Treatment of pre-eclampsia

Radical treatment of preeclampsia consists of rapid delivery, after 48 hours of which the symptoms of the disease subside. Until then, it is important to correct arterial hypertension, BCC deficiency, blood clotting disorders, and also to prevent and stop convulsions.

Arterial hypertension therapy

A clear distinction must be made between the nature of arterial hypertension:

• arterial hypertension, against which the pregnancy occurs;
• pregnancy-induced arterial hypertension.

The first variant of arterial hypertension is hypervolemic, the second is volume-dependent, i.e. when conducting hypotensive therapy, adequate replenishment of the BCC deficit is necessary. Treatment of arterial hypertension depends on the type of hemodynamics of the pregnant woman:

• hyperkinetic - CI > 4.2 l/min/m2;
• OPSS < 1500 dyn x cm-5 x s-1;
• eukinetic - CI = 2.5 - 4.2 l/min/m2;
• OPSS - 1500-2000 dyn x cm-5x s-1;
• hypokinetic - CI < 2.5 l/min/m2;
• OPSS up to 5000 dyn x cm-5 x s-1.

The goal of hypotensive therapy is to convert hyper- and hypokinetic types of blood circulation into eukinetic.

In case of hyperkinetic type of hemodynamics, beta-blockers (propranolol), calcium antagonists (verapamil) are indicated. It should be remembered that propranolol and verapamil have potentiating activity in relation to narcotic and non-narcotic analgesics, the first has a labor-activating effect and the second has a tocolytic effect. Propranolol, like verapamil, reduces the myocardial oxygen demand, being an anti-stress agent. If necessary, the drug is administered intravenously in the appropriate dose:

Verapamil orally 1.7-3.4 mg/kg (up to 240 mg/day), the frequency of administration is determined by clinical appropriateness or Propranolol orally 1.5-2 mg/kg (up to 120 mg/day), the frequency of administration is determined by clinical appropriateness. In case of hypokinetic type of hemodynamics, the drugs of choice are hydralazine and clonidine. It should be remembered that hypokinetic type of blood circulation is accompanied by decreased contractility of the myocardium (echocardiography with determination of EF is necessary: norm - 55-75%):

Hydralazine intravenously 6.25-12.5 mg, then orally 20-30 mg every 6 hours, depending on the blood pressure, or Clonidine orally 0.075-0.15 mg (3.75-6 mcg/kg) 3 times a day or intravenously 1.5-3.5 mcg/kg, the frequency of administration and duration of administration are determined by clinical feasibility. Clonidine has an anti-stress effect, significantly increases sensitivity to narcotic analgesics, anxiolytics and neuroleptics (a powerful analgesic that affects the vegetative component of pain), and has a tocolytic effect. With prolonged use of clonidine by a pregnant woman, the newborn may develop a hypertensive crisis - withdrawal syndrome, which is manifested by severe neurological symptoms (warn the neonatologist).

In the eukinetic hemodynamics variant, beta-blockers (propranolol), calcium antagonists (verapamil), clonidine or methyldopa are used depending on the value of the EF:

Verapamil orally 1.7-3.4 mg/kg (up to 240 mg/day), the frequency of administration is determined by clinical appropriateness or Clonidine orally 0.075-0.15 mg (3.75-6 mcg/kg) 3 times a day or intravenously 1.5-3.5 mcg/kg, the frequency of administration and duration of administration are determined by clinical appropriateness or Methyldopa orally 12.5 mg/kg/day, the duration of administration is determined by clinical appropriateness or Propranolol orally 1.5-2 mg/kg (up to 120 mg/day), the frequency of administration is determined by clinical appropriateness. For eu- and hypokinetic types of hemodynamics, in addition to the indicated drugs or as monotherapy, the use of dihydropyridine calcium antagonists is indicated:

Nimodipine intravenously 0.02-0.06 mg/kg/h, depending on the severity of the condition and the desired result (special indications - for eclampsia and preeclampsia) or Nifedipine orally, sublingually or transbucally 0.05 mg/kg/day (20-40 mg/day), the duration of administration is determined by clinical feasibility. If controlled normotension is necessary, sodium nitroprusside and triphosadenine are indicated. It should be remembered that calcium antagonists, clonidine and nitrates are tocolytics, and beta-blockers are stimulants of uterine contractility. This must be taken into account when selecting antihypertensive therapy to avoid hypo- or hypertonicity of the myometrium.

Methyldopa in doses greater than 2 g/day may provoke the development of meconium ileus in a premature infant.

A sharp drop in blood pressure should not be allowed, since this will affect the uteroplacental and cerebral blood flow.

