Preeclampsia and eclampsia in pregnant women: symptoms, treatment

Causes

The causes of preeclampsia and eclampsia have not yet been precisely established. There are 30 or more theories that explain the causes and mechanisms of development of preeclampsia and eclampsia. But the general opinion of all doctors is that there is a pathology of the placenta, the formation of which is disrupted in the early stages of pregnancy.

If the placental attachment is disrupted (superficially implanted placenta) or there is a deficiency of receptors for placental proteins, the placenta begins to synthesize substances that cause vasoconstriction (vasoconstrictors), which leads to a generalized spasm of all blood vessels in the body to increase pressure in them and increase the supply of oxygen and nutrients substances to the fetus. This leads to arterial hypertension and multiple organ damage (primarily the brain, liver, and kidneys are affected).

Heredity and chronic diseases play an important role in the development of preeclampsia and eclampsia.

Why does eclampsia occur?

There is no exact data on the causes of gestosis. There are several theories that partially explain it. According to the first version, the development of gestosis is caused by genetic disorders of the woman’s body’s adaptation to pregnancy. The second says that the root cause of gestosis is endocrine disorders. In addition, heredity is of great importance in this case. The risk of developing such a pathology is much higher in those women in whose family a mother, grandmother or sister suffered from gestosis.

The risk of eclampsia is aggravated in the presence of untreated chronic foci of infection located in and outside the organs of the reproductive system, as well as in the presence of serious psychological problems.

Symptoms of eclampsia and preeclampsia

Signs of preeclampsia

Preeclampsia is just a short interval between nephropathy and a seizure. Preeclampsia is a dysfunction of vital organs of the body, the leading syndrome of which is damage to the central nervous system:

the appearance of spots before the eyes, flickering, blurriness of objects;
tinnitus, headache, feeling of heaviness in the back of the head;
nasal congestion;
memory disorders, drowsiness or insomnia, irritability or apathy.

Preeclampsia is also characterized by pain in the upper abdomen (“in the pit of the stomach”), in the right hypochondrium, nausea, and vomiting.

An unfavorable prognostic sign is increased tendon reflexes (this symptom indicates convulsive readiness and a high probability of developing eclampsia).

With preeclampsia, swelling increases, sometimes for several hours, but the severity of edema does not matter in assessing the severity of the pregnant woman’s condition. The severity of preeclampsia is determined based on complaints, proteinuria and arterial hypertension (an increase in blood pressure for normotensive patients above 140/90 mm Hg should be alarming). If arterial hypertension is 160/110 or more, they speak of severe preeclampsia.

Kidney damage manifests itself in the form of a decrease in the amount of urine excreted (oliguria and anuria), as well as a high protein content in the urine (0.3 grams in the daily amount of urine).

Signs of eclampsia

Eclampsia is an attack of convulsions that consists of several phases:

First phase. The duration of the first (introductory) phase is 30 seconds. At this stage, small contractions of the facial muscles appear.
Second phase. Tonic cramps are a generalized spasm of all muscles of the body, including the respiratory muscles. The second phase lasts 10-20 seconds and is the most dangerous (the woman may die).
Third phase. The third phase is the stage of clonic seizures. The motionless and tense patient (“like a string”) begins to beat in a convulsive seizure. The convulsions go from top to bottom. The woman is without a pulse or breathing. The third stage lasts 30-90 seconds and is resolved with a deep breath. Then breathing becomes rare and deep.
Fourth phase. The seizure resolves. Characteristic is the release of foam mixed with blood from the mouth, a pulse appears, the face loses its cyanosis, returning to normal color. The patient either regains consciousness or falls into a coma.

