1. Practical lesson №8 Hypertensive condition during pregnancy. Pre-eclampsia, diagnosis, treatment tactics.

2. Definition Preeclampsia - it is not a disease as it never occurs outside of pregnancy, and is a complication that is caused by disruption of the structure, microcirculation and function of the placenta. After termination of pregnancy, preeclampsia symptoms usually begin to decline and subsequently disappear. Preeclampsia - it is not a disease as it never occurs outside of pregnancy, and is a complication that is caused by disruption of the structure, microcirculation and function of the placenta. After termination of pregnancy, preeclampsia symptoms usually begin to decline and subsequently disappear.

3. Classification I. Arterial hypertension induced by pregnancy I. Arterial hypertension induced by pregnancy I.A. Hypertension without proteinuria - hypertension of pregnancy (gestational hypertension) I.A. Hypertension without proteinuria - hypertension of pregnancy (gestational hypertension) I.B. Arterial hypertension with proteinuria - preeclampsia I.B. Arterial hypertension with proteinuria - preeclampsia II. Chronic hypertension preceding pregnancy II. Chronic hypertension preceding pregnancy III. Chronic hypertension with pre-eclampsia or eclampsia layered III. Chronic hypertension with pre-eclampsia or eclampsia layered

4. Hypertension induced by pregnancy HIP - this increase in blood pressure after 20 weeks. HIP - this increase in blood pressure after 20 weeks. Increased blood pressure during pregnancy is considered to be an adaptive response of the body that occurs in response to inadequate perfusion of the various divisions of the vascular bed of a pregnant, vital organs Increased blood pressure during pregnancy is considered to be an adaptive response of the body that occurs in response to inadequate perfusion of the various divisions of the vascular bed of a pregnant, vital organs

5. Criteria HIP Increased diastolic blood pressure above 90 mm ​​ Hg Increased diastolic blood pressure above 90 mm ​​ Hg Increased systolic blood pressure above 140 mm Hg (conditionally) Increased systolic blood pressure above 140 mm Hg (conditionally) The true increase in blood pressure can be judged on the basis of at least 2-fold measurement of blood pressure for 4 hours The true increase in blood pressure can be judged on the basis of at least 2-fold measurement of blood pressure for 4 hours

6. Risk factors for the development of HIP 1 Pregnancy 2 Signs pointing to the lack of an increase in intravascular volume (increase in Hb above 130 g / l, an increase in hematocrit of 40 or more) 3 The absence of physiological decline DBP in the second trimester (less than 75 mm Hg) 4 Increase in SBP of 30 mm Hg from the original, but does not reach 140 mm Hg 5 Raising DBP at 15 mm Hg from the original, but not reach 90 mm Hg 6 intrauterine growth retardation

7. The high-risk group for the development of HIP - Chronic hypertension - Chronic Kidney Disease - Diabetes - Age 35 years - Severe preeclampsia in previous birth - Multiple pregnancy

8. Gestational hypertension Increased blood pressure, was first celebrated in the II half of pregnancy, is a response to an increase in peripheral resistance of blood vessels. Increased blood pressure, was first celebrated in the II half of pregnancy, is a response to an increase in peripheral resistance of blood vessels. This response is adaptive, designed to maintain adequate blood perfusion in vital organs (brain, liver, kidney) This response is adaptive, designed to maintain adequate blood perfusion in vital organs (brain, liver, kidney)

9. Gestational hypertension 1. Bed rest in the left lateral position is recommended for 1-2 hours after each meal 2 Antihypertensive therapy is indicated only in those cases when the dBP greater than 110 mmHg and starts a real risk of the mother (threatening blood pressure above 160/110, or mean blood pressure (SBP) above 125 mmHg) 3 When antihypertensive therapy should not reduce BP to low numbers, it is sufficient decrease to a safe level of 90-100 mm Hg OBP = (sBP +2 dBP)/ 3 OBP = (sBP +2 dBP)/ 3 normally should not exceed 85 mm Hg normally should not exceed 85 mm Hg

10. Preeclampsia is a hypertension + proteinuria in the II half of pregnancy (after 20 weeks.) is a hypertension + proteinuria in the II half of pregnancy (after 20 weeks.) The main clinical manifestations of pre- eclampsia are the three main symptoms: The main clinical manifestations of pre- eclampsia are the three main symptoms:hypertensionproteinuriaswelling

