If an eclamptic attack occurs, a pregnant woman who has lost consciousness must be laid on her side (preferably the right one), tilt her head back to prevent the tongue from retracting, insert rubber or plastic air ducts, remove foam (sometimes mixed with blood) from the mouth, inhale oxygen and air through a mask apparatus KI-ZM or AN-8M. Oxygenation in case of respiratory failure in pregnant women with severe forms of gestosis should be carried out with caution. In case of severe acute respiratory failure, intubation, suction of secretions from the trachea and bronchi, and mechanical ventilation in hyperventilation mode (at CO 2 - 20-22 mm Hg) are necessary. To perform mechanical ventilation, it is necessary to call a resuscitation-surgical team.
After the end of the attack, the pregnant woman should be examined only under conditions of neuroleptanalgesia. If neuroleptanalgesia was not carried out before the onset of eclampsia, after the seizure, 2 ml of 0.5% diazepam solution should be administered; 2-4 ml of 0.25% droperidol solution, 2 ml of 2.5% promethazine solution (or 2 ml of 1% diphenhydramine solution), 1 ml of 2% trimeperidine IV or IM; give anesthesia with nitrous oxide and oxygen. Neuroleptanalgesia weakens the convulsive form of gestosis and prevents the development of the next attack.
It is necessary to find out the obstetric situation: the general condition of the patient (pulse rate, breathing, blood pressure numbers on one and the other arm, the presence of edema, the degree of its severity, gestational age, the presence (absence) of contractions, the shape of the uterus, the presence of local pain on palpation of the uterus, the presence of movement and fetal heartbeat, the presence of bloody discharge from the genital tract.
After stopping the attack of convulsions, it is necessary to begin treatment for gestosis (magnesium sulfate, rheopolyglucin*).
The administration of magnesium sulfate is combined with the administration of drugs that reduce vascular vasoconstriction: bendazole 1% - 3-6 ml and papaverine 2% - 2-4 ml, drotaverine 2% - 2 ml.
At the same time, the patient is given infusion therapy: Mafusol 400-450 ml IV drip or 500 ml of any polyionic solution: Lactosol° or Trisol*, or Lactosol° 250 ml, or trometamol 500 ml, or 500 ml of 5% dextrose solution under control diuresis, since with severe gestosis acute renal failure develops.
To improve the rheological properties of blood, 400 ml of rheopolyglucin* can be administered.
An attempt to quickly transport a patient with a convulsive form of gestosis without prior neurolepsy or neuroleptanalgesia and preliminary treatment of gestosis only aggravates the patient’s condition and the outcome of the disease.
The earlier the treatment of severe forms of gestosis is started at the prehospital stage, the greater the opportunity to support the impaired functions of vital organs - the brain, heart, liver, kidneys and the placenta-fetus complex.
If, against the background of the administration of antispasmodics, magnesium sulfate infusion therapy, the pregnant woman (mother in labor) remains high in blood pressure, administer 10 ml of 2.4% aminophylline solution in 10 ml of isotonic sodium chloride solution.
Other antihypertensive drugs can be administered subcutaneously, intramuscularly or intravenously, clonidine 0.01% 0.5-1.0 ml. The drug is administered under blood pressure control; in the first minutes of administration, a short-term increase in blood pressure is possible! When administered together with antipsychotics, clonidine enhances their sedative effect.
To reduce blood pressure in pregnant women (parturients), it is advisable to use drugs for controlled arterial hypotension: 5% azamethonium bromide - 0.5-1 ml IM or IV in 20 ml of isotonic sodium chloride solution or 5% dextrose solution.
Some patients with eclampsia develop acute respiratory failure. Treatment measures for acute respiratory failure are aimed at:
o restoration and ensuring patency of the airways, if necessary - their drainage;
o improvement of alveolar ventilation and pulmonary gas exchange;
o improving hemodynamics, combating cardiovascular failure.
Patients with eclampsia may develop acute heart failure. To combat it, cardiac glycosides are administered: 0.25-0.5-1 ml of 0.05 strophanthin-K solution or 0.5-1 ml of 0.06% lily of the valley glycoside solution.
A patient with any degree of severity of gestosis should be hospitalized.
COMMON ERRORS
At the prehospital stage, drugs are not administered during transport to prevent recurrent seizures.
Prescribe drugs for intramuscular administration without providing access to a peripheral vein.
Emergency care algorithms for preeclampsia and eclampsia are shown in Fig. 16-7 and 16-8.
Rice. 16-7.Emergency care algorithm for preeclampsia.
Rice. 16-8.Emergency care algorithm for eclampsia.
METHOD OF APPLICATION AND DOSES OF MEDICINES
Medicines prescribed during emergency care medical care for gestosis, are given in table. 16-2.
Table 16-2. Medicines prescribed for late gestosis
| Medicine | Indications |
| Diazepam at a dose of 2-5 mg IV or 10 mg IM | Drug sedation |
| Midazolam 5-10 mg IV or 10-15 mg IM | Drug sedation |
| Plasma replacement solutions at a dose of 200 ml/h | Infusion therapy |
| Dextran solutions 400-800 ml IV at a rate of 60-80 drops/min in combination with 5 ml (100 mg) pentoxifylline solution | Infusion therapy |
| Hydroxyethyl starch preparations | Infusion therapy |
| Nifedipine 10-20 mg sublingually | Antihypertensive therapy |
| Magnesium sulfate at a dose of 400-800 mg IV, depending on the severity of the condition | Antihypertensive therapy |
| Hemodez-N-N* at a dose of 200-400 ml IV drip | |
| Hepatoprotectors (Essentiale Forte* at a dose of 5 ml, ademetionine at a dose of 800 mg) i.v. | When symptoms of liver failure predominate |
CLINICAL PHARMACOLOGY OF DRUGS
Magnesium sulfate causes sedative, hypnotic or narcotic effects. During the process of excretion of magnesium by the kidneys, magnesium sulfate increases diuresis. Magnesium controls the normal functioning of myocardial cells, increases resistance to nervous stress. The competitive antagonism of magnesium and calcium explains the anticoagulant ability of magnesium and, as a result, a decrease in thrombus formation and an improvement in microcirculation. 400-800 mg/injection is administered intravenously, depending on the severity of the condition.
