Gestosis: treatment

With swelling, treatment can be carried out in conditions of women's consultations. Pregnant women with preeclampsia, preeclampsia and eclampsia should be hospitalized in obstetric hospitals located in multidisciplinary hospitals with resuscitation and premature infant care, or perinatal centers.

Therapy of pregnant women is based on the treatment of symptoms and signs of secondary manifestations of gestosis, while pursuing the goal of reducing the incidence of complications from the mother and fetus.

The principles of gestosis therapy consist in the establishment of a curative and protective regimen; restoration of the function of vital organs; fast and gentle delivery.

The creation of a curative-protective regime is carried out due to the normalization of the function of the central nervous system.

Restoration of the function of vital organs along with antihypertensive, infusion-transfusion (ITT) and detoxification therapy, normalization of water-salt metabolism, rheological and coagulation properties of blood, improvement of uteroplacental blood flow includes normalization of structural and functional properties of cell membranes.

Therapy of gestosis is currently necessary to be controlled:

• CVP (within 3-4 cm of water table);
• diuresis (not less than 35 ml / h);
• blood concentration indicators (hemoglobin not less than 70 g / l, hematocrit not less than 0.25 l / l, quantity of red blood cells not less than 2.5 × 10 ¹² / l and platelets not less than 100 × 10 ⁹ / l);
• biochemical indicators of blood (total protein not less than 60 g / l, alkaline phosphatase, AST, ALT, total bilirubin, creatinine within the physiological norm, depending on the method of determination);
• electrolytes (K ⁺ no more than 5.5 mmol / l, Na ⁺ no more than 130-159 mmol / l). Normalization of central nervous system function is carried out through sedative and psychotropic therapy.

In patients with mild to moderate gestosis without extragenital pathology, plant-derived sedatives (valerian rhizomes with roots or valerian rhizomes tincture 3 times a day, herbaceous grass - liquid extract - 20 drops 3-4 times, peony rooting herb, rhizomes and roots - tincture - 1 teaspoonful 3 times) in combination with sleeping pills (nitrazepam 1 tablet per night) or tranquilizers (diazepam, oxazepam) in doses depending on the condition.

With moderate gestosis and pre-eclampsia, all initial manipulations are performed against the background of neuroleptoanalgesia using benzodiazepine tranquilizers, neuroleptics, analgesics, antihistamines, barbiturates according to indications.

Intubation and artificial ventilation are indicated for eclampsia and its complications. In the postoperative or postpartum periods, the transfer of the puerpera to independent breathing is possible no earlier than 2 h after the delivery and only with the stabilization of systolic blood pressure (no higher than 140-150 mm Hg), the normalization of CVP, the heart rate, the rate of diuresis (more 35 ml / h) against the background of recovery of consciousness.

The use of gamma-hydroxybutyric acid, calcium salt is contraindicated because of its ability to cause arterial hypertension and psychomotor agitation.

Hypotensive therapy is performed at a systolic blood pressure level that exceeds the initial before pregnancy by 30 mm Hg. And diastolic - by 15 mm Hg. Art. Currently recommend:

• calcium antagonists (magnesium sulfate up to 12 g / day, verapamil 80 mg 3 times a day, amlodipine 5 mg once a day);
• blockers and stimulators of adrenergic receptors (clonidine 150 mg 3 times a day, betaxolol 20 mg once a day, nebivolol 2.5 mg 2 times a day);
• vasodilators (hydralazine 10-25 mg 3 times a day, sodium nitroprusside 50-100 μg, prazosin 1 mg 1-2 times a day);
• ganglion blockers (azamethonium bromide 5% 0.2-0.75 ml, hexamethonium benzenesulfonate 2.5% 1-1.5 ml).

With mild gestosis, monotherapy (calcium antagonists, antispasmodics) is used, with an average degree - complex therapy for 5-7 days with the subsequent transition to monotherapy in the presence of the effect.

The most effective are the following combinations:

• calcium antagonists + clonidine (85%);
• vasodilators + clonidine (82%).

In severe forms of gestosis, including preeclampsia and eclampsia, complex antihypertensive therapy is performed. At low CVP figures (less than 3 cm H2O) antihypertensive therapy should be preceded by ITT. The drug of choice is magnesium sulfate. The initial dose is 2.5 g dry matter. The total daily dose of magnesium sulfate is not less than 12 g intravenously under the control of respiratory rate, hourly diuresis and activity of knee reflexes. Simultaneously with magnesium sulfate, calcium antagonists can be used: verapamil at 80 mg / day or amlodipine 5-10 mg / day. Calcium antagonists can be combined with clonidine in an individual dose. In the absence of the effect of antihypertensive therapy, short-acting ganglion blockers (azamethonium bromide) or nitrate derivatives (sodium nitroprusside) are used.