11. Diagnostic Criteria On the recommendation of the WHO pre- eclampsia is divided into two forms: On the recommendation of the WHO pre- eclampsia is divided into two forms: light and heavy Light preeclampsia - a double-marked rise in diastolic pressure in excess of 90 to 110 mm Hg. for 4 hours with proteinuria of over 0,3 g / l to 1 g / l Light preeclampsia - a double-marked rise in diastolic pressure in excess of 90 to 110 mm Hg. for 4 hours with proteinuria of over 0,3 g / l to 1 g / l

12. Diagnostic Criteria Severe preeclampsia - a rise in diastolic blood pressure over 110 mmHg + proteinuria greater than 1 g / l, a mild pre-eclampsia or attached in any of the symptoms of threatening eclampsia Severe preeclampsia - a rise in diastolic blood pressure over 110 mmHg + proteinuria greater than 1 g / l, a mild pre-eclampsia or attached in any of the symptoms of threatening eclampsia

13. Signs of threatening eclampsia Sudden changes in emotional state Sudden changes in emotional state The sudden and very high blood pressure The sudden and very high blood pressure Hyperreflexia Hyperreflexia Acute headache (often increasing, not cropped conventional analgesics) Acute headache (often increasing, not cropped conventional analgesics) Impaired vision (improvement or deterioration of vision) Impaired vision (improvement or deterioration of vision) Oliguria (<400 ml of urine in 24 hours) Oliguria (<400 ml of urine in 24 hours) pain in the epigastric region or in the upper right quadrant pain in the epigastric region or in the upper right quadrant Icteric of the skin Icteric of the skin Sudden swelling, especially in the lumbar region and the face Sudden swelling, especially in the lumbar region and the face elevation of liver enzymes in the blood elevation of liver enzymes in the blood Thrombocytopenia Thrombocytopenia Changes in the coagulation system Changes in the coagulation system Symptoms of pulmonary edema Symptoms of pulmonary edema

14. Forms of severe pre-eclampsia Eclampsia Eclampsia HELLP-syndrome HELLP-syndrome Acute fatty liver of pregnant women Acute fatty liver of pregnant women (AFLP )

15. Diagnostic Criteria for Severe Preeclampsia Diagnostic Criteria for Severe Preeclampsia Headaches Visual Disturbances Pulmonary Edema Hepatic Dysfunction RUQ or Epigastric Pain Oliguria Elevated Creatinine Thrombocytopenia or hemolysis Proteinuria of 5 g or more in 24 hrs Systolic BP > 160 to 180 mm Hg Diastolic BP > 110 mm Hg

16. Complications of severe pre- eclampsia Cerebral edema Cerebral edema brain hemorrhage brain hemorrhage DIC DIC acute liver failure acute liver failure acute renal failure acute renal failure hypotonic uterine bleeding or coagulopathic hypotonic uterine bleeding or coagulopathic postpartum septic complications postpartum septic complications ante-and intrapartum fetal death ante-and intrapartum fetal death prematurity prematurity PA PA loss of reproductive organ (hysterectomy) loss of reproductive organ (hysterectomy)

17. Clinical Course of Preeclampsia Eyes Arteriolar Spasm Retinal Hemorrhage Papilledema Transient Scotomata Respiratory System Pulmonary Edema ARDS Liver Subcapsular Hemorrhage Hepatic Rupture Hematopoietic System HELLP Syndrome DIC CNS Seizures Intracranial Hemorrhage CVA Encephalopathy Pancreas Ischemic Pancreatitis Kidneys Acute Renal Failure Uteroplacental Circulation IUGR Abruption Fetal Compromise Fetal Demise

18. Blood pressure measurement. For pre-eclampsia is characterized by: For pre-eclampsia is characterized by: - sBP> 140 mm Hg or + 30 mm Hg from the original; - sBP> 140 mm Hg or + 30 mm Hg from the original; - dBP 2: 90 mm ​​ Hg or + 15 mm Hgfrom the original measurement at double intervals for 2 hours. - dBP 2: 90 mm ​​ Hg or + 15 mm Hgfrom the original measurement at double intervals for 2 hours.

