Symptoms of gestosis

Despite the variety of clinical manifestations, gestosis does not have a single pathognomonic symptom.

The classic triad of symptoms of gestosis is caused by a number of pathogenetic factors that are closely related to each other.

• Edema is a general and excessive accumulation of fluid in tissues after 12 hours of rest in bed. It occurs as a result of a decrease in oncotic pressure (against the background of albuminuria), an increase in capillary permeability, and the release of fluid from the vascular bed into the interstitial space.
• Arterial hypertension is a symptom that develops during pregnancy or in the first 24 hours after delivery in women with previously normal arterial pressure. It occurs as a result of vascular spasm and hyperdynamic systolic function of the heart.
• Proteinuria is a symptom that occurs during pregnancy in the absence of arterial hypertension, edema, and previous infectious or systemic kidney disease. It develops as a result of damage to the renal glomeruli with increased permeability of the basement membrane of their capillaries.

It is necessary to take into account that no pregnancy complication is characterized by such clinical polymorphism, uncertainty and dubiousness of the prognosis for the mother and fetus. It can be said that there are as many clinical variants of gestosis as there are pregnant women with this complication. Currently, monosymptomatic forms of gestosis or variants of the disease with an erased course are often encountered. According to our clinic, monosymptomatic gestosis was detected in 1/3 of those examined, and the classic Zangemeister triad - only in 15% of patients. At the same time, long-term forms of gestosis were recorded in more than 50% of observations. In practical terms, when monitoring a pregnant woman, it is most important to promptly diagnose early signs of gestosis.

Excessive weight gain is one of the earliest symptoms of gestosis. The average gestational age for the onset of pathological weight gain is 22 weeks, while the average period for the development of hypertension is 29 weeks, and proteinuria is 29.4 weeks. The appearance and development of this symptom is due to disturbances in carbohydrate, fat, and water-salt metabolism. The total weight gain throughout pregnancy should not exceed 11 kg, up to 17 weeks - no more than 2.3 kg, at 18-23 weeks - 1.5 kg, at 24-27 weeks - 1.9 kg, at 28-31 weeks - 2 kg, at 32-35 weeks - 2 kg, at 36-40 weeks - 1.2 kg. For a more accurate determination of the optimal weight gain for each woman, you can use the scale of average physiological weight gain. The weekly gain should not exceed 22 g for every 10 cm of height or 55 g for every 10 kg of the initial weight of the pregnant woman.

Arterial hypertension is the most common symptom of gestosis and is a manifestation of systemic vascular spasm. Gestosis is characterized by lability of arterial pressure (asymmetry of numerical values of arterial pressure on the left and right brachial arteries can reach 10 MMHg or more). Therefore, blood pressure in pregnant women should be measured on both arms. Increased vascular tone in gestosis occurs primarily in the microcirculatory link, at the level of capillaries and arterioles, resulting in an increase in diastolic pressure first of all. Therefore, it is also necessary to calculate the average dynamic arterial pressure, taking into account both systolic and diastolic arterial pressure:

ADsr = ADD + (ADs - Add)/3,

Where АДс is systolic blood pressure, АДд is diastolic blood pressure. Edema of pregnant women is a consequence of disturbances of water-salt and protein metabolism. Retention of sodium ions in the body of pregnant women with gestosis leads to an increase in tissue hydrophilicity. At the same time, hypoproteinemia leads to a decrease in the oncotic pressure of blood plasma and diffusion of water into the intercellular space. In hypertensive syndrome, the peripheral spasm itself increases the permeability of the vascular wall, developing tissue hypoxia with the accumulation of underoxidized metabolic products increases the osmotic pressure in the tissues and thus their hydrophilicity. It is customary to distinguish 3 degrees of severity of edema syndrome:

• Grade I - localization of edema only in the lower extremities;
• II degree - their spread to the anterior abdominal wall;
• III degree - generalized.

