GESTOSIS

Gestosis (from lat. gestattio - Pregnancy) occurs, usually after 20 weeks of pregnancy. As the progression of clinically gestosis may manifest in the form of three symptoms: edema, hypertension, proteinuria, that diminished after delivery and most women disappear completely. The term "gestosis" combines a number of pathological condition characterized by multiple organ failure with impaired renal function and live, vascular and nerve system, one and fetoplacental complex.

What gestosis terminology used in the International Classification of Diseases (ICD-10) and English literature? The MKB-10 (010-016) gestosis indicated as follows: • pregnancy-induced edema and proteinuria without hypertension; • pregnancy-induced hypertension without significant proteinuria; • pregnancy-induced hypertension with significant proteinuria; • eclampsia. In English literature, except the term “gestosis ", we use the following terms: "preeclampsia" and "eclampsia", "hypertonia, induced pregnancy" and "EPN-gestosis (EPN - Edema, proteinuria, hypertension), and” toxemia”. For practical use of ICD-10 is inconvenient, so for clinical use (for writing the history of childbirth), we recommends adapted Russian Society of Obstetricians and Gynecologists classification match ICD-10 (Prof., Acad. RAMS GM Saveleva, prof. L . E. Murashko, prof. Radzinsky VE).

Table 13-2.Differeces in ICD-10 and Classification of Russian Society of Obstetricians and Gynecology

ICDClassification of Russian

Society of Obstetricians and Gynecology

O11 Existing previously hypertension with acceding proteinuria

Combined/Associated gestosis*

O12.2 Induced pregnant edema with proteinuria Gestosis*O13 Induced pregnant hypertension without significant proteinuria. Mild pre-ecclampsia (Mild stages of nephropathy)

Mild degree of gestosis*

O14 Pregnancy-induced hypertension with significant proteinuria

Gestosis*

O14.0 Pre-ecclampsia (nephropathy) of medium severity Medium degree of GestosisO14.1 Severe Pre-ecclampsiaO14.9 Pre-ecclampsia (nephropathy) unspecified

Severe degree of gestosisPre-ecclampsia

O15 Eclampsia (Same)O15.0 Eclampsia during pregnancy (Same)

O15.1 Eclampsia during birth (Same)O15.2 Eclampsia during post-partum period (Same)O15.9 Eclampsia with unspecified period (Same)O16 Hypertension of mother is not unspecified (Same)O16 Transient Hypertension during pregnancy (Same)Note. *Degree of severity of gestosis is divided in point scale

sWhat gestosis classification is adopted in Russia? In Russia, we adopted a classification that includes four clinical forms of gestosis: dropsy, nephropathy (three degrees), pre-eclampsia and eclampsia. Transferring forms can be considered as a single stage process, where the hydrocephalus - initial, or light, stage, and the Eclampsia - the ultimate, or most difficult, stage of gestosis. Widely-used terms form the division of gestosis in the "clean" that developed in previously somatic healthy woman, and "combine" that developed against the background of illness of the kidneys, cardiovascular system, etc.

What underlies the pathogenesis of gestosis? In the pathogenesis of gestosis leading recognize generalized spasm of vessels , hypovolemia, change their rheological and coagulation; leaf blood, disorder of microcirculation and water-salt metabolism. These changes cause hypoperfusion tissues and develop in them Dystrophy up to necrosis.

What is dropsy pregnancy pregnant? Dropsy pregnant - the initial stage of development of gestosis. In this case, general state of patients remains satisfactory. Only sometimes they complain of hard breathing and fatigue. The main symptoms of this disease are - Edema and oliguria (Fig. 13-1).

Three degrees of edema: I - lower leg edema, II – Swelling of waist and the anterior abdominal wall III – general edema (anasarca). Absence of visible edema does not always indicate the well. There are so-called hidden edema. At their appearance indicates a rapid increase in body weight of patient. Development of edema accompanied by oliguria, however, on urine analysis absent of pathological changes. Edema seen as dropsy only if they do not disappear after a night's sleep, with pathological weight gain of more than 500 grams per week and more than 2 kg per month.

