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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

The severity of vomiting during pregnancy


Symptoms
Light Medium Heavy
Moderate Significant
Appetite None
decrease decrease
Constantly,
Nausea Moderate Significant
painful
Salivation Moderate Expressed Dense, viscous
Vomiting Frequency 11-15 times and
Up to 5 time 6-10 times more (even
(per days)
Pulse Rate (beats/min) 80-90 90-100 continuously)
> 100
Systolic BP, mmHg 120-110 110-100 < 100
General
Food Retention Partial retention No retention
retention
Extremely 3-5 kg (1 kg per Over 5 kg (2-3kg
Weight Loss rare, up to week, 6-10% of per week, over
5% of initial initial weight) 10% of initial
weight weight)
In 30-40% In 50-60%
Dizziness Rare
patients patients
In 35-80%
Subfebrile fever — Not characteristic
patients
In 20-30%
Icteric skin & sclera — In 5-7% patients
patients
Hyperbilirubinemia,
— 21-40 21-60
mmol / L
Dry skin -+ ++ +++
Stool - Once per 2-3 day Stool retention
Diuresis 900-800 ml 800-700 ml Less than 700ml
Periodically in 20- In 70-100%
Acetonuria —
50% patients 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 vaso-
motor 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.