MODERN PROBLEMS OF GESTOSES
Prepared by professor S.N.Heryak
Ternopol medical state univercity
by I.Y. Gorbachevsky
n Gestoses and hypertensive disorders are among the most common and yet serious conditions seen in obstetrics.
These disorders cause substantial morbidity and mortality for both mother and fetus, despite improved prenatal care.
GESTOSIS OF EARLY TERMS OF PREGNANCY
n ptyalism in pregnancy
RARE FORMS OF GESTOSIS IN PREGNANCY
n hyperemesis gravidarum
n acute fatty liver of pregnancy
n dermatosis gravidarum
n tetania gravidarum
n osteomalacia gravidarum
n bronchial asthma of pregnancy
PREGNANCY INDUCED HYPERTENSION
n Ptyalism in pregnancy
(or excessive salivation).
Ptyalism in pregnancy is especially annoying for a small number of patients, sometimes approaching 1 liter production per day.
n Treatment of ptyalism:
n tincture of belladonna
Medical treatment only slightly so that reassurance of the time-limited nature of the problem is a mainstay of management.
n Nausea and emesis.
At least 66 % of women experience nausea and 50 % emesis in the first trimester, with the frequency of these symptoms lessening as the second and third trimesters ensue.
n The genesis of pregnancy-induced nausea and vomiting.
It may be that the hormonal changes of pregnancy are responsible.
Chorionic gonadotropin, for instance, has been implicated on the basis that its levels are rather high at the same time that nausea and vomiting are most common.
n Degrees of vomiting:
n Light degree of vomiting.
It is accompanying with 2 – 4 times per day episodes of vomiting after taking meals, general state of the woman is satisfactory, light tachycardia may be present.
n Moderate degree of vomiting.
It is accompanying with 5-10 times and more per day episodes of vomiting which don't from taking meals.
Weight loss, ketosis, increased temperature are present.
n Severe degree of vomiting.
It is also called as Hyperemesis
gravidarum (intractable emesis during pregnancy) is a more severe form of nausea and vomiting, occurring in approximately 4 out of 1000 pregnancies.
It is also associated with severe symptoms as well as weight loss, dehydratation, ketosis, and electrolyte disturbances.
n Hospitalization and treatment:
n balanced crystalloid solutions and electrolytes to correct metabolic disturbances in a short time.
n Diet can then be reinstituted slowly and progressively. Frequent small feedings and avoidance of foods that are unpleasant to the patient usually relieve symptoms to a manageable level.
n Recurrences sometimes necessitate repeat hospitalizations.
n Therapeutic abortion for management of this problem is rarely required.
n A variety of antiemetics can be prescribed if the above measures fail to provide adequate relief (Metoclopramide, Meclizine, Promethazine).
n Risk Factors for PIH
n primigravid status, new paternity;
n family history of preeclampsia or eclampsia;
n previous preeclampsia or eclampsia;
n extremes of maternal age (younger than 20 y or older than 35 years of age);
n preexisting hypertensive vascular, autoimmune, or renal disease;
n preexisting renal, pulmonary, thyroid dysfunction;
n Diabetes mellitus;
n Multiple gestation;
n Nonimmune or alloimmune fetal hydrops;
n Hydatidiform Mole.
n Theories of Pregnancy-Induced Hypertension
n Immunological theory
n Genetic predisposition
n Dietary deficiency
n Vasoactive compounds
n Endothelial dysfunction
n Aspects in pathogenesis of hypertensive disorders in pregnancy
1. Generalized vasospasm.
4. Disseminated intravascular coagulopathy.
5. Metabolic impairment as result of hypoxia.
6.Organ dysfunction – renal, hepatic, cardiac and pulmonary, hematological, cerebral problems.
7. Placental dysfunction because the vasospastic changes.
Classification of PIH
(PREGNANCY INDUCED HYPERTENSION)
1. Hypertensive disorders during pregnancy.
2. Edema during pregnancy.
3. Proteinuria during pregnancy.
4. Mild preeclampsia.
5. Moderate preeclampsia.
6. Severe preeclampsia.
n “Isolated” and “superimposed” hypertensive disorders are distinguished.
“Superimposed” hypertensive disorders develop on the underlying preexisting diseases, such as Diabetes Mellitus, Hypertensive disease, kidneys inflammatory diseases, thyroid and pulmonary dysfunction. They have such peculiarities as:
n early beginning;
n severe duration;
n isolated symptoms only presenting (isolated proteinuria, edema, or hypertension);
n presence of atypical clinical findings such as paresthesia, insomnia, hypersalivation.
n Chronic hypertension
Is defined as hypertension present before the twentieth week of gestation or beyond 6 weeks' postpartum.
n Gestational hypertension
Occurs after 20 weeks of pregnancy and doesn’t accompanies with proteinuria.
