Mode of delivery women with preeclampsia in the second half of pregnancy


(57) Abstract:

The invention relates to medicine, obstetrics and anesthesia, and can be used for delivery of women with preeclampsia in the second half of pregnancy. After the implementation of the anesthesia before surgical intervention consistently infusion software 6% NaCl 5.0 ml/kg and 6% solution gidroksietilirovannogo starch, such as perftoran or infocol, or sterisol of 6.0 ml/kg of This invention facilitates the rapid development of mechanisms of urgent adaptation circulatory homeostasis, contributing to the approximation of the circulatory system to akineticheskie type before surgical intervention, and can achieve long-term analgesic effect after a single injection of drugs.

The invention relates to medicine, namely to obstetrics and anestesiologia, and will find wide application in the management of labour in pregnant severe gestosis the second half of pregnancy.

Preeclampsia, being one of the biggest problems of gestational period, results in high levels of maternal and perinatal morbidity and mortality. This Pato is Saveliev, M. and others, 1995; Bednarski A. S. and others, 1995). Perinatal morbidity and mortality when gestosis of pregnant women continue to remain at a high level. In recent years, according to domestic and foreign authors, there is an increase in the number of gestosis due to the severe forms, accompanied by the development of multiple organ failure. The severity of the condition of pregnant women with late gestosis caused by the syndrome of multiple organ failure, which are all signs of critical conditions, expressed in varying degrees (Zilber, A. P., E. Shifman M//Obstetrics eyes anesthesiologist. - Petrozavodsk, 1997). This is hypovolemia, generalized vascular spasm, centralization of circulation, hypoxia, circulatory disturbances in the vital organs - brain, kidneys, liver (Schechtman and others, 1996; silber, A. P. and others, 1997). Worse rheological properties of blood, develops chronic DIC, there is diffusion-perfusion failure, broken all kinds of metabolism (Sidorov I. S., 1998; Krasnopolsky Century. And. and others, 1997).

Currently recognized as a way to reduce the maternal and perinatal mortality in severe forms of preeclampsia in the second half of pregnancy, ageliki forms late preeclampsia should be aimed at ensuring adequate protection of woman from operational stress as well as to create optimal conditions for the adaptation of the fetus in the early neonatal period. Increasing recognition during the conduct of anesthesia in patients with pre-eclampsia who have severe hypertensive response during intubation in General anesthesia can cause hemorrhagic stroke, pulmonary oedema and heart failure, gaining epidural anesthesia (EA) (Zilber, A. P. and others, 1997). Using EA as the basic variant of anesthesia in cases of abdominal delivery by the constitutional court on the occasion of severe preeclampsia in the second half of pregnancy provides a robust antinociceptive protection in the prenatal period CA. Stabilization of the circulatory system, increasing its reserves and adaptive mechanisms when conducting this type of anesthesia can be considered as one of the fundamental options of pathogenetic therapy in this group of patients (Tumanyan S. C., Serikov, M. E., 2002).

One of the fundamental components of anesthesia is infusion-transfusion support. The analysis of numerous domestic and foreign scientific medical literaturethe, showed that many questions remain poorly known, controversial and contradictory. According to some authors, the more severe the hypertension in these patients, the less should be conducted infusion therapy (Ailamazyan E. K. et al.//Emergency care under extreme conditions in obstetric practice. - Saint-Petersburg. - 1993). Others consider it necessary to limit the total quantity of fluid to 800-1000 ml/day (Sidorov I. S.//Late gestosis. - Moscow. - 1996). Some authors recommend preventive introduction crystalloid solutions in the amount of 1200-1500 ml when conducting neuroaxial methods of analgesia during the COP in connection with the risk of arterial hypotension (Zilber, A. P. et al., 1997).

In patent literature we identified several ways of childbirth using neuroaxial methods of analgesia.

The described method of delivery in patients suffering from medium, high myopia and retinal degeneration by RF patent No. 2157667 (2000.10.20), according to which the exercise epidural anesthesia. Define the second stage of labor value eographical factor in the blood vessels of the ciliary tract. If value eographical factor is A.