What are the methods of diagnosing dropsy pregnant? For diagnostics of hidden edema produce regular weighing of women. Weight gain per week

more than 300 g and for all the pregnancies of more than 8-9 kg indicates the presence of the disease. Expose the hidden edema also helps test Мак Клура - Олдриджа: pregnant women with dropsy blister formed by subcutaneous injection of 0.2 ml of saline in the area of the forearm, dissolves in less than 35 minutes. In order to assess diuresis to calculate the water balance: the amount of fluid consumed by a woman, and daily urine output. Revealed thus confirms the diagnosis of oliguria in dropsy pregnancy.

What methods can be used pregnant self-monitoring of hidden edema? For self-monitoring of pregnancy can be used weekly weighing, measuring drunk and exudation, assessed as a <symptom of the ring.> What are the treatments for dropsy pregnant? Treatments of dropsy pregnancy begin on an outpatient basis, and with the ineffectiveness of exercise therapy in obstetrics hospital. Therapy of dropsy is the appointment of a protein salt-free diet without limitation the use of the liquid. In addition, be appointed start discharge day once in 7-10 days. During the discharge of the day the patient receives any form of 1,5 kg of apples or 1,5 kg of low-fat cottage cheese fractional portions. In the treatment of dropsy pregnancy conditions are prescribed sedatives fetopreparations (root of valerian, motherwort, etc.), herbal diuretics (hydrated tea, diuretic collection), and use of diuretics is contraindicated. In order correction of metabolic disorders using total tocopherols (vitamin E), ascorbic acid (vitamin C), rutozid, phospholipids. Apply tools that improve the rheological properties of blood and microcirculation (pentoxifylline, Dypiridamol, xanthine nicotinate), preparations of magnesium. With increasing edema on the background of the therapy of pregnant women is hospitalized in pathology department, where they spend more intensive therapy, including infusible preparations (onco-osmotherapy), as when nephropathy stage I severity. In order to designate desensitization, must start diphenhydramine of 0.05 g 1-2 times a day, and to create an emotional rest - tranquilizers: diazepam at a dose of 0,001 g, 3-4 times a day.

Treatment is performed under strict supervision of the dynamic supervision on present pregnant woman: carefully monitor body weight and diuresis. Hospital discharge is possible only after the complete disappearance of edema, normalization of body weight and diuresis. If pregnant woman does not recover, or the therapy has no effect, gestosis progresses to a more severe stage -nephropathy.

What is Nephropathy? Nephropathy - the next stage of development of dropsy state of gestosis, which lead to a pronounced pathological change in the body of a pregnant woman. Leading role in the

pathogenesis of nephropathy is disorder of vascular system, disruption microcirculation, hypovolemia (decrease in volume of circulating plasma) with involvement in the process of all vital organs and fetoplacental system.

How to distinguish the severity of nephropathy? Distinguish 3 severity of nephropathy: I degree - mild, II - moderate and III – severe nephropathy.

What are the clinical manifestations of nephropathy? The main symptoms - edema and oliguria, hypertension and proteinuria. Three leading symptom in nephropathy - edema, proteinuria and hypertension - are known as triads Tsangemeystera. In dependences of symptoms and severity of distinguish three degrees of severity nephropathy (Table 13.3). In addition, the severity of nephropathy was assessed using tables of Vittlingera and Goeka in modification by GM Saveleva (Table 13-4, 13-5).

Clinical featureStages of nephropathy

I II IIIArterial pressure, mmHg

130 and 90 – 135 and 95

140 and 90 -160 and 100

More than 160 and 100

Proteinuria, g/day <1 1 -3 >3Diuresis,ml/day >1000 400 – 1000 <400Deficit excretion of protein

Until 25% Until 25% 25% and more

SCALE OF VITTLINGERA

Symptoms Stages of protienuria Mark / BallovAbsent 0

Edema Local 2Generalize 4

Until 12 0Addition of weight, kg From 13 - 15 2

16 and more 4Absent 0

Proteinuria, g/ day Until 1 2From 2 to 3 4

From 4 and more 6120 and 80 0

BP, mm Hg 140 and 90 2160 and 100 4

180 and 110 8>1000 0

Daily dieresis, ml 900 – 600 4<500 6

Anuria >6h 8Subjective symptoms Absent 0

Present 4

Total from 2 to 10 ballov – mild stage of nephropathy, from 11 to 20 ballov – moderate nephropathy, more than 21 ballov – severe nephropathy.