Nifedipine- representative of calcium antagonists, active peripheral vasodilator; nifedipine has more pronounced peripheral (decrease in total vascular resistance) than cardiac effects; has a negative inotropic effect (which is compensated by reflex tachycardia); slightly increases cardiac output and improves blood supply to organs and tissues, reduces myocardial oxygen demand. The drug is rapidly absorbed when taken orally. It is usually taken orally (regardless of the time of administration). Recommended doses: 0.01 g (10 mg) 2-3 times a day (no more than 0.04 g per day). To relieve a hypertensive crisis, and sometimes during attacks of angina, the drug is often used sublingually. A tablet (0.01 g) is placed under the tongue until completely dissolved. It is necessary to take into account the rapid increase in the concentration of the drug in the blood with this method of use, the possibility of reflex reactions, and the phenomena of orthostatic hypotension. The drug should be used in a lying position. After taking nifedipine, redness of the face and skin of the upper body, headache, nausea, dizziness, and drowsiness are often observed. Available in tablets and capsules of 0.01 and 0.02 g (10 and 20 mg). Nifedipine solutions for injection are available.
Childbirth is the physiological process of expulsion of the fetus, membranes and placenta through the mother's birth canal.
An EMS doctor (paramedic) may encounter any period of labor: dilation, expulsion, the afterbirth and early postpartum period. A doctor (paramedic) must be able to diagnose periods of labor, assess their physiological or pathological course, find out the condition of the fetus, choose rational tactics for managing labor and the early postpartum period, prevent bleeding in the placenta and early postpartum period, and be able to provide obstetric care for cephalic presentation.
Childbirth outside a hospital most often occurs during premature pregnancy or during full-term pregnancy in multiparous women. In such cases, childbirth usually proceeds rapidly.
CLASSIFICATION
There are premature, urgent and delayed births.
Births that occur between 22 and 37 weeks of gestation, resulting in premature babies, are considered premature. Premature children are characterized by immaturity, with a body weight from 500 to 2500 g and a height from 19-20 to 46 cm. They are characterized by a high percentage of both perinatal mortality and mortality and morbidity of premature children, especially those born at 22-27 weeks of pregnancy (weight bodies from 500 to 1000 g).
Childbirth that occurs at a gestational age of 40 ± 2 weeks and ends with the birth of a live, full-term fetus with a body weight of approximately 3200-3500 g and a height of 46 cm is considered urgent.
Childbirth that occurs during a gestational age of more than 42 weeks and ends in the birth of a fetus with signs of postmaturity: dense skull bones, narrow sutures and fontanelles, pronounced desquamation of the epidermis, dry skin, is considered postterm. Childbirth with a post-term fetus is characterized by a high percentage of birth injuries.
There are physiological and pathological childbirths. A complicated course of labor develops in pregnant women with extragenital pathology, aggravated obstetric and gynecological history, or a pathological course of pregnancy.
The following states are relevant:
Menstrual dysfunction;
History of infertility;
Inflammatory diseases of the internal genital organs;
History of artificial and spontaneous abortions;
Uterine fibroids;
Ovarian tumors;
Scar on the uterus after cesarean section;
Primiparas over 30 years of age and under 18 years of age;
Heart defects (congenital and acquired);
Hypertonic disease;
Diseases of the respiratory system, kidneys, liver;
Diseases of the thyroid gland, nervous system, musculoskeletal system;
Diabetes.
There are three periods during childbirth:
Period of cervical dilatation;
The period of expulsion of the fetus;
Succession period.
CLINICAL PICTURE
Labor for primiparous women lasts 12-14 hours, for multiparous women - 8-10 hours.
First stage of labor(the period of cervical dilation) begins with the first regular labor contractions and ends with complete (9-10 cm) dilation of the cervix, sufficient for the passage of the fetus through the birth canal. Contractions are characterized by spontaneously occurring contractions of the smooth muscle cells of the uterine body, followed by dilation of the cervix and the movement of the fetus along the birth canal outside the maternal body. Contractions at the beginning of labor last approximately 15-20 seconds, at the end - 80-90 seconds, and the intervals between contractions from 10-12 minutes (at the beginning of labor) are reduced to 2-3 minutes.
During contractions, the cervix shortens, smooths, opens and the birth canal forms.
During contractions, the presenting part of the fetus slides along the inner wall of the birth canal, exerting pressure on it, and the walls of the lower segment of the uterus and the birth canal resist the descending presenting part.
During a contraction, the amniotic sac (part of the membranes and amniotic fluid located in front of the presenting part of the fetus) fills and wedges into the cervical canal, which facilitates its opening. The opening of the cervical canal with a whole amniotic sac occurs faster than in its absence.
Untimely rupture of the membranes (premature or late) often disrupts the physiological course of labor. Premature rupture of the membranes contributes to the formation of a large birth tumor, cephalohematoma, on the fetal head, and causes impaired intracranial circulation of the fetus; it is one of the most common causes of fetal asphyxia, stillbirth and early neonatal mortality.
During the physiological course of labor, the amniotic sac is opened at the end of the period of dilatation at the height of one of the contractions and amniotic fluid in the amount of 100-200 ml is poured out.
