Preeclampsia treatment

Radical treatment of preeclampsia is a rapid delivery, 48 hours after which the symptoms of the disease subsided. Up to this point it is important to correct arterial hypertension, shortage of BCC, violations of blood coagulation, and also to prevent and arrest seizures.

Therapy of arterial hypertension

Clear distinction of the nature of arterial hypertension is necessary:

• Arterial hypertension, on the background of which pregnancy occurs;
• arterial hypertension due to pregnancy.

The first variant of arterial hypertension is hypervolemic, the second is volatile, i.e. When carrying out antihypertensive therapy, an adequate replacement of the BCC deficiency is necessary. Treatment of arterial hypertension depends on the type of hemodynamics of the pregnant:

• hyperkinetic - SI> 4.2 l / min / m2;
• OPSS <1500 dyne cm-5 x s-1;
• eukinetic - SI = 2,5 - 4,2 l / min / m2;
• OPSS - 1500-2000 dinh cm-5 s-1;
• hypokinetic - SI <2.5 l / min / m2;
• OPSS to 5000 dyne cm-5 x s-1.

The purpose of antihypertensive therapy is the transfer of hyper- and hypokinetic types of blood circulation to eukinetic.

In the hyperkinetic type of hemodynamics, beta-adrenoblockers (propranolol), calcium antagonists (verapamil) are shown. It should be remembered that propranolol and verapamil have potentiating activity against narcotic and non-narcotic analgesics, the rhodoactivating effect in the first and tocolytic in the latter. Propranolol, like verapamil, reduces myocardial oxygen demand, being an anti-stress drug. If necessary, drugs are used iv in the appropriate dose:

Verapamil inside 1.7-3.4 mg / kg (up to 240 mg / day), the frequency of admission is determined by clinical expediency or Propranolol inside 1,5-2 mg / kg (up to 120 mg / day), the frequency of admission is determined by clinical feasibility. In the hypokinetic type of hemodynamics, the drugs of choice are hydralazine and clonidine. It should be remembered that the hypokinetic variant of the circulation is accompanied by a decrease in the contractility of the myocardium (Echocardiography is necessary with the determination of PV: the norm is 55-75%):

Hydralazine IV 6.25-12.5 mg, then inside 20-30 mg every 6 hours, depending on the value of AD or Clonidine inside 0.075-0.15 mg (3.75-6 μg / kg) 3 r / day or in / in 1,5-3,5 mkg / kg, the frequency of administration and duration of admission are determined by clinical expediency. Clonidine has an anti-stress effect, significantly increases the sensitivity to narcotic analgesics, anxiolytics and neuroleptics (a powerful analgesic that affects the vegetative component of pain), has a tocolytic effect. With prolonged admission of pregnant clonidine in a newborn, it is possible to develop a hypertensive crisis - withdrawal syndrome, which is manifested by severe neurologic symptoms (to warn the neonatologist).

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

Verapamil inside 1.7-3.4 mg / kg (up to 240 mg / day), the frequency of admission is determined by clinical expediency or Clonidine inward 0.075-0.15 mg (3.75-6 μg / kg) 3 r / day or in / in 1,5-3,5 mkg / kg, the periodicity of administration and duration of admission are determined by the clinical expediency or methyldopa inside 12.5 mg / kg / day, duration of admission is determined by clinical expediency or Propranolol inside 1,5-2 mg / kg ( up to 120 mg / day), the frequency of admission is determined by clinical feasibility. In the eu and hypokinetic types of hemodynamics, in addition to the indicated drugs or as monotherapy, the use of dihydropyridine calcium antagonists is indicated:

Nimodipine iv 0.02-0.06 mg / kg / h, depending on the severity of the condition and the desired result (special indications for eclampsia and pre-eclampsia) or Nifedipine inward, under the tongue or tranbuccally 0.05 mg / kg / day (20-40 mg / day), duration of admission is determined by clinical feasibility. If the controlled normotonia is necessary, the use of sodium nitroprusside and trifosadenin is indicated. It should be remembered that calcium antagonists, clonidine and nitrates are tocolytics, and beta-blockers are stimulants of uterine contractile activity. This must be taken into account when selecting hypotensive therapy to avoid hypo- or hypertonic myometrium.

Methyldopa in a dose of more than 2 g / day can trigger the development of meconium intestinal obstruction in a preterm neonate.

You can not allow a sharp drop in blood pressure, t. While uteroplacental and cerebral blood flow is affected.