SCALE OF GOEKA

SymptomsPoints

0 1 2 3Edema No On leg or

pathological increase weight

On leg, anterior abdominal cavity

Generalized

Proteinuria, g/day No 0.033 – 0.132 0.132 – 1.0 1 or moreSystolic arterial pressure, mmHg

Less than 130

130 - 150 150 - 170 170 and more

Diastolic arterial pressure, mmHg

Until 85 85 - 95 90 - 110 More than 110

Duration of manifestation of gestosis

No 36 – 40 or during labour

35 - 30 24 – 30 or earlier

ЗРП, weeks No - Gap from 1 -2 Gap from 3 -4 and more

Background of disease No Manifestation of disease before

pregnancy

Manifestation of disease during

pregnancy

Manifestation of disease before and

during pregnancy

Mild stage of gestosis – less 7 ballov, moderate stage – 8 – 11 ballov, severe stage – 12 ballov

What are the methods of diagnosis of nephropathy?The diagnosis of nephropathy is set on the basis of medical history, clinical picture and the results of laboratory studies. Putting history pregnant, you need to know the total weight gain

during pregnancy. If it is higher than 8.10 kg, with absence of other reasons (e.g., violations of fat metabolism) should think about the appearance of hidden edema.

In the presence of hypertension, attention should be paid, in what stage of pregnancy for the first time increased blood pressure, whether it was there in earlier disease accompanied by hypertension or not. Increased blood pressure in early pregnancy indicates beginning of somatic diseases (hypertension, chronic nephritis, vegetative vascular dystonia by hypertonic type). If gestosis develops on the background of these diseases, it is combined gestosis. Combined gestosis always more severe.

All pregnant women need to produce dynamic control of BP level, which is measured on both hands. Identification asymmetry indications of 10 mmHg and more than level of normal BP shows initial forms of nephropathy. Assessment of BP production lead to the initial level. Increased systolic blood pressure by 15-20%, and diastolic - by 10% in comparison with the outcome should be regarded as an expression of hypertension. Unfavorable prognostic sign is the increase diastolic pressure even at relatively low level of systolic blood pressure (e.g., 135 and 105 mm Hg). It is generally accepted to consider not only systolic and diastolic blood pressure, but average blood pressure (ABP). ABD is calculated by adding the systolic pressure and two diastolics. The resulting amount is divided by 3, the ABD should increase during pregnancy 100 mmHg (ABP = AD + 2DD / 3).

Vascular changes are reflected in the picture fundus. In the study of eye fundus noted phenomenon hypertonic angiopathy: a spasm of retinal arteries and veins with precapillary edema, hemorrhages in the retina and swelling. To identify proteinuria in pregnancy after 32 weeks is to produce a urine sample daily. In the presence of proteinuria in the early stages of urine sample is repeated every 3-4 days. When collection protein in the urine, the appearance of the cylinders to divide the blood content to residual nitrogen, urea, to produce a sample of Zomnitski, analysis of blood electrolytes. Increase number of units of residual nitrogen in the blood, even if his figures are within the physiological, is an unfavorable sign, is evidence of the disorder of nitrogen excretory kidney function.

What liver function abnormalities develop during gestosis? Disorders of the liver develop in severe course of gestosis and expressed changes of protein and lipid metabolism, homeostasis system, which manifests itself in the form of chronic DIC (disseminated intravascular coagulation).

Disorders of the protein function of the liver characterized by reduced protein content in the blood to 60 g /L and below, a shift albumin-globulin coefficient in the direction of globulins (less than 1). Disorders whether pidnogo exchange expressed reduced high density lipoprotein and increased low-density lipoproteins. Reduced functional activity of the liver leads to change general and toxic (not associated with glucoronic acid), an indirect bilirubin. Disorders of

protein, lipid metabolism, affects microcirculation, hypertension and other pathophysiological changes in gestosis contribute to disorder in fetoplacental system which is manifested by hypoxia and fetal hypotrophy. Particularly difficult during gestosis gets when there are situation HELLP syndrome and acute liver steatosis in pregnancy.