In rare cases, by the end of the period of cervical dilatation, the fetal bladder does not rupture and it is the first to be born from the genital slit; in such cases, it is necessary to artificially open the fetal bladder with any instrument (branches of bullet forceps, Kocher forceps, forceps) or a finger, otherwise the fetus will be born in membranes, which can lead to disruption of the transition to extrauterine respiration and asphyxia of the newborn.
Management of the first stage of physiological labor is active-expectant. It is necessary to monitor the development of regular labor, the fetal heartbeat, and the advancement of the presenting part (head). To assess the nature of regular labor, the duration, intensity, frequency, and pain of contractions are determined with a hand placed flat on the mother’s stomach.
When contractions become especially strong and begin to repeat after 3-4-5 minutes (4-5 contractions in 10 minutes), you can think about the full opening of the uterine pharynx.
Listening to the fetal heartbeat during the dilatation period is carried out every 15 minutes until the amniotic fluid is released, and after the water is released - every 5-10 minutes. Normally, the fetal heart rate ranges from 120 to 140 per minute, heart sounds are clear and rhythmic. A persistent slowing of heart sounds to 100 per minute and below, as well as an increase to 160 per minute and above, indicates the onset of intrauterine asphyxia of the fetus.
During the normal course of labor, the process of dilation of the cervix coincides with the gradual advancement of the fetal head; at the end of the first stage of labor, the head is pressed against the entrance to the small pelvis and even slightly enters it.
If the presenting part is unclear, there is a suspicion of rare option insertions (frontal presentation, posterior view of facial presentation, high erect position of the head), transverse or oblique position of the fetus, all measures must be taken to urgently transport the woman in labor to an obstetric hospital.
To prevent uterine rupture during transportation, the woman in labor is given ether mask anesthesia, while oxygen is inhaled through a nasal catheter.
Second stage of labor(expulsion period) - the time from the moment of complete opening of the uterine pharynx until the birth of the fetus. After the water pours out, the contractions stop for a short time. The volume of the uterine cavity decreases. The uterine cavity and vagina constitute the birth canal. The contractions intensify again, the presenting part of the fetus (head or pelvic end) drops to the pelvic floor. The reflex contractions of the abdominal press that occur in this case also cause the woman in labor to push, repeating more and more often - every 5-3-2 minutes. The presenting part of the fetus stretches the genital slit and is born, followed by the birth of the body. Along with the birth of the fetus, the posterior waters flow out.
The expulsion period lasts from one to two hours, but not more than 4 hours. After the birth of the fetus, the third period of labor begins, the placenta, during which the placenta separates from the walls of the uterus and the placenta is born; its duration is from 5 to 20 minutes.
ADVICE FOR THE CALLER
It is necessary to keep the caller in touch until the ambulance arrives.
The woman in labor must be calmed down, isolated from others, and placed on a clean cloth or oilcloth that is at hand. Tight clothing that compresses the stomach and interferes with breathing should be removed. You should not touch your stomach with your hands or stroke it, because... this can cause irregular contractions and disrupt the labor process.
If possible, it is recommended to wash the external genitalia and inner thighs with soap and water or wipe with cotton wool moistened with a 5% alcohol solution of iodine or vodka; cover the anus with cotton wool or a piece of clean cloth. Place a clean cloth, towel, or sheet under the buttocks.
Even if you don’t know what eclampsia and preeclampsia look like in pregnant women, if there is any obvious deterioration in the woman’s condition, you should call ambulance.
Currently, the most important problem in obstetrics for a long time is such pathology as preeclampsia (PE) and eclampsia in pregnant women. Of all pregnant women, there are 5-10% cases of preeclampsia, and only 0.05% of eclampsia. Urgent Care In case of eclampsia during pregnancy, it is important to get the woman to the hospital as soon as possible.
When identifying the disease “preeclampsia”, several mandatory criteria must be met: protein in urine tests (protein exceeds 0.3), increased blood pressure (above 140/90), gestational age of pregnancy from 20 weeks.
Attention! According to statistics, the mortality rate of pregnant and postpartum women due to PE in the world is approximately 12%, in modern countries this figure increases to 30%, which remains the main reason for the acquisition of pathologies and loss of the fetus in the womb.
Main warning signs of preeclampsia
There are several forms of pathology during pregnancy:
- Arterial hypertension - hereinafter referred to as hypertension associated with the fact of pregnancy, which manifested itself for the first time during the entire pregnancy without symptoms of PE.
- Chronic arterial hypertension is a pathology characterized by an increase in blood pressure (from 140/90), detected before pregnancy or before the onset of 20 weeks of the gestational period;
- Chronic arterial hypertension, with complicated preeclampsia;
- Preeclampsia - hereinafter referred to as PE - and eclampsia.
Attention! With preeclampsia during pregnancy, it is of great importance to begin taking measures within 24 hours, to ascertain the severity of hypertension, to determine the method of delivery at any stage of gestation.
The severity of arterial hypertension is determined by pressure indicators:
- Normal pressure is characterized by an upper pressure of 140 mmHg. lower – from 90 mm Hg;
- Moderate hypertension is characterized by systolic pressure 140-159 mm Hg, diastolic pressure – 90-109 mm Hg;
- Severe hypertension is characterized by a systole pressure greater than or equal to 160 mmHg. and diastole greater than or equal to 110 mm Hg.
What should a pregnant woman and her family pay attention to?
How does preeclampsia manifest?
In the area of the nervous system, the following manifestations are possible:
- headache,
- fear of light,
- convulsions,
- tingling feeling,
- crawling sensation;
In the field of the cardiovascular system:
- heart failure,
- high blood pressure,
- critically low level blood volume in the body;
Pregnant women with kidney diseases are under close attention of a gynecologist
Symptoms from the urinary system include:
- decreased amount of urine during urination or its absence,
- presence of protein in urine tests.