19. Urine: Proteinuria is the presence of protein in the urine> 0.3 g / l at any sample or> 0.033 g / l in the daily urine. Proteinuria is the presence of protein in the urine> 0.3 g / l at any sample or> 0.033 g / l in the daily urine. Test with boiling,. In the case of protein and salt by boiling the urine at the top of the tube appears as a blurred cloud "precipitation". By adding 2-3 drops 2-3% acetic acid or 20% sulfosalicylic acid in the presence of protein upper part becomes more turbid, hazy in the absence of urine protein will be transparent. Test with boiling,. In the case of protein and salt by boiling the urine at the top of the tube appears as a blurred cloud "precipitation". By adding 2-3 drops 2-3% acetic acid or 20% sulfosalicylic acid in the presence of protein upper part becomes more turbid, hazy in the absence of urine protein will be transparent.

20. Edema: swelling in the legs occur more than 40% of pregnant women with physiological pregnancy; swelling in the legs occur more than 40% of pregnant women with physiological pregnancy; swelling of face and hands - a sign of pre-eclampsia; swelling of face and hands - a sign of pre-eclampsia; generalized edema (track when pressed saved 12 hours of bed rest or weight gain 2000 for 1 week). generalized edema (track when pressed saved 12 hours of bed rest or weight gain 2000 for 1 week).

21. Laboratory studies. Complete blood obligatory determination of Ht and platelet count. Complete blood obligatory determination of Ht and platelet count. Biochemical blood test: Biochemical blood test: Proteinogramm; Proteinogramm; electrolyte composition of blood plasma; electrolyte composition of blood plasma; urea, creatinine; bilirubin; urea, creatinine; bilirubin; liver enzymes (ALT, ACT, alkaline phosphatase). liver enzymes (ALT, ACT, alkaline phosphatase). Coagulation of blood Coagulation of blood Urinalysis. Urinalysis. Urine culture on flora and sensitivity to antibiotics. Urine culture on flora and sensitivity to antibiotics. ECG. ECG. EEG - indicated. EEG - indicated.

22. The principles of treatment of pre-eclampsia Antihypertensive therapy (dibazol, papaverine, aminophylline, korinfar, clonidine, ganglionic) Antihypertensive therapy (dibazol, papaverine, aminophylline, korinfar, clonidine, ganglionic) Magnesite therapy. Magnesium sulfate has a mild narcotic and tranquilizing effect, diuretic, hypotensive, anticonvulsant, antispasmodic effect, reduces intracranial pressure Magnesite therapy. Magnesium sulfate has a mild narcotic and tranquilizing effect, diuretic, hypotensive, anticonvulsant, antispasmodic effect, reduces intracranial pressure

23. The principles of treatment The maximum daily dose of MgSO4 - 24g (96 ml of a 25% solution of MgSO4). The maximum daily dose of MgSO4 - 24g (96 ml of a 25% solution of MgSO4). In case of overdose MgSO4 observed In case of overdose MgSO4 observed - depression of tendon reflexes - depression of tendon reflexes - Respiratory depression - Respiratory depression - Reduction of urine by the kidney filtration - Reduction of urine by the kidney filtration In case of overdose you must stop the introduction of MgSO4 and enter an antidote to 10 mg of calcium chloride In case of overdose you must stop the introduction of MgSO4 and enter an antidote to 10 mg of calcium chloride

24. Scheme of use of magnesium sulphate in severe pre-eclampsia Loading dose: Loading dose: 25% solution of MgSO4 (4 g, 16 ml) for 5 minutes intravenously 25% solution of MgSO4 (4 g, 16 ml) for 5 minutes intravenously then immediately 40 ml of 25% MgSO4 solution 20 ml (PA5 g) in each buttock i/m and 1 ml of 2% lidocaine in the same syringe then immediately 40 ml of 25% MgSO4 solution 20 ml (PA5 g) in each buttock i/m and 1 ml of 2% lidocaine in the same syringe If convulsions recur after 15 minutes, enter 2 g (8 ml) of 25% MgSO4 i/v for 5 minutes If convulsions recur after 15 minutes, enter 2 g (8 ml) of 25% MgSO4 i/v for 5 minutes If the attack continues, introduced diazepam 10mg centuries for 2 minutes If the attack continues, introduced diazepam 10mg centuries for 2 minutes

25. Scheme of use of magnesium sulphate in severe pre-eclampsia Maintenance dose: Maintenance dose: 5 g (10 ml of 25%) MgSO4 + 1 ml of 2% lidocaine i/m every 4 hours on different buttocks 5 g (10 ml of 25%) MgSO4 + 1 ml of 2% lidocaine i/m every 4 hours on different buttocks Continue treatment magnesium sulfate in 24 hours after the last delivery, or cramps, depending on what occurs last. Continue treatment magnesium sulfate in 24 hours after the last delivery, or cramps, depending on what occurs last. Before you put your make sure that: Before you put your make sure that: The frequency of breathing is normal for at least 16 per minute The frequency of breathing is normal for at least 16 per minute There are knee reflexes There are knee reflexes Amount of urine is not less than 30 ml per hour for the last 4 h Amount of urine is not less than 30 ml per hour for the last 4 h