The described method of delivery in patients suffering from bronchial asthma by RF patent No. 2183974 (2002.06.27), the essence of which is that for 1-1 .5 h before the birth of conduct epidural blockade with holding the catheter in the cranial direction at the level of Th6-Th8 and injected with 0.125% solution of marcaine 4-8 ml once in the process of childbirth. Then spend epidural anesthesia at the level of L2-L4 2% lidocaine solution in the process of childbirth.

There is a method of epidural anesthesia on the patent of Russian Federation №2185199 (2002.07.20) to perform anesthesia on a given segmental level. In the epidural space enter two catheter, guide them in the cranial direction and located at a distance of 4-5 cm from each other. Produce simultaneous introduction through them solutions anesthetic and neutral solution. For anesthesia of the overlying segments of the spinal anesthetic solution is injected into the epidural space through the catheter from the upstream end, and through the catheter downstream end of the injected neutral solution, while for anesthesia of the underlying division changing levels of injection solutions.

The described method of spinal anesthesia on N. A. Urakova the patent of the Russian Federation is a and the abdominal cavity, at delivery. A patient is placed in a sitting position, bent forward, down the legs, spinal puncture the shell and remove 8 ml of the liquor, mix 2 ml CSF 2 ml of a 5% solution of ephedrine hydrochloride and inject this mixture into the spinal canal, after 5 min 1.3 ml of the liquor is mixed with 1.3 ml of 1% aqueous solution dikaina and with 1.5 ml of 2% aqueous solution of sodium chloride, the mixture is cooled to 18-20°C and injected into the spinal canal.

The described method of anesthesia in obstetrics by the RF patent №2203654 (2003.05.10), the essence of which is that produced by the needle Crawford subarachnoid puncture at the L3-4, is injected through this needle medicinal substance into the subarachnoid space, then move the needle back to its launch into the epidural space and give him drugs and medicinal substances injected into the subarachnoid and epidural spaces in the following total dose: 50-100 µg clonidine, fentanyl 100-200 mcg, 2% lidocaine 40-120 mg, after removing the needle from the subarachnoid space into the epidural space enter 10-15 ml of isotonic sodium chloride solution.

The General lack Perechin and none of them affects the tactics of infusion therapy for the treatment of gestosis.

These drawbacks are eliminated in the invention.

The objective of the invention is the development of optimal infusion-transfusion tactics during abdominal delivery patients with severe forms of preeclampsia in the second half of pregnancy, which as a major component of anesthesia is applied EA.

The problem is solved in that during abdominal delivery patients with severe forms of preeclampsia in the second half of pregnancy first perform the anesthesia, and then before the surgery, begin sequential infusion software 6% NaCl 5.0 ml/kg and 6% solutions gidroksietilirovannogo starch (for example, a solution of reportan or infocol, or sterisol) of 6.0 ml/kg

We have developed a composition of infusion therapy provides normovolemic hemodilution (normal pregnancy) during the development of epidural blockade. A positive result from the use of the claimed method of delivery in patients with severe forms of preeclampsia is to substantially increase the efficiency of correction of hemodynamic parameters and gidroidnogo balance at the time of delivery with the use of n the Institute reduces peripheral vascular resistance. This reduces postnagruzku and, thus, to increase the efficiency of the heart. However, the increase in vascular capacitance occurs in the system low pressure (venous return), which may cause a significant decrease in preload and reduced end-diastolic volume of the left ventricle. This leads to the development of the syndrome of small cardiac output with the development of severe hypotension.

To prevent this complication when performing neuraxial methods of pain relief is traditionally recommended strict compliance with the preventive technology infusion therapy.

Our studies have shown that using classic tactics infusion therapy when conducting neuroaxial methods of pain relief in patients with preeclampsia does not reduce the risk of hypotension, as administered liquid under the conditions of this disease quickly leaves the bloodstream moving in the interstitial space. Moreover, the intensive increase in CBV in the background hypokinetic type of blood circulation in severe preeclampsia can lead to even more pronounced hypertensive syndrome, a sharp increase postarrival sharp increase vnutriepreserdna pressure and is accompanied by increased levels of atrial natriuretic peptide (PNP), which is a vasodilator, which leads to the layering of the hypotensive effect of DUP on medication sympathetic blockade.

