Vomiting of pregnant women of moderate severity. Vomiting in pregnant women at different times: diagnosis and treatment. Treatment of vomiting during pregnancy

19.10.2019 Pathology of the uterus

Excessive vomiting of pregnancy (EPP) occurs with a frequency of 3-10 cases per 1000 pregnancies. predominant in the urban population.

Excessive vomiting is a complication of pregnancy, manifested by uncontrollable nausea and vomiting that develops in early pregnancy and leads to fluid and electrolyte imbalance and weight loss.

Carry out rehydration - replenishment of fluid loss, correction of violations of electrolyte metabolism and acid-base balance.

With vomiting lasting 3 weeks or more, drug treatment begins with the appointment of balanced vitamin-mineral complexes, then pyridoxine (vitamin B6) and thiamine (vitamin B1) are added.

Antiemetic (antiemic) drugs should be prescribed strictly in the specified sequence. Each subsequent remedy can be prescribed only if the previous drug is ineffective.

Antiemetic (antiemic) drugs of the 1st group

These drugs are considered safe for mother and fetus:

pyridoxine (vitamin B1), 5% solution is taken at 0.25-0.5 ml 2-3 times a day;

avioplant (ginger rhizome powder) - 250 mg 4 times a day;

mint tablets - 2.5 mg 4 times a day.

Perhaps a combination of drugs of the first group among themselves.

Antiemetic (antiemic) drugs of the 2nd group

These drugs belong to safety group B - there is no evidence of a risk to health.

Means related to prokinetics:

metoclopramide (cerucal, raglan) in the form of a solution is used 2.0 ml (10 mg) intramuscularly or intravenously 2-3 times a day, then 1 tablet (10 mg) 3-4 times a day 30 minutes before meals at bedtime up to 4 weeks

Antiemetics, which are more often positioned as antihistamines (antiallergic) drugs:

dimenhydrinate (aviomarin, dedalon, dramina) 50 mg 4-6 times a day up to 400 mg / day;

diphenhydramine (diphenhydramine) 1% 1 ml intramuscularly, intravenously 1.0-5.0 ml, then in tablets of 0.05 g 3-4 times a day up to 300 mg per day.

Antiemetic (antiemic) drugs of the 3rd group

These drugs belong to safety group C - be careful when using, and are approved for use in pregnant women under strict indications. There are separate data on the danger to the fetus. They act on all body systems and penetrate the placenta. Can only be used from the second trimester of pregnancy:

hyoscine butylbromide (buscopan) solution 2.0 ml (20 mg) subcutaneously, intramuscularly, intravenously 2-3 times a day, then in tablets of 10 mg 3 times a day;

promethazine (pipolfen) solution 2.5% 2.0 ml (50 mg) intramuscularly, intravenously 2-3 times a day, then in tablets of 2-12.5 mg 4-6 times a day (up to 150 mg);

chlorpromazine (chlorpromazine) solution 2.5%, 1.0-2.0 ml (25-50 mg) intramuscularly, intravenously 2-3 times a day (no more than 3 times), then in tablets of 50 mg 3 times a day day (up to 150 mg);

ogdansetron (domegan, eofetron, eofran) solution 0.2%, 2.0 ml (4 mg) or 0.2%, 4.0 ml (8 mg) intravenously slowly drip per 100 ml of saline 1-2 times a day, then in tablets of 4-8 mg 2 times a day (up to 150 mg / day).

Other drugs

Means of other groups, with more serious contraindications, are used only in case of emergency. These include

methylprenisolone (metipred),

aprepitant (emend).

Pregnant women should be prescribed the lowest effective dose of the drug and periodically try to stop it or switch to safer drugs.

If it is impossible to carry out natural nutrition, it is prescribed.

With the ineffectiveness of all methods of treatment and severe water and electrolyte disorders, termination of pregnancy is indicated.

The prognosis for stopping CRP for the mother and fetus is favorable.

(Excessive vomiting of pregnant women, toxicosis, early preeclampsia)

Vomiting of pregnant women is a pathological condition in the first half of pregnancy, attributable to early toxicosis. Occurs in more than half of pregnant women, but only 8-10% of them need treatment.

Diagnosis Excessive pregnancy vomiting is only for women

0

Men are diagnosed with Excessive vomiting of pregnancy. No deaths have been identified.

0 %

mortality in men with the disease Excessive vomiting of pregnancy

95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0

943 071

Women are diagnosed with Excessive vomiting of pregnancy. No deaths have been identified.

0 %

mortality in women with the disease Excessive vomiting of pregnancy

Risk group for the disease Excessive vomiting of pregnant women aged 25-29

Cases of the disease Excessive vomiting of pregnant women have not been identified

In men, the disease is least common at the age of 0+

In women, the disease is least common at the age of 5-9, 50-64, 70-84, 90-94, 95+

The disease is most common in women aged 25-29

Features of the disease Excessive vomiting of pregnant women

non-contagious

High individual and low societal risk

Short description

Vomiting pregnant pathological condition in the first half of pregnancy, attributable to early toxicosis. Occurs in more than half of pregnant women, but only 8-10% of them need treatment. The earlier the onset, the more severe it is. Excessive prolonged vomiting can be complicated by dehydration and weight loss.

Etiology

The etiology has not been determined. Important role in the development of the disease play disturbances in the relationship between the activity of the central nervous system and internal organs. At the beginning of pregnancy, vegetative disorders can be simultaneously caused by hormonal disorders, in particular, an increase in the level of human chorionic gonadotropin (pregnancy hormone) in the body. The factors predisposing to the development of toxicosis include chronic diseases of the gastrointestinal tract, liver, as well as asthenic syndrome.

*** Of great importance is the predominance of excitation in the subcortical structures of the central nervous system (the reticular formation, the centers of regulation of the medulla oblongata). In these areas, the vomiting center and the chemoreceptor trigger zone are located, which regulate the vomiting act, the respiratory, vasomotor and salivary centers, as well as the nuclei of the olfactory system of the brain. The close location of these centers causes sensations of nausea preceding the vomiting act and a number of concomitant autonomic disorders (increased salivation, deepening of breathing, pallor skin due to spasm of peripheral vessels).

In subcortical structures, the predominance of brain excitation with the occurrence of an autonomic response is associated with pathological processes in the genital organs (past inflammatory diseases, intoxications) that disrupt the functioning of the uterine receptor apparatus (it may also be damaged by the fetal egg), which is most likely possible in violation of physiological relationships maternal organism and trophoblast in early gestation.

Development of the disease - pathogenesis

In the pathogenesis of vomiting of pregnant women, the determining links are the violation of neuroendocrine regulation of all types of metabolism, partial (or complete) and dehydration. In the mother's body, with the progression of vomiting, water-salt (hypokalemia), carbohydrate, fat and protein metabolism are gradually disturbed against the background of increasing dehydration, exhaustion and weight loss.

*** During starvation, glycogen stores in the liver and other tissues are initially consumed. Then catabolic reactions are activated (fat and protein metabolism increases). Against the background of inhibition of the activity of enzymatic systems of tissue respiration, the energy needs of the mother's body are satisfied due to the anaerobic breakdown of glucose and amino acids. Under these conditions, β-oxidation of fatty acids is impossible, as a result of which underoxidized metabolites of fat metabolism accumulate in the body - ketone bodies (acetone, acetoacetic and β-hydroxybutyric acids), which are excreted in the urine.

Changes in the organs of a pregnant woman are initially functional in nature, and then, as dehydration increases, catabolic reactions intensify, intoxication with incompletely oxidized products, they pass into dystrophic processes in the liver, kidneys and other organs. Initially, protein-synthetic, antitoxic, pigment and other functions of the liver, excretory function of the kidneys are disturbed; subsequently, dystrophic changes are noted in the central nervous system, lungs, and heart.

Clinical picture

In 50-60% of cases, vomiting of pregnant women is regarded as a physiological sign of pregnancy, and in 8-10% - as a complication of pregnancy (toxicosis). At normal pregnancy and can be no more than 2-3 times a day in the morning, more often on an empty stomach, but this does not violate the general condition of the woman and, accordingly, does not require treatment. As a rule, at the end of the placentation process by 12-13 weeks and stop.

Vomiting, which occurs several times a day, regardless of food intake, is accompanied by a decrease in appetite, a change in taste and smell sensations, a feeling of weakness, and sometimes a decrease in body weight, is referred to as toxicosis. There are vomiting of pregnant women of mild, moderate severity and excessive.

Classification and severity:

I degree - mild form. The frequency of vomiting does not exceed 5 times a day. The general condition does not suffer. Weight loss does not exceed 2-3 kg, pulse rate is not more than 80 beats / min, urine and blood tests are normal.
II degree - moderate. Worried, sometimes subfebrile condition. from 6 to 10 times a day, weight loss of more than 3 kg in 7-10 days, pulse increased to 90-100 beats / min, blood pressure is slightly reduced. Urinalysis showed a positive reaction to acetone.
III degree - excessive (severe) pregnant. repeats up to 20-25 times a day, the general condition deteriorates sharply, sleep is disturbed, weight loss is up to 8-10 kg or more. The pregnant woman cannot take food and water, which causes dehydration and metabolic disorders. The temperature rises to 37.2 - 37.5 ° C, the pulse is up to 120 beats / min, blood pressure decreases, diuresis is reduced. Urinalysis positive for acetone (+++ or ++++), protein, and casts. In the blood increases bilirubin, creatinine. At present, this degree is very rare.

Main symptoms

Diagnostics

1 diagnostic standard established Excessive vomiting of pregnant women

To determine the severity of vomiting, a clinical examination of the patient is necessary: a study of a general blood and urine test; determination in the dynamics of Ht, blood levels of bilirubin, residual nitrogen and urea, electrolytes (potassium, sodium, chlorides), total protein and protein fractions, transaminases, indicators of the acid-base state, glucose. In urine, the level of acetone, urobilin, bile pigments, protein is determined. With significant dehydration in the thickening of the blood, there may be false-normal indicators of the content of Hb, erythrocytes, and protein. The degree of dehydration is determined by the level of Ht. Its value above 40% indicates severe dehydration.

Medical services to determine the diagnosis Excessive vomiting during pregnancy

Clinics for diagnosis

GBU RC Neftekamsk RB

State budgetary institution Rehabilitation Center for Children and Adolescents with Disabilities in Neftekamsk, Republic of Bashkortostan, provides assistance in 5 medical specialties. Has a license to provide 12 medical services. It has been providing services since 2011 on the basis of a license issued by the organization "Ministry of Health of the Republic of Bashkortostan".

452878, Republic of Bashkortostan, Kaltasinsky district, p. Kuterem, st. Oil workers, 33

Limited Liability Company Diagnostic and Treatment Center "Antibol"

Limited Liability Company Therapeutic and diagnostic center "Antibol" provides assistance in 2 medical specialties. Has a license to provide 2 medical services. It has been providing services since 2011 on the basis of a license issued by the organization "Ministry of Health of the Republic of Buryatia".

670031, Republic of Buryatia, Ulan-Ude, Pirogova st., 32, first floor, Letter B, room No. 59

LLC "Galomed"

Limited Liability Company "Galomed" provides assistance in 11 medical specialties. Has a license to provide 15 medical services. It has been providing services since 2010 on the basis of a license issued by the organization "Ministry of Health of the Republic of Bashkortostan".

450106, Republic of Bashkortostan, Ufa, Duvansky boulevard, 30

No

The Ministry of Internal Affairs of the Republic of Karelia provides assistance in 1 medical specialty. Has a license to provide 1 medical services. It has been providing services since 2002 on the basis of a license issued by the organization "Territorial body of Roszdravnadzor in the Republic of Karelia".

185035, Republic of Karelia, Petrozavodsk, st. Lososinskaya, d.8a

Treatment

75 medical procedures prescribed in the treatment of the disease Excessive vomiting of pregnant women

Treatment for vomiting includes non-drug and drug treatments.

With non-drug treatment, great importance must be attached to the diet. In connection with a decrease in appetite, a varied diet is recommended in accordance with the desire of a woman. Food should be easily digestible, contain a large amount of vitamins. It should be taken chilled, in small portions every 2-3 hours, while lying in bed. Mineral alkaline water without gas is shown in small volumes (5-6 times a day). A chilled decoction of ginger or lemon balm is also prescribed in small portions of at least 1 liter per day.

With vomiting of moderate severity, mixtures for enteral nutrition are prescribed.

Given the short gestational age, it is advisable to conduct non-drug treatment in order to exclude the negative effect of drugs on the fetal egg. To normalize the functional state of the cerebral cortex and eliminate autonomic dysfunction, central electroanalgesia, acupuncture, psychotherapy and hypnotherapy are indicated. The use of homeopathic remedies is effective. These methods of treatment may be sufficient in the treatment of patients with mild vomiting of pregnancy, and in moderate and severe cases, they can limit the amount of drug therapy.

With vomiting of pregnant women, drug treatment should be comprehensive:

Drugs that regulate the function of the central nervous system and block the gag reflex;
infusion agents for rehydration, detoxification and parenteral nutrition;
drugs designed to normalize metabolism.

The basic rule of drug therapy for severe and moderate vomiting is the parenteral method of drug administration until a lasting effect is achieved.

Properly organized medical and protective regimen and the elimination of negative emotions play an important role in normalizing the function of the central nervous system. When hospitalized, it is advisable to place the patient in a separate room to exclude reflex vomiting.

Prescribe drugs that directly block the gag reflex: drugs that affect various neurotransmitter systems of the medulla oblongata: M-anticholinergics (atropine), dopamine receptor blockers (neuroleptics - haloperidol, droperidol, phenothiazine derivatives - thiethylperazine), as well as direct dopamine antagonists (metoclopramide) and drugs of central action that block serotonin receptors (ondansetron).

An important link in the treatment is infusion therapy, which includes the use of crystalloids and parenteral nutrition. Crystalloids are designed for rehydration. From crystalloids, complex solutions are used, such as Ringer-Locke solution, trisol, chlosol. For parenteral nutrition, solutions of glucose, amino acids and fat emulsions with a total energy value of up to 1500 kcal per day are used. Insulin is administered to improve glucose uptake. With a decrease in the total volume of blood protein to 5 g / l, colloidal solutions are indicated (for example, a 5–10% solution of albumin to 200–400 ml).

The volume of infusion therapy is 1-3 liters, depending on the severity of toxicosis and the patient's body weight.

The criteria for the sufficiency of infusion therapy are considered to be a decrease in dehydration and an increase in skin turgor, normalization of Ht and diuresis.

Simultaneously with infusion therapy, drugs are prescribed that normalize metabolism.

Therapy is continued until a persistent cessation of vomiting, normalization of the general condition, a gradual increase in body weight. Treatment of mild to moderate vomiting during pregnancy is almost always effective.

Excessive pregnancy in the absence of the effect of complex therapy for 3 days is an indication for termination of pregnancy.

Medical services for the treatment of the disease Excessive vomiting during pregnancy

Clinics for treatment

GKUZ "PRPB"

The Prokhladnensky District Psychiatric Hospital State Public Health Institution provides assistance in 11 medical specialties. Has a license to provide 16 medical services. It has been providing services since 2003 on the basis of a license issued by the organization "Ministry of Health of the Kabardino-Balkarian Republic".

361012, Kabardino-Balkarian Republic, Prokhladnensky district, s. roadside

Limited Liability Company "VLD Group"

Limited Liability Company "VLD Group" provides assistance in 8 medical specialties. Has a license to provide 9 medical services. It has been providing services since 2016 on the basis of a license issued by the organization "Ministry of Health of the Penza Region".

117216, Moscow, st. Koktebelskaya, 11

"Reacenter" LLC

Limited Liability Company "Reacenter" provides assistance in 2 medical specialties. Has a license to provide 2 medical services. It has been providing services since 2002 on the basis of a license issued by the organization "Ministry of Health of the Republic of Bashkortostan".

450000, Republic of Bashkortostan, Ufa, st. Dostoevsky, 160

LLC "ZEVS"

ZEUS Limited Liability Company provides assistance in 6 medical specialties. Has a license to provide 7 medical services. It has been providing services since 2010 on the basis of a license issued by the Moscow Department of Health.

109125, Moscow, st. Lyublinskaya, 9, building 3

Among toxicoses, special attention was paid to the study of the etiology of vomiting of pregnant women, in connection with which various theories appeared. Vomiting of pregnant women was associated with poisoning of the body with toxic metabolic products. It was also believed that it could be the result of maternal sensitization by fetal antigens in histone incompatibility. The occurrence of vomiting was also explained by psychogenic factors (negative emotions, fear of childbirth) or the manifestation of hysterical reactions. The most recognized is the neuro-reflex theory, according to which an important role in the development of the disease is played by disturbances in the relationship between the activity of the central nervous system and internal organs. In this case, the predominance of excitation in the subcortical structures of the central nervous system (the reticular formation, the centers of regulation of the medulla oblongata) is essential. In these areas, the vomiting center and the chemoreceptor trigger zone are located, which regulate the vomiting act. Next to them are the respiratory, vasomotor, salivary centers, the nuclei of the olfactory system of the brain. The close location of these centers causes nausea and a number of accompanying autonomic disorders that precede the vomiting act: increased salivation, deepening of breathing, tachycardia, pallor of the skin due to spasm of peripheral vessels.

The predominance of excitation in the subcortical structures of the brain with the occurrence of a response vegetative reaction is associated with pathological processes in the genital organs (past inflammatory diseases, intoxication) that violate the receptor apparatus of the uterus, and it may also be damaged by the fetal egg. The indicated is observed, most likely, in violation of the physiological relationships of the maternal organism and the trophoblast in the early stages of gestation.

Vegetative disorders at the beginning of pregnancy can be simultaneously caused by hormonal disorders, in particular, an increase in the level of chorionic gonadotropin (CG) in the body. Proof of this is the fact that with multiple pregnancy and hydatidiform mole, when a large amount of hCG is released, vomiting of pregnant women is observed especially often.

Factors predisposing to the development of toxicosis include chronic diseases of the gastrointestinal tract, liver, asthenic syndrome.