What is HELLP syndrome? HELLP syndrome: (H –hemolysis) - hemolytic anemia, (EL – elevated live enzymes) - increase the concentration of liver enzymes in the blood, (LP – low platelet count) – reduce number of platelets in 1ml of blood to 150 thousand or less. In the lab analysis of anemia, thrombocytopenia, increased transferase activity 10 times or more shows rapid early delivery.

What is acute steatosis pregnant? During the acute fatty liver, which usually develops in first pregnancy, distinguish two periods. First, anicteric, can last from 2 to 6 weeks. For him, character s: reduction or loss of appetite, weakness, heartburn, nausea, vomiting, pain and feeling of heaviness in the epigastric region, itchy skin, and decrease body weight. Second, yellow, final period of disease characterized by stormy clinical picture is characterized by hepatic-renal insufficiency: jaundice, oligoanuria, peripheral edema, accumulation of fluid in serous cavities, uterine bleeding, and antenatal death of fetus. For biochemical analysis of blood revealed: hyperbilirubinemia due to direct fraction hypoproteinemia (<60 g / L),hypofibrinoemia (<2 g /L), not expressed thrombocytopenia, a slight increase in transaminases. In vivo acute fatty liver pregnant often develop hepatic coma with dysfunction of the brain from minor disorders of consciousness to his deep loss of inhibition of reflexes.

What are the principles of modern treatment of gestosis? Treatment of pregnant women with nephropathy conducted only under conditions of hospitalization. Therapy of gestosis, based on the known impact of the pathogenesis of disease is complex. It aims to: • normalization of osmotic and oncotic pressure; • elimination of vascular spasm and reduction in blood-pressure; • Establishment of medical protective regime; • elimination of hypoxia and metabolic disorders; • improving the rheological properties of blood and normalization of a system of homeostasis; • maintaining the function of vital organs; • prevention and treatment of hypoxia and malnutrition of the fetus.In the treatment of severe forms of nephropathy apply extra corporal methods of detoxification and dehydration: plasmapheresis and ultra filtration.

What is the basic therapy of gestosis? In modern conditions the basic therapy of gestosis is onco - osmotherapy, which occupies a special place of magnesium sulfate, provides, good therapeutic antihypertensive effects. It contributes to eliminate brain edema, decrease intracranial pressure, hold dehydration and

sedative action, normalizes osmotic pressure. A solution of magnesium sulfate (25%) injected internal stream via infusion pump or, at a small number (up to 200 ml) solution of 5% glucose at a speed of 1 g per hour. Dose determines the degree of severity of gestosis (Table 13-6).

Table 13-6. Basic therapy for gestosis. (onco-osmotherapy)

Nephropathy I degree - Up to 12 g Nephropathy II degree - Up to 18 gNephropathy III degree - Up to 25 g Preeclampsia – Up to 25gEclampsia - Up to 50 g

Of these, 4 g in the first hour, the rest - for 23 hours in equal shares. With intravenous drip of magnesium sulfate is necessary to monitor urine output, tendon reflexes and frequency of respiration, which must not be less than 14 per minute. To normalize oncotic pressure and treatment of hypoproteinemia use intravenous drip 400 ml Hydroxyethylstarch, 200-250 ml one group of fresh frozen plasma or 10-20% albumin solution. Also use the solution dextran (reopoliglukin). At the present time to deal with hypovolemia and impaired microcirculation preference to give preparation of Hydroxyethylstarch, which is able to bind and retain water in the intravascular space in internal vessels.