Infusion treatment of preeclampsia

It is obvious that most solutions used for infusion therapy in pregnant women are hyperosmolar and hyperoncotic. The average plasma volume in pregnant women with mild gestosis is 9% below normal, and 40% below normal in severe cases. Consequently, normalization of plasma volume is the most important task of infusion therapy. It should be remembered that eclampsia is, first of all, a generalized endothelial injury with a sharp increase in its permeability and interstitial hyperhydration. In this regard, infusion of albumin solutions (pulmonary edema), low- and medium-molecular dextrans and gelatin is extremely dangerous. Colloids (dextrans) often cause allergic reactions, can cause coagulopathy (provoke and enhance fibrinolysis, change the activity of factor VIII), reduce the concentration of ionized Ca2+, and cause osmotic diuresis (low-molecular). In sepsis, ARDS/OLP, preeclampsia, eclampsia, colloids can aggravate capillary leak syndrome. Gelatin solutions should be used with great caution. Gelatin increases the release of IL-1b, reduces the concentration of fibronectin, which contributes to a further increase in endothelial porosity. Infection with "mad cow disease" is possible - the pathogen does not die under the sterilization modes used.

Variants of hypervolemic and normovolemic hemodilution with 6 and 10% HES solutions in combination with controlled arterial normotension and efferent treatment methods are shown. HES solutions do not penetrate the placenta, are effective in cases of uteroplacental circulation disorders, and significantly affect capillary leak syndrome and tissue edema, sealing pores in the endothelium that appear in various forms of its damage.

Safety criteria for dilution methods:

• the value of the CODpl should not be less than 15 mm Hg;
• infusion rate - no more than 250 ml/h;
• rate of decrease in average blood pressure - no more than 20 mm Hg/h;
• The ratio of infusion rate to urine output should be less than 4.

The use of osmotic diuretics in preeclampsia and especially in eclampsia is extremely dangerous!

Pregnancy increases fluid filtration into the pulmonary interstitium, creating ideal conditions for the development of interstitial pulmonary hyperhydration. Strict control over the volume of administered solvents is necessary (oxytocin, insulin, heparin, etc. are often administered not through an infusion pump, but drip-feed, without taking into account the volume of solvent and strictly observing the dose/time ratio). Hypertransfusion of crystalloids may be accompanied by hypercoagulation.

Hypertonic solutions (7.5% sodium chloride solution) have a positive effect on MC, do not cause edema, and quickly stabilize hemodynamics, especially in combination with colloids, due to the movement of fluid from the extracellular space into the lumen of the vessels.

The inclusion of dextrose in infusion therapy in pregnant women requires glycemic control.

Treatment of preeclampsia aimed at correcting blood clotting disorders

It is necessary to assess the state of the hemostasis system, especially in severe preeclampsia. Transfusion of FFP, platelet mass, etc. may be required. Risk of infection transmission: hepatitis C - 1 case per 3,300 transfused doses, hepatitis B - 1 case per 200,000 doses, HIV infection - 1 case per 225,000 doses. Transfusion pulmonary edema - 1 per 5,000 transfusions, its cause is the leukoagglutination reaction. In one dose of plasma, the number of donor leukocytes is from 0.1 to 1 x 108. The reaction triggers or contributes to the progression of SIRS and further damage to the endothelium. Plasma prepared from the blood of women who have had multiple births causes the listed complications more often. In this regard, FFP should be used according to the strictest indications: the need to restore coagulation factors!

Medicinal correction of the synthesis of thromboxane A2 and prostacyclin is necessary:

• stimulation of prostacyclin synthesis (low doses of nitrates, dipyridamole, nifedipine);
• slowing down of prostacyclin metabolism (small doses of furosemide, only in the absence of contraindications, are indicated in pregnant women with gestosis against the background of hypertension, monitoring of the BCC is necessary);
• replacement therapy with synthetic prostacyclin (epoprostenol);
• decrease in the synthesis of thromboxane A2.

Prescribed:

• Acetylsalicylic acid orally 50-100 mg 1 time per day, long-term.

Anticonvulsant treatment for preeclampsia

If there is a tendency to convulsions, magnesium sulfate is used.

Magnesium sulfate intravenously 2-4 g over 15 minutes (loading dose), then intravenously by drip 1-2 g/h, maintaining a therapeutic level of magnesium in the blood of 4-8 mcg/l.

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Sedative treatment of preeclampsia

Barbiturates and neuroleptics are used for sedation. The use of anxiolytics (tranquilizers) can cause respiratory depression, skeletal muscle hypotension, urinary and fecal retention, and jaundice in newborns. It is also necessary to remember the side effects of droperidol (Kulenkampf-Tarnow syndrome): paroxysmal hyperkinesis - paroxysmal spasms of the masticatory muscles, tonic spasms of the neck muscles, difficult articulation, hyperreflexia, hypersalivation, bradypnea. Spasm of the muscles of the trunk and limbs (bizarre poses) is possible, which is accompanied by excitement, anxiety, a feeling of fear with clear consciousness. The syndrome is not life-threatening, but due to overdiagnosis of eclampsia, it provokes premature operative delivery.