In the pathogenesis of vomiting of pregnant women, the determining link is a violation of the neuroendocrine regulation of all types of metabolism due to partial (or complete) starvation and dehydration. With the progression of the disease, water-salt (hypokalemia), carbohydrate, fat and protein metabolism in the mother's body are gradually disturbed against the background of increasing dehydration, exhaustion and weight loss. Due to starvation, glycogen stores in the liver and other tissues are initially consumed. Then there is a decrease in endogenous carbohydrate resources, catabolic reactions are activated, in particular, fat and protein metabolism increase. Against the background of inhibition of the activity of enzymatic systems of tissue respiration, the energy needs of the mother's body are satisfied due to the anaerobic breakdown of glucose and amino acids. Under these conditions, p-oxidation of fatty acids is impossible, as a result of which underoxidized metabolites of fat metabolism accumulate in the body - ketone bodies (acetone, acetoacetic and p-hydroxybutyric acids), which are excreted in the urine. In addition, ketosis is maintained by increased anaerobic breakdown of ketogenic amino acids. Against this background, ketonuria develops, the severity of which corresponds to the severity of metabolic disorders in the body of a pregnant woman who has vomiting, oxygenation of arterial blood decreases, and the acid-base balance shifts towards acidosis.

Changes in the organs of a pregnant woman are initially functional in nature, and then, as dehydration, catabolic reactions, intoxication with underoxidized products increase, they pass into dystrophic processes in the liver, kidneys and other organs. Initially, protein-forming, antitoxic, pigment and other functions of the liver, excretory function of the kidneys are disturbed, and subsequently dystrophic changes are observed in the central nervous system, lungs, and heart.

clinical picture. Vomiting of pregnant women is often (in 50-60% of cases) observed as a physiological sign of pregnancy, and in 8-10% it manifests itself as a complication of pregnancy - toxicosis. During normal pregnancy, nausea and vomiting can be no more than 2-3 times a day in the morning, more often on an empty stomach, but this does not violate the general condition of the woman, so no treatment is required. As a rule, at the end of the placentation process, by 12-13 weeks, nausea and vomiting stop.

Toxicosis includes vomiting, which is observed several times a day, regardless of food intake, accompanied by a decrease in appetite, a change in taste and smell sensations, a feeling of weakness, and sometimes a decrease in body weight. Distinguish between vomiting of pregnant women of mild, moderate and excessive. The severity of vomiting is determined by the combination of vomiting with disorders occurring in the body (metabolic processes, functions of the most important organs and systems).

Light vomiting is not much different from that in uncomplicated pregnancy, but is observed up to 4-5 times a day, accompanied by an almost constant feeling of nausea. Despite vomiting, part of the food is retained and significant weight loss of pregnant women is not observed. The decrease in body weight is 1-3 kg (up to 5% of the initial weight). The general condition remains satisfactory, but apathy and decreased performance may be noted. Hemodynamic parameters (pulse, arterial pressure) in most pregnant women remain within the normal range. Moderate tachycardia (80-90 beats / min) is sometimes recorded. There are no changes in the morphological composition of the blood. Diuresis does not change. Acetonuria is absent. Mild vomiting responds quickly to treatment or resolves on its own, so special treatment is not required, but in 10-15% of pregnant women it intensifies and can move to the next stage.

Moderate vomiting (moderate) is expressed in an increase in vomiting up to 10 times a day or more, a deterioration in the general condition and metabolism with the development of ketoacidosis. Vomiting is often accompanied by salivation, resulting in an additional significant loss of fluid and nutrients. As a result of this, dehydration and a decrease in body weight up to 3-5 kg (6% of the initial weight) occur, up to exhaustion. The general condition of pregnant women worsens, significant weakness and apathy occur. The skin is pale, dry, the tongue is covered with a whitish coating, dryish. The body temperature is subfebrile (not higher than 37.5 ° C), tachycardia (up to 100 beats / min) and hypotension are characteristic. A blood test may reveal mild anemia, and a metabolic acidosis can be detected in the analysis of CBS. Diuresis is reduced, there may be acetone in the urine. Constipation is often observed. The prognosis is usually favorable, but with a similar condition, a pregnant woman needs treatment.

Excessive vomiting is rare. Excessive vomiting is characterized by a violation of the functions of vital organs and systems, up to the development of dystrophic changes in them due to severe intoxication and dehydration. Vomiting is observed up to 20 times a day, accompanied by profuse salivation and constant nausea. Food and liquid are not retained. The general condition is severe. There are adynamia, loss of strength, headache, dizziness, body weight decreases rapidly (up to 2-3 kg per week, more than 10% of the initial body weight). The layer of subcutaneous fatty tissue disappears, the skin becomes dry and flabby, the tongue and lips are dry, the smell of acetone is noted from the mouth, the body temperature is subfebrile, but can rise to 38 ° C, severe tachycardia, hypotension occur. Diuresis is sharply reduced.

The level of residual nitrogen, urea, bilirubin, hematocrit increases in the blood, leukocytosis is noted, while the content of albumins, cholesterol, potassium, and chlorides decreases. In the urine, protein and cylindruria, urobilin, bile pigments, erythrocytes and leukocytes are determined, the reaction to acetone is sharply positive.

The prognosis of excessive vomiting is not always favorable. Signs of a threatening condition that determine the indications for emergency termination of pregnancy are an increase in weakness, adynamia, euphoria or delirium, tachycardia up to 110-120 beats / min, hypotension - up to 90-80 mm Hg. Art., yellowness of the skin and sclera, pain in the right hypochondrium, decreased diuresis to 300-400 ml per day, hyperbilirubinemia within 100 µmol/l, increased levels of residual nitrogen, urea, proteinuria, cylindruria.

Diagnostics. Establishing the diagnosis of vomiting during pregnancy is not difficult. To determine the severity of vomiting of pregnant women, in addition to conducting a clinical examination of the patient, a general blood and urine test, it is necessary to determine the dynamics of the following indicators: in the blood - the content of bilirubin, residual nitrogen and urea, hematocrit, electrolytes (potassium, sodium, chlorides), total protein and protein fractions, trans-aminases, indicators of CBS, glucose, prothrombin, in urine - the level of acetone, urobilin, bile pigments, protein. With significant dehydration and thickening of the blood, false-normal values of hemoglobin, erythrocytes, and protein may be noted. The degree of dehydration is determined by the level of hematocrit. Its value above 40% indicates severe dehydration.

Treatment. Treatment of patients who have a mild form of vomiting can be carried out on an outpatient basis, with moderate and severe vomiting - in a hospital. Great importance must be attached to the diet. In connection with a decrease in appetite, a variety of food is recommended at will. It should be easily digestible, contain a large amount of vitamins. It should be taken chilled, in small portions every 2-3 hours in the supine position. Mineral alkaline water is shown in small volumes 5-6 times a day.

Drug treatment for vomiting of pregnant women should be complex: 1) drugs that regulate the function of the central nervous system and block the gag reflex; 2) infusion agents for rehydration, detoxification and parenteral nutrition; 3) drugs designed to normalize metabolism.

To normalize the function of the central nervous system, a properly organized medical and protective regimen and the elimination of negative emotions are of no small importance. When hospitalized, the patient must be placed in a separate room to exclude reflex vomiting.

At the beginning of treatment, given the short gestation period, it is advisable to prescribe non-drug agents to exclude a negative effect on the fetal egg. To normalize the functional state of the cerebral cortex and eliminate autonomic dysfunction, central electroanalgesia, acupuncture, psycho- and hypnotherapy are indicated. These non-pharmacological therapies may be sufficient in the treatment of patients with mild vomiting of pregnancy, and in moderate and severe cases, they can limit the amount of drug therapy.

In the absence of effect, drugs that directly block the gag reflex are used: drugs that act on various neurotransmitter systems of the medulla oblongata: m-anticholinergics (atropine), antihistamines (pipolphen, diprazine, tavegil), dopamine receptor blockers (neuroleptics - haloperidol, droperidol, a phenothiazine derivative - torecan), as well as direct dopamine antagonists (raglan, cerucal). The following combinations are most effective clinically: 1) droperidol (1 ml intramuscularly), atropine (0.5 ml of a 0.1% solution intramuscularly), tavegil (1 ml intramuscularly); 2) cerucal, raglan (2 ml intramuscularly), atropine (0.5 ml 0.1% solution intramuscularly). With hypotension that occurs as a result of the use of these drugs and the disease itself, it is advisable to introduce a 0.1% solution of mezaton.

Fluid therapy for vomiting includes the use of crystalloids, colloids, and parenteral nutrition. Crystalloids are designed for rehydration. From crystalloids, Ringer-Lock complex salt solutions, trisol, chlosol are used. The volume of injected crystalloids should be up to 50% of the total volume of infusion. Of the colloids for detoxification, it is advisable to use gemodez and reopoliglyukin. The volume of colloidal solutions should be 10-15% of the infusion volume. For parenteral nutrition, solutions of glucose and amino acids (alvezin, hydrolysin) are used. In order to better assimilate glucose, it is advisable to administer insulin in small doses. The volume of injected drugs for parenteral nutrition should be at least 35-40% of the total infusion volume.

The total volume of infusion therapy is 1-3 liters, depending on the severity of toxicosis and the patient's body weight. The criteria for the sufficiency of infusion therapy are a decrease in dehydration and an increase in skin turgor, normalization of hematocrit, and an increase in diuresis.

Against the background of infusion therapy, drugs are prescribed that normalize metabolism. For this purpose, cofactors of bioenergy metabolism are used: cocarboxylase (0.1 g), riboflavin mononucleotide (1 ml of a 1% solution intramuscularly); vitamin C (up to 5 ml of a 5% solution). To stimulate anabolic reactions in tissues, splenin (2 ml intramuscularly), peridoxal phosphate (2 ml intramuscularly), riboxin (0.2 g 3 times a day), folic acid (0.001 g 3 times a day) are prescribed.

Complex therapy is continued until a stable cessation of vomiting, normalization of the general condition, a gradual increase in body weight. Treatment of mild to moderate vomiting in pregnancy is almost always effective. Excessive vomiting of pregnant women in the absence of the effect of complex therapy for 3 days is an indication for termination of pregnancy.

Symptoms	Severity of pregnancy vomiting
Light	Medium	heavy
Appetite	moderately reduced	significantly reduced	missing
Nausea	moderate	significant	persistent, painful
salivation	moderate	pronounced	thick viscous
Frequency of vomiting (per day)	up to 5 times	6-10 times	11-15 times or more (up to continuous)
Pulse rate (bpm)	80-90	90-100	over 100
Systolic BP	120-110 mmHg	110-100 mmHg	below 100 mmHg
food retention	mostly keep	partially hold	don't hold back
Weight loss	extremely rarely up to 5% of ref. masses	3-5 kg (1 kg per week, 6-10% original weight)	over 5 kg (2-3 kg per week, over 10% of original weight)
Dizziness	rarely	in 30-40% of patients (moderately expressed)	in 50-60% of patients (significantly expressed)
Subfebrile condition	–	uncharacteristic	in 35-80% of patients
Jaundice of the sclera and skin	–	in 5-7% of patients	in 20-30% of patients
Hyperbilirubinemia	–	21-40 µmol/l	21-60 µmol/l
Dry skin	– +	+ +	+ + +
Chair		once every 2-3 days	stool retention
Diuresis	900-800 ml	800-700 ml	less than 700ml
Acetonuria	–	periodically at 20-50%	at 70-100%

III degree - heavy (excessive) vomiting of pregnant women. The general condition of the woman is deteriorating sharply. Vomiting occurs up to 20-25 times a day, sometimes with any movement of the patient. Sleep disturbance, adynamia. The loss of body weight is up to 8-10 kg. The skin and mucous membranes become dry, the tongue is lined. The body temperature rises (37.2-37.5 ° C). Tachycardia up to 110-120 beats / min, blood pressure decreases. Pregnant women retain neither food nor water, which leads to dehydration and metabolic disorders. All types of metabolism are disturbed. Daily diuresis is reduced, acetonuria, often protein and casts in the urine. Sometimes the content of hemoglobin in the blood increases, associated with dehydration.

In blood tests, hypo- and dysproteinemia, hyperbilirubinemia, increased creatinine; shift of acid-base balance towards acidosis. In the study of electrolytes, a decrease in potassium, sodium and calcium is found.

Treatment of patients with vomiting of pregnant women should be complex and differentiated, with a simultaneous multilateral impact on various aspects of the pathogenesis of the disease.

Complex therapy of vomiting of pregnant women includes drugs that affect the central nervous system, normalize endocrine and metabolic disorders (in particular, water and electrolyte balance), vitamins. During treatment, it is necessary to observe the medical-protective regimen. It is impossible to place two such patients in the ward, since a recovering woman may experience a relapse of the disease under the influence of a patient with continued vomiting.

In order to normalize the function of the central nervous system, electrosleep or electroanalgesia are used. The duration of exposure is 60-90 minutes. The course of treatment consists of 6-8 sessions. Hypnosuggestive therapy can be used to influence the central nervous system. Give a good effect various options reflexology.

To combat dehydration of the body, detoxification and recovery of CBS, infusion therapy is used in the amount of 2.0-2.5 liters per day. Ringer-Locke solution (1000-1500 ml), 5.0% glucose solution (500-1000 ml) with ascorbic acid (5.0% solution 3-5 ml) and insulin (based on 1 unit of insulin per 4.0 g of dry matter glucose). To correct hypoproteinemia in pregnant women with an extremely severe course, it is possible to use albumin (10.0 or 20.0% solution in an amount of 100-150 ml), fresh frozen plasma. The drug of choice is currently a solution of hydroxyethyl starch. In violation of CBS, intravenous administration of sodium bicarbonate (5.0% solution) or lactosol, etc. is recommended. As a result of the elimination of dehydration and loss of salts, as well as a deficiency of plasma proteins, the condition of patients improves rapidly.

Cerucal, torecan, droperidol, etc. can be used to suppress the excitability of the vomiting center. The main rule of drug therapy for severe and moderate vomiting is the parenteral method of administration for 5-7 days (until a lasting effect is achieved).

The complex therapy of vomiting of pregnant women includes intramuscular injections of vitamins (B 1, B 6, B 12, C) and coenzymes (cocarboxylase). Use drugs (small tranquilizers) that have a sedative effect on the central nervous system and help reduce vomiting. The drug has a prolonged antihistamine activity.

The criteria for the adequacy of infusion therapy are a decrease in dehydration and an increase in skin turgor, normalization of hematocrit, an increase in diuresis, and improvement in well-being. Complex therapy is continued until a stable cessation of vomiting, normalization of the general condition, a gradual increase in body weight. An extract is made 5-7 days after the cessation of vomiting.

The ineffectiveness of the therapy is an indication for termination of pregnancy. Indications for termination of pregnancy are:

incessant vomiting;

Increasing dehydration of the body;

Progressive weight loss;

Progressive acetonuria within 3-4 days;

Severe tachycardia;

Violation of the functions of the nervous system (adynamia, apathy, delirium, euphoria);

Bilirubinemia (up to 40-80 µmol/l) and hyperbilirubinemia of 100 µmol/l is critical;

Icteric staining of the sclera and skin;

Subfebrile condition.

Salivation (ptyalismus) may accompany vomiting of pregnant women, rarely occurs as an independent form of early toxicosis. With severe salivation per day, a pregnant woman can lose 1 liter of fluid. Abundant salivation leads to dehydration of the body, hypoproteinemia, maceration of the skin of the face, negatively affects the psyche, body weight decreases.

Treatment of severe salivation should be carried out in a hospital. Assign mouthwash with infusion of sage, chamomile, oak bark, menthol solution, as well as agents that reduce salivation (cerucal, droperidol). With a large loss of fluid, Ringer-Locke solutions, 5.0% glucose, a solution of hydroxyethyl starch are prescribed intravenously. With significant hypoproteinemia, according to strict indications, solutions of albumin and fresh frozen plasma are used. A good effect is achieved during hypnosis, acupuncture. To prevent and eliminate maceration of facial skin with saliva, lubrication with zinc paste, Lassar paste or petroleum jelly is used.

Dermatoses of pregnant women- rare forms of early toxicosis. This is a group of various skin diseases that occur during pregnancy and disappear after it ends. Dermatoses appear in the form of itching, urticaria, herpetic eruptions.

The most common form of dermatosis is pruritus during pregnancy ( pruritus gravidarum). Itching may appear in the first months and at the end of pregnancy, be limited to the area of the external genitalia or spread throughout the body. Itching is often excruciating, causing insomnia, irritability, or depressed mood. Itching during pregnancy must be differentiated from diseases that are accompanied by itching: diabetes mellitus, fungal skin diseases, trichomoniasis, allergic reactions.

Treatment consists in prescribing desensitizing sedatives (diphenhydramine, pipolfen), vitamins B 1 and B 6, and general ultraviolet irradiation.

Tetany of pregnant women (tetania gravidarum) is manifested by convulsions of the muscles of the upper limbs ("obstetrician's hand"), less often lower extremities(“ballerina leg”), faces (“fish mouth”). The basis of the disease is a decrease or loss of the function of the parathyroid glands and, as a result, a violation of calcium metabolism. In severe cases of the disease or exacerbation of latent tetany during pregnancy, the pregnancy should be terminated. For treatment, parathyroidin, calcium, dihydrotachysterol, vitamin D are used.

Osteomalacia in pregnancy (osteomalacia gravidarum) is extremely rare in its expressed form. Pregnancy in these cases is absolutely contraindicated. More often, an erased form of osteomalacia is observed - symphysiopathy. The disease is associated with a violation of phosphorus-calcium metabolism, decalcification and softening of the bones of the skeleton. The main manifestations of symphysiopathy are pain in the legs, pelvic bones, muscles. There are general weakness, fatigue, paresthesia; the gait ("duck") changes, tendon reflexes increase. Palpation of the pubic joint is painful. On radiographs of the pelvis, a divergence of the bones of the pubic joint is sometimes found, however, unlike true osteomalacia, there are no destructive changes in the bones. An erased form of osteomalacia is a manifestation of hypovitaminosis D.

A good effect in the treatment of the disease is the use of vitamin D, fish oil, general and local ultraviolet radiation, progesterone.

Acute yellow liver atrophy (atrophia heratis blava acuta) is extremely rare and may be the outcome of excessive pregnancy vomiting or occur independently. As a result of fatty and protein degeneration of liver cells, a decrease in the size of the liver occurs, the occurrence of necrosis and atrophy of the liver. The disease is extremely severe (intense jaundice, itching, vomiting, convulsive seizures, coma), usually leads to the death of the patient.

Treatment consists of immediate termination of pregnancy, although termination of pregnancy rarely improves the prognosis.

Bronchial asthma in pregnancy (asthma bronchiale gravidarum) is very rare. The cause of the disease is hypofunction of the parathyroid glands and impaired calcium metabolism.