In the area of the circulatory system, symptoms such as:
- decrease in hemoglobin level in the blood,
- a significant decrease in platelet count and impaired hemostasis;
In fetal development, possible symptoms are:
- fetal death during pregnancy,
- intrauterine fetal hypoxia;
In the gastrointestinal tract, symptoms may include:
- pain in the stomach area,
- urge to vomit, release of vomit;
The consequences of suffering severe PE, which determine the most unfavorable outcome: kidney pathologies, abruption of a properly formed placenta, pulmonary edema, HELLP syndrome, pneumonia, cerebral hemorrhage and others.
For preeclampsia during pregnancy, it is important to start taking action within 24 hours
Main signs of eclampsia
Attention! If the following symptoms develop:
- dyspnea,
- chest pain,
- in a blood test - a decrease in the number of platelets,
- increased liver enzymes.
- increased blood pressure
- vaginal bleeding of any amount,
It is necessary to take emergency measures to eliminate them, as they indicate the development of a critical situation. To confirm the diagnosis and objectively assess the severity, it is necessary to conduct a comprehensive examination.
First aid for eclampsia
Since complicated gestosis is accompanied by convulsions, this is the main sign of the development of eclampsia. The algorithm for providing first aid before the doctors arrive will be as follows:
| Action | Description |
|---|---|
 | If you do not have the necessary knowledge to provide first aid, you can call 03 to receive advice and an algorithm of actions. |
 | Contact an ambulance (describe the situation in detail; an ambulance will be needed to transport the woman. |
 | Place the patient on the left side of the body. Under the limbs there are blankets and pillows, which are necessary to soften the blows of the hands and feet during an attack. The side position allows foam and vomit to pass out properly without clogging the airways. |
 | In short pauses between attacks, it is necessary to remove vomit and mucus from the mouth to ensure breathing. |
 | If possible, it is necessary to administer an intravenous injection of magnesium to stop repeated attacks (administer 20 ml of the drug within 30 minutes). |
Difficulties in diagnosing eclampsia
Making a diagnosis is complicated by the fact that eclampsia does not have specific symptoms that would correspond only to it. Cramps, swelling, and proteinuria can be symptoms of other diseases that have nothing to do with gestosis.
The problem is being actively studied by gynecologists, studies are being conducted and morbidity statistics are being calculated. To date, several main examination methods have been identified to identify the initial stage of the disease - preeclampsia:
- Blood pressure control. To fully establish eclampsia, it is necessary to monitor the pressure over time.
- Measuring the amount of protein in urine tests using a daily sample (Zimnitsky test).
If preeclampsia is confirmed, subsequent convulsive seizures will indicate that the disease has acquired a complicated stage - eclampsia.
Therapeutic measures
Currently, there are no methods for preventing and treating preeclampsia that will be effective in every case of the disease. The main and most important method of treating severe forms of PE and eclampsia remains timely delivery.
The video in this article contains information about the treatment of PE and eclampsia.
Treatment of the disease should be aimed at achieving the following goals:
- exclusion of seizures (magnesium sulfate);
- determining the most accurate date of birth and method of delivery;
- antihypertensive therapy (nifedipine, atenolol, methyldopa, etc.)
Emergency situations
When emergency delivery is required. To make a decision on an emergency birth with signs of preeclampsia, bleeding from the birth canal with the risk of abruption of a fully located placenta and oxygen starvation of the child in the acute phase are used.
At the end of labor, women with severe preeclampsia may develop the dangerous HELLP syndrome. This diagnosis is made based on possible manifestations:
- Hemolysis – free hemoglobin found in serum and urine;
- Low *Elevated Liverenzimes – excessive amounts of liver enzymes such as ALT and AST;
- Platelets – insufficient number of platelets in the blood.
HELLP – syndrome, manifestations.
All this, undoubtedly, determines the high relevance of providing emergency care to a woman with signs of eclampsia, HELLP syndrome, severe eclampsia, since it is these factors that determine the risk of death of the mother and child.
A pregnant woman and her relatives should be attentive to any changes in her condition. With symptoms of preeclampsia and eclampsia, there is a threat to the life of not only the child, but also the woman herself. You need to know how to recognize this condition, and even in case of doubt, begin to provide emergency care.
Pregnant women preeclampsia or eclampsia, must be hospitalized in the obstetrics and gynecology department.
Before transport to hospital Convulsive readiness is stopped on the spot. For this purpose, intravenous administration of 1-2 ml of 0.1% rausedil solution, 2-4 ml of 0.5% seduxen solution (Sibazon), 2-4 ml of 0.25% droperidol solution or I is used. ml 2% promedol solution. To maintain the functioning of the heart, cardiac glycosides such as corglucon are administered intravenously in physiological solution in generally accepted dosages. High blood pressure is relieved by intramuscular injection of ganglion blockers such as pentamine. Along the way, if necessary, the patient is given preventive treatment for convulsive readiness.
Upon admission to hospital In the emergency department, all necessary manipulations should be performed under anesthesia with nitrous oxide mixed with oxygen.
A patient in the intensive care unit placed in an individual ward, exclude the possibility of exposure to external stimuli (loud sound, pain, bright light) and, depending on the type of gestosis, carry out specific therapy.