Infusion-transfusion therapy (ITT) is used to normalize the volume of circulating blood, colloid osmotic pressure of plasma, rheological and coagulation properties of blood, macro- and microhemodynamics.

• In the composition of ITT along with crystalloids (Mafusol - potassium chloride + magnesium chloride + sodium chloride + sodium fumarate, "Hlosol" - sodium acetate + sodium chloride + potassium chloride) include infukol.
• The ratio of colloids and crystalloids, the volume of ITT depends on the hematocrit value (not lower than 0.27 l / l and not more than 0.35 l / l), diuresis (50-100 ml / h), HPP (not less than 3-4 cm of water ), hemostatic parameters (at least 70% antithrombin level, endogenous heparin not lower than 0.07 U / ml), blood pressure, protein content in plasma (not less than 50 g / l).

With the prevalence of ITT in colloids, complications such as colloidal nephrosis and aggravation of hypertension are possible; In case of an overdose of crystalloids hyperhydration develops.

When carrying out ITT, the rate of fluid administration and its ratio to diuresis are important. At the beginning of infusion, the rate of administration of solutions is 2-3 times higher than that of diuresis, subsequently, against the background or at the end of fluid administration, the amount of urine per hour should exceed the volume of the injected liquid by a factor of 1.5-2.

To normalize diuresis with gestosis of mild and moderate degree, in the absence of effect from bed rest, diuretic phytogens are used (juniper fruits 1 tablespoon 3 times a day, bearberry leaves 30 ml 3 times a day, horsetail grass, orthosiphon staminate leaves, cowberry leaves , cornflower blue flowers, birch buds) and herbal diuretics (lepepedeza capitate tincture, lepidhedis two-color shoots) 1-2 teaspoons a day.

In the absence of effect from the latter, prescribe potassium-sparing diuretics (hydrochlorothiazide + triamterene for 1 tablet for 2-3 days).

Saluretics (furosemide) are administered in moderate to severe gestosis with the restoration of CVP to 3-4 cm of water. The content of the total protein in the blood is not less than 50 g / l, hyperhydration phenomena, with diuresis less than 30 ml / h.

In the absence of the effect of furosemide administration at the maximum dose (500 mg / day fractional), for the purpose of dehydration, isolated ultrafiltration is used.

With the development of acute renal failure, the patient is transferred to a specialized nephrological department for hemodialysis. Normalization of rheological and coagulation properties of blood should include one of the disaggregants. Assign dipyridamole (2 tablets 3 times) or pentoxifylline (1 tablet 3 times), or xantinol nicotinate (1 tablet 3 times) or acetylsalicylic acid. Dipiridamole is one of the most effective drugs, it corrects the placental blood flow, prevents dystrophy of the placenta, eliminates fetal hypoxia. Possible use of anticoagulants - low molecular weight heparins (calcium supraparin, sodium enoxaparin, dalteparin sodium). Disaggregants are initially used in the form of intravenous solutions, in the following - tablets, not less than 1 month.

Indication for the use of low molecular weight heparins (calcium supraparin, sodium enoxaparin, dalteparin sodium) - decrease in the level of endogenous heparin to 0.07-0.04 ED / ml and lower, antithrombin III to 85.0-60.0% and lower, chronometric and structural hypercirculation according to thromboelastogram, increased platelet aggregation to 60% and higher. Low molecular weight heparins are used with the possibility of dynamic laboratory monitoring of blood coagulation properties. They should not be used for thrombocytopenia, severe hypertension (BP 160/100 mm Hg or higher), since there is a threat of hemorrhage.

Antioxidants (vitamin E, actovegin, solcoseryl), membrane stabilizers containing polyunsaturated fatty acids (phospholipids, soya bean oil + triglycerides, omega-3 triglycerides [20%]) normalize the structural and functional properties of cell membranes and cellular metabolism.

Correction of structural and functional disorders of cell membranes in pregnant women with mild gestosis is achieved by including in the treatment complex tableted preparations (vitamin E up to 600 mg / day), as well as phospholipids 2 drops 3 times a day).

With gestosis of moderate to severe degree, membrane-active substances are administered intramuscularly and intravenously until the effect is obtained, followed by switching to tablets, the course up to 3-4 weeks.