Treatment includes the appointment of calcium supplements, B vitamins, sedatives. Bronchial asthma of pregnant women must be differentiated from an exacerbation of bronchial asthma that existed before pregnancy.

Prevention of early toxicosis consists in the timely treatment of chronic diseases, the elimination of mental stress, and the adverse effects of the external environment. Of great importance is the early diagnosis and treatment of initial (mild) manifestations of toxicosis, and, consequently, the prevention of the development of severe forms of the disease.

Test questions:

1. Name the main forms of early toxicosis.

2. Classification of vomiting of pregnant women according to severity.

3. Clinic of mild vomiting of pregnant women.

4. Clinic of an average degree of vomiting of pregnant women.

5. Clinic of severe vomiting of pregnant women.

6. The volume of treatment for mild vomiting of pregnant women.

7. The volume of treatment with an average degree of vomiting of pregnant women.

8. The volume of treatment for severe vomiting of pregnant women.

9. Indications for termination of pregnancy in case of vomiting of pregnant women.

10. Tactics in acute yellow liver atrophy.

Task #1

A 24-year-old pregnant woman was admitted to the department with complaints of nausea, vomiting 3-5 times a day, more often after meals, loss of appetite, irritability. Over the past week, there was a decrease in body weight by 1 kg. The gestation period is 6-7 weeks.

The general condition at admission is satisfactory. Body temperature is normal. Skin and mucous membranes of normal color and moisture. Pulse 90 bpm. Blood pressure 120/70 mm Hg. Art.

Analysis of blood and urine without pathological changes.

Diagnosis? Management plan?

Task #2

A 21-year-old pregnant woman was brought to the department by ambulance. Pregnancy 7-8 weeks. Complaints of constant nausea, vomiting 15-16 times or more per day, does not hold food. Weakness, apathy. For 10 days, a decrease in body weight by 3.5 kg.

The patient's condition is moderate, emaciated, the smell of acetone from the mouth. The temperature is subfebrile, the skin is icteric, dry. Pulse 110 bpm in 1 min, weak filling and tension. Blood pressure 90/60 mm Hg. Art. Heart sounds are muffled. Tongue coated white, dry. The abdomen is soft and painless. Diuresis is reduced to 400 ml per day. In the blood, an increase in residual nitrogen, urea, bilirubin, a decrease in the content of albumins, cholesterol, potassium, chlorides. In the analysis of urine, protein and cylindruria, the reaction to acetone is sharply positive.

Diagnosis? Management plan?

GESTOSIS

The duration of the lesson is 180 minutes.

Purpose of the lesson: study of etiology, pathogenesis, clinical manifestations preeclampsia, diagnostic methods and additional research methods, principles of therapy and prevention of this pathology: the choice of the method and term of delivery, depending on the severity of preeclampsia; the need for interaction between an obstetrician-gynecologist and an anesthesiologist to develop a plan for intensive care of preeclampsia.

The student must know: Definition of the concept of preeclampsia, classification, pathogenesis, clinic, diagnosis, differential diagnosis; Therapy during pregnancy, childbirth, postpartum period; The impact of this pathology on maternal and perinatal morbidity and mortality: The significance of the Zangemeister triad in the diagnosis of this pathology, clinical and laboratory methods studies (ophthalmoscopy, ultrasound, hemostasiogram, cardiomonitoring, etc.); Pharmacological drugs used in the treatment of preeclampsia, the basic principles of intensive care and emergency medical care in severe forms of the disease, as well as the principles of childbirth and the choice of method of delivery in this pathology.

The student must be able: collect anamnesis, examine the pregnant woman, evaluate the data of laboratory and additional studies, make a diagnosis and assess the severity of preeclampsia, prescribe treatment.

Place of class: ward of the department of pathology of pregnant women, intensive care ward (eclampsia ward), study room.

Equipment: case histories, tables, heart monitor, ultrasound machine, blood pressure monitor, infusion pump, emergency kit for eclampsia.

Lesson plan:

Organizational issues, substantiation of the topic of the lesson - 10 minutes.

Control of the initial level of knowledge of students - 35 minutes.

Theoretical analysis and demonstration of pregnant women with preeclampsia, analysis of their birth history. Training in the method of examination and detection of clinical manifestations of the disease, evaluation of indicators of additional research methods. Studying the principles of rational therapy and evaluating its effectiveness. Eclampsia Emergency Kit Demonstration - 140 minutes.

Summing up the lesson, homework - 5 minutes.

Preeclampsia is a syndrome of multiple organ functional failure that develops against the background of pregnancy and is pathophysiologically associated with it. Preeclampsia occurs in the second half of pregnancy, after delivery, the symptoms of preeclampsia decrease, and in most women they completely disappear. Thus, the etiological factor in the occurrence of preeclampsia is pregnancy.

The frequency of preeclampsia remains high (on average from 10 to 30%) and does not tend to decrease. Significantly more often, preeclampsia is found in pregnant women with extragenital pathology (kidney disease, of cardio-vascular system etc.), in old and young primiparas, in women from a socio-economically disadvantaged group of the population. Preeclampsia is considered hereditarily predisposed and more often occurs in pregnant women whose close relatives (mothers, sisters) suffered from preeclampsia.

In modern obstetrics, along with the term "gestosis", the terms "OPG-gestosis" are used ( O teki, P roteinuria, G hypertension), “late toxicosis”, “nephropathy”, abroad - “toxemia of pregnant women”, “preeclampsia”, “hypertension induced by pregnancy”, etc. The variety of terms denoting this complication of pregnant women is due to the fact that true reason The disease still remains unclear, which is confirmed by the previously used terms that reflect the constant search for the causes of this complication of pregnancy - "allergosis", "neurosis", "nephrosonephritis".

The constant search for the causes of preeclampsia is dictated by the sad statistics of maternal mortality: preeclampsia is among the top three leading causes of death for women who perform reproductive functions.

The current understanding of the causes of preeclampsia includes more than 20 theories.

:These include: Infectious; intoxication (the term "toxicosis of pregnant women"); renal; hemodynamic; Theory of intoxication and damage to the endothelium; Endocrinological; Placental (morphological changes in the placenta, impaired hormone production). Some of these theories are currently only of historical interest. Of the well-known modern theories of the occurrence of gestosis, corticovisceral (neurogenic), immunoallergic, and adaptive deserve attention. Most researchers are inclined to believe that the occurrence of preeclampsia is polyetiological.

According to modern concepts, preeclampsia is considered as genetically determined insufficiency of the processes of adaptation of the mother's body to the new conditions of existence that arise with the development of pregnancy. Preeclampsia is a complex symptom complex of metabolic disorders, manifested by the disintegration of the functions of the central and autonomic, endocrine and immune systems, the homeostasis system, the cardiovascular system, the dysfunction of the liver, kidneys, and the mother-placenta-fetus system.

A large role in the development of pregnancy complications belongs to the complex of violations of the processes of trophoblast invasion and gestational restructuring of the spiral arteries associated with the vital activity of the fetus and placenta. As pregnancy progresses, all organs and systems of the mother's body are involved in the process of adaptation to one degree or another. Changes in them are of a secondary nature and are due to primary disorders that occur in the fetal-placental complex. Violation of the gestational transformation of the spiral arteries dramatically impairs placental function and uteroplacental blood flow. As a result, substances are formed in the utero-placental complex that increase the blood pressure in the mother.

In the second half of pregnancy, a number of physiological changes take place in the body of pregnant women, predisposing to the development of preeclampsia. These are: An increase in the volume of circulating blood up to 150% of the initial level; moderate increase in peripheral resistance; Formation of uteroplacental blood flow; Increased pulmonary blood flow with a tendency to hypertension; Partial occlusion in the system of the inferior vena cava; measured hypercoagulability; An increase in the glomerular filtration rate due to an increase in the effective renal plasma flow; Moderate proteinuria (more than 300 mg per day); Decreased absorption in the tubules; Delay sodium reabsorption due to progesterone; Increase in aldosterone in the blood by 20 times.

The main pathophysiological aspects of the development of preeclampsia are: 1. Violation of microcirculation, spasm of arterioles, endothelial dysfunction, changes in intravascular volume (decrease in plasma volume, increase in hemoglobin and hematocrit), progressive decrease in resistance to the pressor action of catecholamines and angiotensin; II. Blood coagulation is disturbed (a chronic syndrome of disseminated intravascular coagulation develops). Kidney damage occurs in the form of glomerular endotheliosis, which has an almost complete resemblance to membranous glomerulonephritis. Excessive release of renin and angiotensin, increased activity of aldosterone, decreased detoxification and protein-forming functions of the liver, development of renal failure against the background of ischemia, fluid retention in the interstitial space, and metabolic acidosis are observed. With the progression of gestosis, cerebral edema, cerebral vasospasm, hemorrhages develop, which are manifested by brain symptoms and the onset of convulsive seizures. Violation of the uteroplacental blood flow leads to intrauterine hypoxia of the fetus and its malnutrition.

Preeclampsia has a wide range of clinical manifestations, which is reflected in the classification this disease according to clinical signs. Gestosis is divided into 4 forms: dropsy, gestational nephropathy (mild, moderate, severe), preeclampsia, and eclampsia. Various forms gestosis is considered as stages of a single pathological process, however, each of them requires certain diagnostic and therapeutic measures.

In foreign classification, hypertension of pregnant women, preeclampsia and eclampsia of pregnant women are distinguished. The disadvantage of this classification is the grouping of mild and severe forms of the disease into one group.

The World Health Organization (1989) suggests the following classification:

1. Arterial hypertension of pregnant women without proteinuria.

2. Proteinuria of pregnant women.

3. Preeclampsia - a combination of arterial hypertension with proteinuria.

4. Eclampsia.

5. Hidden arterial hypertension, latent kidney disease and other diseases that appear only during pregnancy.

6. Previously known diseases accompanied by arterial hypertension.

7. Pre-eclampsia and eclampsia, complicating previously known:

arterial hypertension,

Kidney disease.

International classification of diseases X revision (ICD X: 010-016), 1998, adapted by the Russian Society of Obstetricians and Gynecologists, 2006:

ICD	Classification for RF
0.11 Pre-existing hypertension with associated proteinuria	combined preeclampsia*
0.12.2 Pregnancy-induced edema with proteinuria	preeclampsia*
0.13 Pregnancy-induced hypertension without significant proteinuria. Mild preeclampsia (mild nephropathy)	mild preeclampsia*
0.14 Pregnancy-induced hypertension with significant proteinuria	preeclampsia*
0.14.0 Moderate preeclampsia (nephropathy)	moderate preeclampsia
0.14.1 Severe preeclampsia	severe preeclampsia
0.14.9 Pre-eclampsia (nephropathy), unspecified	Preeclampsia
* The severity of preeclampsia is determined by a point scale

According to this classification, each type of preeclampsia is divided according to the time of occurrence: into those that occurred during pregnancy, during childbirth and in the first 48 hours of the postpartum period.

Some experts point out monosymptomatic forms of gestosis: hypertension of pregnant women, proteinuria of pregnant women. Almost all obstetricians recognize the need to separate gestoso: On "clean" that occur in somatically healthy women; And "combined", which developed against the background of extragenital diseases preceding pregnancy.

The classic triad of symptoms of preeclampsia (edema, proteinuria and hypertension), described in 1913 by the German obstetrician Zanggemeister, is due to a number of pathogenetic factors that are interconnected and are manifestations of violations of the vital functions of the body. The clinic of gestosis and its diagnosis is based on the definition of the symptoms of the Zangenmeister triad.

The mildest form of gestosis is dropsy pregnant, which is manifested by edema. There are 4 degrees of their distribution: 1st degree - swelling of the legs, 2nd degree - swelling of the legs and abdomen, 3rd degree - swelling of the legs, abdomen and face, 4th degree - anasarca. The dynamics of the increase in the body weight of a pregnant woman due to edema is increasing - more than 350 g per week. Decreased daily diuresis. The deficit of water release can reach 30-60% or more. Treatment of this form of gestosis can be done on an outpatient basis, but with an increase in edema, the pregnant woman is hospitalized in a hospital. Dropsy of pregnant women can pass into the next stage of gestosis - nephropathy of pregnant women.

Classic signs nephropathy are edema, proteinuria and hypertension. The classic "triad" of symptoms is observed in 50% of cases. Currently, the clinical course of preeclampsia is characterized by the blurring of the course and an increase in the number of asymptomatic and atypical forms of the disease. More rare forms include monosymptomatic gestosis: hypertension in pregnant women and proteinuria. However, these forms of gestosis are no less dangerous.

It is customary to distinguish three degrees of nephropathy (Table 13.1).

Table 13.1

This division does not always justify itself in practice, therefore, to assess the severity of preeclampsia, it is advisable to use the Wittlinger or Goek scale, which allows you to objectify some clinical signs (Tables 13.2, 13.3). Assessment of the severity of preeclampsia is carried out in points. The sum from 2 to 10 points - mild degree of nephropathy, from 11 to 20 points - moderate degree of nephropathy, more than 20 points - severe nephropathy.

Table 13.2

Wittlinger scale

Table 13.3

Goek's gestosis severity scale modified by G.M. Savelyeva
Symptoms	Points

Edema	No	On the shins or pathological weight gain	On the shins, anterior abdominal wall	Generalized
Proteinuria	No	0,033 - 0,132	0,132 - 1,0	1.0 or more
Systolitic blood pressure (mm Hg)	below 130	130 -150	150 - 170	170 and above
Diastolic blood pressure (mmHg)	up to 85	85 - 95	90 - 110	110 and above
Time of onset of gestosis, weeks	No	36 - 40 weeks or in labor	35 - 30 weeks	24 - 30 weeks and earlier
FGR (fetal growth retardation, weeks)	No	-	1 - 2 weeks behind	3-4 weeks delay or more
Background diseases	No	The manifestation of the disease before pregnancy	The manifestation of the disease during pregnancy	The manifestation of the disease before and during pregnancy

Mild degree of preeclampsia	- up to 7 points
Average degree	- 8-11 points
heavy	- 12 points or more

In practical terms, it is useful to determine the average blood pressure by the formula:

Normally, mean blood pressure should be no more than 100 mm Hg. Art., an increase in the rate by 15 mm Hg. indicates the onset of the disease.

In order to diagnose preeclampsia, it is necessary to weigh pregnant women, measure blood pressure on both hands, examine urine weekly in the third trimester of pregnancy, carry out a thorough obstetric examination, and if necessary, involve other specialists (oculist, therapist, neuropathologist, etc.). Apply a test for tissue hydrophilicity according to McClure-Aldrich (a "blister" is determined after intradermal injection of 0.9% NaCl, which resolves in less than 35 minutes with edema). Determination of proteinuria and control of diuresis are of traditional importance. The diagnosis of renal dysfunction deserves special attention. For this purpose, the level of proteinuria and cylindruria in single and daily urine samples, the relative density of urine and daily diuresis in the urine sample according to Zimnitsky are determined (isosthenuria and nocturia are characteristic of preeclampsia). Indicators of a biochemical blood test are also of diagnostic value: hypoproteinemia, a decrease in the albumin-globulin ratio below one, an increase in the content of urea and creatinine, etc. An important role is played by the study of the blood coagulation system, in which thrombocytopenia is possible (a decrease in the number of platelets to 160 thousand and below), an increase in fibrin degradation products. Ophthalmoscopy is an informative method for assessing the condition of the fundus vessels, which reveals angiopathy, hemorrhages, edema and retinal detachment.

It is known that gestosis is a prognostically unfavorable complication of pregnancy not only for the mother, but also for the fetus: against the background of the course of gestosis, fetoplacental insufficiency develops, leading to fetal hypotrophy, and sometimes to its antenatal or intranatal death. Thus, in order to assess the condition of the fetus during pregnancy, a dynamic ultrasound study is performed with dopplerometry of the vessels of the uterine-fetoplacental system, cardiomonitoring.

Preeclampsia is differentiated from kidney diseases (glomerulo- and pyelonephritis), hypertension.

The next stage in the development of gestosis is preeclampsia. In addition to the signs characteristic of nephropathy, symptoms of cerebrovascular accident, increased intracranial pressure and cerebral edema appear: headache, blurred vision, pain in the epigastric region, nausea, vomiting, drowsiness, decreased response to external stimuli or, conversely, excitement and euphoria. The duration of preeclampsia can be from several hours to several minutes.

The highest form of gestosis is eclampsia- the most severe form of preeclampsia, the main manifestation of which is convulsions with loss of consciousness against the background of vasospasm, hemorrhages and cerebral edema. Seizures can occur suddenly, but more often develop against the background of symptoms of preeclampsia. Clinical manifestations of eclampsia develop in a certain sequence. There are 4 stages of a convulsive seizure: 1st stage - fibrillar contractions of the muscles of the face; 2nd stage - tonic convulsions with respiratory failure and loss of consciousness; 3rd stage - clonic convulsions, at the height of the seizure, blood pressure rises sharply, hemorrhages appear, cerebral edema progresses (the same changes appear in the lungs and other parenchymal organs); 4th stage - resolving.

Complications of eclampsia: heart failure, pulmonary edema, cerebral coma, cerebral hemorrhage, retinal hemorrhage, liver and kidney failure, disseminated intravascular coagulation syndrome, premature detachment of a normally located placenta, hypoxia and fetal death.

With this pathology, all manipulations (vaginal examination, venipuncture, etc.) are performed under mask anesthesia. If there are precursors of an attack of eclampsia, droperidol 5-10 mg is administered in combination with seduxen 5-10 mg. If convulsive readiness is not stopped, then promedol 20 mg or pipolfen 25-50 mg are additionally administered. When an attack occurs, a mouth expander is introduced, the tongue is captured with a tongue holder, assisted ventilation is started with a mask or transferred to artificial lung ventilation, drugs are administered intravenously, as in the case of eclampsia precursors. Antihypertensive therapy is started against the background of a medical treatment and protective regimen. Strict control of the patient's respiratory rate and heartbeat is carried out. In parallel, infusion therapy is carried out in order to replenish the BCC.

In severe forms of gestosis, it can develop HELLP syndrome, which got its name from the first letters of clinical manifestations: H - H emolisis (hemolysis), EL - EL evated liver enzymes (increased levels of liver enzymes), LP - L ow platelets (low platelet count).

HELLP syndrome usually occurs in the third trimester of pregnancy. The clinical picture of the disease is characterized by a rapid increase in symptoms. Initial manifestations are nonspecific and include headache, fatigue, malaise, nausea, vomiting, pain in the abdomen and especially in the right hypochondrium. Most characteristic manifestations diseases: jaundice, vomiting with blood, hemorrhages at injection sites, progressive liver failure, convulsions, coma.