1. Sedative therapy for gestosis. The optimal drug for influencing the central nervous system is rausedil, which has a sedative and hypotensive effect (1 ml ampoules of 0.1% or 0.25% solution); it is administered 1-2.5 mg IV slowly. Rausedil can be successfully replaced with the tranquilizer sibazon (synonyms: seduxen, relanium). The drug is administered slowly, intravenously, diluted in 10-20 ml of physiological solution in an amount of 10-20 mg (2-4 ml). The neuroleptic droperidol has a good effect. It is also administered intravenously slowly, in dilution, in a dose of 5-10 mg (2-4 ml of 0.25% solution). These drugs reduce the excitability of brain centers and help stabilize blood pressure. To enhance the effect of sedatives, in order to desensitize and obtain an antihistamine effect, the use of drugs such as diphenhydramine (1-2 ml of 1% solution) is indicated. In case of high convulsive readiness and the need for emergency manipulations, oxygen-nitrous oxide anesthesia is indicated. If it is necessary to quickly put the patient under anesthesia, fluorotane can be used as an induction anesthesia, followed by a transition to another anesthetic.
2. Antispasmodic and antihypertensive therapy for preeclampsia, eclampsia. When carrying out antihypertensive therapy, it is necessary to combine the use of powerful, fast-acting, but with a short clinical effect, drugs such as ganglion blockers, with constant background administration of drugs that have a less powerful effect, but a longer duration of action (dibazol, no-spa, aminophylline).
Treatment for preeclampsia, eclampsia should begin with a slow intravenous injection of 3-4 ml of 1% dibazole solution (see also the topic HYPERTENSION CRISES), and then 10-20 ml of 2.4% aminophylline solution. Background medications may be antispasmodics such as no-shpa in standard doses. In the absence of the desired effect from the above antihypertensive therapy, you can try using ganglion blockers such as benzohexonium in the form of 1 ml of 1% solution IV or IM or arfonade (250 mg diluted in 150-200 ml of saline, slowly IV , drip, under constant blood pressure monitoring).
Good multilateral effect has magnesium sulfate. V. N. Serov (1989) recommends adhering to the following principles for the selection and rate of administration of this drug depending on the value of average blood pressure: up to 120 mm Hg. Art. - 30 ml of 25% magnesium sulfate solution; from 121 to 130 mm Hg. Art. - 40 ml of 25% solution, above 130 mmHg. Art. - 50 ml in 400 ml of rheopolyglucin. The recommended rate of administration is about 100 ml/hour, therefore the entire infusion will take 4 hours.
3. Infusion therapy for preeclampsia, eclampsia. In the pathogenetic therapy of eclampsia, one of the first places is occupied by infusion therapy (IT), the purpose of which is to replenish the volume of blood volume, restore normal tissue perfusion and organ blood flow, eliminate hemoconcentration and hyperproteinemia, and correct acid-base balance. They are carried out under the control of Ht and diuresis. It is not recommended to reduce the hematocrit below 30%. The total amount of fluid administered during IT should not exceed 1200-1400 ml/day, and the rate of administration should be 20-40 drops/min. Correction of hypoproteinemia is carried out by intravenous drip administration of blood replacement solutions, 100-200 ml of albumin or 150-200 ml of dry plasma. To normalize blood rheology, 400 ml of rheopolyglucin is administered intravenously. 4. Other types of therapy. To normalize vascular permeability, 5-8 ml of 5% ascorbic acid solution and hormones such as prednisolone in a dose of 60-100 mg are prescribed. To normalize the rheological and coagulation properties of blood, heparin is used at a dose of 350 units/kg/day, trental, and chimes. Dehydration therapy includes intravenous administration of 40-60 mg of Lasix. To relieve intoxication, use intravenous administration of 200-400 ml of hemodez and 200-400 ml of glucose-novocaine mixture (200 ml of 20% glucose solution, 200 ml of 0.5% novocaine solution, insulin 14-16 units). At the same time, intrauterine fetal hypoxia is prevented: oxygen inhalation, intravenous administration of glucose solutions, Riboxin, etc.
82. Eclampsia. Emergency help.
Eclampsia– clinical stage late gestosis, which is characterized by clinically pronounced multiple organ failure syndrome, against the background of which one or more attacks occur.
Clinic
Each attack lasts 1-2 minutes and has several phases that gradually replace each other.
Preconvulsant phase– characterized by small twitching of the facial muscles, closing of the eyelids, lowering of the corners of the mouth. Lasts 20-30 s.
Tonic convulsions phase characterized by tension in the muscles of the torso, the body arches, the head falls back, breathing stops, the face turns blue, loss of consciousness occurs, and the pulse is not detected. Lasts 20-30 s.
Clonic phase lasts 20-30 s and is manifested by violent chaotic contraction of the muscles of the face, torso and limbs. Then the convulsions weaken, heavy, hoarse breathing appears, foam is released from the mouth, which, due to biting the tongue, is colored with blood.
Seizure resolution phase- the convulsions stop, the patient may remain in a comatose state for some time, gradually comes to her senses, but does not remember anything that happened to her. Sometimes the coma lasts several hours, in other cases it can turn into a new attack of convulsions, which can be provoked by any irritation (pain, noise, bright light, medical manipulation, etc.). The number of attacks can range from 1-2 to 10 or more. If an attack of convulsions lasts more than 30 minutes, this condition is considered as eclamptic status.
First aid during seizures
1. Call a doctor immediately.
2. Start treatment on the spot. Place the patient on a flat surface in a lying position on the left side, avoiding injury.
3. While holding the woman, quickly clear the airway. To do this, carefully open your mouth, inserting a mouth dilator or placing a spatula (spoon) wrapped in gauze or a twisted cloth between the molars.
4. Grab the tongue with a tongue holder and bring it out to prevent it from retracting (when the tongue retracts, the root blocks the airways), insert the airway. If spontaneous breathing is still possible, administer oxygen inhalation if possible.
5. During clonic convulsions, to prevent injury from blows, cover the patient with blankets, place a pillow under her head and hold it carefully.
