Early Pregnancy Toxaemia

EARLY PREGNANCY TOXAEMIA Early pregnancy toxaemia and gestosis - diseases of women, which happen due to the development of fetal eggs or some of its elements, is characterized by a multiple symptoms. When you remove the fetal eggs or its elements the disease usually stops. Early toxicosis developed in the first half of pregnancy, while gestosis (formerly known as "late toxicosis of pregnant women", toxaemia of pregnancy, preeclampsia) - in the second half. EARLY TOXICOSIS PREGNANT Early toxicosis occurs usually in the first weeks and ends on 12-16 weeks of pregnancy. What nosological forms belong to the early toxicity? In early toxicosis include frequent drooling, pregnancy vomiting, as well as rare forms of toxicosis: chorea of pregnancy, osteomalacia, bronchial asthma of pregnancy, dermatoses, tetanus, acute yellow liver dystrophy, etc. What are the clinical manifestations of excessive salivation (ptyalism)? Drooling (ptyalism) begins with excess saliva in the mouth of pregnant woman. Woman swallows it, which leads to overfilled stomach with saliva. This, in turn, causes vomiting and increase weight of the patient. In some cases ptyalism may appear as an independent disease and with a moderate flow of saliva that moved easily. In severe ptyalism, saliva can reach several liters daily. This leads to the on loss of proteins, carbohydrates, vitamins, salts and dehydration. What is the clinical picture of vomiting during pregnancy? The clinical picture of vomiting in pregnancy, as the name of the disease manifests mainly - vomiting. Depending on the severity of the symptoms are divided into light form, moderate and heavy. Severe vomiting during pregnancy is also called pernicious vomiting of pregnant. What is the clinical picture of mild vomiting during pregnancy? In mild vomiting during pregnancy, the overall condition of the patient remains satisfactory. Vomiting is not more than 5 times a day. This reduces the appetite and inhibits the mood of pregnant women. The patient does not lose weight. Body temperature remains in the normal range. Blood and urine samples have no pathological changes. What is the clinical picture in moderate vomiting during pregnancy?

The average degree of the general condition of the patient deteriorated markedly. Vomiting observed up to 10 times a day, and it is no longer associated with eating. Loss of body weight up to 2-3 kg in two weeks, tachycardia up to 100 beats per minute, ketonuria, and low-grade temperature is not typical. No significant changes of acid-base status of blood yet. In the study of electrolytes, there is a slight decrease in the normal sodium with normal potassium. What is the clinical picture of severe vomiting during pregnancy? In severe vomiting, patients is intoxicated, disturbed in sleep, appears adynamia. Patient vomits sometimes up to 20-25 times a day. By this time, dehydration develops. The skin is dry, turgor* and flaccid. Weight loses up to 5-8 kg per month. Tachycardia reaches to 110-120 beats per minute. Quite often there is hypotension. Body temperature rises up to sub febrile. Appear expressed acetonuria, the shift of acid-base status in the direction of acidosis. In the study of electrolytes, moderate decrease in potassium, sodium and calcium. In the blood, determine the hypo-and dysproteinemia, hyperbilirubinemia, increased hemoglobin and hematocrit (haemoconcentration), creatinine. The general condition of the patient becomes serious. *Skin turgor is a sign of dehydration. To determine skin turgor, one grasps the skin on the back of the hand, lower arm, or abdomen between two fingers so that it is tented up. The skin is held for a few seconds then released. Skin with normal turgor snaps rapidly back to its normal position. Skin with decreased turgor remains elevated and returns slowly to its normal position. What are the diagnostic methods of salivation and vomiting in pregnancy? Diagnosis of these pathological conditions is easy. Well collected history and observation of the patient by doctor can accurately establish a diagnosis and assess the severity of the pathological process. While diagnosing these pathological state, blood and urine tests are important indicators. In the study of blood high hematocrit is seen, which indicates thickening of the blood; increased residual nitrogen, bilirubin, decrease chlorides and acidosis appear. In urine test, acetone is detected. Investigation of urine acetone (ketone bodies), is the most accessible and informative in the diagnosis and to assess the severity of early toxicosis. Other than acetone, protein and cylinders also appear in urine. Increase ketonuria and proteinuria, appearance of icterus of the skin and sclera, increased body temperature is unfavorable prognostic sign, indicating the ineffectiveness of the therapy.