One of the main symptoms of HELLP syndrome is hemolysis, which is manifested by the presence of wrinkled and deformed erythrocytes in a blood smear, polychromasia. The destruction of red blood cells leads to the release of phospholipids and intravascular coagulation - chronic DIC.

THERAPY OF GESTOSIS

Treatment of preeclampsia is advisable to carry out in conjunction with an anesthesiologist-resuscitator. Treatment of preeclampsia should be pathogenetically justified and depend on the severity of preeclampsia. With any severity of preeclampsia, the base is onco-osmotherapy. Therapy also includes an effect on the central nervous system (the concept of a therapeutic regimen according to Stroganov), antihypertensive therapy (drugs of central and peripheral action, ganglioblockers, magnesium therapy), elimination of vascular disorders, hypovolemia, chronic DIC, normalization of water and electrolyte , protein, carbohydrate balance, blood acid-base balance, uteroplacental blood flow, etc.

When conducting therapy, you should coordinate the appointment with the anesthesiologist and adhere to the following provisions:

Influence the central nervous system in order to create a therapeutic and protective regimen;

Eliminate hypovolemia;

Remove generalized vasospasm (magnesia therapy);

Improve blood flow in the kidneys and stimulate their urinary function;

Regulate water-salt metabolism;

Normalize metabolism and vascular permeability;

Normalize the rheological and coagulation properties of blood;

Carry out antioxidant therapy;

Prevention and treatment of intrauterine hypoxia and fetal hypotrophy;

Prevent aggravation of preeclampsia by timely gentle delivery;

Deliver with adequate anesthesia (preferably epidural anesthesia), early amniotomy, using controlled normotherapy

Preeclampsia is a pathology that occurs during pregnancy, the development of which is based on the formation of immune complexes resulting from a response to the penetration of fetal antigens into the mother's body through a disturbed utero-placental barrier.
Classification of gestoses.
According to the development period, the following forms of gestosis are distinguished:
1. Early preeclampsia: formed during the first half of pregnancy, usually from 1 to 3 months.
2. Late preeclampsia: formed in the second half of pregnancy during the last 2-3 months of pregnancy.
3. Rare forms of preeclampsia: they can form in any trimester.
Classification of gestoses according to Nikolaev:
1. Light preeclampsia: characterized by an increase in blood pressure by no more than 20% of normal numbers, and proteinuria of not more than 1.0 g / l.
2. Moderate severity of preeclampsia: characterized by an increase in blood pressure from 20% to 40% of normal numbers, and proteinuria of not more than 2.0 g / l.
3. Severe preeclampsia: characterized by an increase in blood pressure by more than 40% of normal numbers, and proteinuria of 3.0 g/l or more.
In the ICD-10 classification, gestosis is included in class XV, in the block - O10-O16 Edema, proteinuria and hypertensive disorders during pregnancy, childbirth and the postpartum period.
Early gestosis includes vomiting of pregnant women. In ICD-10, this corresponds to the following headings:
O21 Excessive vomiting of pregnancy
O21.0 Mild or moderate vomiting of pregnancy
O21.1 Excessive or severe vomiting of pregnant women with metabolic disorders
O21.2 Late vomiting of pregnancy
O21.8 Other forms of vomiting complicating pregnancy
O21.9 Vomiting of pregnancy, unspecified
In the clinical classification, 3 degrees of severity of vomiting of pregnant women are distinguished:
1. Mild form of vomiting - vomiting occurs after eating, no more than 5 times a day. The general condition is not worsened. As a rule, passes independently.
2. Moderate vomiting - occurs up to 15 times a day, is not associated with food intake, the general condition worsens, signs of exhaustion and dehydration appear. It does not go away on its own, without treatment it turns into excessive vomiting.
3. Excessive vomiting - the frequency of occurrence of 20 times a day or more, pronounced signs of intoxication, dehydration and exhaustion.
Rare forms of gestosis include:
1. Dermatoses of pregnant women;
2. Jaundice of pregnant women or cholestatic hepatosis of pregnant women;
3. Acute fatty degeneration of the liver or acute fatty
4. Hepatosis of pregnant women;
5. Tetany (chorea) of pregnant women;
6. Osteomalacia of pregnant women;
7. Neuro- and psychopathy of pregnant women;
8. Bronchial asthma of pregnant women;
9. Arthropathy.

In ICD-10, these forms correspond to class XV, block: Other obstetric conditions not elsewhere classified (O95-O99).
Late gestosis includes multiple organ failure syndrome, manifested by: DIC-syndromo, HELLP-syndrome, preeclampsia, eclampsia, coma, renal failure. In ICD-10, it corresponds to Class XV, Block (O10 - O16) Block: Edema, proteinuria and hypertensive disorders during pregnancy, childbirth and the puerperium.

The pathogenesis of preeclampsia is based on acute damage to the vascular endothelium and membranes of blood cells (primarily erythrocytes and platelets), resulting in violation of:
1. Rheological properties of blood
2. Coagulopathy occurs
3. The ability of the vascular endothelium to regulate the level of arterial pressure decreases.
4. Hypoxia of organs and tissues occurs.

As a result, these mechanisms trigger a cascade of reactions that cause preeclampsia, forming a variety of symptoms and syndromes.
Primarily, vascular disorders occur in the placenta, then the process spreads, generalizing to capture the vessels of all organs and tissues. Vascular damage is caused by the immunological nature of the damage that occurs as a result of the penetration of fetal antigens into the mother's bloodstream. In response to this, the compliment education system is launched. It should be emphasized that due to the intensive organogenesis and development of the functional systems of the fetus, immune complexes are constantly in morphological and structural dynamics. For intensive saturation of maternal blood with fetal antigens, a number of factors must develop, such as:
1. Increased vascular permeability.
2. Fetoplacental insufficiency.
3. Violation of the immune system.
The severity of the development of preeclampsia depends on the combination of provoking factors and the degree of development of the adaptive systems of the mother's body.
Take a break, treat yourself to shopping, go shopping without going through the store mobile phones…. You deserve gifts - do not deprive yourself of this.

pages: 45-55

Diseases that occur only in pregnant women and are associated with pregnancy, i.e. associated with it, called gestosis. Gestosis (toxicosis) is divided into early and late. Rare forms of gestosis are singled out as a separate group. Early gestosis includes vomiting of pregnant women, salivation (ptyalism) and some other, more rare, types of this pathology.

The problem of vomiting in pregnant women has been around for a long time: the first mention of it can be found in papyri dating back to 2000 BC. It may seem surprising, but excessive vomiting in pregnancy (EPP) until the middle of the twentieth century. was one of the leading causes of maternal death. At present, it has been possible to achieve a significant reduction in mortality in PR, but this pathology is still the leader in the structure of obstetric morbidity. From 50 to 90% of patients during pregnancy suffer from nausea and vomiting. Complaints appear on the 9th-10th week of gestation, reach a maximum on the 11th-13th and usually resolve on their own by the 12th-14th week. However, in 1-10% of cases, vomiting and nausea may disturb the patient up to the 20-22nd week of pregnancy.

During the physiological course of pregnancy in a woman's body, adaptive changes occur in almost all organs and systems that are regulated by the nervous system with the participation of endocrine glands. There is a theory that nausea and vomiting that occurs in early pregnancy (i.e., during embryogenesis) are an evolutionary defense mechanism to prevent pathogenic microorganisms and toxins from food from entering the woman's body. This is indirectly supported by the fact that patients suffering from vomiting and nausea during pregnancy are less likely to have miscarriages and stillbirths.

Thus, CRP requires intensive care in a hospital in 0.3-2% of cases. In addition, early gestosis is often associated with other forms of obstetric pathology (pregnancy hypotension, iron deficiency anemia, threatened miscarriage, late gestosis), and also contribute to the development of perinatal pathology (chronic hypoxia, fetal malnutrition, developmental defects of the nervous system, neonatal asphyxia). Among the extragenital diseases associated with CRP and complicating the course of pregnancy, heartburn, atonic constipation, and functional disorders of cardiac activity can be noted.

Etiology and pathogenesis of early gestosis

Factors contributing to the development of gestosis

According to a large study conducted in Canada, it was found that CRH is more often observed in the presence of such background pathologies as hyperthyroidism (including its subclinical forms), mental disorders, a history of molar pregnancy, diseases of the gastrointestinal tract (GIT). ), diabetes mellitus, bronchial asthma. Also, the risk of VRP is higher during pregnancy with a female fetus and during multiple pregnancy. Some studies have found that pregnant women with a low socioeconomic status and a low level of education, as well as women who have noted nausea and vomiting during a previous pregnancy, with a history of intolerance to combined oral contraceptives in history, and multiparous patients are more susceptible to this condition. Among other risk factors for vomiting in pregnant women, ethnicity, professional status, the presence of fetal abnormalities (trisomy, triploidy, dropsy), rapid weight gain, history of infertility, a short interval between the previous and present pregnancy, the presence of a corpus luteum of pregnancy in the right ovary are noted. . There is also an opinion about the role of genetic predisposition in the pathogenesis of early gestosis. This is supported by the data that the probability of developing preeclampsia is 8 times higher in the daughters of patients with a history of preeclampsia in comparison with the general population.

It should be noted that smoking during pregnancy and age over 30 years are associated with a low risk of developing RHD. Nausea and vomiting in patients with preeclampsia can be caused by increased sensitivity of the olfactory organ and features of the vestibular apparatus. During examination, many women indicate that the smell of cooked food, especially meat, is a trigger for nausea. A certain similarity between the symptoms of CRH and the symptoms of "seasickness" suggests that some cases of CRH are a manifestation of subclinical forms of vestibular disorders.

Findings from various studies regarding the role Helicobacter pylori in the pathogenesis of the development of CRH are very controversial. However, it should be remembered that persistent nausea and vomiting that does not go away after the second trimester of pregnancy may be associated with an exacerbation of peptic ulcer associated with H. pylori. Also, a certain role in the pathogenesis of the development of CRH belongs to the background pathology of the hepatobiliary system and lipid metabolism disorders.

Theories of the occurrence of gestosis

Until now, a single concept has not been developed to explain the pathophysiology of nausea and vomiting in pregnant women. It is thought to be due to a complex interplay of neurogenic, hormonal, immunological, placental, biochemical, and psychological factors. Currently, preeclampsia is defined as a condition arising from the inability of the adaptive mechanisms of the maternal organism to adequately meet the needs of the developing fetus.

Neuroreflex (cortical-visceral) theory is that the growth of the ovum and the gradually increasing irritation of the endometrial receptors can lead to an increase in the excitability of subcortical formations and enhance the response of the autonomic nervous system. Ultimately, all this can cause reflex changes in the hemodynamics of the mother's body. With the pathology of the endometrium and links of the receptor chain, the likelihood of pathological abnormalities increases. This theory is confirmed by the fact that gestosis of pregnant women often occurs precisely against the background of neuropsychic stress. In addition, electroencephalography in patients with gestosis reveals functional changes in the subcortical structures of the brain.

hormonal theory. Patients with RHD often have higher levels of human chorionic gonadotropin (hCG), which can stimulate thyroid stimulating hormone (TSH) receptors in the thyroid gland. Peak values of hCG are detected precisely in the first trimester of pregnancy. In some patients with RHD, a clinic of hyperthyroidism can be observed. However, most often there is a reduced level of TSH (in 50-70% of cases) and an increased level of free thyroxine (T4) without any clinical manifestations of hyperthyroidism. Circulating thyroid antibodies are not detected, and the size of the gland is not enlarged. This transient hyperthyroidism associated with RRP usually resolves spontaneously and thyroid function returns to normal without antithyroid therapy. A number of studies have noted a positive correlation between the level of hCG in the blood plasma and the concentration of free T4. The authors attribute the severity of nausea to the degree of thyroid stimulation. As for the correlation of high levels of estradiol with the severity of nausea and vomiting in pregnant women, there are conflicting opinions in the literature.

immunological theory is that the development of preeclampsia contributes to the mismatch of histocompatibility factors between mother and fetus. It is assumed that the development of preeclampsia is characterized by a combination of HLA homozygosity and a defect in the recessive gene of the immunological response. It is possible that during pregnancy in such patients the mechanisms that ensure the tolerance of the maternal organism to the developing embryo turn out to be untenable.

biochemical theory CRH is associated with activation of the sympathetic peripheral nervous system and increased production of tumor necrosis factor α. In addition, a number of authors note a change in the concentration of adenosine, which is a suppressor of excessive activation of the sympathetic nervous system and the production of cytokines, which may be a determining factor in the pathogenesis of CRH. In patients with this pathology, an increase in the level of fetal DNA is reflected in the indicators of the mother's blood serum and may be due to the fact that trophoblast cells are destroyed by the woman's hyperactive immune system. All these data together suggest that the occurrence of RRP may be associated with immunological changes that occur during pregnancy.

placental theory. According to this concept, the placenta plays an important role in the pathogenesis of gestosis. Supporters of the placental theory call humoral factors of placental origin as a trigger for preeclampsia. It is assumed that in patients with preeclampsia, for some reason, the migration of trophoblast into the vessels of the uterus is disturbed. The spiral uterine arteries do not change their structure during pregnancy. Relationships in the trophoblast-spiral artery system are disrupted, spasm occurs, intervillous blood flow worsens and, as a result, hypoxia of the tissues of the uteroplacental complex occurs. This entails a violation of the vasoactive properties of the endothelium and the release of vasoconstriction mediators. Long-term production of vasoconstrictors causes a number of pathological changes in hemodynamics, CNS, hormonal status, metabolism and acid-base balance of the body.

Psychogenic theory. Psychological problems associated with pregnancy may indirectly cause nausea and vomiting. The degree of influence of this factor on the physical condition of a woman is determined by her internal mood for pregnancy and the level of sociocultural development. Severe forms of early gestosis, such as CRP, most often occur against the background of severe chronic psychological stress. The literature describes cases of the development of CRH associated with exacerbation of mental illness, depression and psychosomatic disorders.

Clinic of ChRB with early gestosis

The main complaints in early gestosis are nausea, vomiting, weakness, pronounced taste perversions and olfactory quirks, loss of appetite, and sleep disturbance. Objectively noted weight loss, tachycardia, hypotension, fever, changes in urine and blood tests.

The main clinical symptom is vomiting. Depending on the frequency of episodes of vomiting throughout the day, as well as on the degree of violations of water-salt, carbohydrate, protein, fat metabolism, acid-base, vitamin balance, functions of the endocrine glands, there are three degrees of severity of vomiting in pregnant women:

light form;
moderate vomiting;
severe form, or CRP.

In most (80-90%) cases, mild vomiting resolves spontaneously or is easily treated with diet and rest. With vomiting in pregnant women of moderate severity, and especially in its severe form, the disease is accompanied by hemodynamic, metabolic and neuroendocrine disorders, changes in water-salt metabolism occur, vascular tone decreases, liver function is impaired, excretion of estrogens and glucocorticoids changes, and the level of oxygenation of arterial blood decreases. Due to the pathological catabolism of proteins in the blood, the concentration of ammonia increases, which, along with increased elimination of CO 2 (the result of hyperventilation), leads to the development of a mixed form of alkalosis. The rheological properties of blood are disturbed, the volume of circulating blood (CBV) decreases, mainly due to the volume of circulating plasma. In addition, hematocrit indicators increase, the aggregation ability of erythrocytes increases, blood viscosity increases (mainly due to an increase in the concentration of fibrinogen), and manifestations of polyhypovitaminosis increase. As exhaustion, intoxication, and dehydration increase, dystrophic changes occur in the liver, kidneys, brain, and other organs, which can ultimately lead to the development of multiple organ failure. Diagnosis of vomiting of pregnant women and its forms is based on an assessment of clinical data and results. laboratory research (

Table 1. The severity of vomiting (Ventskovsky B.M. et al., 2005; with additions)

Criteria	The severity of vomiting and the stage of the disease
Criteria	I (mild) - neurotic, allergic stage	II (middle) - toxic stage	III (severe) - indomitable vomiting of pregnant women (hyperemesis gravidarum), dystrophic stage
General state	Significantly not violated	Violated, complaints of weakness, sometimes dizziness. Psycho-emotional lability, sometimes depression	Severe, impaired consciousness, lethargy, polyneurotic pain, muscle wasting. There may be euphoria, hallucinations, convulsions, increased skin and tendon reflexes
Dream	not violated	violated	violated
Appetite	Normal	lowered	Missing
Nausea	Moderate, occurs several times during the day	Almost constant	Constant, unbearable
Vomit	2-5 times a day. Vomiting occurs on an empty stomach, may be caused by food intake or unpleasant odors	6-10 times a day	11 times a day or more. Inclination to vomit on empty stomach or at night. Pain in the epigastrium
Fainting	Rarely	Found in 30-40% of patients	In 50-60% of patients
Body temperature	Normal	Sometimes subfebrile temperature	Subfebrile (37.2-37.5 ° C), sometimes rises to 38 ° C
Pulse rate	slight increase, up to 90 bpm	Tachycardia, 90-100 bpm	> 100 bpm
systolic blood pressure	120-110 mmHg Art.	Hypotension, 110-100 mmHg Art.	severe hypotension,
Digestion	Mainly absorbed	Partially absorbed	Not digestible
Weight loss	Up to 5% of the original, no more than 2 kg per week	6-10%, 3-5 kg per week	> 10%
Leather	Humidity of the skin and mucous membranes remains normal	Dry skin. Sometimes yellowness of the skin and sclera (in 5-7% of cases)	Yellowness of the sclera and skin (in 20-30% of patients), severe dehydration, a symptom of a “dust trail” (when you run a finger over the skin, a white strip is visible, consisting of exfoliated epidermal flakes), impaired tissue turgor, petechiae on the skin and mucous membranes, hemorrhages in conjunctiva
defecation	Chair 1 time in 2-3 days	Constipation, stool 1 time in 3-4 days	Prolonged constipation of an atonic nature
Diuresis	900-800 ml/day	800-700 ml/day	Oliguria (
Analysis of urine	Possible acetonuria (+)	Acetonuria (++-+++) in 20-50% of patients	Ketonuria, reaction to acetone is sharply positive (+++-++++), albuminuria, cylindruria. In urine - formed elements of blood, urobilin. The smell of acetone from the mouth and from the skin
Blood analysis	Without changes	In 20-30% hyperbilirubinemia (up to 40 µmol/l and higher)	Hematocrit values are high due to a decrease in BCC and plasma volume. increasing leukocytosis. Hyperbilirubinemia (40-80 µmol/l), hypo- and dysproteinemia, hypoalbuminemia. High levels of urea, creatinine. Due to the violation of protein and water-salt metabolism, the content of cholesterol, chlorides decreases

Differential diagnosis of prolonged vomiting during pregnancy

Diseases and pathologies of the gastrointestinal tract:

food poisoning;
infectious diseases (including viral hepatitis);
gastroenteritis;
pathology of the hepatobiliary system (including cholelithiasis, hepatitis);
obstruction of the small intestine;
stomach ulcer;
pancreatitis;
appendicitis;
stomach cancer.

