Gestoz (late toxicoses of pregnant women, PTG) – the pathological conditions of the second half of pregnancy which are characterized by a triad of the main symptoms: hypostases (hidden and visible), proteinuria (availability of protein in urine), hypertensia (permanent increase in arterial pressure). Is followed by disorders of functions of the vital systems: cardiovascular, nervous, endocrine, hemostasis. On severity of violations distinguish , dropsy of pregnant women, a nephropathy of pregnant women, a preeklampsiya and an eklampsiya. Can be the reason of maternal and child mortality.
Gestoz or late toxicosis of pregnant women is called the complicated current of the III trimester of pregnancy which is characterized by development of deep violations in vitals and systems, especially in the vascular course and blood circulation. Gestoz begins to develop after 18-20 weeks of pregnancy, and comes to light most often after 26-28 weeks. Gestoz accompanies 20-30% of pregnancies and is one of the most frequent reasons of the complicated childbirth (in 13-16% of cases), including, maternal mortality and death of a fruit. In clinical forms of a gestoz distinguish dropsy, a nephropathy, a preeklampsiya and an eklampsiya of pregnant women. Clinical forms of a gestoz can also be consecutive stages of uniform pathological process, beginning with hypostases at dropsy of pregnant women and gradually developing in the most severe form – an eklampsiya.
Late toxicoses of pregnant women divide into the pure and combined gestoza. Pure develops against the background of pregnancy at the women who do not have associated diseases, and combined – at the women having various diseases in the anamnesis. The adverse current of a gestoz is observed at the pregnant women having a hypertension, renal pathology (pyelonephritis, glomerulonefrit), by diseases of biliary tract and a liver (dyskinesia, earlier postponed hepatitis), endocrine glands (adrenal glands, thyroid, a pancreas), violations of lipidic exchange.
Reasons and mechanisms of development of a gestoz
Still the obstetrics and gynecology have several theory about the reasons and development of a gestoz therefore it is often called "a disease of theories". Kortiko-vistseralnaya the theory treats as a disease at which the physiological interrelation between bark and subcrustal structures of a brain is broken that causes reflex changes in vessels and the blood circulatory system. The important place in development of a gestoz is allocated to violation of hormonal regulation of the vital functions, and also the immunological conflict of fabrics of a fruit and mother. Also are suggested about a heredity role in emergence of a gestoz. The opinion on the combined influence of various factors in the mechanism of development of a gestoz is considered standard.
At the heart of the violations causing emergence of the generalized angiospasm causing violation of blood supply of fabrics and bodies lies. The vascular spasm causes increase in arterial pressure, reduction of total amount of the blood circulating in the vascular course. These mechanisms of development of a gestoz lead to violation of food and normal functioning of cages and fabrics. Defeat of an internal cover of vessels – the endoteliya causes increase in permeability of a vascular wall and sweating of liquid in fabrics, change of fluidity, viscosity and coagulability of blood, tendency to a tromboobrazovaniye in the vascular course. The greatest sensitivity to insufficient blood supply and oxygen starvation cells of a brain, kidneys, a liver and a placenta have.
At a gestoza of pregnant women there are structural and functional violations in a brain: microcirculation violation, formation of blood clots, dystrophic changes of nervous cages, development of melkotochechny or melkoochagovy hemorrhages, increase in intra cranial pressure. Violation of functioning of kidneys at a gestoza can variously be shown: from emergence in protein urine before development of a sharp renal failure. Disorder of blood circulation in liver tissues at a gestoza causes development of focal necroses and hemorrhages. Violation of placentary blood supply at a gestoza leads to development of a hypoxia and a pre-natal arrest of development of a fruit.
Clinical manifestations of a gestoz
As early manifestation of a gestoz serves the dropsy which is characterized by a delay in an organism of liquid and emergence of persistent hypostases. In the beginning hypostases usually happen hidden, and it is possible to judge them only on excessive (over 300 g a week) or to uneven increase in body weight. Emergence of visible, obvious hypostases forms a basis to classification of stages of dropsy:
- The I stage of dropsy – hypostases of legs (feet and shins)
- The II stage of dropsy - hypostases of legs and a forward belly wall of a stomach
- The III stage of dropsy - hypostases of legs, a stomach, hands and the person
- The IV stage of dropsy – generalized, universal hypostases
Hypostases at a gestoza develop as a result of reduction of a diuresis and a delay in a liquid organism. Hypostases at first are formed on anklebones, then extend above. Sometimes hypostases are at the same time formed on a face. In the mornings puffiness is less expressed since during a night dream liquid is distributed on all fabrics evenly. During the day hypostases fall by the lower extremities and a bottom of a stomach.
At dropsy the general health and a condition of pregnant women usually is not broken. At the expressed hypostases of the woman complain of fatigue, feeling of weight in legs, I am eager. At development of a gestoz hypostases come to light by survey, systematic weighing of the woman and measurement of her diuresis. Development of hypostases at a gestoza is demonstrated by an excessive increase of body weight and a negative diuresis (prevalence of amount of the drunk liquid over allocated).