What are the principles of treatment of these nosological forms of early toxicosis? Early toxicosis treated as following principle: • the impact on the central nervous system; • Eliminates dehydration; • Desensbilization; • Remove intoxication; • Eliminated the effects of prolonged fasting

Table 13-1: Scheme for establishing the severity of pregnancy vomiting Symptoms Appetite Nausea Salivation Vomiting Frequency (per days) Pulse Rate (beats/min) Systolic BP, mmHg Food Retention Weight Loss Dizziness

The severity of vomiting during pregnancy Light Medium Heavy Moderate Significant None decrease decrease Constantly, Moderate Significant painful Moderate Expressed Dense, viscous 11-15 times and Up to 5 time 6-10 times more (even continuously) 80-90 90-100 > 100 120-110 General retention Extremely rare, up to 5% of initial weight Rare

Subfebrile fever

—

Icteric skin & sclera

—

Hyperbilirubinemia, mmol / L Dry skin Stool Diuresis

110-100

< 100

Partial retention

No retention

Over 5 kg (2-3kg per week, over 10% of initial weight) In 50-60% patients In 35-80% Not characteristic patients In 20-30% In 5-7% patients patients 3-5 kg (1 kg per week, 6-10% of initial weight) In 30-40% patients

—

21-40

21-60

-+ 900-800 ml

++ Once per 2-3 day 800-700 ml

+++ Stool retention Less than 700ml

Acetonuria

—

Periodically in 2050% patients

In 70-100% patients

How do we treat drooling (ptyalism)? Salivation has the same treatment as that of vomiting (treatment, psychotherapy, physiotherapy procedures, infusions, etc.). Recommended treatment in hospital is to treat and protect, by regulatating function of the nervous system, metabolism, during dehydration, infusion therapy is given. At the same time, mouthwash infusion of sage, chamomile, 0,5% solution of procaine is recommended. If serious, atropine 0.0005 g, 2 times a day can be given. For prevention of maceration of skin, petroleum jelly (vaselin) is smeared. How to treat mild vomiting in pregnancy? Treatment as outpatient with body weight control and urine tests to check content of ketone bodies. A variety of foods on request is recommended to increase appetite. It should be with at least chilled small meals every 2-3 hours in lying position; it is recommended to drink 1 liter of chilled infusion of ginger and lemon balm during the day. Drink alkaline mineral water without gas in small amount for 5-6 times a day. To normalize the functional state of the cerebral cortex and to eliminate autonomic dysfunction, central electroanalgesia, acupuncture, and psycho-hypnotherapy, phonophoresis solution of thiamine and other methods of non-pharmacological therapy is recomended. If it’s not effective, drugs that directly blocking the gag reflex is used: M-cholinolytic (atropine), dopamine receptor blockers (neuroleptics - haloperidol, droperidol, phenothiazine derivatives - tietilperazine), as well as direct antagonists of dopamine (metoclopramide). How to treat moderate vomiting in pregnancy? In moderate vomiting, pregnant patients should be hospitalized. In one ward, there should not be two pregnant women with early toxicosis. In order to impact central nervous system, as in mild vomiting in pregnancy, it is advisable to apply electrohypnotics or electroanalgesia. To inhibit emetic center, intramuscular metoclopramide, triethylperazine is effective, but if these drugs is not effective- droperidol is given. To prevent dehydration and hypoproteinemia, inject intravenously crystalloid and colloid solutions, 0.9% sodium chloride, 5% glucose solution, hydroxyethyl starch and others). In cases of severe hypoproteinemia, 100 ml 10% solution of albumin or fresh frozen plasma is given. Per day, pregnant women should get 2-2.5 liters of liquid. To eliminate intoxication, prescribe intravenous infusion of 5% glucose solution with 1000ml of insulin,