Candidate of Medical Sciences L. E. Kuznetsova

Minsk State Medical College
Every day around the world, about 830 women die from preventable causes related to pregnancy and childbirth; 99% of all maternal deaths occur in developing countries. Women die as a result of complications during and after pregnancy, childbirth. Most of these complications develop during pregnancy and can be prevented. Other complications may exist before pregnancy but become worse during pregnancy. Adolescent girls are at higher risk of complications and death from pregnancy than older women. Thanks to qualified care before, during and after childbirth, the lives of women and newborns can be saved. For the period 1990–2015 maternal mortality worldwide has decreased by almost 44%. The main complications that lead to 75% of all maternal deaths are: severe bleeding (mainly postpartum hemorrhage); infections (usually after childbirth); high blood pressure during pregnancy (preeclampsia, eclampsia); postpartum complications; unsafe abortion. Most maternal deaths are preventable. Proven effective measures to save the lives of women and newborns include the following: the use of magnesium sulfate for eclampsia, antibiotics for premature rupture of membranes, corticosteroids for the prevention of respiratory distress syndrome in premature newborns. Although most pregnancies are uncomplicated, high-quality antenatal care is essential to identify and manage complicated pregnancies. Timely prevention and treatment reduces maternal and perinatal morbidity and mortality, as well as severe neonatal morbidity and mortality. Preeclampsia, eclampsia: algorithm for providing emergency medical care to pregnant women by a paramedic team Preeclampsia is one of the most severe and common types of obstetric pathology. Preeclampsia is a pathological condition that occurs in the second half of pregnancy (after 20 weeks) and is characterized by arterial hypertension (AH) in combination with proteinuria and often with edema, manifestations of multiple organ or multisystem dysfunction and failure. Domestic and foreign authors argue that preeclampsia is not an independent disease. This is a syndrome caused by the inability of the mother's adaptive systems to meet the needs of the growing fetus. Preeclampsia is based on disorders of the general blood circulation with the development of multiple organ failure. As pregnancy progresses, preeclampsia progresses, manifesting itself as a triad of symptoms: proteinuria, hypertension and edema (excessive weight gain). According to statistics, in the Republic of Belarus the frequency of late gestosis is 7.3–10.5%, in Russia – 20–25%, in the USA – 23–28%, in developing countries it reaches 30–35%. The average incidence of preeclampsia in pregnant women has increased worldwide from 7 to 35%. In the structure of causes of maternal mortality in Russia, gestosis (preeclampsia) consistently ranks third and amounts to 11.8–14.8%. In our country, maternal mortality is not registered. Eclampsia is the occurrence of an attack or a series of convulsive attacks in a pregnant woman with clinical preeclampsia of any severity that cannot be explained by other causes (tumor, stroke, epilepsy, etc.). Precursors of eclampsia are convulsive readiness, headache, hypertension, and increasing visual disturbances. Eclampsia is the most severe form of gestosis, characterized by acute cerebral edema, high intracranial hypertension, cerebrovascular accident, ischemic and hemorrhagic damage to brain structures. The urgency of the problem is related to the following points: preeclampsia is one of the most severe and common types of obstetric pathology, which leads to multiple organ failure; high frequency of obstetric complications during pregnancy, childbirth and the postpartum period (premature abruption of a normally located placenta, labor anomalies, bleeding in the afterbirth period, development of fetal growth restriction syndrome, placental insufficiency); eclampsia and hypertensive syndrome are the second most common obstetric causes of perinatal mortality in European countries; women who have had preeclampsia or eclampsia subsequently suffer from hypertension (70–72%), kidney diseases (9.4%), pathologies of the nervous system (20%), etc.; the high incidence of maternal and perinatal morbidity and