Symptoms of Gestosis

Despite the variety of clinical manifestations, gestosis has no pathognomonic symptom.

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

• Edema is a general and excessive accumulation of fluid in the tissues after a 12-hour rest in bed. They arise as a result of a decrease in oncotic pressure (against the background of albuminuria), an increase in the permeability of capillaries 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 birth in women with previously normal blood pressure. It arises from spasm of blood vessels and hyperdynamic systolic function of the heart.
• Proteinuria is a symptom that occurs during pregnancy in the absence of arterial hypertension, swelling and previous infectious or systemic kidney disease. It develops as a result of lesions of the renal glomeruli with an increase in the permeability of the basal membrane of their capillaries.

It should be taken into account that no complication of pregnancy distinguishes such clinical polymorphism, uncertainty and doubtfulness of the prognosis for the mother and fetus. We can say that there are so many clinical variants of gestosis, how many pregnant women with this complication. Currently, there are often monosymptomatic forms of gestosis, or variants of the disease with an erased course. According to our clinic, monosymptomatic gestosis was detected in 1/3 of the examined, and the classical triad Tsangemeister - only 15% of patients. At the same time, the long-term forms of gestosis were recorded in more than 50% of the observations. In practical terms, when monitoring a pregnant woman, it is most important to diagnose early signs of gestosis in a timely manner.

Excess weight gain is one of the earliest symptoms of gestosis. The average gestational age of onset of abnormal 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 caused by violations of carbohydrate, fat and water-salt metabolism. The total weight gain during the whole pregnancy should not exceed 11 kg, up to 17 weeks - not more than 2.3 kg, at 18-23 weeks - 1.5 kg, at 24-27 weeks - 1.9 kg, in 28- 31 weeks - 2 kg, 32-35 weeks - 2 kg, 36-40 weeks - 1.2 kg. To more accurately determine the optimal weight gain for each woman, you can use a scale of average physiological weight gain. Weekly increment should not exceed 22 g for every 10 cm of growth or 55 g for every 10 kg of the initial mass of the pregnant.

Arterial hypertension is the most common symptom of gestosis and is a manifestation of systemic vascular spasm. For gestosis, the lability of blood pressure is characteristic (asymmetry of numerical values of arterial pressure on the left and right humeral arteries can reach 10 MMHg and more). Therefore, the measurement of blood pressure in pregnant women should be done on both hands. The increase in vascular tone in gestosis occurs primarily in the microcirculatory unit, at the level of capillaries and arterioles, as a result of which, in the first place, there is an increase in diastolic pressure. Therefore, it is also necessary to calculate the average dynamic blood pressure, taking into account both systolic and diastolic blood pressure:

ADCP = ADq + (ADc - Add) / 3,

Where АДс - systolic arterial pressure, BPd - diastolic arterial pressure. Edemas of pregnant women are a consequence of violations of water-salt and protein metabolism. The delay of sodium ions in the body of pregnant women with gestosis leads to an increase in the hydrophilicity of the tissues. At the same time, hypoproteinemia leads to a decrease in the oncotic pressure of blood plasma and the diffusion of water into the intercellular space. In hypertensive syndrome, peripheral spasm itself increases permeability of the vascular wall, developing tissue hypoxia with accumulation of under-oxidized metabolic products increases osmotic pressure in the tissues and thus their hydrophilicity. It is accepted to distinguish 3 degrees of severity of edematous syndrome:

• I degree - localization of edema only on the lower extremities;
• II degree - spreading them to the anterior abdominal wall;
• III degree - generalized.

Diagnosis of apparent swelling is not difficult. In the diagnosis of concealed swelling it is necessary to take into account nocturia, a decrease in diuresis less than 1000 ml with an aqueous load of 1500 ml, a pathological or uneven weight gain, a positive "ring" symptom. For early detection of concealed edema, a sample is used to hydrophilicize the tissues according to McClure-Aldrich: after intradermal administration of 1 ml of isotonic NaCl solution, the blister dissolves in less than 35 minutes.

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

Great importance in the diagnosis of gestosis and evaluation of the severity of its course is given to the determination of the protein composition of blood serum. Gestosis is characterized by hypoproteinemia and disproteinemia (a decrease in the ratio of the level of albumins to globulins), which is evidence of a violation of the protein-forming function of the liver. Reduction of the total protein concentration to 50 g / l and expressed disproteinemia are criteria for severe gestosis.

Impaired brain function at the preclinical stage can be diagnosed with Doppler neurosonography. Clinically, they appear in the form of pre-eclampsia and eclampsia. The observation of pregnant women with preeclampsia has shown that the clinical manifestations of preeclampsia vary widely: headaches of different locations, visual impairment, pain in the right hypochondrium or vagibastrium, nausea, vomiting, heat, nasal breathing, nasal congestion, itching, drowsiness, or , on the contrary, the state of excitation. Objective symptoms of pre-eclampsia: facial hyperemia, coughing, hoarseness, tearfulness, inadequacy of behavior, hearing loss, speech difficulties, cyanosis, tachypnea, motor excitement, chills, hyperthermia. The most pronounced pathological change of the nervous system in gestosis is eclampsia - convulsive seizure. At present, in connection with the more active tactics of administering pregnant women with severe forms of gestosis, the incidence of preeclampsia has significantly decreased, and eclampsia in obstetric hospitals is practically not found.