Diagnosis of obvious edema is not difficult. When diagnosing hidden edema, it is necessary to take into account nocturia, a decrease in diuresis to less than 1000 ml with a water load of 1500 ml, pathological or uneven weight gain, a positive "ring" symptom. For early detection of hidden edema, a tissue hydrophilicity test according to McClure - Aldrich is used: after intradermal administration of 1 ml of isotonic NaCl solution, the blister resolves in less than 35 minutes.

Urine analysis reveals proteinuria, which is a consequence of renal vascular spasm, causing disruption of gas exchange and nutrition of the renal glomeruli. Under the influence of these factors, the permeability of endothelial cells of the vessels in the glomeruli increases sharply. The amount of protein in the urine increases sharply with the prevalence of an immunological conflict in the genesis of gestosis.

Determining the protein composition of blood serum is of great importance in diagnosing gestosis and assessing its severity. Gestosis is characterized by hypoproteinemia and dysproteinemia (a decrease in the ratio of albumin to globulin levels), which is evidence of a violation of the protein-forming function of the liver. A decrease in the concentration of total protein to 50 g/l and pronounced dysproteinemia are criteria for a severe course of gestosis.

Preclinical brain dysfunctions can be diagnosed using Doppler neurosonography. Clinically, they manifest as preeclampsia and eclampsia. Observation of pregnant women with gestosis has shown that the clinical manifestations of preeclampsia vary widely: headache of various localizations, visual impairment, pain in the right hypochondrium or epigastrium, nausea, vomiting, feeling of heat, difficulty breathing through the nose, nasal congestion, skin itching, drowsiness or, conversely, a state of excitement. Objective symptoms of preeclampsia: facial flushing, coughing, hoarseness, tearfulness, inappropriate behavior, hearing loss, speech difficulties, cyanosis, tachypnea, motor agitation, chills, hyperthermia. The most pronounced pathological change in the nervous system in gestosis is eclampsia - a convulsive seizure. Currently, due to more active tactics for managing pregnant women with severe forms of gestosis, the number of cases of preeclampsia has significantly decreased, and eclampsia is practically not encountered in obstetric hospitals.

The condition of the fetoplacental system in gestosis reflects the severity and duration of the pathological process. The frequency of intrauterine growth retardation in gestosis is 40%, perinatal morbidity reaches 30%, and perinatal mortality is 5.3%. Perinatal outcomes are directly related to the state of the uteroplacental, fetoplacental and intraplacental blood circulation. For an adequate assessment of the condition of the intrauterine fetus, it is necessary to perform ultrasound, Doppler and cardiotocographic studies with an assessment of the severity of blood flow disorders in the mother-placenta-fetus system according to Doppler data and the severity of chronic intrauterine hypoxia of the fetus according to CTG data.

Along with such classic complications of gestosis as acute renal failure, cerebral coma, cerebral hemorrhage, respiratory failure, retinal detachment, premature detachment of a normally located placenta, HELLP syndrome and acute fatty hepatosis of pregnancy (AFGP) are currently becoming increasingly important.

HELLP syndrome: hemolysis - H (Haemolysis), elevated liver enzymes - EL (Elevated liver enzymes), low platelet count - LP (Low plated count). In severe nephropathy and eclampsia, it develops in 4-12% of cases and is characterized by high maternal (up to 75%) and perinatal mortality. HELLP syndrome occurs in the third trimester of gestation, most often at 35 weeks.

The clinical picture is characterized by an aggressive course and a rapid increase in symptoms. Initial manifestations are nonspecific and include headache, fatigue, vomiting, abdominal pain, most often localized in the right hypochondrium or diffuse. Then there is vomiting, stained with blood, hemorrhages at injection sites, increasing jaundice and liver failure, convulsions, severe coma. Liver rupture with bleeding into the abdominal cavity is often observed. In the postpartum period, profuse uterine bleeding is observed due to disorders in the coagulation system. HELLP syndrome can manifest itself in the clinic of total premature detachment of a normally located placenta, accompanied by massive coagulopathic bleeding and rapid development of hepatorenal failure.