What drugs are used additionally for hypertension? Hypertension used antihypertensive preparations: • aminophylline - intravenously 10 ml of 2.4% solution; aminophylline vasorelaxant, spasmolytic improves renal blood flow and reduces tubular reabsorption, reapplied aminophylline after 6 h, does not recommend the drug for severe tachycardia; • dibasol - 4-6 ml 0,5-1% solution injected intramuscularly 2-3 times per day; • methyldopa reduces blood pressure, slows heart rate, decrease peripheral vascular resistance; contraindicated in acute liver disease; designate from 0,25 g to 1 g per day in 2-3 doses; • Clonidine - lowers blood pressure, reduces peripheral vascular resistance, has sedative effect; appoint 0,075 mg 2-4 times a day sublingually, should not be combined with other hypotensive drugs, with severe gestosis injected IV slowly from 0,9% sodium chloride to 1 ml 0.01% solution; •Nifedipine – blocker of slow calcium channel, lowers arterial blood pressure, increases peripheral artery pressure; used by 10-20 mg 3 times per day sublingual ; not apply when tachycardia; shown at threat for premature birth; • Prazosin – selective alpha adrenoblocker decreases blood pressure, decreases total peripheral vascular resistance, improves renal and brain blood supply; to be taken by 0.5 mg 2-3 times a day; • Nitroprusside sodium (and other drugs of nitric oxide) reduces blood pressure, prescribed by

50-100 mg / day; • nebivolol - highly selective beta-blocker, modulate synthesis of nitric oxide, appointed by 2.5 mg, 2 times a day; • azamethonium bromide, 5% solution, referred to as ganglioblocker, injected with 0.9% sodium chloride in the amount of 1,0 ml. Ganglioblockers apply in case of insufficient effect of other antihypertensive therapy. Using ganglia blockers must carefully control arterial blood pressure. Repeat introduction of the preparation within 1-2 hours.

In avoidance of orthostatic collapse within 2 h after the introduction of ganglinoblockers pregnant women should stay in horizontal position. In the first stage of labor used azamethonium bromide of 50 mg of IM or IV. Intravenous azamethonium under the control of blood pressure in the second stage of labor is called "controlled normotonii" or "controlled hypotension".

By what methods and means we can achieve the elimination of hypoxia, intoxication, metabolic disorders and increased blood volume? To eliminate hypoxia and metabolic disorders using a solution phospholipid (Essentiale), 2-5 ml of ascorbic acid in a 5% solution (injected), total tocopherols, or a-tocopherol acetate (vitamin E), but 200-300 mg per day. The latter has antioxidant activity and normalizes the activity of platelets.

Increased Blood volume, improve microcirculation, removal of intoxication, correction of metabolic disorders produced using infusion therapy. Indication for infusion therapy are severe forms of dropsy pregnancy, nephropathy, preeclampsia, and eclampsia.

What means are used to improve the rheological properties of blood and normalization of homeostasis? • To improve rheological properties of blood and normalization of the homeostasis system used pentoxiphylline, which improves microcirculation and reduces viscosity of blood. Assign the drug in pill form, but 0.2 g, 2-3 times daily or 5 ml, diluted in 200 ml 5% glucose solution or dextran. • Acetylsalicylic acid normalizes platelet aggregation, reduces permeability of capillaries. Applied by low dose, 100 mg per day. • Heparin or Nadroparin calcium - anticoagulant direct action, apply a dose of 2,5-5 thousands ME (heparin)or 0,2-0,3 ml (nadroparin calcium) 1-2 times a day. Drugs injected into the subcutaneous space of abdomen. Therapy straight anticoagulant absent only under the supervision of the homeostasis system. • Solution Hydroxyethylstarch normalizes microcirculation and improves the rheological properties of blood, it is injected by intravenous drip (200-400 ml).

What are the principles of fluid therapy? The duration of therapy is determined by its efficiency. When severe nephropathy, infusion therapy is carried out daily. The composition of it changes depending on the clinical and laboratory data. Infusion therapy in pregnant women with gestosis need to be done in caution under the control of urine output and hematocrit, which is lower than 27% said on hemodilution, and increased more than 45% - about hemoconcentration, also requires monitoring of acid-base status of blood, its biochemical composition and homeostasis. total fluid intake of pregnant woman with gestosis should more than 1200-1400 ml per day, in condition of normal diuresis. Infusion therapy is done until a persistent improvement in the overall condition, decrease blood pressure, restoration of diuresis. At birth and during the heavy nephropathy number of input of liquid is limited to 300-500 ml.