The combination of a triad of symptoms is characteristic of a nephropathy of pregnant women with gestozy: hypostases, a hypertension of pregnant women (increase in arterial pressure) and a proteinuria (emergence in protein urine). Even existence of any two specified symptoms, allows to speak about a nephropathy. Development of a nephropathy at a gestoza, as a rule, is preceded by dropsy of pregnant women. Increase in indicators of arterial pressure up to 135/85 mm hg is regarded as manifestation of a nephropathy above. At a gestoza to know basic data of arterial pressure before pregnancy and in the first half of pregnancy.
Pathological increase in arterial pressure at pregnant women increase in its systolic indicators from 30 mm hg above in comparison with initial figures and diastolic - from 15 mm hg is considered above. Especially important indicator at a gestoza is rise in the diastolic pressure demonstrating decrease in placentary blood circulation and oxygen insufficiency of a fruit.
Development of dangerous complications at a gestoza (bleedings, a premature otsloyka of a placenta, death of a fruit) is caused not so much by high rates of arterial pressure, how many its fluctuations. The proteinuria (emergence in protein urine) at a gestoza demonstrates progressing of a current of a nephropathy. At the same time at the pregnant woman the daily diuresis (urine volume) decreases to 500-600 ml or less. The diuresis is lower and the current of a nephropathy is longer, the further forecast for a current and the result of pregnancy is worse.
Also the combined forms of a gestoz - the nephropathy which developed against the background of a hypertension, nephrite, heart diseases etc. worsen the forecast. At a long current the nephropathy can pass into heavier stage of a gestoz – a preeklampsiya, to cause development of a renal failure, bleedings, premature birth, hypoxias and hypotrophies of a fruit, asphyxia of newborns, pre-natal death of a fruit. At inspection of women with gestozy the characteristic of the vessels of an eye bottom reflecting a condition of brain blood circulation has important diagnostic value.
Preeklampsiya at a gestoza of pregnant women usually develops from severe forms of a nephropathy and is characterized by primary disorder of blood circulation of the central nervous system. Headaches, weight in a nape, pain in the right podreberye and subspoon area, nausea, quite often vomiting join nephropathy symptoms in this stage of a gestoz. Also the memory violation, drowsiness or sleeplessness, irritability, slackness, indifference, disorder of sight (feeling of a veil, fog, grid and flashing of front sights before eyes) demonstrating violation of blood circulation of a brain and damage of a retina are noted. Quite often there are pains in an epigastriya and the right podreberye caused by small hemorrhages in walls of a stomach and tissue of a liver.
The main indicators characterizing a stage of a preeklampsiya of a gestoz of pregnant women:
- arterial pressure - 160/110 mm hg above;
- amount of protein in urine - from 5 g and more in days;
- diuresis less than 400 ml;
- visual and brain violations;
- nausea and vomiting;
- decrease in platelets in blood and indicators of system of coagulability of blood;
- disorder of functions of a liver.
The heaviest manifestation of a gestoz of pregnant women is the eklampsiya which is characterized by progressing of signs of a nephropathy and preeklampsiya, and also spasms with consciousness loss. At an eklampsiya development of a convulsive attack can be provoked by the external irritating factors: river pain, sound, bright light, stress. Duration of a convulsive attack makes 1-2 minutes, the century, persons begins with twitching of muscles, extending then to muscles of extremities and all body. The look stiffens, pupils are rolled up under a mobile eyelid, corners of a mouth fall, fingers of hands clench in fists.
In 30 seconds tonic spasms develop: the body of the pregnant woman strains and extended, the backbone is curved, the head is thrown back back, jaws clench, skin gets a cyanotic shade. In view of involvement of respiratory muscles there comes the termination of breath and loss of consciousness. During this period there can come hemorrhage in a brain and the death of the pregnant woman.
10-20 seconds later there come clonic spasms: the patient fights in spasms, continuously moving hands and legs and, as if, jumping up in a bed. In 30 seconds-1,5 minutes, by the end of an attack of a spasm weaken and stop, breath appears hoarse, with release of foam from a mouth. Quite often, in connection with biting of language, foam is painted by blood. In 30 seconds breath is leveled, skin turns pink, pupils are narrowed. After consciousness return the patient does not remember an attack, feels the general weakness and a headache. Any irritants (injections, a loud talk, researches, pain) can cause the beginning of a new attack.
At an eklampsiya there can be life-threatening mothers and a complication fruit: a hemorrhagic stroke, hypostasis of a brain and lungs, an otsloyka of a retina, an otsloyka of a placenta, hemorrhage in kidneys and a liver, a coma. At a gestoza development of a bessudorozhny form of an eklampsiya when coma develops suddenly against the background of high rates of arterial pressure is dangerous. Often such form of an eklampsiya is caused by a cerebral hemorrhage and conducts by a lethal outcome.