Pathologies of the genitourinary system:

pyelonephritis;
uremia;
node necrosis with uterine myoma;
urolithiasis disease.

Metabolic disorders:

diabetic ketoacidosis;
porphyria;
Addison's disease;
hyperthyroidism.

Neurological disorders:

vegetovascular dystonia of the hypotonic type;
brain concussion;
meningitis;
brain pseudotumor;
cerebellar damage;
migraine;
CNS tumor.

Conditions associated with pregnancy:

nausea and vomiting in pregnant women;
acute fatty hepatosis of the liver;
preeclampsia.

Drug poisoning.

The icteric syndrome, often observed in RH, requires special attention in the differential diagnosis, since it can cause an erroneous diagnosis of viral hepatitis. In the etiology of jaundice during vomiting in pregnant women lie metabolic disorders, and only in advanced cases can fatty degeneration of the liver develop due to starvation. Jaundice as a symptom of early preeclampsia occurs against the background of repeated vomiting and increasing dehydration. At the same time, icterus of the skin and mucous membranes is mild, jaundice does not have a cyclical development, there are no signs of an infectious-toxic syndrome, hepatosplenomegaly is not observed. In viral hepatitis, jaundice is pronounced, there are cyclical development of the disease, thrombohemorrhagic syndrome, hepato- and splenomegaly, urine becomes dark color, the feces become discolored. In this case, repeated vomiting is a sign of severe fulminant hepatitis. The analysis of indicators of laboratory tests facilitates the differential diagnosis of these conditions. Jaundice against the background of early preeclampsia is accompanied by hyperbilirubinemia (1.5-2 times higher than normal), mainly due to indirect bilirubin. An increase in the level of alanine aminotransferase is most often not observed, tests for the detection of markers of viral hepatitis are negative. In addition, acetonuria appears with gestosis, and thrombohemorrhagic syndrome is observed very rarely.

Therapy of vomiting with early gestosis

Therapeutic tactics depend on the severity of preeclampsia, and measures taken can range from simple changes in diet to the use of antiemetics and parenteral nutrition. At any severity of vomiting, the pregnant woman should be offered hospitalization. Only with mild forms of early gestosis, outpatient treatment is allowed, subject to dynamic control of body weight and regular urine tests for acetone. Vomiting of moderate and severe degree requires treatment of a pregnant woman in a hospital. It is necessary to explain to the woman the reason for her condition. Although the role of the psychological factor in the pathogenesis of vomiting in pregnant women has not been fully proven, it can be recommended that the patient consult a psychologist.

Basic principles for the treatment of vomiting in pregnant women:

normalization of the ratio between the processes of excitation and inhibition in the central nervous system;
elimination of hypovolemia and correction of violations of the rheological properties of blood;
fight against acidosis, intoxication and dehydration of the body;
elimination of violations of water-electrolyte metabolism and metabolism;
correction of deficiency of vitamins and microelements;
improvement of uteroplacental circulation;
treatment of comorbidities.

The effectiveness of the therapy is judged by the reduction and cessation of vomiting, weight gain, normalization of urine and blood tests. With intractable RRP, termination of pregnancy is indicated due to the risk of complications that are life-threatening for the woman. Unfavorable prognostic symptoms are:

icteric skin color;
body temperature > 38 °C without infection;
persistent tachycardia (> 120 beats / min);
severe bilirubinemia;
hallucinations, coma.

Complications of CRP:

dehydration;
violation of the functions of vital organs (heart, liver and kidneys);
acute yellow atrophy of the liver (very rare, but can cause fatal complications);
abortion;
Mallory-Weiss syndrome.

Treatment of vomiting in pregnant women should be complex and differentiated with a simultaneous multilateral impact on various links in the pathogenesis of the disease. An important point is a balanced diet and compliance with the drinking regimen. Food should be high-calorie, fortified and easily digestible. In connection with a decrease in appetite, the diet of a pregnant woman should contain foods that do not provoke nausea and cause appetite. Avoid spicy foods and alcohol. The diet must contain foods that contain a lot of protein (including essential amino acids), minerals, and vitamins. First of all, it is meat, seafood, dairy products. Particularly valuable in the diet of a pregnant woman are fatty varieties of sea fish as an important source of protein and fish oil, which includes fat-soluble vitamins, in particular A and D. In addition, in comparison with meat, fish contains a lot of phosphorus and calcium (the latter are better absorbed in the presence of vitamin D). Sea fish and seafood are especially rich in trace elements, incl. iodine.

Dairy products are a source of easily digestible proteins. Milk contains lactose, which is directly used to form glycogen. The most optimal in terms of chemical composition and digestibility among dairy products are cottage cheese and fermented milk products. In the latter, lactose, under the influence of lactic acid bacteria, turns into lactic acid, which ensures the absorption of calcium and phosphorus. Dairy products and calcium preparations are more rational to use in the afternoon. Be sure to include leafy greens, foods containing vitamin A or carotenoids in the diet. In CRP, it is recommended to have breakfast without getting out of bed. It is desirable that the woman does not participate in cooking.

Eat only if you feel hungry or want to snack, regardless of the meal times.
Recommended fractional meals (6-8 times a day), the intervals between meals should be small.
Avoid fatty and spicy foods, emetogenic foods and odors.
It is advisable to eat soft or dry foods.
Stop taking iron tablets.
Increase the amount of protein-rich foods in your diet (meat, fish, dairy products).
In the mornings, when vomiting is especially pronounced, dry unsweetened cookies (biscuits, crackers), broth can be recommended.
Peppermint or ginger herbal teas, jellies, cool or frozen desserts may be helpful.

Loss of fluid and salts during vomiting and severe ptyalism leads to dehydration and changes in the body's acid-base balance. Long-term loss of salts is accompanied by the transfer of water from the vascular bed into the cells, salt-deficient (extracellular) dehydration develops. In this regard, the BCC is significantly reduced, the general condition of the patient progressively worsens. Hemodynamic disorders are observed, the processes of formation and excretion of urine are sharply slowed down. The osmotic concentration of CSF increases, as a result of which cerebral edema and convulsions may develop. With a progressive decrease in the level of potassium in the blood, intestinal paresis increases, and cardiac disorders increase. Therefore, one of highlights in the treatment of patients with CRP is the observance of the drinking regimen.

Pregnant women suffering from vomiting are shown to take mineral alkaline waters in small portions (50-100 ml each) 5-6 times a day. The total volume of fluid consumed should be 2-2.5 l / day (taking into account the volume of intravenous infusion therapy, if it is carried out). Drinking water should be slightly warm (38-40 ° C) to facilitate its absorption. It is not recommended to drink liquid later than 30 minutes before a meal and within 1.5 hours after a meal. It is important to inform the patient that with proper drinking regimen and normal kidney function, urination should occur every 2-3 hours.

Non-drug treatment of vomiting in pregnancy

Given the numerous manifestations of dysfunction of organs and systems, the development of which entails vomiting of pregnant women, it is sometimes advisable to use auxiliary non-drug therapy. First of all, we are talking about physiotherapeutic methods for the treatment of vomiting, such as electrosleep, central electroanalgesia, acupuncture and laser reflexology, galvanization or diathermy of the cervical sympathetic nodes of the collar zone and abdominal plexus, endonasal electrophoresis of vitamin B1 with novocaine or diphenhydramine. There is experience in the treatment of vomiting in pregnant women with the help of acupuncture, acupuncture, acupressure, hypnotherapy, but this requires the involvement of specialists in rare specialties. Efferent methods of treatment (plasmapheresis), physiotherapy exercises and psychotherapy are also used.

Medical treatment of vomiting in pregnant women

For mild vomiting in pregnant women, medications can be taken orally. In PRP, drugs are administered only parenterally until the ability to retain food appears. Due to the fact that early gestosis develops during the period of embryogenesis, sometimes there are difficulties in choosing drugs for drug therapy.

This is due to the fact that some studies have found an increase in the frequency of congenital fetal malformations in patients who used these drugs, compared with pregnant women who did not take them. Since there are no reliable data on the teratogenic effects of antiemetics, it should be remembered that any of the drugs approved for use during pregnancy should be used at the minimum therapeutic dosages and only after an assessment of the benefit / risk ratio.

infusion therapy. It is prescribed to eliminate dehydration, replenish bcc, normalize water and electrolyte balance, eliminate hypoproteinemia and intoxication phenomena.

The total volume of infusion therapy is 1-3 l / day, depending on the severity of the condition and body weight of the pregnant woman. Infusions are carried out intravenously drip with an interval of 1-2 days (if necessary, daily). To eliminate hypoproteinemia, intravenous drip administration of protein preparations (plasma, protein 100 ml of a 10% solution, albumin 100 ml of a 10% solution, etc.) is prescribed every other day. If the acid-base balance is disturbed towards acidosis, a 4-5% solution of sodium bicarbonate 100-150 ml is used for 3-4 days and a 10% solution of calcium chloride 10 mg under the control of the CBS of the blood. In severe form of the disease and severe intoxication, infusion therapy is supplemented with the introduction of mixtures of amino acids, polyglucin, rheopolyglucin, refortan. The volume of infusion therapy is 2-2.5 l / day. The criteria for adequate infusion therapy are the normalization of hematocrit, skin turgor, increased diuresis, persistent improvement in well-being, cessation of vomiting and a gradual increase in body weight.

Correction of metabolic disorders. Metabolic disorders in preeclampsia inevitably lead to the development of endogenous intoxication. Toxic metabolic products damage the membrane structures of hepatocytes and the liver parenchyma, which leads to a decrease in its enzymatic function and disruption of the synthesis of amino acids and proteins. The leading role in the development of these pathological processes belongs to the dysfunction of microsomal enzymes, in particular cytochromes P 450 . The use of hepatoprotectors contributes to the activation of the process of restoration of microsomal enzymes, an increase in the content of cytochromes P 450 in the liver, a decrease in the rate of their inactivation and an improvement in biochemical processes in the liver.

regulation of tissue metabolism. Depletion of endogenous carbohydrate stores leads to ketosis. This condition is associated with inhibition of the activity of enzymatic systems of tissue respiration. In order to stimulate aerobic oxidation, the introduction of bioenergy metabolism cofactors (cocarboxylase, lipoic acid, calcium pantothenate, riboflavin mononucleotide) is pathogenetically determined, with the help of which pyruvic and lactic acids are launched into the Krebs cycle. After the elimination of the bioenergetic deficit, it is recommended to prescribe stimulants of tissue anabolic reactions (splenin, pyridoxal phosphate, riboxin, folic acid). It is expedient to use α-tocopherol acetate.

Improvement of uteroplacental circulation and gas exchange of the embryo (fetus) achieved through the use of oxygen therapy, vasoactive drugs. In the treatment of patients with early gestosis, antioxidant drugs (vitamin E, ascorbic acid) are used to normalize lipid peroxidation and prevent secondary placental insufficiency.

Homeopathic medicines and phytotherapy in the treatment of vomiting in pregnant women. To reduce the reflex excitability of the central nervous system and regulate cardiac activity, an infusion of rhizomes and roots of valerian officinalis is used. Valeric acids block enzymes that break down γ-aminobutyric acid (GABA), an inhibitory mediator of the central nervous system. An increase in the concentration of GABA leads to a pronounced sedative and muscle relaxant effect. A very promising and effective direction in the treatment of early gestosis is the appointment of homeopathic preparations containing the following components: Nux vomica, Ipecacuanha, Nux moschata, Veratrum album, Tabacum, Chamomilla, Iris versicolor, Phosphorus, Pulsatilla.

Drugs for regulating the activity of the central nervous system and blocking the pathological gag reflex. For this purpose, the following groups of drugs are used:

vitamins of group B (B 1, B 6);
antihistamines - promethazine, dimenhydrinate;
direct dopamine antagonists - metoclopramide, domperidone;
serotonin receptor antagonists - ondansetron;
dopamine receptor blockers - droperidol, haloperidol;
glucocorticosteroids - methylprednisolone.

Sometimes, in severe cases of intractable vomiting, tranquilizers (trioxazine) are prescribed to pregnant women. With severe hypersalivation, M-anticholinergics (atropine) are used. Data on antiemetic drugs, their mechanisms of action, dosages and possible use during pregnancy are presented in

Table 2. Antiemetics used in PRP

Active substance/ a drug	Dosages and features of administration	Application during pregnancy
B vitamins
Pyridoxine (vitamin B6)	Inside 0.05-0.1 g / day after meals in 1-2 doses for at least 3 weeks; or 1-2 ml of 1-5% solution 1 time per day. The course of treatment - 1-2 months	Category A. Risk to the fetus has not been identified in controlled human studies. One study showed that oral vitamin B6 25 mg every 8 hours (75 mg/day) was more effective than placebo in treating nausea and vomiting in pregnancy. At pharmacological doses, vitamin B6 is not teratogenic.
Thiamine (vitamin B1)	Intramuscularly 0.025-0.05 g of thiamine chloride 1 time per day. Inside 10 mg 1-3 times a day. Doses in terms of thiamine bromide are slightly higher (approximately 1.3 times), since the latter has a larger molecular weight	Category A. Fetal risk not identified in controlled human studies
Antihistamines
Promethazine (phenergan, diprazine, pipolfen)	Inside after meals, 25 mg 2-3 times a day or every 4-6 hours. Intramuscularly, 1-2 ml of a 2.5% solution 3-4 times a day. Intravenously as part of lytic mixtures - 2 ml	Category C. Promethazine crosses the placental barrier. Use with caution after evaluating the benefit to mother/potentially harmful effects on the fetus
Dimenhydrinate (Dedalone, Dramina, Aviomarin)	50-100 mg every 4-6 hours as needed. The maximum daily dose is 400 mg	Category C*. Contraindicated for use in the first trimester of pregnancy. In the II-III trimester, the use of the drug is possible with extreme caution if the expected effect of therapy outweighs the potential risk to the fetus.
diphenhydramine (diphenhydramine)	Inside 30-50 mg 1-3 times a day for 10-15 days. Intramuscularly 0.01-0.05 g 1% solution. Intravenous drip 0.02-0.05 g diphenhydramine in 100 ml of isotonic sodium chloride solution	Category C. It is not recommended to prescribe in the III trimester of pregnancy. The risk to the fetus has been identified in animal studies, similar studies in humans have not been conducted. The drug may be recommended if the expected positive effect from its use is higher than the potential risk to the fetus
Meclozine (meclizine, bonin)**	For nausea and vomiting in pregnant women, the drug is usually effective at a daily dose of 25-50 mg.	Category C. As world experience shows, the use of meclozin in pregnant women did not reveal signs of teratogenic effects. However, in experimental studies, certain teratogenic effects of meclozin when administered at high doses (up to 25-50 mg/kg) were observed in rats. However, such changes did not occur in other experimental animals, including monkeys. Thus, when prescribing meclozine, it is necessary to compare the possible risk and potential benefit of using the drug.
*5-HT3 (serotonin) receptor antagonist*
Ondansetron (sturgeon, isotron, zofran, emetron)	Intravenous stream slowly or as a short infusion 2-4 mg every 6-8 hours	Category B. Contraindicated in the first trimester of pregnancy. The safety of the use of ondansetron for the fetus when prescribing the drug during pregnancy in women has not been established. In experimental studies on animals, the use of the drug did not disrupt the development of the embryo or fetus and did not affect the course of pregnancy, pre- and postnatal development. However, since animal studies are not always predictive in humans, a drug can only be recommended for use if the expected benefit from its use is greater than the potential risk to the fetus.
*Direct dopamine antagonists*
Domperidone (motilium lingual, motoricum)	10 mg 3-4 times a day before meals. With severe nausea and vomiting, 20 mg 3-4 times a day are prescribed.	Category C. Risk to the fetus has been identified in animal studies, but similar data in women are limited. The drug may be recommended if the expected positive effect from its use is higher than the potential risk to the fetus
Metoclopramide (cerucal)	Inside 10 mg up to 4 times a day 30 minutes before meals. Intramuscularly, intravenously (stream slowly, drip) 2 ml 3-4 times a day	Category B Contraindicated in the first trimester of pregnancy. In the II and III trimesters are prescribed for health reasons
*Dopamine receptor blockers*
Haloperidol (halopril, halomond, senorm)	To stop nausea and vomiting of central origin, 2.5-5 mg of the drug is administered intramuscularly or intravenously.	The use of the drug during pregnancy is possible only if the expected benefit is greater than the possible teratogenic effect.
Droperidol	The dose of the drug is determined individually, taking into account age, body weight, the use of other drugs. For the prevention of nausea and vomiting, the drug is used in the form of intramuscular injections or intravenously slowly in a stream at a dose of 2.5-5 mg (1-2 ml). At the same time, it is necessary to provide support for adequate BCC	During pregnancy, the ratio of the expected positive effect of the drug to the risk of a possible negative effect on the fetus should be assessed.
Prochlorperazine (Meterazine, Compazine, Dicopal, Nipodal)**	Inside after meals, 5-10 mg 3-4 times a day	Category C. The risk to the fetus has been identified in animal studies, but similar studies have not been conducted in humans. The drug may be recommended if the expected positive effect from its use is higher than the potential risk to the fetus
*Glucocorticosteroids*
Methylprednisolone (solu-medrol, depo-medrol, metipred)	Intravenously, 16 mg every 8 hours for 3 days, then the dose is reduced to the minimum effective. The drug is used if other antiemetics have been ineffective	Category C. The risk to the fetus has been identified in animal studies, but these have not been conducted in humans***. Pregnancy is a relative contraindication, especially the first trimester. The drug may be recommended if the expected positive effect from its use is higher than the potential risk to the fetus
* Some authors indicate that dimenhydrinate can be categorized as B. At the same time, according to some manufacturers, experimental studies have shown that dimenhydrinate causes the development of cardiovascular defects and inguinal hernia in the fetus, on the basis of which it can be categorized D. Not registered in Ukraine. * October 14, 2010 The New England Journal of Medicine published new guidelines for choosing a strategy for treating nausea and vomiting in pregnant women (N Engl J Med. 2010;363:1544-1550, ACOG Guidelines for Treating Nausea and Vomiting in Pregnant Women ). A meta-analysis of four studies showed that the use of drugs of the glucocorticosteroid group for the treatment of RRP before 10 weeks of gestation was associated with a 3-4-fold increase in the risk of cleft palate (“cleft lip” or “cleft palate”) in the fetus, on the basis of which the drug can be attributed to category D and should be used only if other groups of drugs have not been effective.

