Obstetrics and Gynecology - A. M. Gromova 2000

Early toxicosis in pregnant women. Late gestoses
Late Gestoses
Management of Preeclampsia

Management of mild and moderate Preeclampsia.

I. Strict bed rest and supportive care.

II. Diet therapy (a balanced high-protein diet rich in Vitamins and microelements; fluid restriction to 700-800 ml and sodium chloride to 2.5-5 g per day).

III. Pharmacotherapy:

1. Sedatives (seduxen 0.005 g three times daily or valerian ROOT tincture 20 drops three times daily), herbal cocktails, reflexology.

2. Antihypertensive drugs: — dibazole 0.5% solution 2-4 ml intramuscularly twice daily; — papaverine 2% solution 2 ml 3 times daily; — glucose-novocaine mixture intravenously (100 ml of 20% glucose solution and 100 ml of 0.25% novocaine solution); — rauwolfia Alkaloids (raunatin 0.002 g three times daily or rausedil 0.00025 g 2-3 times daily); — for persistent, Treatment-resistant Hypertension — ganglionic blockers (1 ml of 5% pentamine solution intramuscularly or pyrilen 0.005 g 3 times daily); — angiotensin-converting Enzyme Inhibitors (captopril 6.25 mg three times daily after meals).

3. Desensitizing therapy (diphenhydramine 1% - 1 ml twice daily or tavegyl 0.001 g twice daily).

4. Vascular wall reinforcement (ascorutin 1 tablet three times daily, calcium gluconate 0.5 g three times daily).

5. In case of marked edema — infusion therapy with hyperoncotic and hyperosmotic solutions (100 ml of 10% albumin solution, 150 ml of concentrated plasma, or 400 ml of rheopolyglucin) followed by the administration of 40 mg of furosemide.

6. Myocardial METABOLISM-improving agents (riboxin 10% solution, 10 ml intravenously once daily; essential Phospholipids 5-10 ml pre-diluted with the patient's Blood intravenously, daily) and agents that specifically stimulate ANP production by cardiomyocytes of the right atrium (potassium orotate 0.5 g three times daily, 1 hour before meals; Methionine 0.5 g three times daily; nicotinic acid 0.1 g 3 times daily; Folic acid 0.003 g three times daily).

7. Stimulation of low-pressure volume receptors via body blood redistribution to trigger ANP release by secretory cardiomyocytes, using either an anti-g-suit (compression of the pregnant woman's shins and thighs with a pneumatic pressure of 50-60 mm Hg for 1 hour daily for 7-12 days) or Water-immersion compression (submersion of patients in a water-filled tub (t-34°C) up to the level of the cervical vertebra VI for 1.5-2 hours daily or every other day, 6-12 Procedures).

8. Correction of central hemodynamics disorders (corglycon intravenously as a bolus of 1 ml of 0.06% solution in 20 ml of saline once daily for 3-5 days, followed by a maintenance dose of digoxin 0.25 mg 1-2 times daily; verapamil 80 mg three times daily for 10 days).

9. Improvement of hemorheological properties (persantin, trental, under coagulogram control, or complamin 300 mg intravenous drip in rheopolyglucin solution).

10. Stimulation of prostacyclin synthesis (low-dose aspirin — 60 mg daily or nitroglycerin — 0.0015 g daily).

11. Nitric oxide Donors (erenit 10 mg 3-4 times daily before meals).

12. Antioxidant therapy (combined use of 5% unithiol solution 10 ml intravenously, vitamin E 100 mg daily, and ascorbic acid 200 mg daily).

13. Enterosorbents (activated charcoal 2 tablets 3-4 times daily).

14. Improvement of uteroplacental blood flow for the Prevention of Fetal Hypoxia: glucose 5-10% solution 500 ml with 50 mg of cocarboxylase, 10 ml of 5% ascorbic acid solution, and Insulin at a rate of 1 unit per 4 g of dry glucose weight; sigetin 2 ml of 2% solution intravenously, 5% sodium bicarbonate solution, teonicol 0.15 g three times daily.

To prevent respiratory distress syndrome (RDS) in the newborn, given the potential need for emergency Pregnancy termination between 28 and 36 weeks, it is advisable to use mucosolvan (1 vial — 50 ml, intravenously for 4-5 days) or dexamethasone (4 mg intramuscularly twice daily for 3 days). The duration of treatment for pregnant women with mild preeclampsia is up to 3 weeks, and for moderate preeclampsia, 5-7 days. Upon achieving remission, resolution of symptoms, and normalization of biochemical parameters during a two-week hospital stay, patients may be discharged home provided the physician is confident that strict antenatal supervision by an obstetrician-gynecologist will be maintained at least 2-3 times a week in each specific case. If the slightest clinical signs of gestosis recur, re-hospitalization is required. In the absence of positive dynamics in the patient's condition during treatment or if her condition worsens, early delivery is indicated.

Management of severe preeclampsia

Treatment of severe preeclampsia is carried out for 24-48 hours, and the lack of a positive effect is an indication for pregnancy termination, as its continuation in the presence of marked hemodynamic, volemic, and Metabolic Disorders is inappropriate and leads to a further deterioration of the condition of both the fetus and the pregnant woman.