6. After the end of the attack of convulsions, use a gauze cloth, clamped on a forceps and moistened with a furatsilin solution, free the upper respiratory tract from foam, mucus, vomit (or using an electric suction) and, if possible, inhale oxygen.
7. For a long time apnea begin forced ventilation immediately.
8. In case of cessation of cardiac activity, perform closed cardiac massage in parallel with mechanical ventilation.
9. To prevent the next attack of seizures, as prescribed by the doctor, administer 16 ml of a 25% solution magnesium sulfate intravenously for 5 minutes under the control of blood pressure and heart rate (this drug has a pronounced anticonvulsant and sedative effect, and also gives a diuretic and hypotensive effect). If attacks continue, another 2 g of magnesium sulfate (8 ml of 25% solution) is administered over 3-5 minutes. Instead of an additional bolus of magnesium sulfate, use diazepam intravenously (10 mg) or sodium thiopental(450-500 mg) for 3 minutes.
After emergency care is provided, the patient is transported on a stretcher with the upper body slightly elevated by a specialized machine to the anesthesiology and intensive care department. In the department, the patient is placed in a separate darkened room or in the intensive care unit, where medical-protective regime, she is constantly supervised. All manipulations and examinations are carried out under the guise of anesthesia (nitrous oxide with oxygen, hexenal, sodium thiopental). Be sure to mobilize the main veins, carry out catheterization of the bladder to account for enuresis, and, if necessary, aspiration of the stomach contents with a probe to prevent regurgitation.
Complex drug treatment is carried out for 3-6 hours in order to stabilize the pregnant woman’s condition and prepare for emergency delivery.
Preeclampsia and eclampsia are severe stages of gestosis and represent a serious complication of pregnancy. According to statistics, the percentage of preeclampsia is 5-10%, and eclampsia 0.5% among the total number of women in labor, pregnant women and postpartum women.
Preeclampsia is a preconvulsive condition that is characterized by a significant rise in blood pressure, high protein content in the urine and severe edema (not the main prognostic sign).
Eclampsia is a seizure that either resolves or progresses to a coma.
Kinds
Preeclampsia and eclampsia are classified according to the period associated with pregnancy:
- preeclampsia and eclampsia in pregnancy;
- preeclampsia and eclampsia of the mother;
- preeclampsia and eclampsia of the postpartum mother.
Preeclampsia has 2 degrees of severity: moderate and severe.
Eclampsia, depending on the prevailing manifestations, is divided into cerebral, comatose, hepatic and renal.
Causes
The causes of preeclampsia and eclampsia have not yet been precisely established. There are 30 or more theories that explain the causes and mechanisms of development of preeclampsia and eclampsia. But the general opinion of all doctors is that there is a pathology of the placenta, the formation of which is disrupted in early dates pregnancy.
If the placental attachment is disrupted (superficially implanted placenta) or there is a deficiency of receptors for placental proteins, the placenta begins to synthesize substances that cause vasoconstriction (vasoconstrictors), which leads to a generalized spasm of all blood vessels in the body to increase pressure in them and increase the supply of oxygen and nutrients substances to the fetus. This leads to arterial hypertension and multiple organ damage (primarily the brain, liver, and kidneys are affected).
Heredity and chronic diseases play an important role in the development of preeclampsia and eclampsia.
Symptoms of eclampsia and preeclampsia
Signs of preeclampsia
Preeclampsia is just a short interval between nephropathy and a seizure. Preeclampsia is a dysfunction of the vital organs of the body, the leading syndrome of which is damage to the central nervous system:
- the appearance of spots before the eyes, flickering, blurriness of objects;
- tinnitus, headache, feeling of heaviness in the back of the head;
- nasal congestion;
- memory disorders, drowsiness or insomnia, irritability or apathy.
Preeclampsia is also characterized by pain in the upper abdomen (“in the pit of the stomach”), in the right hypochondrium, nausea, and vomiting.
An unfavorable prognostic sign is increased tendon reflexes (this symptom indicates convulsive readiness and a high probability of developing eclampsia).
With preeclampsia, swelling increases, sometimes for several hours, but the severity of edema does not matter in assessing the severity of the pregnant woman's condition. The severity of preeclampsia is determined based on complaints, proteinuria and arterial hypertension (an increase in blood pressure for normotensive patients above 140/90 mm Hg should be alarming). If arterial hypertension is 160/110 or more, they speak of severe preeclampsia.
Kidney damage manifests itself in the form of a decrease in the amount of urine excreted (oliguria and anuria), as well as a high protein content in the urine (0.3 grams in the daily amount of urine).
Signs of eclampsia
Eclampsia is an attack of convulsions that consists of several phases:
- First phase. The duration of the first (introductory) phase is 30 seconds. At this stage, small contractions of the facial muscles appear.
- Second phase. Tonic cramps are a generalized spasm of all muscles of the body, including the respiratory muscles. The second phase lasts 10-20 seconds and is the most dangerous (the woman may die).
- Third phase. The third phase is the stage of clonic seizures. The motionless and tense patient (“like a string”) begins to beat in a convulsive seizure. The convulsions go from top to bottom. The woman is without a pulse or breathing. The third stage lasts 30-90 seconds and is resolved with a deep breath. Then breathing becomes rare and deep.
- Fourth phase. The seizure resolves. Characteristic is the release of foam mixed with blood from the mouth, a pulse appears, the face loses its cyanosis, returning to normal color. The patient either regains consciousness or falls into a coma.
Diagnostics
Differential diagnosis of preeclampsia and eclampsia must first be carried out with an epileptic seizure (“aura” before the attack, convulsions). Also, these complications should be distinguished from uremia and brain diseases (meningitis, encephalitis, hemorrhages, neoplasms).