Laboratory signs of HELLP syndrome are: increased transaminase levels (AST over 200 U/L, ALT over 70 U/L, LDH over 600 U/L), thrombocytopenia (less than 100*10 ⁹ /L), decreased antithrombin III levels (less than 70%), intravascular hemolysis and increased bilirubin.

OJGB most often develops in primigravidas. There are 2 periods in the course of the disease. The first is anicteric and can last from 2 to 6 weeks. It is characterized by: decreased or lack of appetite, weakness, heartburn, nausea, vomiting, pain and a feeling of heaviness in the epigastrium, skin itching, weight loss. The second is icteric and is the final period of the disease, characterized by stormy clinical manifestations of liver and kidney failure: jaundice, oliguria, peripheral edema, fluid accumulation in the serous cavities, uterine bleeding, antenatal death of the fetus. Biochemical blood tests reveal: hyperbilirubinemia due to the direct fraction, hypoproteinemia (less than 60 g / l), hypofibrinogenemia (less than 2 g / l), mild thrombocytopenia, a slight increase in transaminases.

Assessment of the severity of gestosis, basic principles of therapy and obstetric tactics. Many methods for determining the severity of OPG-gestosis that existed until recently took into account only the clinical manifestations of gestosis as criteria and did not reflect the objective state of pregnant women. This is due to the fact that the picture of the disease has changed recently: gestosis often occurs atypically, beginning in the second trimester of pregnancy. The outcome of pregnancy for the mother and fetus largely depends not only on the general clinical manifestations of gestosis, but also on the duration of its course, the presence of fetoplacental insufficiency and extragenital pathology. Therefore, the most acceptable at present should be considered the classification of gestosis and distinguishing between mild, moderate and severe gestosis. Preeclampsia and eclampsia are considered complications of severe gestosis. This classification is convenient for practicing doctors, since the criteria used in it do not require expensive and lengthy methods, and at the same time allows for an adequate assessment of the severity of the disease). A score of up to 7 points corresponds to mild severity, 8-11 - moderate, and 12 and above - severe.

The objective criteria of severe nephropathy and preeclampsia are the following signs:

• systolic blood pressure 160 mmHg and above, diastolic blood pressure 160 mmHg and above;
• proteinuria up to 5 g/day or more;
• oliguria (urine volume per day less than 400 ml);
• hypokinetic type of central maternal hemodynamics with increased total peripheral vascular resistance (more than 2000 dyn*s*cm ^-5 ), severe renal blood flow disorders, bilateral blood flow disorders in the uterine arteries; increased PI in the internal carotid artery more than 2.0; retrograde blood flow in the suprapubic arteries;
• lack of normalization or deterioration of hemodynamic parameters against the background of intensive therapy for gestosis;
• thrombocytopenia (100-10 ⁹ /l), hypocoagulation, increased activity of liver enzymes, hyperbilirubinemia.

The presence of at least one of these signs indicates a serious condition of the pregnant woman and often precedes eclampsia.

Preeclampsia is characterized by the following symptoms:

• headaches of various localizations;
• deterioration of vision;
• nausea and vomiting;
• pain in the right hypochondrium or epigastrium;
• hearing loss;
• speech difficulties;
• feeling of heat, facial flushing, hyperthermia;
• difficulty breathing through the nose, nasal congestion;
• skin itching;
• drowsiness or a state of excitement;
• coughing, hoarseness, tachypnea;
• tearfulness, inappropriate behavior, motor agitation.

The presence of at least one of these symptoms indicates a serious condition of the pregnant woman and often precedes eclampsia.

Eclampsia is the most severe stage of gestosis, characterized by seizures during pregnancy, childbirth or 7 days after childbirth, not caused by epilepsy or other seizure disorders and/or coma in pregnant women with preeclampsia in the absence of other neurological conditions.

The clinical course of gestosis varies from mild to severe forms. In most pregnant women, the disease progresses slowly and the disorder does not go beyond the mild form. In others, the disease progresses more quickly - with a change from mild to severe form within days or weeks. In the most unfavorable cases, there is a fulminant course with progression from mild to severe preeclampsia or eclampsia within a few days or even hours.

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