mortality depends on the underestimation of severity and reliable diagnostic criteria, which leads to inadequate therapy and various complications depending on the timeliness and method of delivery and the volume of anesthesiological and resuscitation care. To date, there is no unified theory of the etiology and pathogenesis of preeclampsia. The main links in pathogenesis are acute endotheliosis, which occurs in the second half of pregnancy; vascular disorders in the “mother – placenta – fetus” system; generalized vasoconstriction (placenta, kidneys, liver, lungs, brain); hypovolemia, impaired rheological properties of blood, development of disseminated intravascular coagulation syndrome. Preeclampsia most often develops against the background of pathology of the cardiovascular and endocrine systems, multiple pregnancies, and Rh conflict. Risk factors for developing preeclampsia: first pregnancy; woman's age over 35 years; extragenital diseases (chronic hypertension, kidney disease, liver disease, collagenosis, diabetes mellitus, vascular disease, antiphospholipid syndrome); BMI is more than 35; multiple pregnancy; violation of fat metabolism; repeat pregnancy, long (more than 10 years) break after the last birth; pathological weight gain during pregnancy; diastolic blood pressure – 80 mm Hg. Art. and higher; proteinuria when registering for pregnancy (more than one plus on the test strip when tested twice or a loss of ≥ 300 mg/l of protein in a daily serving); high level of perceived pain; preeclampsia or history of eclampsia. Classification of preeclampsia and eclampsia according to ICD-10 Block II of the obstetrics section is called “Edema, proteinuria and hypertensive disorders during pregnancy, childbirth and the postpartum period (O10–O16).” O10 Pre-existing hypertension complicating pregnancy, childbirth and the postpartum period O11 Pre-existing hypertension with associated proteinuria O12 Pregnancy-induced edema and proteinuria without hypertension O13 Gestational hypertension without significant proteinuria O14.0 Moderate pre-eclampsia (moderate) O14.1 Severe pre-eclampsia O14.9 Preeclampsia, unspecified O15 Eclampsia O15.0 Eclampsia during pregnancy O15.1 Eclampsia during childbirth O15.2 Eclampsia in the postpartum period Clinical classification of hypertensive disorders during pregnancy: preeclampsia (moderate, severe) and eclampsia; preeclampsia (moderate, severe) and eclampsia against the background of chronic hypertension; gestational (pregnancy-induced) hypertension; chronic hypertension (existing before pregnancy); hypertensive disorders; secondary (symptomatic) hypertension. Preeclampsia: systolic blood pressure (SBP) ≥ 140 mmHg. Art. and/or diastolic blood pressure (DBP) ≥ 90 mm Hg. Art.; in women with initial hypotension – an increase in SBP by 30 mmHg. Art. and/or DBP by 15 mm compared to baseline. Diagnostics Identify signs characteristic of moderate preeclampsia: stage of pregnancy, whether it is registered, familiarize yourself with the data of the exchange card; pathological weight gain (more than 500 g/week); increase in edema; increased blood pressure; changes in urine tests (proteinuria); decrease in daily diuresis; the appearance of itching of the skin; the appearance of headaches, dizziness; visual impairment (flickering “fly spots”, fog before the eyes); lethargy, lethargy, insomnia. Assess the condition of the pregnant woman: general condition; condition of the skin; degree of impairment of consciousness; visible swelling of the lower extremities, puffiness of the face; excess blood pressure (compared to baseline by 20–30 mm Hg); pulse, breathing and heart rate. Severe preeclampsia is characterized by various combinations of the following symptoms: headache; blurred vision, flashing “spots” before the eyes; pain in the epigastrium, right hypochondrium, often combined with headaches; nausea, vomiting; “convulsive readiness” – hyperreflexia; agitation or depressed consciousness; increase in blood pressure to 170/110 mm Hg. Art. and higher; generalized edema; oliguria (diuresis – 600 ml/day and below); low hourly diuresis (less than 60 ml/h); cutaneous hemorrhagic syndrome in the form of petechiae. Eclampsia The clinical picture consists of four periods: 1. Preconvulsive period (duration – 20–30 s). Small twitches of the muscles of the face and upper limbs are noted, and a frozen gaze appears fixed in one direction. 