The diagnosis of preeclampsia and eclampsia is established based on a combination of instrumental and laboratory data:
- Blood pressure measurement. Increasing blood pressure to 140/90 and maintaining these numbers for 6 hours, increasing systolic pressure by 30 units and diastolic by 15.
- Proteinuria. Detection of 3 or more grams of protein in the daily amount of urine.
- Blood chemistry. An increase in nitrogen, creatinine, urea (kidney damage), an increase in bilirubin (decomposition of red blood cells and liver damage), an increase in liver enzymes (AST, ALT) - impaired liver function.
- General blood analysis. An increase in hemoglobin (a decrease in the volume of fluid in the vascular bed, that is, blood thickening), an increase in hematocrit (viscous, “stringent” blood), a decrease in platelets.
- General urine analysis . Detection of protein in urine in large quantities (normally absent), detection of albumin (severe preeclampsia).
Treatment of eclampsia and preeclampsia
A patient with preeclampsia and eclampsia must be hospitalized in a hospital. Treatment should be started immediately, on the spot (in the emergency room, at home in case of calling an ambulance, in the department).
An obstetrician-gynecologist and a resuscitator are involved in the treatment of these pregnancy complications. The woman is hospitalized in the intensive care ward, where a therapeutic-protective syndrome is created (a sharp sound, light, touch can provoke a convulsive attack). Additionally, sedatives are prescribed.
The gold standard for treating these forms of gestosis is the intravenous administration of a solution of magnesium sulfate (under the control of blood pressure, respiratory rate and heart rate). Also, to prevent seizures, droperidol and relanium are prescribed intravenously, possibly in combination with diphenhydramine and promedol.
At the same time, the volume of circulating blood is replenished (intravenous infusions of colloids, blood products and saline solutions: plasma, rheopolyglucin, infucol, glucose solution, isotonic solution, etc.).
Blood pressure is controlled by prescribing antihypertensive drugs (clonidine, dopegit, corinfar, atenolol).
During pregnancy up to 34 weeks, therapy aimed at maturing the fetal lungs (corticosteroids) is carried out.
Emergency delivery is indicated in the absence of a positive effect from therapy within 2-4 hours, with the development of eclampsia and its complications, with placental abruption or suspicion of it, with acute oxygen deficiency (hypoxia) of the fetus.
First aid for an attack of eclampsia:
Turn the woman on her left side (to prevent aspiration of the respiratory tract), create conditions that reduce trauma to the patient, do not use physical force to stop convulsions, and after an attack, clear the oral cavity of vomit, blood and mucus. Call an ambulance.
Medication relief of an attack of eclampsia:
Intravenous administration of 2.0 ml of droperidol, 2.0 ml of relanium and 1.0 ml of promedol. After the end of the attack, the lungs are ventilated with a mask (oxygen), and in the case of a coma, the trachea is intubated with further mechanical ventilation.
Complications and prognosis
The prognosis after an attack (coma) of eclampsia and preeclampsia depends on the severity of the patient’s condition, the presence of extragenital diseases, age and complications.
Complications:
- placental abruption;
- acute intrauterine fetal hypoxia;
- hemorrhages in the brain (paresis, paralysis);
- acute liver and kidney failure;
- HELLP syndrome (hemolysis, increased liver enzymes, decreased platelets);
- pulmonary edema, cerebral edema;
- heart failure;
- coma;
- death of a woman and/or fetus.
Some studies during pregnancy
Fortunately, most happy mothers do not know about eclampsia in pregnant women, since this condition occurs only in 0.05% of women. However, among the problems of modern obstetrics, the question of diagnosis and treatment of this disease is more acute than ever and requires further study, because domestic and foreign gynecology interprets it differently.
This dangerous condition is preceded by a variant called preeclampsia. Such pathological changes in the body are recorded in 5-10% of pregnant women. From our article you will learn why these dangerous ailments occur, how to recognize and eliminate them.
Specifics of definitions
Eclampsia and preeclampsia are conditions of pathological disorders in the body of a pregnant woman. Neither the first nor the second ailment can be called an independent disease, since they are a consequence of insufficient functionality of systems and diseases of internal organs. Moreover, their symptomatic manifestations are always accompanied by disturbances in the functioning of the central nervous system of varying degrees of severity.
Note!
Eclampsia and preeclampsia are conditions that occur only in pregnant women, in women during childbirth and in the first days after delivery.
The condition occurs as a consequence of disruptions in the relationship in the mother-placenta-fetus chain during pregnancy. The causes and symptoms of the pathology vary, so in world medical practice there is still no uniform approach to its classification. Thus, in obstetrics in America, Europe and Japan, such syndromes are associated with manifestations of arterial hypertension during pregnancy. Russian doctors believe that such manifestations are gestosis, or rather, their forms complicated by convulsions.
Preeclampsia is a syndrome that develops in the second trimester of pregnancy, with characteristic signs of persistent disorders, which are accompanied by edema and the appearance of protein in the urine.
Eclampsia is a clearly manifested symptom of a dysfunction of the brain, the main symptom of which is an attack of convulsions that quickly progress. Seizures and coma are the result of a malfunction of the central nervous system due to excessive blood pressure. 
Features of classification manifestations
The World Health Organization considers pathological disorders in the following sequence:
- Chronic course of arterial hypertension, recorded before conception;
- Hypertension that arose as a reaction of the body to the appearance and development of the fetus during pregnancy;
- Mild stage of preeclampsia;
- Severe stage of preeclampsia;
- Eclampsia.
Note!
The development of eclampsia does not always occur according to the scheme considered: it can also occur after a mild degree of preeclampsia.