What is medical protective regime for V.V. Stroganov? Medical protective mode based on the decrease of excitability of the brain, stabilization neurovegetative reaction. At the present time to reach with help neurotropic preparations - neuroleptics (droperidol), tranquilizer (diazepam) and narcotics (trimeperidin). For progressive state neurolepsy combine IV diazepam and droperidol.

What is the tactics of labor with nephropathy? In addition to stated above therapy in childbirth, shown early and thorough anesthesia. The best method of anesthesia for in nephropathy is epidural anesthesia, which, exclude pain relief effect, provoke arterial hypotension. All activities and manipulations in patients with nephropathy II and III stage conducted after the introduction of tranquilizers or neuroleptics (vaginal examination, IV infusion and opening of amniotic sac, etc.). To make early amiotomy must have opening of the amniotic sac in latent phase of labor, up to 3-4 cm opening cervix of the uterus. This helps reduce the intrauterine pressure and acceleration of labour.In the second stage of labor with high blood pressure showed permission with help of obstetrician forceps to a quick end the birth. It is allowed to avoid operations of imposition of obstetrical forceps, if the arterial pressure is lowered with the help of normotonic (hypotonia) ganglionblockers.

Deliveries are constant monitoring mother, fetus and activity of the uterus, requiring a partogramm. Non rational management of pregnancy and childbirth, absent treatment or its inefficiency can lead to the development of the next phase of gestosis - preeclampsia.

What is pre-eclampsia and what are its clinical manifestations? Pre-eclampsia - an intermediate stage between nephropathy and eclampsia. In the development pre-eclampsia to clinical manifestation of nephropathy, there are symptoms indicating dysfunction of the central nervous system - symptoms of hypertensive encephalopathy. Patients complain of headache, pain in the epigastric region, blurred vision, nausea and vomiting.

There is a rise of all symptoms: blood pressure increased to 180 and 110 mmHg and more, increased proteinuria, and increased edema. Blood pressure is characterized by rapid rise with a simultaneous decrease in its amplitude. When examining eyeball, there is a sharp angiospasm of arterioles, hemorrhage, and edema and detachment of retina. Azotemia increases, hypoxia develops until severe acidosis, deteriorating function of all critically important organs, reduces utero-placental blood flow, progresses to chronic DIC. Any stimulus can lead to the development of convulsive seizure - eclampsia.

What therapy and tactics for symptoms of pre-eclampsia? When pre-eclampsia symptoms appears (headache, amblyopia, pain in the epigastric region), patients is immediately anesthetized and begin intensive therapy, as such in nephropathy III degree/stage. Ineffective treatment or deterioration of the pregnant woman in labor or no conditions for natural delivery, deliver via caesarean section. If this condition happens in the second stage of labor, immediate elective delivery with help of obstetric forceps must be done. All manipulations and operations are performed under anesthesia, as pre-eclampsia can quickly developed into next stage of gestosis - eclampsia.

What is eclampsia? Eclampsia - the most dangerous stage of gestosis, characterized by rapid growth of cerebral symptoms and the appearance of seizures. The danger of an attack of eclampsia is the fact that during the attack, bleeding may occur in the retina of the eye and the brain or other vital organs, and therefore the possibility of loss of vision and a fatal outcome. The fetus may die from hypoxia due to disturbance of utero-placental circulation, which can be acute (premature placenta abruptio) or chronic (and worsening angiospasm and progressive DIC syndrome).

What are the clinical symptoms of eclampsia? Development of eclampsia is preceded by symptoms that indicate a significant stimulation of the central nervous system. Note that increase reflex irritability (hypereflexia), hyperesthesia. Bright light, noise, pain stimuli can provoke seizures.

Clinically, eclampsia can be divided into four stages:• 1st stage - short. Pregnant appear small fibrillating muscle, twitching of eyelids, extension

of muscles of the face and upper limbs. Staring look. Breathing is normal. This period lasts about 20-30sec.