Infusion treatment of preeclampsia

Obviously, most of the solutions used for infusion therapy in pregnant women are hyperosmolar and hyperoncotic. The average volume of plasma in pregnant women with lung infection is 9% below normal, 40% in severe cases. Consequently, the normalization of the plasma volume is the most important task of infusion therapy. It should be remembered that eclampsia is, first of all, generalized damage to the endothelium with a sharp increase in its permeability and interstitial hyperhydration. In this regard, extremely infectious solutions of albumin (pulmonary edema), low- and medium-molecular dextrans and gelatin. Colloids (dextrans) often give allergic reactions, can cause coagulopathy (provoke and intensify fibrinolysis, change the activity of factor VIII), reduce the concentration of ionized Ca2 +, cause osmotic diuresis (low molecular weight). In sepsis, ARDS / SALP, pre-eclampsia, eclampsia, colloids can aggravate the capillary leakage syndrome. Gelatin solutions should be used with great care. Gelatin increases the release of IL-1b, reduces the concentration of fibronectin, which further increases the porosity of the endothelium. Infection with "rabies rabies" is possible - the pathogen does not die under the sterilization regimes used.

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

Safety criteria for dilution methods:

• value of COD. Should be no less than 15 mm Hg. P.
• infusion rate - no more than 250 ml / h;
• rate of decline ADR. - no more than 20 mm Hg. Item / hour;
• the ratio of infusion rate and urine separation should be less than 4.

It is extremely dangerous to use osmotic diuretics in pre-eclampsia and especially with eclampsia!

Pregnancy helps increase fluid filtration in pulmonary interstitium, creating ideal conditions for the development of interstitial pulmonary hyperhydration. It is necessary to take strict account of the volume of injected solvents (still often oxytocin, insulin, heparin, etc. Are injected not through the infusomat, but drip, without taking into account the volume of the solvent and exact compliance with the dose / time of administration). Hypertransfusion of crystalloids can be accompanied by hypercoagulability.

Hypertensive solutions (7.5% sodium chloride solution) have a positive effect on MK, do not cause edema, quickly stabilize hemodynamics, especially in combination with colloids, by moving fluid from the extracellular space into the lumen of the vessels.

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

Treatment of pre-eclampsia, aimed at correcting blood clotting disorders

It is necessary to assess the state of the hemostasis system, especially with severe preeclampsia. It may be necessary to transfuse FFP, platelet mass, etc. The risk of transmission of infection: hepatitis C - 1 case for 3,300 transfused doses, hepatitis B - 1 case for 200 000 doses, HIV infection - 1 case for 225 000 doses. Transfusion pulmonary edema - 1 per 5000 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 initiates or promotes the progression of CVD and further damage to the endothelium. Plasma, prepared from the blood of multicompared women, listed complications gives more often. In this regard, FFP should be applied according to the most stringent indications: the need to restore clotting factors!

A pharmacological correction of the synthesis of thromboxane A2 and prostacyclin is necessary:

• stimulation of prostacyclin synthesis (small doses of nitrates, dipyridamole, nifedipine);
• slowing the metabolism of prostacyclin (small doses of furosemide, only in the absence of contraindications, are indicated in pregnant women with gestosis against GB background, control of bcc is necessary);
• replacement therapy with synthetic prostacyclin (epoprostenol);
• reduction of synthesis of thromboxane A2.

Assign:

• Acetylsalicylic acid inside 50-100 mg 1 p / day, long.

Anticonvulsant treatment of preeclampsia

If there is a convulsive readiness, magnesium sulfate is used.

Magnesium sulfate iv / 2-4 g for 15 min (loading dose), then drip 1-2 g / h intravenously, maintaining a therapeutic level of magnesium in the blood of 4-8 mokv / l.

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Sedative treatment of preeclampsia

For the purpose of sedation, barbiturates and neuroleptics are used. The use of anxiolytics (tranquilizers) can cause respiratory depression, skeletal muscle hypotension, urinary retention and caloric discharge, and jaundice in newborns. It should be remembered about the side effects of droperidol (Kulenkampf-Tarnov syndrome): paroxysmal hyperkinesis - paroxysmal convulsions of the masticatory muscles, tonic cramps of the neck muscles, complicated articulation, hyperreflexia, hypersalivation, bradypnoea. A spasm of muscles of the trunk and extremities (pretentious postures) is possible, which is accompanied by excitement, anxiety, a feeling of fear with clear consciousness. The syndrome does not pose a threat to life, but due to overdiagnosis of eclampsia provokes early operative delivery.