Is defined as the development of hypertension with proteinuria or edema (or both), induced by pregnancy, generally in the second half of gestation.
n 1. Hypertension in pregnancy.
n It is generally defined as a diastolic blood pressure of 90 mm Hg or greater, as a systolic blood pressure at or above 140 mm Hg at two estimations with the interval 4 hours
n or 160/110 mm Hg at once
n or as an increase in the diastolic blood pressure of at least 15 mm Hg or in the systolic blood pressure of 30 mm Hg or more when compared to previous blood pressures.
n 2. Weight gain.
It is a sudden increase in weight may precede the development of preeclampsia.
Weight increase of about much more than 400 g per week is abnormal.
n 3. Edema.
n Peripheral edema is common in pregnancy, especially in the lower extremities;
n however, persistent edema unresponsive to resting in the supine position is not normal, especially, when it also involves the upper extremities and face.
n 4. Headache.
It is unusual in milder cases but frequent in more severe disease.
It is often frontal but may be occipital, and it is resistant to relief from ordinary analgetics.
n 5. Abdominal pain.
n Epigactric or right upper quadrant pain. Often is a symptom of severe preeclampsia and may be indicated of imminent convulsions.
n It may be the result of stretching of the Hepatic capsule, possibly by edema and hemorrhage. Tenderness over the liver should be presented.
n 6. Visual disturbances.
A spectrum of visual disturbances, ranging from slight blurring of vision to scotomas to partial or complete blindness, may accompany preeclampsia.
These develop as a result of vasospasm, ischemia, and petechial hemorrhages
within the occipital cortex.
n 7. Hyperreflexia.
The patellar and achilles deep tendom reflexes should be carefully elicited and noted this symptom.
The demonstration of clonus at the ankle is especially worrisome.
n 8. Loss of consciousness or seizures.
Any history of loss of consciousness or seizures, even in the patient with a known seizure disorder may be significant.
n Laboratory findings of PIH. Maternal studies
n Laboratory findings of PIH. Fetal studies
n Diagnostik of Eklampsia
n Differential diagnosis of chronic hypertension and preeclampsia
n Assessment of different stages of PIH severity
n Clinical signs of severe preeclampsia
n General edema
n weight gain exceeds more than 900 g in a week
n cerebral or visual disturbances such as headache and scotomata
n pulmonary edema or cyanosis
n epigastric or right upper quadrant pain, evidence of hepatic dysfunction
n Oligouria (less than 500 ml/ day)
n Complications of preeclapsia
n Maternal – placenta abruption, cerebral hemorrhage, renal and liver insufficiency, disseminated intravascular coagulopathy, adrenal insufficiency, eclampsia.
n Fetal – intrauterine growth retardation, intranatal fetal death, infant morbodity and mortality.
n Is characterized typically by those same abnormalities as severe preeclampsia with the addition of convulsions.
n The seizures are grand mal and may appear during pregnancy, during labor, or postpartum.
n the convulsions of eclampsia
n the convulsions of eclampsia
n Principles of PIH treatment
n Termination of the pregnancy with the least possible trauma to the mother and the fetus.
n Birth of the infant.
n Complete restoration of the health of the mother.
The severity of the preeclampsia and the maturity of the fetus are the primary considerations in the management of preeclampsia.
n 1. Bed rest. Preferably with as much of the time as possible spent in a lateral decubitus position. In this position, cardiac function and uterine blood flow are maximized and maternal blood pressures in most cases are normalized. This improves uteroplacental function, allowing normal fetal growth and metabolism.
n Ambulatory treatment has no place in the management of PIH.
n Bed-rest throughout the greater part of the day is essential.
Mild preeclampsia – expectant management
Sedative drugs for normalization of status of central nervous system:
n Droperidol – 2 ml IM,
n Seduxen – 2 ml IM.
n These drugs should be combined with Droperidol – 0,25 % - 2ml IM or IV
Antihypertensive therapy eliminates vasospasm of macro- and microcirculation.
