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Eclampsia

Eclampsia is a late toxicosis of pregnancy, characterized by convulsive seizures followed by a coma.

The etiology of eclampsia , as well as dropsy and nephropathy of pregnant women is considered unified. Eclampsia is the most severe form of late pregnancy toxicity (see). In eclampsia, as in nephropathy of pregnant women, there is a characteristic triad of clinical symptoms - edema, albuminuria and hypertension ; symptoms of damages of TsNS join them - spasms (see), coma (see).

Pathological changes in eclampsia occur in the brain, liver, kidneys; changes in the central nervous system are the most severe. Characteristic: sharp edema of the brain, often pinpoint hemorrhages; hemorrhages of the big sizes are observed usually at eclampsia against the background of a previously existing hypertension. In the liver, on the basis of thrombosis, hemorrhages under its capsule, decompensation of liver cells are observed. In the kidneys, there are significant degenerative changes, less often there are necrotic lesions of the cortical layer of the kidneys.

The course and symptoms . Eclampsia seizures are usually preceded by preeclampsia syndrome: a few hours before an eclamptic seizure, a pregnant woman complains of a headache, sharp pains in the epigastric region, and vomiting may occur. There are various changes from the point of view: in some cases, the pregnant woman sees everything “as if in a fog”, in others - the flickering of “flies” before her eyes; less often, temporary full blindness may occur.

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The eclampsia fit contains three phases following one after the other. It begins with loss of consciousness; the gaze of the pregnant woman is fixed on one point, the head deviates to the side; fibrillary twitches of the facial muscles appear. This introductory phase lasts up to 30 sec .; it is followed by a phase of tonic convulsions, in which the whole body bends, the head leans backwards, the jaws are compressed, breathing is delayed. This phase lasts 20-25 seconds. The next, longer phase - the appearance of clonic convulsions - indiscriminate contractions of the muscles of the body and limbs. The seizure ends with a deep whistling breath, foam appears from the mouth, breathing is restored. After a seizure, the woman is in a coma. There are cases of eclampsia in which the woman remains comatose for a day, with up to 10-15 or more seizures (eclamptic status) can occur.

There are eclampsia during pregnancy, childbirth and postpartum eclampsia. With eclampsia in childbirth, usually after the delivery of a woman, seizures do not recur. If eclampsia has developed in the last months of pregnancy, premature labor may occur due to seizures, and labor activity, despite the use of drugs, increases.

Often, after the relief of eclampsia, pregnancy may continue, but if the symptoms of late toxicosis (especially albuminuria, hypertension) continue, indicating a severe form of toxicosis, then in the coming days you should be afraid of a repetition of eclampsia (recurrent eclampsia). A particularly severe form is non-convulsive eclampsia; With this form, the pregnant woman falls into a severe coma, often fatal. Adverse signs of eclampsia are: slight yellowness, tachycardia , a sharp decrease in blood pressure ( hypotension ).

Observed and atypical forms of eclampsia, often having a lighter flow; may be eclampsia without severe hypertension; in other cases, albuminuria is absent.

In puerperas who have had eclampsia in the postpartum period , there may be a serious complication in the form of acute renal failure . As a result of necrosis of the cortical layer of the kidneys, anuria develops; the amount of urine per day is less than 100 ml, the urine has the form of a coffee grounds.

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Eclampsia (eclampsia; from Greek. Eklampsis - flash, sudden onset) - severe toxicosis of the second half of pregnancy, characterized by the appearance of seizures.

There are four periods in the development of eclampsia: 1) eclampsism, characterized by edema, albuminuria and hypertension; 2) pre-eclampsia, in which symptoms of increased intracranial pressure (headache, blurred vision, agitation, vomiting) are added to the phenomena of eclampsia; 3) convulsive period; 4) the period of recovery.

Typical eclampsia is characterized by the sudden onset of seizures, which are sometimes preceded by epigastric pain, a solar symptom of irritation.

At the beginning of the seizure, small fibrillary twitches appear, mainly of the facial muscles, which are then transmitted to the upper limbs (this period lasts from a few seconds to half a minute). Then comes the most dangerous period for the mother and the fetus, lasting from 20 to 25 seconds. There are tonic contractions of skeletal muscles, loss of consciousness, respiratory arrest, sharp cyanosis of the skin and mucous membranes, dilated pupils, sometimes a woman bites her tongue. After this period, clonic convulsions appear, covering the trunk, upper and lower extremities. Breathing becomes difficult, foam comes from the mouth (in the case of a bite of the tongue - with an admixture of blood). Later, convulsions, gradually weakening, disappear. The duration of this state is from 40 seconds. up to 1.5-2 minutes

At the end of the seizure, the patient falls into a coma: lies motionless, has no consciousness, breathing is noisy, hoarse. A coma can be replaced by a new attack. If this does not occur, the patient gradually regains consciousness, normal breathing and sensitivity are restored; usually there is a general weakness and headache. The duration of a coma is different, sometimes it can last for hours, which, of course, worsens the prognosis. At the end of the seizure, the patient does not remember anything about what happened. In especially severe cases of eclampsia, the convulsive stage may fall completely (eclampsia without seizures).