Domestic obstetrics adheres to a different classification of pathology. Unlike foreign colleagues, Russian doctors assume that preeclampsia lasts a short period of time, followed by eclampsia. In Europe and America, preeclampsia is diagnosed if blood pressure exceeds 140/90 mm. rt. Art., swelling is clearly visible on the woman’s body, and the amount of protein in the daily dose of urine is more than 0.3 g/l.
Russian experts classify these same signs as nephropathy, the severity of which is determined by the severity of symptoms. The stage of preeclampsia is diagnosed if the following symptoms are added to the 3 signs described above:
- Decreased vision clarity;
- , accompanied by ;
- A sharp decrease in the amount of urine excreted.
That is, foreign experts consider nephropathy an emergency condition requiring immediate hospitalization.
The development of nephropathy and the degree of its manifestation are presented in the table.
Severe degree refers to complicated forms of pathology, when proteinuria is accompanied by the following symptoms:
- Impaired quality of vision;
- Severe attacks of headache;
- Pain syndrome in the stomach;
- Nausea accompanied by vomiting;
- Readiness for seizures;
- Massive swelling throughout the body;
- A sharp decrease in urine output per day;
- Pain on palpation of the liver;
- Changes in laboratory blood parameters.
The more severe the form of pathological changes, the greater the likelihood that the growing embryo will not withstand drug therapy, and the development of the fetus will be stopped.
There are also forms of the disease, the course of which depends on the time of their occurrence:
- Manifestations during pregnancy. The most common form of pathology. Threatens the life of mother and baby. There is a danger of termination of pregnancy when the fetus cannot withstand the effects of medications used for treatment.
- During the period of childbirth in women. Occurs in 20% of all recorded cases. It poses a danger to the life of the baby and mother. The attack is provoked by childbirth.
- Pathology that develops after the birth of a child. Appears very rarely in the first days after birth.
Note!
All forms of eclampsia develop according to the same pattern, therefore, their symptoms and treatment will be identical.
It is worth dwelling on the classification, which is based on dysfunction of any organ. In this case, the clinical picture of the disease will be different.
- Typical form. It manifests itself as severe swelling of the entire body, high blood pressure, intracranial pressure, and proteinuria.
- Atypical shape. Occurs as a result of prolonged labor in women in labor with weak nervous system. It manifests itself as cerebral edema without pronounced symptoms of swelling of the subcutaneous tissue. In this case, slightly elevated blood pressure and moderate proteinuria are observed.
- The conditions in which eclampsia manifests itself differ from the previous 2. Swelling and elevated blood pressure readings are insignificant. It is characterized by a large accumulation of fluid in the peritoneal cavity and amniotic sac.
Characteristic symptoms
In patients with a convulsive form of gestosis, the manifestations of pathology can be combined into a system of general symptoms that should be familiarized with before providing emergency care for eclampsia. These include the following manifestations:
- Persistent increase in blood pressure;
- Swelling, which most often affects the upper parts of the body;
- Frequent attacks of convulsions, the duration of which is 1-2 minutes, have small intervals between each other. Possible loss of consciousness for a short time.
- Eclamptic status. Frequent seizures occur when a woman is in a coma and does not regain consciousness.
Convulsive symptom is a clear consequence of eclampsia. The stages of its development and the characteristic symptoms of each stage are presented in the table.
Note!
After the stage of clinical convulsions, a woman may not recover. In this case, a state of coma occurs, which develops under the influence of cerebral edema. The duration of the coma depends on the time the swelling is eliminated. The longer it lasts, the less chance of a favorable outcome.
Any of the symptoms described above requires emergency care, be it eclampsia or preeclampsia. The patient should be immediately sent to the gynecological department, having previously provided emergency eclamptic care during an attack.
Specifics of first aid
Considering that the serious condition of gestosis is based on, it is impossible to do without qualified assistance from medical personnel. Treatment methods will also be prescribed by the doctor, and the emergency care algorithm for eclampsia will be as follows:
- Call an emergency medical team, informing the dispatcher about the extremely serious condition of the pregnant woman;
- It is necessary to place the patient on her left side;
- Cover the woman with soft things: blankets, pillows, blankets. This way you can prevent injury during a seizure;
- If necessary, fix the tongue so that it does not stick;
- Between attacks of convulsions, carefully remove accumulated vomit from the mouth.
To eliminate the recurrence of serial seizures, you can administer a magnesium solution intravenously.
The possibilities are determined by the arriving doctors, and assistance to the expectant mother should be carried out in an ambulance, since it may be necessary to restore breathing. They also carry out emergency measures to reduce blood pressure.
Therapeutic measures
At the initial stage of treatment for pregnant women and women in labor, it is advisable to use drugs that relieve seizures and reduce blood pressure. At the same time, swelling is relieved, which worsens the woman’s general condition.
Note!
The use of any one direction of therapy will only worsen the patient’s condition: the use of anticonvulsants without normalizing blood pressure is pointless.
Carrying out sulfate infusion therapy includes the use of such drugs.
- Medicines that relieve seizures:
- Emergency (Droperidol, Magnesia);
- Supporters (Fulsed, Andakin);
- Strengthening the sedative effect (Glycine, Diphenhydramine).
- Drugs that lower blood pressure:
- Emergency (Nifediline);
- Supportive (Methyldopa).
Note!
You need to control your blood pressure by taking medications throughout your pregnancy. All medications are used intravenously or intramuscularly.
If the attacks are severe and difficult to treat, emergency delivery is indicated. Indications for its implementation include the following symptoms:
- from the birth canal;
- Placental abruption;
- Fetal hypoxia.
At the same time, they begin to stimulate labor after stopping the attack of convulsions, choosing a natural method of delivery, since anesthesia with caesarean section may provoke another attack.
In all other cases, therapy is carried out with magnesia and prescribed medications until the severity of the pathology and the general health of the mother and baby are clarified.