2. The period of tonic convulsions (duration – 20–30 s). Following the twitching of the upper limbs, the head is thrown back, the body is stretched, tense, the spine bends, the face turns pale, the jaw clenches tightly, the pupils dilate and go under the upper eyelid, breathing stops, the tongue is bitten, the pulse is difficult to palpate, there is no consciousness. 3. The period of clonic convulsions: they spread downwards, there is no breathing, the pulse is not noticeable, the face is purple-blue, the veins are tense. 4. Period of seizure resolution. A deep, intermittent inhalation occurs, foam appears from the mouth (sometimes mixed with blood), breathing becomes regular, cyanosis disappears, the woman regains consciousness, but consciousness is twilight. The duration of the attack is 1.5–2 minutes. Clinical forms of eclampsia: isolated seizures; series of convulsive seizures (status); non-convulsive (the most severe). Providing emergency medical care at the prehospital stage Preeclampsia is an indication for hospitalization! Today, most authors consider it unacceptable to treat preeclampsia (preeclampsia) in an outpatient setting. It is important to provide first aid at home, in antenatal clinics and during transportation of a pregnant woman to the hospital. The ambulance must be equipped with equipment for administering nitrous-oxygen anesthesia if necessary. Routing of pregnant women: moderate preeclampsia - hospitalization in the department of pathology of pregnant women of a second/third level obstetric hospital; severe preeclampsia - hospitalization in the intensive care unit of a third-level institution. The issue of transportation is decided individually. Providing emergency medical care to pregnant women with severe preeclampsia should begin as early as possible. Algorithm for providing medical care for severe preeclampsia Anticonvulsant therapy: the drug of choice for the prevention of seizures is magnesium sulfate (intravenous only; initial dose - 10-20 ml of a 25% solution as a bolus over 5-10 minutes, maintenance dose - 1-2 g/ hour through an infusion pump; daily dose – 25 g of dry matter), is not an antihypertensive drug. Antihypertensive therapy: drugs to quickly lower blood pressure (nifedipine tablets - 10 mg, clonidine - 0.075-0.15 mg intravenously; clonidine can be used). Algorithm for providing medical care for the development of eclampsia: Treatment begins on the spot. Don't leave a woman alone. Place the woman on her left side (to reduce the risk of aspiration). Protect the patient from harm, but do not actively restrain her. Prepare equipment (airway, suction, mask and bag, oxygen) and give oxygen at a rate of 4–6 l/min. After an attack, immediately begin magnesium therapy (20 ml (4-6 g) of a 25% solution intravenously over 5-10 minutes; if the seizures recur, diazepam 10 mg intravenously or sodium thiopental 450-500 mg; maintenance dose of magnesium therapy - 1 -2 g/hour intravenous drip. Obstetric tactics: eclampsia is an absolute indication for delivery. If the cause of convulsions is not determined, the woman is treated as in the case of eclampsia, and the true cause of convulsions continues to be clarified. Modern principles for the prevention of severe forms of preeclampsia and eclampsia Preventive measures are carried out with in order to exclude the development of severe forms of preeclampsia and eclampsia in high-risk pregnant women and during the period of their discharge from the hospital.Prevention of preeclampsia is carried out in accordance with the principles of evidence-based medicine: the use of antiplatelet agents (aspirin in low doses - 75 mg/day) from the 13th week of gestation ; calcium supplements (at a dose of at least 1 g/day) throughout pregnancy. Also, preventive measures are carried out against the background of treatment of extragenital pathology, according to indications. Of course, primary care has a leading role in the prevention of preeclampsia. Moreover, prevention must begin before pregnancy and continue throughout the entire gestation period. Prevention of gestosis during pregnancy should begin from the 8th–9th week of gestation. Preventive measures are carried out constantly. Preeclampsia is easier to prevent than to treat.