Therefore, pathogenetically substantiated impact during delivery of patients suffering from severe forms of gestosis second half of pregnancy, is not only a decrease in the total peripheral resistance, and concurrent therapy, aimed at ensuring adequate preload. This ultimately should lead to a significant increase in stroke volume and, therefore, adaptation of the circulatory system.

As shown by the results of our research, conducting neuroaxial methods of analgesia reduces initially increased total peripheral resistance in patients with preeclampsia and balanced infusion therapy conducted during the development of conduction block, provides adequate preload due to the normalization of BCC development normovolemic hemodilution, the corresponding normal pregnancy.

Developed qualitative and quantitative composition of infusion therapy is the combined use of hyperosmolar solution of sodium chloride with rastia hyperosmolar solutions - this is a significant increase CGO due to the movement of fluid from the extracellular space into the bloodstream. Short-term hemodynamic effect - the main disadvantage of a hyperosmolar solution of sodium chloride due to the fact that it quickly passes through the capillary wall and leaves the bloodstream. These drawbacks are eliminated by combining hyperosmolar solution of sodium chloride solutions gidroksietilirovannogo starch (HES). In addition, positively charged sodium ions bind with protein molecules, which become electrically neutral. As a consequence, the ability of proteins to pass through the capillary walls is reduced, they can be delay in the bloodstream, along with water and electrolytes (the effect of the Gibbs-Donnan). As a result of this colloid osmotic pressure of plasma is increased by 50% compared with the proper values. BSE - ISO-osmolar, isotonic colloid solution which does not contain glucose, and other electrolytes (CA, Mg). After intravenous molecules HES gradually broken down by amylase serum. It is believed that the solutions of the BSE, as well as other colloidal solutions, such as dextran or drugs is amym effect on coagulation factors and other parts of hemostasis. However, the risk of anaphylactoid reactions when using HES just 0,006%, which is less in comparison with other colloids (Helama H.//Actual problems of anesthesiologie and resuscitation. Infusion tactics with traumatic shock. - Arkhangelsk. - 1998. - S. 181). In this regard, the BSE is the drug of choice for infusion therapy.

Thus, we use tactics infusion software at the time of delivery of patients suffering from severe forms of gestosis second half of pregnancy, using neuroaxial methods of analgesia contributes to the rapid development of mechanisms of urgent adaptation circulatory homeostasis, contributing to the approximation of the circulatory system to akineticheskie type.

The specific implementation of the inventive method is illustrated in the following clinical example.

The patient And society, 27 years old, weight 71 kg, case history No. 435, received 20.03.02 in the maternity ward with a diagnosis of Pregnancy 36-37 weeks, preeclampsia second half of pregnancy, nephropathy III degree. When entering HELL 180/120, 175/120 MMHg, heart rate of 102 1,. Complaints of a headache. It was noted pronounced swelling of the upper and lower extremities. In blood Ht 41%, total is the caesarean section. In the operating catheterized peripheral vein. Made a puncture of the epidural space T12- L1. Put 350 mg lidocaine 60 mg of bupivacaine (a total of 16 ml of R-RA), and then made the infusion of 6% R-RA NaCl 400 ml, then 6% R-RA sterisol 500 ml By the time of skin incision HELL 140/80 MMHg, pulse rate 84 in 1,. Surgery - without features. Born male child 7-8 points on the Apgar. Intraoperative blood loss of 700 ml Infusion therapy during surgery 1300 ml of 0.9% S. NaCl. All during anesthesia and surgery entered 2200 ml of liquid. Diuresis 120 ml. Hemodynamics during surgery AD 130-140/80 MMHg, heart rate 78-84 1,. 30' after the operation HELL 130/80 MMHg, pulse rate 86 in 1,, Ht 34%,+3.9 mmol/l, Na+134 mmol/L.