According to the recommendations of the American College of Obstetricians and Gynecologists (2004, 2009), the first line of therapy for nausea and vomiting in pregnant women is vitamin B 6 preparations alone or in combination with the antihistamine drug doxylamine. According to V.A. Tutelyan, V.B. Spiricheva et al. (2002), pyridoxine deficiency during pregnancy is manifested by nausea, persistent vomiting, loss of appetite, irritability, insomnia, and the appointment of vitamin B 6 reduces these phenomena. It should be borne in mind that the signs of vitamin B6 deficiency are more pronounced with magnesium deficiency in the body, since this trace element is necessary for the activation of pyridoxine-dependent enzymatic systems.

Magnesium lowers neuromuscular excitability, has an antispastic effect, enhances intestinal motility and bile secretion, affects carbohydrate-phosphorus metabolism, protein synthesis, participates as a cofactor or activator of many enzymes, and has an alkalizing effect on the body. The daily requirement for magnesium for women is 0.3 g, and during pregnancy and lactation it rises to 0.45 g due to an increase in BCC, the growth of the fetus and uterus.

A pathological vicious circle is formed - with FRP, magnesium deficiency aggravates the patient's condition, which leads to an increase in magnesium loss with vomiting and the inability to replenish its required amount through food.

Under conditions of reduced magnesium concentration, pathological activation of calcium-dependent contractile reactions in the myometrium occurs, and thus the threat of abortion increases, especially in the II-III trimester. With concomitant arterial hypertension, the blood supply to the placenta and the fetoplacental complex is disturbed, the content of vasoconstrictor factors in the blood increases, which aggravates the risk of miscarriage (Tsarkova M.A., 2010). Magnesium deficiency leads to an increase in aldosterone secretion, fluid retention in the body and the development of edema.

Pyridoxine (vitamin B 6) is extremely important for the functioning of the nervous system, indispensable in the complex treatment of stress, depressive and convulsive conditions, a number of neurological pathologies, nausea and vomiting. This is explained by the fact that with a deficiency of pyridoxine, the formation of GABA in brain tissues is disrupted, as a result of which the excitability of the nervous system increases. Of particular concern should be the symptoms of vitamin B6 deficiency during pregnancy. With a deficiency of pyridoxine, the patient may experience depression, psychosis, increased irritability. The drug is prescribed during the gestation period with toxicosis, since it alleviates the condition with anorexia, nausea and vomiting in pregnant women. In a number of studies, pyridoxine has shown its effectiveness in depression: it has a positive effect on the production of norepinephrine and serotonin (Ogunyemi D.A., Fong A., 2009). The daily requirement of a woman for vitamin B6 during pregnancy and lactation is 2.1-2.3 mg.

All this makes it possible to assert that the use of medicines containing vitamin B6 and magnesium in early gestosis and CRP is pathogenetically justified (Gromova O.A., 2006; Gromova O.A., Serov V.N., 2008; Tsarkova M.A. ., 2010; Tomilova I.K., Torshin I.Yu. et al., 2010).

Such a combined preparation containing both magnesium and vitamin B 6 is Magvit. One of the main indications for its appointment is the prevention of complications associated with a deficiency of magnesium and / or vitamin B 6 .

Magvit is presented in the form of enteric tablets, which is a fundamentally new approach to the use of magnesium and vitamin-containing products. Each Magvit tablet contains 470 mg magnesium lactate dihydrate (equivalent to 48 mg Mg 2+) and 5 mg pyridoxine. Magnesium absorption occurs in the small intestine by passive and accelerated diffusion. For its absorption, the conditions of a moderately acidic or alkaline environment are best. It is especially important to follow a diet rich in protein products of animal origin and vitamin B 6 . The key point that ensures the effectiveness of the use of magnesium-containing drugs is the targeted transport of magnesium ions directly to the site of absorption, i.e. into the small intestine. This problem is solved due to the presence of a protective shell on the Magvit tablets, which protects the active substance from the aggressive acidic environment of the higher gastrointestinal tract. It is the presence of an enteric form of a magnesium-containing preparation that makes it possible to effectively ensure the transport and release of the active ingredients of Magvit directly in the small intestine.

It should be noted that the issue of prescribing this drug during pregnancy and lactation is decided by the doctor, taking into account the benefit / risk ratio individually for each patient and child (fetus). When evaluating this ratio, the following should be taken into account. Firstly, the use of vitamin B 6 in combination with magnesium is advisable as a pathogenetic therapy for PRP. Secondly, it is an integral part of the correction of electrolyte imbalances that develop against the background of RRP, since hypomagnesemia is the most important risk factor for increased uterine contractility, impaired uteroplacental circulation, and preeclampsia.

The article is published with the support of GlaxoSmithKline MGVT/10/UA/27.02.2012/5970
References in the amount of 15 sources
located on the journal website: www.website
Prepared by Olga Zhigunova

Toxicosis(gestoses) are the conditions of pregnant women that occur in connection with the development of the entire fetal egg or its individual elements, characterized by a multiplicity of symptoms, of which the most constant and pronounced are dysfunction of the central nervous system, vascular disorders and metabolic disorders. When the fetal egg or its elements are removed, the disease, as a rule, stops. These states Pregnant women are classified according to their age of occurrence. Distinguish between early toxicosis and late gestosis. They differ in their clinical course. Early toxicosis is usually observed in the first trimester, and it disappears at the beginning of the second trimester of pregnancy. Gestosis occurs in the second or third trimesters of pregnancy.

PATHOGENESIS

There were many theories trying to explain the mechanism for the development of early toxicosis: reflex, neurogenic, hormonal, allergic, immune, cortico-visceral. In the pathogenesis of early toxicosis, the leading role is occupied by a violation of the functional state of the central nervous system. In the early stages of pregnancy, the symptoms of early toxicosis (neurosis) are manifested by a disorder in the function of the gastrointestinal tract. Food reflexes are associated with the autonomic centers of the diencephalic region. The afferent signals coming here from the periphery can be perverse (either due to changes in the uterus receptors or in the pathways), changes are possible in the centers of the diencephalic region themselves, which can change the nature of the response efferent impulses. When the sensitivity of the system is disturbed, a change in reflex reactions quickly occurs, a violation of nutritional functions: loss of appetite, nausea, salivation (salivation), vomiting. A huge role in the occurrence of early toxicosis is played by neuroendocrine and metabolic disorders, therefore, with the progression of the disease, changes in water-salt, carbohydrate and fat, and then protein metabolism gradually develop against the background of increasing exhaustion and weight loss. Violation of the hormonal state can cause pathological reflex reactions. With vomiting of pregnant women, a temporary coincidence of the onset of vomiting with a peak in the content of chorionic gonadotropin is noted, and a decrease in corticosteroid function of the adrenal glands is often noted.

CLINICAL COURSE

Common (vomiting of pregnant women, salivation) and rare forms of early toxicosis (dermatoses of pregnant women, tetany, osteomalacia, acute yellow liver atrophy, bronchial asthma of pregnant women) are distinguished.

Vomiting pregnant(emesis gravidarum) occurs in about 50-60% of pregnant women, but no more than 8-10% of them need treatment. The earlier vomiting occurs during pregnancy, the more severe it is. Depending on the severity of vomiting, three degrees of severity are distinguished: mild, moderate and severe.

With mild (I degree) vomiting of pregnant women the general condition of the patient remains satisfactory. Vomiting is observed 5 times a day more often after meals, sometimes on an empty stomach. This reduces appetite and depresses the mood of a pregnant woman. The patient loses no more than 3 kg in weight, body temperature remains within the normal range. Humidity of the skin and mucous membranes remains normal, the pulse rate does not exceed 80 beats / min. Arterial pressure does not change. Clinical analyzes of urine and blood without pathological changes.

II degree - vomiting of moderate severity .The general condition of the woman is noticeably disturbed: vomiting is observed from 6 to 10 times a day and is no longer associated with food intake, weight loss is from 2 to 3 kg in 1.5-2 weeks. Subfebrile temperature is possible. The moisture content of the skin and mucous membranes remains normal. Tachycardia up to 90-100 beats / min. Blood pressure may be slightly reduced. Acetonuria in 20-50% of patients.

III degree - severe (excessive) vomiting of pregnant women. The general condition of the woman is deteriorating sharply. Vomiting occurs up to 20-25 times a day, sometimes with any movement of the patient. Sleep disturbance, adynamia. Loss of body weight up to 8-10 kg. The skin and mucous membranes become dry, the tongue is lined. The body temperature rises (37.2-37.5° ). Tachycardia up to 110-120 beats / min, blood pressure decreases. Pregnant women retain neither food nor water, which leads to dehydration and metabolic disorders. All types of metabolism are disturbed. Daily diuresis is reduced, acetonuria, often protein and casts in the urine. Sometimes the content of hemoglobin in the blood increases, associated with dehydration. In blood tests, hypo- and dysproteinemia, hyperbilirubinemia, increased creatinine. Shift of acid-base balance towards acidosis. In the study of electrolytes, a decrease in potassium, sodium and calcium is found.

SCHEME FOR ESTABLISHING THE SEVERITY OF PREGNANT VOMITING

Symptoms	Severity of pregnancy vomiting
Symptoms	Light	Medium	heavy
Appetite	Moderately reduced	Significantly reduced	Missing
Nausea	Moderate	Significant	Constant, painful
salivation	Moderate	Expressed	thick viscous
Frequency of vomiting (per day)	3-5 times	6-10 times	11-15 times or more (up to continuous)
Pulse rate	80-90	90-100	Over 100
Systolic BP	120-110 mmHg	110-100 mmHg	Less than 100 mmHg
food retention	Mainly holding	Partially hold	Don't hold back
Weight loss	1-3 kg (up to 5% of the original weight)	3-5 kg (1 kg per week, 6-10% of the original weight)	More than 5 kg (2-3 kg per week, more than 10% of the original weight)
Dizziness	Rarely	In 30-40% of patients (moderately expressed)	In 50-60% of patients (significantly expressed)
Subfebrile condition	ѕ	Seen rarely	In 35-80% of patients
Jaundice of the sclera and skin	ѕ	In 5-7% of patients	In 20-30% of patients
Hyperbilirubinemia	ѕ	21-40 µmol/l	21-60 µmol/l
Dry skin	- +	++	+++
Chair		Once every 2-3 days	stool retention
Diuresis	900-800 ml	800-700 ml	Less than 700ml
Acetonuria	ѕ	Periodically 20-50%	70-100%

Manifestations of early toxicosis of pregnant women must be differentiated from a number of diseases in which vomiting is also noted (food poisoning, gastritis, pancreatitis, cholelithiasis, stomach cancer, neuroinfection, etc.).

TREATMENT

Treatment of patients with vomiting of pregnant women should be complex and differentiated with a simultaneous multilateral impact on various aspects of the pathogenesis of the disease.

Complex therapy of vomiting of pregnant women includes drugs that affect the central nervous system, normalize endocrine and metabolic disorders (in particular, water and electrolyte balance), antihistamines, vitamins. During treatment, it is necessary to observe the medical-protective regimen. It is impossible to place two such patients in the ward, since a recovering woman may experience a relapse of the disease under the influence of a patient with continued vomiting.

To normalize the function of the central nervous system, electrosleep or electroanalgesia are used. The duration of exposure is 60-90 minutes. The course of treatment consists of 6-8 sessions. Hypnosuggestive therapy can be used to influence the central nervous system. A good effect is given by various options for reflexology.

To combat dehydration of the body, to detoxify and restore KOS, infusion therapy is used in the amount of 2.0-2.5 liters per day. Ringer-Locke solution (1000-1500 ml), 5.0% glucose solution (500-1000 ml) with ascorbic acid (5.0% solution 3-5 ml) and insulin (based on 1 unit of insulin per 4.0 g of dry matter glucose). To correct hypoproteinemia, albumin (10.0 or 20.0% solution in the amount of 100-150 ml), plasma is used. In violation of CBS, intravenous administration of sodium bicarbonate (5.0% solution) or lactosol, etc. is recommended. As a result of the elimination of dehydration and loss of salts, as well as albumin deficiency, the condition of patients improves rapidly.

The complex therapy of vomiting of pregnant women includes intramuscular injections of vitamins (B

1 , B 6 , B 12 , C) and coenzymes (cocarboxylase). Diprazine (pipolphen) is used, which has a sedative effect on the central nervous system, which helps to reduce vomiting. The drug has a prolonged antihistamine activity. The complex of drug therapy includes other antihistamines - suprastin, diazolin, tavegil, etc.

The criteria for the adequacy of infusion therapy are a decrease in dehydration and an increase in skin turgor, normalization of hematocrit, an increase in diuresis, and improvement in well-being. Complex therapy is continued until a stable cessation of vomiting, normalization of the general condition, a gradual increase in body weight. Extract 5 - 7 days after the cessation of vomiting.

The ineffectiveness of the therapy is an indication for termination of pregnancy.

Indications for termination of pregnancy are:

incessant vomiting;

Increasing dehydration of the body;

Progressive weight loss;

Progressive acetonuria within 3-4 days;

Severe tachycardia;

Violation of the functions of the nervous system (adynamia, apathy, delirium, euphoria);

Bilirubinemia (up to 40-80 µmol/l) and hyperbilirubinemia of 100 µmol/l is critical;

Icteric coloration of the sclera and skin.

The basis for the prevention of early toxicosis is the identification and elimination of psychogenic factors and the improvement of women with chronic diseases of the liver, gastrointestinal tract, etc. before pregnancy.

Salivation(ptyalismus) may accompany vomiting of pregnant women, rarely occurs as an independent form of early toxicosis. With severe salivation per day, a pregnant woman can lose 1 liter of fluid. Abundant salivation leads to dehydration of the body, hypoproteinemia, maceration of the skin of the face, negatively affects the psyche, body weight decreases.

Treatment of severe salivation should be carried out in a hospital. Assign rinsing of the mouth with infusion of sage, chamomile, oak bark, menthol solution and agents that reduce salivation (cerucal, droperidol). With a large loss of fluid, Ringer-Locke solutions, 5.0% glucose are prescribed intravenously. With significant hypoproteinemia, an infusion of albumin and plasma solutions is indicated. A good effect is achieved during hypnosis, acupuncture. To prevent and eliminate maceration of facial skin with saliva, lubrication with zinc paste, Lassar paste or petroleum jelly is used.

Dermatoses of pregnant women- rare forms of early toxicosis. This is a group of various skin diseases that occur during pregnancy and disappear after it ends. Dermatoses appear in the form of itching, urticaria, herpetic eruptions.

The most common form of dermatosis is itching of pregnant women (pruritus gravidarum). Itching may appear in the first months and at the end of pregnancy, be limited to the area of the external genital organs or spread throughout the body. Itching is often excruciating, causing insomnia, irritability, or depressed mood. Itching during pregnancy must be differentiated from diseases that are accompanied by

itching: diabetes mellitus, fungal skin diseases, trichomoniasis, allergic reactions.

Treatment consists in prescribing sedatives, desensitizing (diphenhydramine, pipolfen), vitamins B

1 and B 6 , total ultraviolet exposure.

Tetany of pregnant women(tetania gravidarum) is manifested by muscle spasms of the upper extremities ("obstetrician's hand"), less often of the lower extremities ("ballerina's leg"), face ("fish mouth"). The basis of the disease is a decrease or loss of the function of the parathyroid glands and, as a result, a violation of calcium metabolism. In case of a severe course of the disease or an exacerbation of latent tetany during pregnancy, the pregnancy should be terminated. For treatment, parathyroidin, calcium, dihydrotachysterol, vitamin D are used.

Osteomalacia in pregnancy (oste omalacia gravidarum) in a pronounced form is extremely rare. Pregnancy in these cases is absolutely contraindicated. More often, an erased form of osteomalacia is observed - symphysiopathy. The disease is associated with a violation of phosphorus-calcium metabolism, decalcification and softening of the bones of the skeleton. The main manifestations of symphysiopathy are pain in the legs, pelvic bones, muscles. There are general weakness, fatigue, paresthesia; the gait ("duck") changes, tendon reflexes increase. Palpation of the pubic joint is painful. On radiographs of the pelvis, a divergence of the bones of the pubic joint is sometimes found, however, unlike true osteomalacia, there are no destructive changes in the bones. An erased form of osteomalacia is a manifestation of hypovitaminosis D.

Treatment of the disease. A good effect is the use of vitamin D, fish oil, general ultraviolet irradiation, general and local, progesterone.

Acute yellow atrophy of the liver.(atrophia heratis blava acuta) is extremely rare and may be the result of excessive vomiting during pregnancy or occur independently. As a result of fatty and protein degeneration of liver cells, a decrease in the size of the liver occurs, the occurrence of necrosis and atrophy of the liver. The disease is extremely severe (intense jaundice, itching

,vomiting, convulsive seizures, coma), usually leads to the death of the patient.

Treatment consists of immediate termination of pregnancy, although termination of pregnancy rarely improves the prognosis.

Bronchial asthma in pregnancy(asthma bronchiale gravidarum) is very rare. The cause of bronchial asthma is hypofunction of the parathyroid glands and impaired calcium metabolism.

Treatment: calcium preparations, B vitamins, sedatives, usually give a positive result.

Bronchial asthma of pregnant women must be differentiated from an exacerbation of bronchial asthma that existed before pregnancy.

Prevention of early toxicosis consists in the timely treatment of chronic diseases, the elimination of mental stress, and the adverse effects of the external environment.

Of great importance is the early diagnosis and treatment of initial (mild) manifestations of toxicosis, and, consequently, the prevention of the development of severe forms of the disease.

Vomiting is a reflex controlled by the brain. Impulses to the vomiting center come from different systems and internal organs - the stomach and esophagus, heart, intestines, etc. If a malfunction occurs, poisoning with poisons, then protection in the form of purification immediately follows - an emetic syndrome. During pregnancy, it occurs for various reasons.