26. The principles of treatment Sedative therapy (seduksen, Relanium, sibazon, diazepam), droperidol, antihistamines Sedative therapy (seduksen, Relanium, sibazon, diazepam), droperidol, antihistamines Hepatic (essenciale, lipostabil) Hepatic (essenciale, lipostabil) Diuretics exacerbate hypovolaemia apply only in complicated forms of severe pre-eclampsia Diuretics exacerbate hypovolaemia apply only in complicated forms of severe pre-eclampsia Prevention of fetal distress syndrome (dexamethasone 12 mg h-s 12 hours - 3 days) Prevention of fetal distress syndrome (dexamethasone 12 mg h-s 12 hours - 3 days)

27. Indications for early delivery: Lack of effect of treatment: Lack of effect of treatment: When mild preeclampsia for 10 days When mild preeclampsia for 10 days In severe pre-eclampsia in 24 hours In severe pre-eclampsia in 24 hours eclampsia, eclamptic coma, acute renal hepatic failure, cerebral hemorrhage, anuria, HELLP-syndrome, retinal detachment and retinal hemorrhages, amaurosis. eclampsia, eclamptic coma, acute renal hepatic failure, cerebral hemorrhage, anuria, HELLP-syndrome, retinal detachment and retinal hemorrhages, amaurosis. Additional indication for delivery: fetoplacental insufficiency (intrauterine hypoxia and fetal malnutrition) with the preparation for the operation - up to 2 hours. Additional indication for delivery: fetoplacental insufficiency (intrauterine hypoxia and fetal malnutrition) with the preparation for the operation - up to 2 hours.

28. Indications for operative delivery The deterioration of the woman or the growth of signs threatening eclampsia The deterioration of the woman or the growth of signs threatening eclampsia The appearance of convulsive twitches The appearance of convulsive twitches Uncontrolled hypertension Uncontrolled hypertension LIUD or deterioration of the fetus (by ultrasound and CTG) LIUD or deterioration of the fetus (by ultrasound and CTG) Amourosis (blindness due to retinal detachment) Amourosis (blindness due to retinal detachment) obstetric indications obstetric indications

29. 33-34 weeks Delivery Delivery Decisions - Severe Preeclampsia Maternal deterioration? Severe IUGR? Fetal compromise? In labor? >34 weeks gestation? 28-32 weeks Corticosteroids Antihypertensive drugs Daily evaluation of maternal and fetal conditions until 33- 34 weeks Yes Delivery within 24 hours Amniocentesis Immature fluid Corticosteroids Deliver 48 hours later Mature fluid No Adapted from University of Tennessee, Memphis, management plan for patients with severe preeclampsia, Sibai, BM, in Obstetrics: Normal and Problem Pregnancies, 3 rd Edition, Gabbe, SG, Niebyl, JR, Simpson, JL.

30. Vaginal preferable to caesarean section, as in severe pre-eclampsia of additional surgical trauma causes a variety of physiological disorders, exacerbating the severity of the patient's condition. Vaginal preferable to caesarean section, as in severe pre-eclampsia of additional surgical trauma causes a variety of physiological disorders, exacerbating the severity of the patient's condition.

31. Delivery Decisions for Severe Preeclampsia II Vaginal delivery preferred Vaginal delivery preferred Cesarean delivery for Cesarean delivery for Continuous seizures or other emergency Continuous seizures or other emergency Fetal distress Fetal distress Unfavorable cervix Unfavorable cervix Severe prematurity Severe prematurity Anesthesia Anesthesia Epidural vs. general Epidural vs. general

32. Eclampsia

33. Eclampsia - a disease that occurs during pregnancy, childbirth and the postpartum period, in which the blood pressure reaches such a high level that there is a threat to the life of the mother and child. Form of late toxicosis of pregnancy. Eclampsia - a disease that occurs during pregnancy, childbirth and the postpartum period, in which the blood pressure reaches such a high level that there is a threat to the life of the mother and child. Form of late toxicosis of pregnancy.