Delivery by the present method was conducted 79 pregnant, which made surgical delivery by the constitutional court on the occasion of severe preeclampsia in the second half of pregnancy, intractable on the background of conservative therapy. The average age of the women was date 26,06±0,34 years, body mass 73,62±0,42 kg the Main indications for delivery were expressed hypertensive syndrome 32 (40.5 percent), increasing proteinuria 38 (48.1 percent) expressed vnutritrahealno (23-31 week). On the severity of the condition of the woman was as follows: nephropathy II-III degree in 68 (86,1%) women, pre-eclampsia 11 (13.9 per cent) women.

To assess the state of homeostasis was performed by standard clinical and biochemical blood tests. The main parameters of the circulatory system parturients were evaluated according to polarography. Oncotic pressure of blood plasma and the osmolarity was calculated by the calculation means. For comparative evaluation of the original background was determined the original BCC, CGO, ACE, Ht, Na+and+plasma, proteinemia, HR, FBC, C, UPSS patients first (normal pregnancy) and second (preeclampsia II half of pregnancy) groups. Subsequently, these same parameters were measured in the dynamics of the patients of the second group (the control key). Research carried out for 30 minutes before the start of the operation (original background), at the time of skin incision (start of operation), 20 minutes after the start of the operation and at the end of operation. Statistical processing of results was performed on a computer with basic software package “Microsoft Office 2000”.

The results of these studies in the preoperative period showed that patients with severe forms of gestosis II half of pregnancy against the about 53.5%). Registered a significant increase in UPSS (76.5%). Along with these changes in the AP and SI were reduced by 36.6 and 24.4%, respectively. That is, the initial state of the cardiovascular system was characterized by hypokinetic type blood. The original background of the patients were characterized by hypoproteinemia, plasma hyponatremia.

All parturients as a core component of anesthesia was used neuroaxial method of anesthesia. The epidural space was functionals at the level of T12-L1. Drugs used for EA - marcain (0,8±0,1 mg/kg), naropin (1,2±0,1 mg/kg), lidocaine (4,8±0.4 mg/kg) or their combination. Means for neuroaxial method of anesthesia combined with adjuvantly - clonidine (50,4±23,2 g) and/or morphine (2,1±0.4 mg). Premedication with vazopressorov was not conducted. After graduating from the prenatal stage KS sedative effect was achieved by the administration of intravenous drugs benzodiazepinovogo series - diazepam (20,7±6.4 mg) or midazolam (10,3±2.1 mg). To mitigate syndrome aortocaval compression (ACC) to extract the fetal patient was in the position of levorotary 15-20°.

Fluid therapy in the perioperative period is l/kg, at the end of which it was made infusion solution BSE (reportan 6%, or infocal 6%, or sterisol 6%) of 6.0 ml/kg Infusion therapy during surgery with crystalloids (0.9% NaCl, ringer's solution) 5 ml/kg + volume of intraoperative blood loss. The time of prenatal stage KS 4,4±0,2 min operation KS 46±2.9 minutes. Blood loss was determined gravimetrically and amounted to 653±57 ml

This method eases pain and improves safety and efficiency neuroaxial methods of anesthesia in patients with severe preeclampsia, promotes the rapid development of mechanisms of urgent adaptation circulatory homeostasis, contributing to the approximation of the circulatory system to akineticheskie type before surgical intervention, and can achieve long-term analgesic effect after a single injection of drugs that reduces the invasiveness and drug loading on the body of a pregnant woman and her fetus, thus reducing the development of life-threatening complications.

The inventive method of delivery of pregnant women with preeclampsia in the second half of pregnancy has been tested on enough bulk material and can be widely used in obstetric surrounding conducting neuroaxial methods of anesthesia, characterized in that after the implementation of the anesthesia before surgical intervention consistently infusion software 6% NaCl solution 5.0 ml/kg and 6% solution gidroksietilirovannogo starch, such as perftoran, or infocol, or sterisol, 6,0 ml/kg


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