Nausea and subsequent vomiting begin at 4-5 weeks. Strengthening of the condition occurs upon reaching the 9th week. Complete cessation in most cases is noted at 16-18 weeks. Rarely, this period can stretch up to 22 weeks. The condition can be observed after 22 weeks. This indicates a late gestosis. The condition is manifested by edema, vomiting, high pressure. Protein is found in the urine.

These symptoms may indicate a normal pregnancy or a mole and an ectopic attachment of the fetus!

If the reflex is repeated on an empty stomach, and bile is present in the vomit, it is necessary to be examined for diseases of the intestines and stomach.

Brown color, blood - symptoms of dangerous pathologies.

Frequent vomiting leads to dehydration and electrolyte imbalance in the body. Ions are important for mother and child! Electrolytes affect health and development!

Classification and severity of vomiting

The tactics of treatment directly depends on the severity of the disease. The classification includes three degrees:

First. The attack happens no more than 5 times a day. The expectant mother leads an active lifestyle, feels cheerful. Normal blood pressure is observed, pulse rates are within 80 beats / min. During toxicosis, a weight loss of 2-3 kg is acceptable. Urinalysis does not contain acetone bodies, there are no violations in blood biochemistry.
Second. Gag reflexes occur 6 to 10 times a day. The state of health is bad, the woman complains of weakness, the pregnant woman is constantly sleepy, fatigue from everyday affairs quickly sets in. medical analysis blood shows values within the normal range. Acetone appears in the urine. The heartbeat is rapid - within 90-100 beats / min. Weight loss - up to 7 kg within 10 days.
Third. The most dangerous and severe degree. A pregnant woman is tormented by constant indomitable vomiting. The frequency of attacks can reach 25 times a day. Due to poor health, the patient is starving. The body does not receive water and food necessary for the development of the fetus. Acetone appears in the blood - up to 3-4 pluses. Against the background of acetonemic syndrome, the body temperature rises to 37.6 degrees, the pulse quickens - 120 beats / min. and more. A woman loses more than 8 kg. Urine from a lack of liquid departs badly, in small portions. As a result of a combination of these symptoms, a complication occurs - dehydration. It can be recognized by the following signs: general weakness, loss of consciousness, increased drowsiness, low blood pressure and high temperature.

Clinical analysis of urine will help to make a diagnosis. If bilirubin and creatinine are elevated, protein, acetone and cylinders are determined, which means that the kidneys and liver are affected. The yellow tint of the eyes and skin are signs of increased bilirubin. The affected liver provokes the appearance of blood in the vagina. Repeated vomiting can cause rupture of the esophagus. If blood is present in the vomit, seek immediate medical attention.

The described symptoms apply only to vomiting of pregnant women. If, in addition to nausea and cleansing of the stomach, there is pain in the abdominal region, diarrhea, fever above 38 degrees, a headache, then the disease has a different pathogenesis of development and is included in another group in the ICD classification. The following pathologies are possible: cholecystitis, intestinal obstruction, exacerbation of pancreatitis.

Vomiting combined with dizziness is a reason to be examined. This is a clear symptom of a missed pregnancy. When the fetus decomposes, poisons enter the circulatory system, intoxication of the body occurs.

Methods for treating nausea at different times

Therapy of the emetic syndrome depends on the severity of the condition. The period and individual characteristics of the woman's body must be taken into account.

Vomiting treatment table different terms pregnancy:

Trimester	Severity of the condition	Treatment
First (1-13 weeks)	1 degree	Does not require the use of medicines. To improve well-being, a diet with reduced calorie and fat content of dishes, with frequent and fractional meals is shown. It is important to improve sleep patterns. Recommended: food rich in pyridoxine (chicken, avocado, beans, eggs, fish); the use of dried fruits and nuts; chewing cumin seeds; alkaline water without gas. To reduce nausea, you can drink warm water on an empty stomach, tea with ginger root, rinse your mouth with chamomile decoction.
	2 degree	The treatment course includes taking antiemetics (Metoclopramide, Osetron), vitamins, folic acid, sorbents. Hofitol will help reduce the negative impact on the liver and support its work. Eat often, but in small portions.
	3 degree	A constant attack of vomiting poses a danger to the bearing of the fetus and the life of a woman. Nutrition through the mouth is excluded, for the relief of acetonemic syndrome, the doctor prescribes the introduction of antiemetics through a vein by droppers. Vitamin B6 is administered intramuscularly to maintain the body.
2nd trimester (13-26 weeks)	Late toxicosis	Treatment is strictly in stationary conditions due to the risk of complications in the heart, lungs, kidneys.
3rd trimester (26-40 weeks)	Late toxicosis	Treatment in a hospital

Early emetic syndrome of the 1st degree is subject to treatment at home. it normal reaction, which does not require the use of medicines and other means of conservative medicine. To eliminate nausea, we apply folk experience and the method of forced cleansing to improve well-being.

Starting from the second trimester, with regular ailments, swelling and vomiting, careful diagnosis and management of pregnancy under the strict supervision of a doctor in a hospital is necessary. Self-medication is excluded! Taking medications only as directed!

Survey

To clarify the root cause of the symptom, women turn to a gastroenterologist who conducts diagnostic measures aimed at assessing the morphological features and functionality of the digestive system. Pregnant women are prescribed only those studies that will not harm the body of the unborn child. The most informative for diagnosis are the following instrumental and laboratory methods:

Ultrasound procedure. During gestation, abdominal ultrasound is performed for dyspeptic disorders as a screening method. During sonography, it is possible to visualize the structure of the gastrointestinal tract, identify signs of pathology, and evaluate the contractile function of smooth muscles. In the 3rd trimester of pregnancy, due to an increase in the uterus, the information content of ultrasound decreases.
Endoscopy. EGDS using a flexible endoscope is prescribed for pregnant women at any time in the absence of absolute contraindications. On examination, the structure of the mucous membrane of the upper gastrointestinal tract is studied. The method is informative for the diagnosis of reflux esophagitis, inflammatory changes in the wall of the stomach and part of the duodenum. Additionally, intragastric and intraesophageal pH-metry is carried out.
Blood test. To determine the degree of toxicosis and the depth of protein-energy deficiency, a biochemical blood test is performed. To rule out damage to the hepatobiliary system, bilirubin and liver tests are evaluated. If a violation in the endocrine system of a pregnant woman is suspected, a blood test for sex and thyroid hormones is performed. According to indications, antibodies to Helicobacter pylori infection are determined.
Fecal analyzes. Diseases of the gastroenterological profile, which are accompanied by vomiting, always cause changes in the coprogram. First, a standard coprogram is carried out. Then, according to indications, more specific studies are performed - analysis of feces for elastase, determination of fecal antigen to H. Pylori. To exclude chronic bleeding, a reaction to occult blood is made.

To confirm GERD as the root cause of vomiting in pregnant women, intraesophageal manometry is prescribed, during which relaxation of the cardiac sphincter and an increase in pressure in the body of the esophagus are determined. All patients need a gynecological examination to assess the condition of the fetus. In the absence of gastroenterological pathology, consultations of other specialists are recommended.

Why does pregnant feel sick?

The exact cause of nausea and vomiting during pregnancy is not known. It is believed that these symptoms may occur under the influence of hormonal changes that occur to a woman in the first 12 weeks of pregnancy, in particular, under the influence of human chorionic gonadotropin (hCG), one of the main hormones of pregnancy. Women who have the highest level of hCG in their blood, for example, with multiple pregnancies, are more likely to experience symptoms of toxicosis.

In addition, the influence of the nervous system is assumed: increased excitation in those parts of the brain that are responsible for the gag reflex or a lack of vitamin B6. The first weeks of pregnancy are more difficult for women with diseases of the gastrointestinal tract, liver diseases and other chronic diseases.

It is believed that the tendency to nausea and vomiting during pregnancy is inherited. If the first weeks of pregnancy were difficult for your mother, it can be assumed that you will also have to experience the symptoms of toxicosis. As a rule, nausea and vomiting recur in subsequent pregnancies.

There are other risk factors that increase the likelihood of nausea and vomiting early in pregnancy:

motion sickness in transport, for example, in a car;
nausea when taking contraceptives containing estrogen;
- when the body mass index is equal to or greater than 30;
stress;
multiple pregnancy, such as twins or triplets;
first pregnancy.

EDEMAS DURING PREGNANCY

Most early symptom gestosis - edema. Fluid retention in the body of pregnant women at the first stages of the development of the disease is associated to a greater extent with impaired water-salt metabolism, retention of sodium salts, increased permeability of the vascular wall due to endothelial damage and hormonal dysfunction (increased activity of aldosterone and antidiuretic hormone).

Obstetrics - gynecology

Anatomical and physiological features of the female body
Clinical diagnostic methods during pregnancy
Laboratory diagnostics during pregnancy
Instrumental diagnostics during pregnancy
Physiological pregnancy
Pathology of pregnancy
Toxicosis of pregnant women and gestosis
Infections during pregnancy
Miscarriage
Pregnancy and diseases of the cardiovascular system
Pregnancy and venous disease
Respiratory diseases and pregnancy
Digestive diseases and pregnancy
Diseases of the kidneys and bladder during pregnancy
Pregnancy and endocrine pathology
Pregnancy and benign formations
Pregnancy and cancer
Pregnancy and surgical pathology
Bleeding in obstetrics
Pathological childbirth
postpartum period
Neonatology
Abortion Methods

Diagnostics

Diagnosis is based on the detection of edema in the second half of pregnancy, not associated with extragenital diseases. Hidden edema is detected during the systematic weighing of the pregnant woman in the antenatal clinic (1 time in 2 weeks).

Treatment. Limiting fluid intake (up to 700 - 800 ml / day) and table salt (up to 3 - 5 g / day). Food is predominantly milky - vegetable with a high content of vitamins. Severe edema is an indication for hospitalization. Assign bed rest, limiting fluid and salt intake, fasting days once a week (1 kg of apples or 400 g of cottage cheese), vitamins. 20-40 ml of a 40% solution is injected intravenously, hypothiazide is given orally at 25 mg 1-2 times a day, together with potassium chloride, 1 g 3 times a day for 3-4 days.
Nephropathy often develops against the background of dropsy or previous extragenital diseases (hypertension, nephritis), such forms of toxicosis are called combined. It is characterized by a triad of symptoms: edema, hypertension, proteinuria. Often there are only two symptoms in any combination, or one of them (monosymptomatic toxicosis). Perhaps the appearance of cerebral symptoms. In severe cases, a transition to preeclampsia and eclampsia is possible. Nephropathy has an adverse effect on the fetus (hypotrophy, intrauterine death).

Treatment stationary. Salt-free diet, fluid restriction, fasting days, vitamin therapy, glucose preparations, intramuscular injection of magnesium sulfate 20 ml of a 25% solution 4-5 times a day (no more than 25 g of a pure substance per day), oxygen therapy, dibazol, papaverine, reserpine , diuretics, rutin, glucose, 50 ml of a 40% solution in / in. Pregnant women with severe forms of nephropathy are led by an obstetrician together with an anesthesiologist (intensive care). In such cases, droperidol is prescribed at 10–15 mg (4–5 ml of a 0.25% solution) intramuscularly or intravenously (inject slowly!), Seduxen 10 mg (2 ml of a 0.5% solution) intravenously . These drugs are prescribed to reduce the excitability of the centers of the brain and stabilize blood pressure. To eliminate vascular spasm, 10 ml of a 2.4% solution of aminophylline, 1 ml of a 0.25% solution of rausedil, 4-5 ml of a 2% solution of no-shpa are injected intravenously. Dehydration is carried out by prescribing mannitol (30 - 60 g of a 20% solution in / in), lasix (2 - 4 ml of a 1% solution). To relieve intoxication, hemodez (200-400 ml) and a glucosone-vocaine mixture (200 ml of 20% glucose solution, 200 ml of 0.5% novocaine solution, 15 IU of insulin) are prescribed intravenously. Correction of hypoproteinemia and hypovolemia is carried out by introducing albumin (100-200 ml) or dry plasma (150 ml). Reopoliglyukin (400 ml IV) is used to normalize microcirculation. All of the listed therapeutic measures are carried out in the intensive care unit or intensive care unit.

Treatment continue for 2-5 days until the persistent disappearance of cerebral symptoms, stabilization of blood pressure and restoration of normal diuresis. Then the patients are transferred to the ward of pathology of pregnant women. For the prevention of intrauterine fetal hypoxia, 20 ml of a 40% glucose solution IV, oxygen inhalation, cordiamine 2 ml IM, cocarboxylase 50 mg IM and 2 ml 1% solution of sigetin IM are prescribed.
Preeclampsia is characterized by the appearance against the background of previous nephropathy complaints of severe headache, blurred vision, pain in the epigastric region.

Treatment similar to the treatment of severe forms of nephropathy.
Eclampsia is characterized by convulsions with loss of consciousness. Most often occurs against the background of a severe form of nephropathy or preeclampsia. An attack of convulsions develops in a certain sequence: Stage I - small fibrillar contractions of the muscles of the face appear, passing to the upper limbs; Stage II - tonic convulsions of the muscles of the entire skeletal muscles; the patient loses consciousness, there is no breathing, the pupils are dilated, cyanosis of the skin and mucous membranes; Stage III - clonic convulsions of the muscles of the trunk, then the upper and lower extremities; irregular breathing appears, foam is released from the mouth; Stage IV - coma. Currently, eclampsia is characterized a small amount of seizures that occur against the background of a relatively mild form of nephropathy or preeclampsia.

Complications eclampsia: fall in cardiac activity, cerebral hemorrhage, pulmonary edema; intrauterine fetal hypoxia, intrauterine fetal death.

Treatment based on the principles developed by V. V. Stroganov: the creation of a medical and protective regime; carrying out activities aimed at normalizing the most important functions of the body; the use of medications to eliminate the main manifestations of eclampsia;
fast and safe delivery.

Treatment is performed by an obstetrician together with an anesthesiologist in the intensive care unit or in a specially equipped ward. All manipulations (obstetric studies, blood pressure measurement, injections, catheterization, etc.) are performed under anesthesia. If a seizure occurs, they give ether-oxygen anesthesia or resort to neuroleptanalgesia (droperidol - 4-5 ml of a 0.25% solution in / in, seduxen - 2 ml of a 0.5% solution in / in). During the II and III stages of the seizure, anesthesia is temporarily stopped. After the cessation of the seizure, short-term anesthesia is again given to prevent a new seizure. Removable dentures are removed, a mouth expander is inserted between the jaws. The patient is given oxygen after each seizure. Carry out the same drug therapy as in severe nephropathy. Eclampsia in childbirth requires accelerated delivery (early opening of the fetal bladder, the imposition of obstetric forceps). C-section produced according to strict indications:
incessant attacks of eclampsia; prolonged coma; hemorrhage in the fundus, retinal detachment; severe oliguria or anuria; pulmonary edema; premature detachment of a normally located placenta.

Prevention late toxicosis is carried out in antenatal clinics (training in hygiene of pregnant women, physio-psychoprophylactic training, etc.). A big role belongs early detection toxicosis

ICD-10 diagnosis code O14.9

Titles

Pregnancy gestosis.

WOMEN'S DISEASES

What complications can result without treatment?

Untimely or inadequate treatment of excessive vomiting of pregnant women can lead to the formation of complications such as:

blindness, brain damage;
liver disease;
rupture and perforation of the esophagus;
loss of consciousness, coma, death;
kidney failure;
pancreatitis;
deep venous thrombosis;
sepsis (including fungal), local infections;
venous thrombosis;
thromboembolism of the pulmonary artery;
rupture of the spleen;
fatty infiltration of the placenta.

When to see a doctor if you feel sick during pregnancy?

Reasons for the development of CRP

Factors that increase the likelihood of developing this complication have been established:

first pregnancy;
multiple pregnancy;
obesity;
pregnancy diabetes;
age primiparous (over 30 years old);
young primiparous;
nausea and vomiting during a previous pregnancy;
chronic diseases accompanied by reduced nutrition.

Additional risk factors also include pre-pregnancy diseases:

dental diseases;
bronchial asthma;
thyroid disease;
psychological disorders;
smoking pregnant.

Description

Gestosis is a complication of a normal pregnancy, characterized by a disorder of a number of organs and systems of the body.
It is believed that the pathogenesis is based on generalized vasospasm and subsequent changes associated with impaired microcirculation, hypoperfusion, and hypovolemia.

GESTOSIS

Preeclampsia (from the Latin "- estatio" - pregnancy) is a complication of a physiologically occurring pregnancy, characterized by a deep disorder in the function of vital organs and systems, developing, as a rule, after 20 weeks of pregnancy. The classic triad of symptoms in this case is: increased blood pressure, proteinuria, edema.

The basis of gestosis is generalized vasospasm, hypovolemia, changes in the rheological and coagulation properties of blood, microcirculation disorders and water-salt metabolism. These changes cause tissue hypoperfusion and the development of dystrophy in them up to necrosis.

Symptoms

This complication is first diagnosed at the beginning of the first trimester, from the 4th to the 10th week. Symptoms can persist up to 18-20 weeks.

The main symptoms are:

indomitable vomiting;
weight loss by 5% or more of the initial weight;
hypersalivation (increased secretion of saliva).

In this case, it is possible that

hypovitaminosis,
pain in the abdomen
weight loss,
acid-base imbalance,
increased levels of liver enzymes,
increase in blood pressure.

Review

Nausea and vomiting in early pregnancy occurs in many women. These symptoms may accompany a normal pregnancy, but in some cases they are a sign of toxicosis and require treatment.

Morning sickness, nausea, and even vomiting are commonly considered to be among the signs of pregnancy. Indeed, about half of all women experience these symptoms in the early stages of bearing a child: nausea and vomiting begin 6 weeks after the last menstruation and gradually disappear by 12-14 weeks of pregnancy. In most cases, nausea and vomiting are mild and do not threaten the health of the expectant mother and baby.

Normally, nausea and vomiting of pregnant women occurs more often in the morning, on an empty stomach, no more than 2-3 times a day. It does not disturb the general condition of the woman, does not reduce appetite, does not cause weight loss or other signs of illness, and does not require treatment.

However, in 8-10% of cases, nausea and vomiting during pregnancy are very severe, continue until the 20th week of pregnancy and can be harmful. If vomiting in a pregnant woman occurs more often 3 times a day, is not associated with food intake, is accompanied by a change in taste and olfactory sensations, leads to weakness, loss of appetite, weight loss, it is considered a manifestation of toxicosis - a pregnancy pathology that must be treated under the guidance of a doctor. Severe toxicosis during pregnancy requires hospitalization.