The condition of the fetoplacental system in gestosis reflects the degree of severity and duration of the pathological process. The frequency of intrauterine growth retardation in gestosis is 40%, perinatal morbidity is 30%, and perinatal mortality is 5.3%. Perinatal outcomes are in direct relationship with the state of utero-placental, fruit-placental and intraplacental blood circulation. For an adequate assessment of the state of the intrauterine fetus, it is necessary to perform ultrasound, Doppler and cardiotocography studies with an assessment of the degree of severity of blood flow disorders in the mother-placenta-fetus system according to the Dopplerometry and severity of chronic intrauterine fetal hypoxia according to CTG.

Along with classic complications of gestosis such as acute renal failure, cerebral coma, cerebral hemorrhage, respiratory insufficiency, retinal detachment, premature detachment of the normally located placenta, HELLP-syndrome and acute fatty hepatosis of pregnant women (OZHGB) are becoming increasingly important.

HELLP-syndrome: haemolysis-H (Haemolysis), elevation of liver enzymes - EL (Elevated liver ensimes), low number of platelets - LP (Low plateled 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, more often at a period of 35 weeks.

The clinical picture is characterized by an aggressive course and a rapid increase in symptoms. The initial manifestations are nonspecific and include headache, fatigue, vomiting, abdominal pain, more often localized in the right hypochondrium or diffuse. Then there are vomiting, colored blood, hemorrhages at the injection site, increasing jaundice and liver failure, convulsions, pronounced coma. Often there is a rupture of the liver with a bleeding into the abdominal cavity. In the postpartum period, due to disorders in the coagulation system, profuse uterine bleeding is observed. HELLP-syndrome can be manifested by the clinic of total premature detachment of the normally located placenta, accompanied by massive coagulopathic bleeding and rapid formation of hepatic-renal failure.

The laboratory signs of the HELLP syndrome are: an increase in the level of transaminases (ACT more than 200 U / L, ALT more than 70 U / L, LDH more than 600 U / L), thrombocytopenia (less than 100 * 10 ⁹ / L), decrease in antithrombin III (less 70%), intravascular hemolysis and increased bilirubin.

OZHGB is more likely to develop in the primitive. During the disease, there are 2 periods. The first one - jaundiced, can last from 2 to 6 weeks. It is characterized by: a decrease or lack of appetite, weakness, heartburn, nausea, vomiting, pain and a feeling of heaviness in the epigastrium, skin itching, weight loss. The second - icteric - the final period of the disease, is characterized by a tumultuous clinic of hepatic renal failure: jaundice, oliguria, peripheral edema, fluid accumulation in serous cavities, uterine bleeding, antenatal fetal death. Biochemical blood test reveals: hyperbilirubinemia due to the direct fraction, hypoproteinemia (less than 60 g / l), hypofibrinogenemia (less than 2 g / l), no expressed thrombocytopenia, insignificant increase in transaminases.

Assessment of the severity of gestosis, the basic principles of therapy and obstetric tactics. Many methods of determining the severity of OPG gestoses 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 recently the picture of the disease has changed: gestosis is often atypical, begin in the II 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 classification of gestosis and distinguishing gestosis of mild, moderate and severe degree should be considered as the most acceptable at the present time. Preeclampsia and eclampsia are considered complications of severe gestosis. This classification is convenient for practical doctors, since the criteria used in it do not require expensive and lengthy methods, and at the same time allows an adequate assessment of the severity of the disease). Scoring up to 7 points corresponds to mild, severity, 8-11 - medium, and 12 and higher - severe.

The following criteria are the objective criteria for severe nephropathy and preeclampsia:

• systolic blood pressure 160 MMHg and above, diastolic arterial PO MMHg and above;
• protenuria up to 5 g / day or more;
• oliguria (volume of urine per day less than 400 ml);
• hypokinetic type of central maternal hemodynamics with elevated OPSS (more than 2000 dyne * s * cm- ⁵ ), pronounced disorders of renal blood flow, bilateral violation of blood flow in the uterine arteries; increased PI in the internal carotid artery more than 2.0; retrograde blood flow in the suprapubic arteries;
• absence of normalization or worsening of hemodynamic parameters against the background of intensive therapy of gestosis;
• thrombocytopenia (100-10 ⁹ / l), hypocoagulation, increased activity of hepatic enzymes, hyperbilirubinemia.

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

Pre-eclampsia is characterized by the following symptoms:

• headache of different localization;
• impaired vision;
• nausea and vomiting;
• pain in the right hypochondrium or epigastrium;
• hearing loss;
• verbal difficulties;
• a feeling of heat, hyperemia of the face, hyperthermia;
• obstructed nasal breathing, stuffy nose;
• skin itching;
• drowsiness or state of excitement;
• coughing, hoarse voice, tachypnea;
• tearfulness, inadequate behavior, motor excitement.

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

Eclampsia is the most severe stage of gestosis, characterized by convulsive seizures during pregnancy, childbirth or 7 days after birth, not caused by epilepsy or other convulsive 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. In most pregnant women, the progression of the disease is slow and the disorder does not go beyond the mild form. In others, the disease progresses faster - with a change from mild to severe in days or weeks. In the most unfavorable cases there is fulminant flow with progression from mild to severe preeclampsia or eclampsia for several days or even hours.

[1], [2], [3], [4]