In patients with moderate gestosis and intrauterine growth retardation of the fetus at the gestation period of up to 30-32 weeks or less, soybean oil and triglycerides are administered 100 ml every 2-3 days and "Solcoseryl" per 1 ml for 15-20 days.

Conducted complex therapy of gestosis is directed simultaneously at the normalization of uteroplacental blood circulation. In addition, beta-adrenomimetics (hexoprenaline) are used for this purpose.

Immunotherapy with allogeneic lymphocytes of the husband (immunocytotherapy) and immunoglobulin. The mechanism of therapeutic effect of immunocytotherapy by allogeneic lymphocytes is associated with the normalization of the processes of immune recognition of the fetal alloantigens by the maternal organism and the enhancement of suppressor mechanisms [34]. Immunization of the mother with allogeneic lymphocytes of the husband, reactivating the weakened local immune response, activates the synthesis of interleukins and growth factors, the secretion of placental proteins, which ensure the normal development of pregnancy. Immunocytotherapy is carried out once a month. The optimal pregnancy time for immunocytotherapy is 15-20, 20-24, 25-29 and 30-33 weeks.

The control is performed by weekly general clinical study for 1 month. The multiplicity of the introduction of lymphocytes depends on the clinical effect, proteinuria, hemodynamic parameters, body weight and the level of placental proteins in the blood serum.

Extracorporeal methods of detoxification and dehydration - plasmapheresis and ultrafiltration - are used in the treatment of severe forms of gestosis.

Indications for plasmapheresis:

• severe gestosis with gestation terms up to 34 weeks and no effect of ITT for the purpose of prolonging pregnancy;
• complicated forms of preeclampsia (HELLP-syndrome and OZHGB) for relief of hemolysis, DIC-syndrome, elimination of hyperbilirubinemia. Indications for ultrafiltration:
• post-eclampsia coma;
• edema of the brain;
• uncontrollable pulmonary edema;
• anasarca.

Discrete plasmapheresis and ultrafiltration are carried out by a specialist who has been trained in the department of extracorporeal methods of detoxification.

Studies of recent years have shown that calcium-containing supplements can achieve a reduction in the incidence of hypertension, pre-eclampsia, premature birth. It is interesting to note that gestation did not develop in pregnant women with a transplanted kidney during treatment with glucocorticoids (methylprednisolone) and immunosuppressive therapy with cytostatics (cyclosporine), and the existing dropsy did not change to a heavier form. In addition, in the prevention of distress syndrome glucocorticoids in women with severe gestosis, there was an improvement in the condition and the possibility of prolonging their pregnancy more than 2 weeks.

In the treatment of gestosis, the duration of therapy in pregnant women is important. With mild gestosis, hospital treatment is advisable to be performed within 14 days, with an average of 14-20 days. In the future, measures are taken to prevent the recurrence of gestosis in a woman's consultation. With severe gestosis, hospital treatment is carried out before delivery.

Management and treatment of pregnant women with HELLP-syndrome and OBZHB:

• intensive preoperative preparation (ITT);
• urgent abdominal delivery;
• substitution and hepatoprotective therapy;
• prevention of massive blood loss during surgery and in the postpartum period;
• antibacterial therapy.

Treatment of pregnant women and puerperas for these complications is carried out with additional control every 6 hours:

• the number of erythrocytes and platelets;
• total protein;
• bilirubin;
• prothrombin index;
• APTTV;
• blood coagulation time according to Lee-White;
• level of hepatic transaminases.

Urgent abdominal delivery is performed against a background of complex intensive therapy.

Infusion-transfusion therapy is supplemented with hepatoprotectors (10% glucose solution in combination with macro-doses of ascorbic acid - up to 10 g / day), replacement therapy [freshly frozen plasma at least 20 ml / (kilogram), transfusion of thromboconcentrate (at least 2 doses) at a platelet level less than 50х10 ⁹ / l]. In the absence of thromboconcentrate, administration of at least 4 doses of plasma enriched with platelets, which can be prepared from reserve donors on different types of centrifuges in a soft sedimentation regime, is acceptable. With an increase in systolic blood pressure above 140 mm Hg. Art. Shows the conduct of relative controlled hypotension.

This complex therapy is performed against the background of administration of glucocorticoids (prednisolone at least 500 mg / day intravenously).