Eklampsy at a gestoza of pregnant women should differentiate from an epileptic attack which is characterized by existence of epilepsy in the anamnesis of the woman, normal analyses of urine and indicators of arterial pressure, epileptic shout before a convulsive attack.
Diagnostics of a gestoz
At diagnostics of a gestoz take amnestichesky data, complaints of the pregnant woman, results of objective and laboratory researches into account. For the purpose of assessment of extent of violations at a gestoza it is expedient to conduct researches:
- the curtailing system of blood (koagulogramm);
- general blood test;
- general and biochemical analyses of urine;
- biochemical indicators of blood;
- ratios of volume of the used liquid and the emitted urine;
- arterial pressure;
- dynamics of change of body weight;
- conditions of an eye bottom.
For specification of a condition of a fruit and a placentary blood-groove at a gestoza ultrasonography and doppler sonography of a uterine and placentary blood-groove is carried out. At a gestoza consultations of the oculist, the therapist, the neurologist, the nephrologist are in addition necessary.
Complications of a gestoz
Development of complications of a gestoz is always accompanied by death of the pregnant woman and a fruit. The current of a gestoz can be complicated by development of renal and heart failure, hypostasis of lungs, hemorrhages in a liver, adrenal glands, kidneys, intestines, a spleen, a pancreas.
Characteristic complications of a gestoz are premature peeling of normally located placenta, the placentary insufficiency conducting to an arrest of development, a hypoxia and a hypotrophy of a fruit. At a heavy current of a gestoz HELLP syndrome which name is an abbreviation of symptoms can develop: H - a gemoliza, EL - increases in level of hepatic enzymes, LP - decrease in level of platelets.
Treatment of a gestoz
The basic principles of treatment of the arisen gestoz are: implementation of hospitalization and observance of medical and guarding actions, elimination of violations in functioning of vitals and systems, a careful and bystry rodorazresheniye. Out-patient treatment of a gestoz is allowed only at the I stage of dropsy. Pregnant women with heavy gestoza (a nephropathy, preeklampsiy, eklampsiy) are hospitalized in hospitals with existence of the resuscitation block and office for premature children. In especially hard cases of a gestoz early termination of pregnancy is shown.
Medical actions at a gestoza are directed to prevention and treatment of the complicated pregnancy and pre-natal violations of a fruit (a hypoxia, a hypotrophy and an arrest of development) by normalization:
- activity of the central nervous system;
- circulation, coagulability, viscosity of blood;
- exchange processes;
- conditions of a vascular wall;
- indicators of arterial pressure;
- water-salt exchange.
Duration of treatment of a gestoz depends on degree of expressiveness of its manifestations. At easy degree of a nephropathy hospitalization is performed not less, than for 2 weeks, at average degree – for 2-4 weeks taking into account a condition of a fruit and the pregnant woman with the subsequent extract under observation in antenatal clinic. Severe forms of gestoz (a nephropathy, a preeklampsiya and an eklampsiya) are treated in a hospital under observation of resuscitators up to a rodorazresheniye.
The early rodorazresheniye at a gestoza is shown at a resistant nephropathy of average weight if the effect of treatment is absent within 7-10 days; severe forms of a gestoz in cases of unsuccessfulness of actions of intensive therapy for 2-3 h; the nephropathy which is followed by an arrest of development and growth of a fruit against the background of the carried-out treatment; eklampsiya and its complications.
Independent childbirth at gestoza of pregnant women is allowed at satisfactory condition of the woman in labor, efficiency of the carried-out therapy, lack of pre-natal violations of development of a fruit by results of cardiomonitor and ultrasonic researches. Negative dynamics with gestozy (increase in indicators of arterial pressure, existence of brain symptoms, increase of a hypoxia of a fruit) serves as the indication to an operational rodorazresheniye in a condition of the pregnant woman.
Prevention of a gestoz
The factors contributing to development of a gestoz are: hereditary predisposition, chronic pathology of internals at the pregnant woman (kidneys, heart, a liver, vessels), a Rhesus factor conflict, polycarpous pregnancy, a large fruit, pregnancy at the woman is more senior than 35 years. Prevention of a gestoz at women with risk factors has to be carried out since the beginning of the II trimester of pregnancy.
For the purpose of prevention of development of a gestoz in pregnant women the organization of the rational mode of rest, food, physical activity, stay in the fresh air is recommended. Even at normal development of pregnancy restriction of the use of liquid and salt, especially in its second half is necessary. An important component of prevention of a gestoz is conducting pregnancy throughout all term: early registration, regular visits, control of body weight, arterial pressure, laboratory researches of urine etc. Purpose of medicamentous prevention at gestoza depends on associated diseases and is carried out according to individual indications.