I. Strict bed rest and supportive care in the intensive care unit with sound and light isolation. Continuous monitoring of blood pressure, diuresis, blood counts, vital organ function, and fetal condition.

II. A rational high-protein diet with fluid restriction (up to 600-700 ml, but for no more than 1-3 days).

III. Pharmacotherapy:

1. Sedative therapy using a combination of tranquilizers (trioxazine 0.6 g 3-4 times daily, seduxen 10 mg intravenously or intramuscularly), neuroleptics (droperidol 0.0025-0.005 g intramuscularly or intravenously), narcotic analgesics (promedol 2 ml of 1% solution or predione 40 ml of 2.5% solution slowly intravenously), and diphenhydramine 1 ml of 1% solution.

2. Hypotensive therapy.

Controlled hypotension using magnesium sulfate, adjusted according to baseline blood pressure. If the baseline mean arterial pressure (MAP) is 110-120 mmHg, administer 30 mL of a 25% magnesium sulfate solution in 400 mL of rheopolyglucin at an infusion rate of 100 mL of hemodilutant per hour. At a

mean arterial pressure ranging from 121 to 130 mmHg, the magnesium sulfate dose should be increased to 40 mL, and if the MAP exceeds 130 mmHg, it should be further increased to 50 mL of the 25% solution. A sharp drop in blood pressure must be avoided. The optimal goal is to reduce MAP by 10-20 mmHg During the first hour of infusion. The ratio of the infusion rate to the urine output rate should be maintained within 1.5-3.5.

If hypotensive therapy is ineffective and blood pressure remains at 160-170/105-110 mmHg, ganglionic blockers are indicated (pentamine 50 mg in 5% glucose solution administered intravenously via drip at a rate of 50 mL over 10 minutes until MAP decreases to 125-130 mmHg, followed by the administration of magnesium sulfate to stabilize readings at a normal level).

Against the Background of magnesium therapy, other antihypertensive agents may be used: - clonidine 1 mL of 0.01% solution 2-3 times daily; - combined use of ß-blockers (anaprilin, obzidan) and calcium channel blockers of the nifedipine group; - angiotensin-converting enzyme inhibitors (captopril 6.25 mg three times daily); - peripheral vasodilators (apressin, nitroglycerin); - antispasmodics (euphyllin 5-10 mL of 2.4% solution intravenously 2-3 times daily, dibazol 2-6 mL of 0.5% intravenously with papaverine 2% 2-4 mL intramuscularly 2-3 times daily); - glucose-novocaine mixture administered intravenously via drip.

3. Controlled hypervolemic hemodilution regimen.

Fluid administration should begin with low-molecular-weight dextrans (rheopolyglucin, rheoglucman) and protein preparations (albumin, plasma). Subsequently, the administration of crystalloids is possible; for the correction of metabolic disorders, sodium bicarbonate (administered cautiously under the control of the blood acid-base balance!) and polyionic solutions are indicated. Following the correction of hypovolemia, Diuretics should be administered (lasix at 0.01-0.02 g for every 100 mL of fluid administered intravenously).

4. Intensification of cardiac function: - cardiac Glycosides: corglycon, digoxin, calcium channel blockers of the verapamil group; - improvement of myocardial metabolism: riboxin 10% 10 mL intravenously; essentiale 5-10 mL intravenously, pre-diluted with the patient's blood; - enhancement of the ability of cardiomyocytes to synthesize ATP (methionine, potassium orotate, nicotinic acid, folic acid at dosages similar to those used in the treatment of mild preeclampsia).

5. Improvement of Liver function: legalon, essentiale 1-2 capsules 3 times daily, riboflavin 0.6 mg daily, pyridoxine 1 mL of 5% solution intramuscularly.

6. Enterosorbents (activated charcoal 2 tablets 3-4 times daily), hemisorbents SKN-3, SKN-4M (1 tablespoon 3-4 times daily) two hours before or after meals, or extracorporeal detoxification via plasmapheresis 4-5 times every other day in volumes of 300-500 mL.

7. Glucocorticoids as indicated to compensate for decreased adrenal cortex function, used with caution taking blood pressure into account (dexamethasone 4-8 mg daily, hydrocortisone 0.05-0.08 g daily).

8. To improve cerebral Circulation: piracetam 20-25 mL of 20% solution in 200 mL of normal saline.

9. To prevent the onset of pulmonary insufficiency — Oxygen therapy, etimizol 1% solution at a dose of 0.5-1 mg per 1 kg of body weight intravenously slowly 1-2 times daily, lobeline hydrochloride 1% 1 mL subcutaneously 1-2 times daily.

10. Improvement of blood rheological properties by administering a rheopolyglucin-heparin mixture at a rate of 5-6 mL of rheopolyglucin and 340 IU of heparin per 1 kg of the patient's body weight. Half of the calculated heparin mixture is administered intravenously, and the remainder subcutaneously every 4-6 hours throughout the day in equal doses, followed by a gradual reduction of the heparin dose. This treatment should be monitored via coagulogram (a reduction in blood clotting by no more than 2 times compared to normal is acceptable). If symptoms of disseminated intravascular coagulation appear, the rheopolyglucin-heparin mixture should be administered with plasma containing antithrombin III.

11. Antioxidant therapy, prevention of fetal hypoxia, as in the treatment of mild preeclampsia.