34. Etiology The etiology and pathogenesis are not fully understood. There are more than 30 theories of eclampsia, the most common of these are: The etiology and pathogenesis are not fully understood. There are more than 30 theories of eclampsia, the most common of these are: genetic Factors genetic Factors thrombophilia thrombophilia Extragenital infection Extragenital infection There is no single test to predict with reasonable certainty eclampsia. There is no single test to predict with reasonable certainty eclampsia. The main trigger preeclampsia - placentofetal failure in combination with other maternal risk factors. The main trigger preeclampsia - placentofetal failure in combination with other maternal risk factors.

35. Сlinic Each attack lasts for 1-2 minutes and has several phases, gradually changing each other. Each attack lasts for 1-2 minutes and has several phases, gradually changing each other. Pre- convulsions phase - characterized by small twitching of facial muscles, by closing the eyelids, lowering the corners of his mouth. Lasts 20-30 seconds. Pre- convulsions phase - characterized by small twitching of facial muscles, by closing the eyelids, lowering the corners of his mouth. Lasts 20-30 seconds. Phase tonic convulsions characterized by muscle tension in the body, the body arched, head tilted back, breathing stops, his face turning blue, comes a loss of consciousness, pulse is not detected. Lasts 20-30 seconds. Phase tonic convulsions characterized by muscle tension in the body, the body arched, head tilted back, breathing stops, his face turning blue, comes a loss of consciousness, pulse is not detected. Lasts 20-30 seconds. Phase clonic convulsions continues with 20-30 and manifests stormy chaotic muscle contractions of face, trunk and extremities. Then the cramps subside, there is a heavy, wheezing, mouth stands foam that due to biting tongue stained with blood. Phase clonic convulsions continues with 20-30 and manifests stormy chaotic muscle contractions of face, trunk and extremities. Then the cramps subside, there is a heavy, wheezing, mouth stands foam that due to biting tongue stained with blood. Phase resolution of attack - convulsions cease, the patient for some time may be in a comatose state, gradually comes to life, but does not remember anything that happened to her. Sometimes coma lasting several hours, in other cases, it may move to a new bout of seizures, which can trigger any irritation (pain, noise, bright lights, medical manipulation, etc.). The number of seizures may be from 1.2 to 10 or more. If an attack of convulsion lasts more than 30 minutes, this condition is considered as eclamptic status. Phase resolution of attack - convulsions cease, the patient for some time may be in a comatose state, gradually comes to life, but does not remember anything that happened to her. Sometimes coma lasting several hours, in other cases, it may move to a new bout of seizures, which can trigger any irritation (pain, noise, bright lights, medical manipulation, etc.). The number of seizures may be from 1.2 to 10 or more. If an attack of convulsion lasts more than 30 minutes, this condition is considered as eclamptic status.

36. Diagnostics Diagnosis of renal eclampsia is simple enough. In the event of seizures during pregnancy or after childbirth, without doubt diagnosed eclampsia. Complexity can only represent the differential diagnosis if caused convulsive seizure is the first manifestation of acute nephritis. For more accurate diagnosis can be used as diagnostic methods such urinalysis and ECG. Diagnosis of renal eclampsia is simple enough. In the event of seizures during pregnancy or after childbirth, without doubt diagnosed eclampsia. Complexity can only represent the differential diagnosis if caused convulsive seizure is the first manifestation of acute nephritis. For more accurate diagnosis can be used as diagnostic methods such urinalysis and ECG.

37. Treatment Since the etiology of the disease is unclear, only etiopathogenetic treatment is early delivery. Before and after delivery also apply the following treatments: Since the etiology of the disease is unclear, only etiopathogenetic treatment is early delivery. Before and after delivery also apply the following treatments: Ensuring strict rest, elimination of visual, auditory, tactile and pain. Ensuring strict rest, elimination of visual, auditory, tactile and pain. Eliminating vasospasm leading to hypertension. Eliminating vasospasm leading to hypertension. Dehydration therapy that promotes increased diuresis and warning cerebral edema. Dehydration therapy that promotes increased diuresis and warning cerebral edema. Oxygen therapy - Oxygen inhalation. Oxygen therapy - Oxygen inhalation.

38. Fit eclampsia.

39. Fit eclampsia. Biting tongue (own case).

40. Changes in kidney and liver during pregnancy toxicosis: 1 - kidney nephropathy ("kidney pregnant"); 2-3 - Kidney for eclampsia; 4 - small hemorrhagic necrosis of the liver due to the formation of thrombosis; 5 - the same section on the liver.

41. Thanks for attentions !!!