• 2nd stage is characterized by tonic convulsions. Pale face, clenched, jaw dilated eyes. Unconsciousness. Breathing stops, the pulse not presence. The period lasts about 20-30s.

• 3rd stage is characterized by clonic convulsions, following each other and spread downward. Unconsciousness. Breathing difficulties or none at all, the pulse is not identified, the person becomes a purplish-blue. Gradually the spasms stopped. The period lasts from 30 sec to 1 min or more.

• 4th stage - Resolution of attack. Restored the breath of his mouth stands ieiistaya saliva mixed with blood as a result of the biting tongue. Face is pink in color, narrowed eyes, pulse

is at first frequent and thready. After the attack, the patient is in coma, and then slowly becomes conscious. On the fit, patient did not remember complaining of headache, weakness, broken. Eclampsia causes progression of severe multiple organ failure that can lead to death of women.

What are the complications encountered in severe gestosis and eclampsia? Outcome of severe forms of gestosis and eclampsia may be:

• heart failure accompanied by pulmonary edema; • brain hemorrhage, thrombosis, cerebral edema, coma; • DIC with circulatory disturbance of the vital organs, and bleeding; • hepatic insufficiency; • renal failure; • acute syndrome of respiratory disorders- ASRD • bleeding in the retina and its detachment; • premature placenta abruptio; • Hypoxia, malnutrition, the death of the fetus.

What is the tactics physician in eclampsia? Tactics of doctor is to provide emergency and intensive care. At the time of seizure, to avoid biting of the tongue, impose gag and glossotilt. Pregnant women must immediately anesthetize, better to use halothene. With anesthesia comes a comprehensive intensive care. All manipulation and intervention is performed under general anesthesia. One of the stages of emergency relief is immediate delivery. If there are no conditions for delivery through the vaginal with obstetric forceps, then do caesarean section under endotracheal anesthesia, followed by mechanical ventilation.

Indications of doing cesarean section in gestosis are: • deterioration despite ongoing therapy; • eclampsia (if there are no conditions for labor with obstetric forceps); • cerebrovascular disturbance; • coma; • acute renal failure; • premature placenta abruptio; • Deterioration of a viable fetus.

In the second period, labor ends with the operation with obstetric forceps. Intensive therapy is continued until there is a persistent improvement (achievement of stable hemodynamics, normalization of liver function and kidney).

Which obstetric pathology may lead to gestosis? Gestosis is a serious danger to the health of mother and newborn. High blood pressure, dysfunction of critically important organs and hemostasis, morphological changes in the

placenta caused by gestosis, can lead to premature detachment of the placenta. With disorder of tissue metabolism in myometrium from women giving birth in the first and second stage of labor may develop weakness of the clan's activities and in the postpartum period - hypotonic bleeding. In pregnant women with gestosis, circulating blood volume – CBV (Объем Циркулирующей Крови - ОЦК) reduced, so even a small amount of blood loss but can cause decompensation. In expected mothers with gestosis, it is necessary to prevent bleeding by intravenous oxytocin at the end of the second period, in the third stage of labor and early postpartum period.

In the presence of blood loss during delivery, blood must be adequately filled with time and volume. In gestosis, physiological blood loss may amount to 0.3% of body weight (in healthy birth up to 0.5%). Blood loss is one of the most frequent causes of terminal states in patients with gestosis. The terminal condition can also be a consequence of disorders of cerebral circulation with brain hemorrhage or severe injury of parenchymal organs - hepatic-renal insufficiency.

This pathology, as gestosis can not affect the condition of the fetus. As a result of disturbance of utero-placental blood circulation and gas exchange in the fetus, chronic hypoxia may developed and, as a consequence - placental insufficiency. Chronic hypoxia has often become the cause of asphyxia in the birth of children. Therefore, during childbirth is necessary to prevent fetal hypoxia, and after the birth, to be ready to provide newborn with intensive care benefits.

What are the risk factors for development of gestosis? Risk factors for the development of gestosis are extragenital pathology, the presence of gestosis in amnesis, young age and late pregnancy, multiple pregnancies.