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Literature used 1. Obstetrics and gynecology.
Clinical recommendations / ed. V. I. Kulakova. – M., 2006. – P. 136–171. 2. Current issues of modern obstetrics: gestosis in pregnant women - problem and solutions / A. M. Torchinov [et al.] // Attending physician. – 2010. – No. 11. – P. 16–22. 3. Medical observation and provision of medical care to women in obstetrics and gynecology. – Minsk, 2021. 4. Clinical protocols for providing emergency medical care to the adult population. Appendix 20 to the order of the Ministry of Health of the Republic of Belarus dated June 13, 2006 No. 484. 5. Preeclampsia and eclampsia: modern classification, etiopathogenesis, diagnosis, treatment and emergency care: educational method. allowance / V. N. Sidorenko [etc.]. – Minsk, 2021. – 20 p. 6. Directory of a doctor at the antenatal clinic / under general. ed. Yu. K. Malevich. – M., 2014. – P. 86–97. preeclampsia, eclampsia

Diagnostics

Differential diagnosis of preeclampsia and eclampsia must first be carried out with an epileptic seizure (“aura” before the attack, convulsions). Also, these complications should be distinguished from uremia and brain diseases (meningitis, encephalitis, hemorrhages, neoplasms).

The diagnosis of preeclampsia and eclampsia is established based on a combination of instrumental and laboratory data:

Blood pressure measurement. Increasing blood pressure to 140/90 and maintaining these numbers for 6 hours, increasing systolic pressure by 30 units and diastolic by 15.
Proteinuria. Detection of 3 or more grams of protein in the daily amount of urine.
Blood chemistry. An increase in nitrogen, creatinine, urea (kidney damage), an increase in bilirubin (red blood cell breakdown and liver damage), an increase in liver enzymes (AST, ALT) - liver dysfunction.
General blood analysis. An increase in hemoglobin (a decrease in the volume of fluid in the vascular bed, that is, blood thickening), an increase in hematocrit (viscous, “stringy” blood), a decrease in platelets.
General urine analysis. Detection of protein in urine in large quantities (normally absent), detection of albumin (severe preeclampsia).

Treatment of eclampsia and preeclampsia

A patient with preeclampsia and eclampsia must be hospitalized in a hospital. Treatment should be started immediately, on the spot (in the emergency room, at home in case of calling an ambulance, in the department).

An obstetrician-gynecologist and a resuscitator are involved in the treatment of these pregnancy complications. The woman is hospitalized in the intensive care ward, where a therapeutic-protective syndrome is created (a sharp sound, light, touch can provoke a convulsive attack). Additionally, sedatives are prescribed.

The gold standard for treating these forms of gestosis is the intravenous administration of a solution of magnesium sulfate (under the control of blood pressure, respiratory rate and heart rate). Also, to prevent seizures, droperidol and relanium are prescribed intravenously, possibly in combination with diphenhydramine and promedol.

At the same time, the volume of circulating blood is replenished (intravenous infusions of colloids, blood products and saline solutions: plasma, rheopolyglucin, infucol, glucose solution, isotonic solution, etc.).

Blood pressure is controlled by prescribing antihypertensive drugs (clonidine, dopegit, corinfar, atenolol).

During pregnancy up to 34 weeks, therapy aimed at maturing the fetal lungs (corticosteroids) is carried out.

Emergency delivery is indicated in the absence of a positive effect from therapy within 2-4 hours, with the development of eclampsia and its complications, with placental abruption or suspicion of it, with acute oxygen deficiency (hypoxia) of the fetus.

First aid for an attack of eclampsia:

Turn the woman on her left side (to prevent aspiration of the respiratory tract), create conditions that reduce trauma to the patient, do not use physical force to stop convulsions, and after an attack, clear the oral cavity of vomit, blood and mucus. Call an ambulance.

Medication relief of an attack of eclampsia:

Intravenous administration of 2.0 ml of droperidol, 2.0 ml of relanium and 1.0 ml of promedol. After the end of the attack, the lungs are ventilated with a mask (oxygen), and in the case of a coma, the trachea is intubated with further mechanical ventilation.