at rate of 1 U of insulin per 4 g of dry weight of glucose, and also add 4.6 ml of 5% solution ascorbic acid. In addition, inject intravenously 1000 ml Ringer-Locke solution and 200-300 ml of 5% solution of sodium bicarbonate. It is advisable to treat patients with close supervision of the acid-base status and blood electrolytes. In potassium deficiency, we should prescribed drugs and potassium. Taking into consideration disturbance of redox processes, recommend the intramuscular injection of 1 ml of vitamins B-B1, and B6 alternately every other day. How to treat severe vomiting during pregnancy? In severe vomiting during pregnancy, to suppress the excitation of the emetic center, we used neuroleptic - droperidol. Droperidol acts in cerebral cortex and reticular formation, has anti-emetic effect and suppresses vasomotor reflexes, improves peripheral circulation by vasodilatation. Considering the regulation of metabolism, prescribe intravenous phospholipids solution + multivitamins (Essentialé), which is also bioantioxidant and hepatoprotectors. To stop dehydration, infusion therapy is given on daily basis: crystalloid and colloid solutions (0.9% solution sodium chloride, 5% glucose solution, hydroxyethyl starch and Ringer-Locke solution, and 5% solution of sodium bicarbonate, etc.). In the case of pronounced hypoproteinemia, introduce 100 ml 10% solution of albumin or fresh frozen plasma. In a day, pregnant women should get 3 liters of liquid. How long should be treated suffers early toxicosis pregnant and when you need to terminate a pregnancy? It is advisable to start treatment of early toxicosis until it is effective, or a totally cured. After the end of all appointed treatment, the state of pregnancy should be followed within 3-5 days. If it is still effective, a pregnant woman may be discharged home. If there is no effect, toxemia progresses, increase in urine acetone, presence of signs of hepatic insufficient, the pregnancy must be aborted. What is the indication for abortion? The indications for abortion are: • recurring vomiting; • growing dehydration; • progressive reduction of body weight; • progressing ketonuria within 3-4 days; • marked tachycardia; • Dysfunction of the nervous system (adynamia, apathy, delirium, euphoria);

• bilirubinemia (up to 40-80 mmol / L) and hyperbilirubinemia 100 mmol /L is critical; • icteric stain of the sclera and skin; • permanent subfebrile temperature. What is the clinic and therapy dermatosis pregnant? Dermatosis is manifested by pregnant skin itching of the whole body, often most pronounced itch in the area of the external genitalia. As a result of scratching the skin, inflammation appears with bright-red skin and local edema. Itching can be so intolerable that we have to stop the pregnancy. Medical therapy must be considered from the lowest toxicity: topically with Silica in suberythemic doses (until it turn temporarily red (erythematous)), antihistamine ointment, benzocaine, menthol, and in more severe cases with prednisolone or hydrocortisone, as general supplements - vitamin B and C drugs therapy, etc. To reduce reaction of the central nervous system, prescribe sedative or better, phytotherapy. What is the clinic of acute yellow liver dystrophy? It is a severe manifestation of toxicity. As a result of intoxication, fatty degeneration of liver cells occurs, thus degeneration of the liver. The liver decreases in size, the patient developed jaundice, and then acute liver failure, which is manifested by convulsions, and coma. Acute yellow atrophy of the liver is an absolute indication for abortion. If the pregnancy continues, the disease progresses and it may leads to death. What is the treatment strategy of such rare forms early toxicosis, as osteomalacia, chorea pregnant, and bronchial asthma of pregnancy? In these rare severe forms of early toxicosis, it’s advisable to abort.