It is started if BP > 150/100 mmHg
n Methyldopa – a2 adrenoagonists, false neurotransmission in the dose 250-500 mg 3- 4 time a day – FIRST-LINE DRUG
n Labetalol – a- and b- adrenergic blockers – in the dose 100-400 mg 2-3 times per day (10-20 mg IV every 10 minutes till 300 mg) –SECOND-LINE DRUG
n Atenolol – b1- adrenergic blockers in the dose 25-100 mg once a day
n Metoprolol - b1- adrenergic blockers in the dose 12,5-50 mg 2 times per day
n Nifedipine – calcium-channel blocker – in the dose 10 mg po q 4-8 hours;
n Hydralazine – miometrial vasodilator (if diastolic pressure is repeatedly above 110 mm Hg ) An initial dose of 5 mg given every 10 minutes till 20 mg until suitable blood pressure is achieved.
n Spasmolytic agents – No-spani 2 % - 2-4 ml IM, Papaverine hydrochloride – 2 % - 2-4 ml IM, Plathyphillinum – 0,2 % - 2, 0 – twice a day, Dibasol – 1 % 2-4 ml IM or IV, Euphyllinum – 2,4 % 10, 0 IV.
n Magnesium Sulfate
n It is used when diastolic pressure is > 110 mm Hg
n It is used to arrest and prevent the convulsions of eclampsia
n It has spasmolytic, sedative, antihypertensive and anticonvulsant effects.
n Schemes of magnesium administration in the case of severe preeclampsia and eclampsia
Intravenous administration of Magnesium Sulfate – 4 gram 16 ml 25 % during 5 minutes very slowly (it is dissolved in 34 ml isotonic solution).
Maintenance dose is 1g-2g/hour (7, 5 g – 30 ml 25 % solution is dissolved in 220 ml isotonic solution – 3, 33 % Magnesial solution)
The maximal dose of magnesium during a day in the case of severe preeclampsia is 50-80 ml
(12,5 –24 g).
n During prescription of magnesium sulfate
n a. The patellar reflex is present.
n b. Respirations are not depressed (> 14 respiratory act in a minute) .
n c. Urine output the previous 4 hours exceeded 100 mL.
Reversal of the effects of excessive magnesium concentrations is accomplished by the slow intravenous administration of 10% calcium gluconate
Normalization of blood reology because of hemoconcentration
Limitated intravenous fluid therapy under control of blood volume, hematocrit, diuresis.
Primarily saline (lactated Ringer’s, isotonic solution) should be given at a rate of 60-125 ml per hour
n PROTOCOL FOR TREATING ECLAMPSIA
n Turn patient on the side
n Establish airways and administer oxygen
n Pulmonary ventilation – elimination of hypoxia
n Magnesial therapy. Immediate delivery within 3 to 6 hours. Continue to administer magnesium for at least 24 hours after delivery or last convulsion.
n Hypotensive therapy – if DBP > 110 mm Hg
n PROTOCOL FOR TREATING ECLAMPSIA
n Attention! In the case if severe preeclampsia and eclampsia three catheters should be inserted obligatory:
n 1 – into central vein - v. subclavia for a fluid therapy and controlling of central venous pressure;
n 2 – into urinary bladder for controlling of diuresis per hour;
n 3 – transnasal catheterisation of stomach for prevention of Mendelson’s syndrome.
n Duration of treatment
n Mild preeclampsia – 7-10 days
n Moderate preeclampsia – 7-10 days
n Severe preeclampsia – 24 hours and termination of pregnancy
n Eclampsia – 5 hours and termination of pregnancy
n Preeklampsia and HELLP-Syndrom
n HELLP SYNDROME
HELLP is the acronym for a specific set of hypertensive patients who have:
n Hemolysis - anemia
n Elevated Liver enzymes – liver dysfunction,
n Low Platelet count – hemorrgages.
n cardiovascular stabilization,
n correction of coagulation abnormalities - Platelet transfusion
n correction of liver dysfunction
n immediate delivery.
n liver dysfunction
n Acute fatty liver of pregnancy.
It is a rare complication of pregnancy, but its severity and maternal mortality rate of 30 % make its timely diagnosis and treatment of importance. It is usually occurs late in pregnancy in primagravidas and characterized by vague gastrointestinal symptoms becoming worse over several days' time. Thereafter headache, mental confusion, and epigastric pain may ensue, and if untreated, there may be rapid development of coagulopathy, corna, multiple organ failute and death. Laboratory findings include an initial modest elevation in bilirubin and an elevation of transaminase levels.
Treatment of this serious complication is correction of coagulopathy and electrolyte imbalances, cardiorespiratory support, and delivery as feasible by the vaginal route, if possible.