Prevention

Prevention of gestosis.
Who is at risk?
* Women who will become mothers for the first time;
* expecting twins;
* ladies over 35;
* mothers with chronic diseases (vegetovascular dystonia, obesity, diabetes mellitus, hypertension or chronic pyelonephritis);
* having sexually transmitted infections (chlamydia, mycoplasmosis, ureaplasmosis).
Women with edema, mild and moderate preeclampsia are treated in the department of pathology of pregnant women. If preeclampsia is severe, and even more so there are signs of preeclampsia (preconvulsive condition) or the patient has suffered an eclamptic (convulsive) attack, then treatment is carried out in the intensive care unit. The survey plan usually includes:
* blood tests (general, biochemical, coagulogram - determination of coagulability;
* urine tests (general, daily protein loss, Zimnitsky test);
* assessment of the condition of the fetus (ultrasound, cardiotocography and dopplerometry);
* It is obligatory to consult a therapist, an oculist, in severe forms of preeclampsia - a neurologist.

VOMITING OF PREGNANT WOMEN (EMESIS - RAVIDARUM)

ETIOLOGY (CAUSES) OF VOMITING DURING PREGNANCY

The etiology has not been determined. An important role in the development of the disease is played by disturbances in the relationship between the activity of the central nervous system and internal organs. Of great importance is the predominance of excitation in the subcortical structures of the central nervous system (the reticular formation, the centers of regulation of the medulla oblongata). In these areas, the vomiting center and the chemoreceptor trigger zone are located, which regulate the vomiting act, the respiratory, vasomotor and salivary centers, as well as the nuclei of the olfactory system of the brain. The close location of these centers causes nausea and a number of accompanying vegetative disorders (increased salivation, deepening of breathing, tachycardia, pallor of the skin due to spasm of peripheral vessels) preceding the vomiting act.

here are pregnant women. Vomiting during pregnancy 2 comments

Nausea and vomiting during pregnancy: what to do?

First of all, to get rid of nausea during pregnancy, it is recommended to change the diet and lifestyle, namely:

get plenty of rest, as fatigue can increase nausea;
if nausea is felt immediately after waking up, there is no need to rush to get up, if possible, you should eat a piece of bread or cookies in bed;
drink plenty of fluids, such as water, and drink little and often to prevent vomiting;
give up cold, tart or sweet drinks;
eat more carbohydrates (bread, rice, pasta) and less fat;
most women digest salty foods like toast, crackers, and crispbread better than sweet and peppery (spicy) foods;
it is better to eat a little, but often, than several large portions a day, but you must eat;
give preference to chilled food, as it smells less hot, and the smell of food can cause nausea;
avoid foods or smells that cause nausea;
it will be better if someone else cooks the food, but if you have to do it, then it is better to cook something bland, not greasy, such as baked potatoes or spaghetti, easy to cook;
try to distract yourself: the more you think about nausea, the stronger it is;
wear comfortable clothes that do not squeeze the stomach.

Some other non-drug remedies also help relieve nausea and vomiting during pregnancy. Ginger or Melissa reduce the severity of symptoms of toxicosis during pregnancy. So far, the negative impact of these herbal remedies during pregnancy has not been found. You can add them to drinks or other dishes or make a decoction. For some women, gingerbread cookies or drinks help with nausea. In each case, you can try different products to find what works.

Acupressure(pressure on acupressure points) of the wrist can also help relieve pregnancy nausea. For this, special bracelets can be worn on the forearms. Some research suggests that pressure on certain points on the body triggers the release of chemicals in the brain that relieve nausea and vomiting. Bye negative impact acupressure during pregnancy was not found, but some women noted numbness, pain and swelling of the hand.

Drug treatment of toxicosis during pregnancy

If the nausea and vomiting are very bad and diet and lifestyle changes don't help, your doctor may prescribe a short course of an antiemetic drug that you can take during pregnancy. These funds may have side effects. They are rare but may include muscle cramps.

Some antihistamines (medicines used to treat allergies such as hay fever) also help with nausea. Your doctor may prescribe an antihistamine that is safe for pregnant women.

SALIVORATION DURING PREGNANCY

Salivation (ptualismus) - increased salivation and loss of a significant amount of fluid (up to 1 liter per day). Salivation can be an independent manifestation of toxicosis or accompany vomiting of pregnant women.

sleepwalking during pregnancy. Increased salivation
Author: Obstetrics. National leadership. Ed. E.K. Ailamazyan, V.I. Kulakova, V.E. Radzinsky, G.M. Savelyeva 2009.

PREGNANT JAUNDICE

Jaundice associated with pregnancy may be due to cholestasis, acute fatty liver.

jaundice pregnant. Jaundice during pregnancy
Author: Obstetrics. National leadership. Ed. E.K. Ailamazyan, V.I. Kulakova, V.E. Radzinsky, G.M. Savelyeva 2009.

Sources

https://toxikos.ru/rvota/beremennyh
https://www.KrasotaiMedicina.ru/symptom/vomiting/pregnancy
https://spb.napopravku.ru/symptoms/toshnota-i-rvota-pri-pregnancy/
http://www.MedSecret.net/akusherstvo/toksikozy-beremennyh-i-gestoz
https://gipocrat.ru/boleznid_idd2117.phtml
https://kiberis.ru/?p=30003
https://OGivote.ru/simptom/chrezmernaya-rvota-beremennyh.html

ETIOLOGY (CAUSES) OF VOMITING DURING PREGNANCY

At the beginning of pregnancy, vegetative disorders can simultaneously be due to hormonal disorders, in particular, an increase in hCG levels in the body. Proof of this is the fact that with multiple pregnancy and cystic drift, when a large amount of hCG is released, vomiting of pregnant women occurs especially often.

The factors predisposing to the development of toxicosis include chronic diseases of the gastrointestinal tract, liver, as well as asthenic syndrome.

PATHOGENESIS

In the pathogenesis of vomiting of pregnant women, the determining links are the violation of neuroendocrine regulation of all types of metabolism, partial (or complete) starvation and dehydration. In the mother's body, with the progression of vomiting, water-salt (hypokalemia), carbohydrate, fat and protein metabolism are gradually disturbed against the background of increasing dehydration, exhaustion and weight loss. During starvation, glycogen stores in the liver and other tissues are initially consumed. Then catabolic reactions are activated (fat and protein metabolism increases). Against the background of inhibition of the activity of enzymatic systems of tissue respiration, the energy needs of the mother's body are satisfied due to the anaerobic breakdown of glucose and amino acids. Under these conditions, β-oxidation of fatty acids is impossible, as a result of which underoxidized metabolites of fat metabolism accumulate in the body - ketone bodies (acetone, acetoacetic and β-hydroxybutyric acids), which are excreted in the urine.

In addition, ketosis is maintained by increased anaerobic breakdown of ketogenic amino acids. Against this background, ketonuria develops, oxygenation of arterial blood decreases, and the acid-base balance shifts towards acidosis.

CLINICAL PICTURE

In 50-60% of cases, vomiting of pregnant women is regarded as a physiological sign of pregnancy, and in 8-10% - as a complication of pregnancy (toxicosis). During normal pregnancy, nausea and vomiting can be no more than 2-3 times a day in the morning, more often on an empty stomach, but this does not violate the general condition of the woman and, accordingly, does not require treatment. As a rule, at the end of the placentation process, by 12–13 weeks, nausea and vomiting stop.

Table 31-1. Severity of pregnancy vomiting

Symptoms	Severity of pregnancy vomiting
Symptoms	Easy	Medium	Heavy (excessive)
Frequency of vomiting per day	3-5 times	6–10 times	11–15 times or more (up to continuous)
Pulse rate per minute	80–90	90–100	over 100
Systolic BP	120–110 mmHg	110–100 mmHg	below 100 mmHg
Weight loss per week	1-3 kg (up to 5% of the original weight)	3–5 kg (1–1.5 kg per week, 6–10% of initial weight)	over 5 kg (2-3 kg per week, over 10% of the original weight)
Increase in body temperature to subfebrile numbers	Missing	Rarely seen	Common (in 35–80% of patients)
Jaundice of the sclera and skin	Missing	In 5–7% of patients	In 20-30% of patients
Hyperbilirubinemia	Missing	21–40 µmol/l	21–60 µmol/l
Dry skin	+	++	+++
Chair	Daily	Once every 2-3 days	stool retention
Diuresis	900–800 ml	800–700 ml	Less than 700 ml
Ketonuria	+, ++	+, ++, +++ (periodically in 20–50% of patients)	+++, ++++ (in 70–100% of patients)

Note: +, ++, +++ - degree of expression.

Mild vomiting is observed up to 4-5 times a day and is accompanied by an almost constant feeling of nausea.

Despite vomiting, part of the food is retained and significant weight loss of pregnant women is not noted. The decrease in body weight is 1-3 kg per week (up to 5% of the initial weight). The general condition remains satisfactory, however, patients may notice apathy and decreased performance. Hemodynamic parameters (pulse, blood pressure) in most pregnant women remain within the normal range. Sometimes noted moderate tachycardia (80-90 beats / min), hypotension. Diuresis does not change. Acetonuria is absent. There are no changes in the morphological composition of the blood. Mild vomiting responds quickly to treatment or resolves on its own, so special treatment is not required. However, in 10–15% of pregnant women, it intensifies and can move to the next stage.

Increased vomiting up to 10 times a day or more, worsening of the general condition and metabolism with the development of ketoacidosis indicates a moderate severity. Vomiting is often accompanied by salivation, resulting in an additional significant loss of fluid and nutrients. As a result, dehydration and a decrease in body weight up to 3-5 kg per week (6% of the initial weight) progress to exhaustion. The general condition of pregnant women worsens, there is significant weakness and apathy. The skin is pale, dry, the tongue is covered with a whitish coating, dryish. Body temperature can be subfebrile (not higher than 37.5 ° C), tachycardia (up to 100 beats / min) and arterial hypotension are characteristic. Diuresis is reduced. In the urine, acetone is determined in 20-50% of pregnant women. Mild anemia can be detected in a blood test, and metabolic acidosis can be detected in a CBS analysis. Often, patients report constipation. The prognosis for timely treatment is usually favorable.

Excessive vomiting (severe), which is rare, is characterized by a violation of the functions of vital organs and systems, up to the development of dystrophic changes in them due to severe intoxication and dehydration. Vomiting is noted up to 20 times a day; it is accompanied by profuse salivation and constant nausea. Food and liquid are not retained. The general condition is severe. Patients complain of headaches, dizziness. Note adynamia; body weight decreases rapidly (up to 2–3 kg per week, i.e. over 10% of the initial body weight). The subcutaneous fat layer disappears, the skin becomes dry and flabby, the tongue and lips are dry, the smell of acetone is felt from the mouth; body temperature is subfebrile, but can rise up to 38 ° C; there is severe tachycardia, hypotension. Diuresis is sharply reduced.

With excessive vomiting in the blood, the levels of residual nitrogen, urea, and bilirubin increase. An increase in Ht and the number of leukocytes is characteristic. At the same time, the content of albumins, cholesterol, potassium, and chlorides decreases. In urine, protein and cylinders, urobilin, bile pigments, erythrocytes and leukocytes are determined. The reaction of urine to acetone is sharply positive.

With excessive vomiting, the prognosis is not always favorable. Signs of a threatening condition that determine indications for an emergency termination of pregnancy are an increase in weakness, adynamia, euphoria or delirium, tachycardia (up to 110–120 beats / min), hypotension (up to 90–80 mm Hg), jaundice of the skin and sclera, pain in the right hypochondrium, decreased diuresis (up to 300-400 ml per day), hyperbilirubinemia (within 100 μmol / l), increased levels of residual nitrogen, urea, proteinuria, cylindruria.

DIAGNOSTICS

Establishing the diagnosis of vomiting during pregnancy is not difficult. To determine the severity of vomiting, a clinical examination of the patient is necessary: a study of a general blood and urine test; determination in the dynamics of Ht, blood levels of bilirubin, residual nitrogen and urea, electrolytes (potassium, sodium, chlorides), total protein and protein fractions, transaminases, CBS, glucose. In urine, the level of acetone, urobilin, bile pigments, protein is determined. With significant dehydration in the thickening of the blood, there may be false-normal indicators of the content of Hb, erythrocytes, and protein. The degree of dehydration is determined by the level of Ht. Its value above 40% indicates severe dehydration.

DIFFERENTIAL DIAGNOSIS

Manifestations of early toxicosis of pregnant women must be differentiated from a number of diseases, which are also characterized by vomiting (food poisoning, gastritis, pancreatitis, cholelithiasis, stomach cancer, thyrotoxicosis, neuroinfection and other pathological conditions).

TREATMENT OF VOMITING DURING PREGNANCY

GOALS OF TREATMENT

The goal of treatment is to restore water-salt metabolism, metabolism, and the functions of vital organs.

INDICATIONS FOR HOSPITALIZATION

With mild vomiting, treatment can be carried out on an outpatient basis, with moderate and severe vomiting - in a hospital.

NON-MEDUCATIONAL TREATMENT OF VOMITING

Great importance must be attached to the diet. In connection with a decrease in appetite, a varied diet is recommended in accordance with the desire of a woman. Food should be easily digestible, contain a large amount of vitamins.

It should be taken chilled, in small portions every 2-3 hours, while lying in bed. Mineral alkaline water without gas is shown in small volumes (5-6 times a day). A chilled decoction of ginger or lemon balm is also prescribed in small portions of at least 1 liter per day.

With vomiting of moderate severity, mixtures for enteral nutrition are prescribed.

Given the short gestation period, in order to exclude the negative effect of drugs on the fetal egg, it is advisable to conduct non-drug treatment. To normalize the functional state of the cerebral cortex and eliminate autonomic dysfunction, central electroanalgesia, acupuncture, psychotherapy and hypnotherapy are indicated. The use of homeopathic remedies is effective. These methods of treatment may be sufficient in the treatment of patients with mild vomiting of pregnancy, and in moderate and severe cases, they can limit the amount of drug therapy.

MEDICAL TREATMENT OF VOMITING

With vomiting of pregnant women, drug treatment should be comprehensive:

The basic rule of drug therapy for severe and moderate vomiting is the parenteral method of drug administration until a lasting effect is achieved.

The volume of infusion therapy is 1-3 liters, depending on the severity of toxicosis and the patient's body weight.

The criteria for the sufficiency of infusion therapy are considered to be a decrease in dehydration and an increase in skin turgor, normalization of Ht and diuresis.

Simultaneously with infusion therapy, drugs are prescribed that normalize metabolism. Taking into account vomiting, it is advisable to prescribe them parenterally: riboflavin (1 ml of a 1% solution intramuscularly), ascorbic acid (up to 5 ml of a 5% solution intravenously, intramuscularly), actovegin (5 ml intravenously), essential phospholipids (5 ml intravenously).

Excessive vomiting of pregnant women in the absence of the effect of complex therapy for 3 days is an indication for termination of pregnancy.

TERMS AND METHODS OF DELIVERY

An increase in ketonuria and proteinuria, the appearance of icteric coloration of the skin and sclera, an increase in body temperature to subfebrile values are considered prognostically unfavorable signs indicating the ineffectiveness of the therapy.

The ineffectiveness of the therapy is an indication for termination of pregnancy. So, indications for abortion are:

Lack of effect from complex therapy for three days;
incessant vomiting;
increasing dehydration of the body;
progressive weight loss;
progressive ketonuria within 3-4 days;
severe tachycardia;
dysfunction of the nervous system (adynamia, apathy, delirium, euphoria);
bilirubinemia (up to 40–80 µmol/l), hyperbilirubinemia 100 µmol/l is critical;
icteric coloration of the sclera and skin.

INFORMATION FOR THE PATIENT

A pregnant woman should know that a normal pregnancy can be physiologically accompanied by nausea and vomiting with a frequency of 2-3 times a day. The deterioration is transient and does not require treatment. In addition to following a diet, it is worth taking easily digestible food in small portions.

Antiemetic (antiemic) drugs of the 1st group

Antiemetic (antiemic) drugs of the 2nd group

Antiemetic (antiemic) drugs of the 3rd group

Other drugs

Diagnosis Excessive pregnancy vomiting is only for women

0

0 %

943 071

0 %

Risk group for the disease Excessive vomiting of pregnant women aged 25-29

Features of the disease Excessive vomiting of pregnant women

Short description

Etiology

Development of the disease - pathogenesis

Clinical picture

Main symptoms

Diagnostics

Medical services to determine the diagnosis Excessive vomiting during pregnancy

Clinics for diagnosis

GBU RC Neftekamsk RB

Limited Liability Company Diagnostic and Treatment Center "Antibol"

LLC "Galomed"

No

Treatment

Medical services for the treatment of the disease Excessive vomiting during pregnancy

Clinics for treatment

GKUZ "PRPB"

Limited Liability Company "VLD Group"

"Reacenter" LLC

LLC "ZEVS"

Etiology and pathogenesis of early gestosis

Clinic of ChRB with early gestosis

Differential diagnosis of prolonged vomiting during pregnancy

Therapy of vomiting with early gestosis

Classification and severity of vomiting

Methods for treating nausea at different times

Survey

Why does pregnant feel sick?

EDEMAS DURING PREGNANCY

Obstetrics - gynecology

Diagnostics

Titles

WOMEN'S DISEASES

What complications can result without treatment?

When to see a doctor if you feel sick during pregnancy?

Reasons for the development of CRP

Description

GESTOSIS

Symptoms

Review

Prevention

VOMITING OF PREGNANT WOMEN (EMESIS - RAVIDARUM)

ETIOLOGY (CAUSES) OF VOMITING DURING PREGNANCY

Nausea and vomiting during pregnancy: what to do?

Drug treatment of toxicosis during pregnancy

SALIVORATION DURING PREGNANCY

PREGNANT JAUNDICE

ETIOLOGY (CAUSES) OF VOMITING DURING PREGNANCY

PATHOGENESIS

CLINICAL PICTURE

DIAGNOSTICS

DIFFERENTIAL DIAGNOSIS

TREATMENT OF VOMITING DURING PREGNANCY

GOALS OF TREATMENT

INDICATIONS FOR HOSPITALIZATION

NON-MEDUCATIONAL TREATMENT OF VOMITING

MEDICAL TREATMENT OF VOMITING

TERMS AND METHODS OF DELIVERY

INFORMATION FOR THE PATIENT

Drawing with kids Finger painting for children 1 2 years old

Drawing lessons with young children Drawing lesson for children 2 4 years old