in combination with seduksenom (2 ml intravenously). As the patient's condition improves, the intervals between administrations are increased, and the doses are reduced.
3. See clause 6 of Scheme 1.
4. See clause 5 of Scheme 1.
5. If hypotensive therapy (points 3 and 4) is insufficient to obtain an effect, it is enhanced either with drugs of rauwolfia (depression of 0,02-0,04 g inside or 10-15 mg intramuscularly), which begin to act no earlier than through 3- 6 h, or beta-adrenoblockers (obzidan, anaprilin) and beta-adrenomimetics (partusisten, etc.).

Chloromethiazole (hypotensive, anticonvulsant and sedative action) can be used instead of them on 2 g per day intravenously.

6. See clauses 2, 7, 8, 10, 12, 14 of Scheme 1.

Indications for cesarean section. Along with those mentioned above:

• incessant seizures not controlled by therapy;
• amaurosis;
• retinal disinsertion;
• anuria;
• threat of hemorrhage in the brain;
• a prolonged coma;
• severe toxicosis, not amenable to conservative treatment (with unprepared birthmarks);
• eclampsia in the presence of obstetric (pelvic presentation, narrow pelvis, large fetus, acute yellow atrophy of the liver, complications in childbirth, signs of DVS, burdened obstetric anamnesis) or extragenital pathology.

In cesarean section, curettage is recommended to remove tissue - a source of spasmogenic substances. Compulsory full compensation for hemorrhage, which at a caesarean section is at least 1 liter.

[1], [2], [3], [4], [5], [6],