In the postoperative period, the replenishment of plasma clotting factors [fresh-frozen plasma 12-15 ml / (kgxut)], hepatoprotective therapy (glutamic acid) against a background of massive antibacterial therapy, according to indications, is carried out by plasmapheresis and ultrafiltration, on the background of careful clinical and laboratory control.

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Tactics of management of pregnancy and childbirth

With the effectiveness of ongoing gestosis therapy, pregnancy continues until the time that guarantees the birth of a viable fetus, or before the onset of labor.

At present, with severe forms of gestosis, more active tactics of pregnancy management are carried out. Indications for early delivery are not only eclampsia and its complications, but also severe gestosis and preeclampsia in the absence of the effect of therapy for 3-12 hours, as well as moderate gestosis in the absence of the effect of therapy for 5-6 days.

At present, the indications for cesarean section have been expanded:

• eclampsia and its complications;
• complications of preeclampsia: coma, cerebral hemorrhage, acute renal failure, HELLP-syndrome, OBGB, retinal detachment and hemorrhage into it, premature detachment of the normally located placenta, etc .;
• severe gestosis and preeclampsia with an untreated cervix and the presence of indications for early delivery;
• combination of gestosis with other obstetric pathology;
• long-existing gestosis (more than 3 weeks).

Cesarean section in gestosis is carried out against the background of epidural anesthesia. After extraction of the fetus for bleeding prophylaxis, it is advisable to inject 20,000 units of aprotinin intravenously bolus followed by 5 IU of oxytocin. Intraoperative blood loss is compensated with freshly frozen plasma, a solution of hydroxyethyl starch (6 or 10%), and crystalloids.

If it is possible to conduct labor through the natural birth canal, a prostaglandin gel is administered to improve the functional state of the uterus and prepare the cervix for the cervical canal or for the posterior vaginal vault. With the prepared cervix, the uterus is amniotomized with subsequent induction.

When delivering through the natural birth canal in the first stage of childbirth, along with the application of classical methods (early opening of the fetal bladder, adequate antihypertensive therapy, ITT not more than 500 ml), stage-by-stage prolonged analgesia, including epidural anesthesia.

In the second stage of labor, the most optimal continuation of epidural anesthesia.

When administering labor in pregnant women with gestosis, prevention of bleeding in the second period is necessary, adequate replacement of blood loss in the third and early postpartum period.

In the postpartum period, ITT is carried out in full for at least 3-5 days, depending on the regression of the symptoms of the pathological process under the control of clinical and laboratory data.

The most common mistakes in the treatment of severe forms of gestosis:

• underestimation of the severity of the condition;
• inadequate therapy and / or its untimely conduct;
• uncontrolled ITT, which promotes hyperhydration;
• incorrect tactics of delivery - management of births through natural birthmarks in severe forms of gestosis and their complications;
• inadequate prophylaxis of bleeding.

Obstetrical tactics. If there is an effect of ongoing gestosis therapy, pregnancy continues until the time that guarantees the birth of a viable fetus or before the onset of labor.

Currently, with moderate and severe forms of gestosis, an active tactic of pregnancy management is carried out. Indication for early delivery is not only eclampsia and its complications, but severe forms (in the absence of the effect of therapy for 3-6 hours) and moderate (with no effect of therapy for 5-6 days) forms of gestosis.

Indications for caesarean section for gestosis are:

1. Eclampsia and its complications.
2. Complications of preeclampsia (coma, cerebral hemorrhage, arthritis, HELLP-syndrome, OZGBB, retinal detachment, hemorrhage into it, premature detachment of the normally located placenta, fetoplacental insufficiency).
3. Gestosis severe, pre-eclampsia with an untreated cervix.
4. Combination of gestosis with other obstetric pathology.

In severe forms of gestosis, cesarean section is performed only under endotracheal anesthesia. The use of epidural anesthesia is permissible only for mild and moderate-severe forms of gestosis.

If it is possible to conduct labor through the natural birth canal for the preparation of the cervix, prostaglandin-containing gels (cerviprost) should be used. With the prepared cervix, an amniotomy is performed, followed by induction.

When delivering through the natural birth canal, a gradual prolonged analgesia is carried out, including epidural anesthesia.

The most common mistakes in the treatment of gestosis are:

• underestimation of the history and clinical methods of research;
• incorrect interpretation of laboratory-instrumental methods of research;
• inadequate therapy and its untimely beginning;
• uncontrolled ITT, which promotes hyperhydration;
• wrong tactics of delivery;
• inadequate prophylaxis of bleeding.