In differential diagnosis, it is first necessary to distinguish eclampsia from epilepsy. Recognition of the latter help data history (seizures before pregnancy, no changes in the fundus, the rapid recovery of consciousness after a seizure).

Sometimes it is not easy to differentiate eclampsia from acute hypertensive encephalopathy, in which there can also be sudden attacks of tonic and clonic convulsions followed by a state of deep coma, similar to those of eclampsia. In these cases, diagnosis can be helped by knowledge of the clinical picture of hypertension (see). The comatose state of eclampsia should be distinguished from diabetic and uremic cola (see). Finally, it should be borne in mind and the possibility of bleeding in the brain.

The cause of convulsions in eclampsia is the increase in reflex excitability of the cerebral cortex. Therefore, anything that can cause her irritation (birth pain, rough external or internal examination, surgical interventions without anesthesia, catheterization, etc.), can reflexively cause convulsions.

The prognosis for eclampsia depends on its clinical form and the features of the course of eclampsia, and also on the time of its onset.

Eclampsia occurs during pregnancy (eclampsia gravidarum), childbirth (eclampsia sub partu) and after them (eclampsia puerperalis). Starting during pregnancy, eclampsia can cause childbirth and end with it. There may be the so-called intercurrent form of eclampsia, when the seizures that began during pregnancy are stopped under the influence of treatment, the pregnancy persists, then urgent delivery occurs, and the eclampsia seizures do not recur. In some cases of eclampsia during pregnancy, the seizures first stopped after a while appear again (recurrent form of eclampsia in pregnant women). Beginning during pregnancy, the seizures can continue in childbirth and the postpartum period. Eclampsia sub partu can spread to the postpartum period.

There are three clinical forms of eclampsia.
1. A typical form. It is more common in pregnant women with hypersthenic type, is accompanied by large edema of subcutaneous tissue and tissues of internal organs, as well as increased intracranial pressure, severe albuminuria; at the same time there is hypertension.
2. Not quite typical form. It is more common in prolonged childbirth, mainly in women with labile nervous system; usually there is only swelling of the brain, swelling of the subcutaneous tissue does not happen. In such cases, only symptoms of increased intracranial pressure with moderate and changing hypertension are observed; albuminuria, especially at the beginning, is completely absent.
3. Uremic form of eclampsia, which is based on nephritis, which was before pregnancy or developed during pregnancy. More common in pregnant asthenic physique. In this form of edema of the subcutaneous tissue and tissues of internal organs are absent or weakly expressed, which indicates an insufficient barrier function of the connective tissue. At the same time free fluid can accumulate in the abdominal and thoracic cavities, as well as in the fetal bladder.

In the liver, there are severe degenerative changes up to necrosis and hemorrhages, inclusive. This hepato-renal failure also causes general severe intoxication, CNS depression, high hypertension, and sometimes jaundice.

Eclampsia is a life-threatening disease for the mother and the fetus. Causes of mother's death with her can be: asphyxia and impaired blood circulation during convulsions; intoxication; cerebral hemorrhage; an infection to which the organism of a pregnant woman with eclampsia is especially susceptible; pulmonary edema. Eclampsia is the harder, the more time passes from the onset of seizures to childbirth; therefore, the earlier eclampic convulsions develop during pregnancy, the worse the prognosis for the mother and fetus. Especially dangerous is the relapsing form of eclampsia in pregnant women; a more favorable prognosis is given by its intercurrent form, which began close to the period of expulsion of the fetus.

The most favorable prognosis for a typical, but not fully developed eclampsia in cases where the process is limited only to the sphere of the central nervous system. More often, such a "brain" form of eclampsia is observed in childbirth; her fits are stopped immediately after the delivery. Mortality in her, as a rule, is not observed. A typical, fully developed eclampsia proceeds harder. If it develops during pregnancy, then with proper and rational therapy can be cured, pregnancy will develop further, and eclampsia will proceed according to the type of "intercurrent" form. Rare cases of recurrent eclampsia (during pregnancy), which is extremely difficult.

Frequent causes of death in typical eclampsia are pulmonary edema and lobar pneumonia that develops on this basis, as well as septic postpartum processes. As a result of the prolonged stage of convulsions, asphyxia and cardiac arrest may occur (the convulsive stage of eclampsia becomes paralytic).

If a typical eclampsia cures, changes caused by edema and blood circulation disorders, resp. hypertension, soon disappear, the functional state of the organs after some time returns to normal. Thus, the prognosis for a typical eclampsia is relatively favorable. The exceptions are cases of eclampsia that developed in the early stages of pregnancy and soon after childbirth.

A less favorable prognosis for atypical uremic form of eclampsia, in which there is severe damage to the parenchymal organs, especially the kidneys and liver. With the same form of eclampsia, hemorrhages in the brain are more common, leading to death, as well as “eclampsia without convulsions”, in which the convulsive stage falls out and immediately begins the stage of paralysis. Changes in the organs that occur with the uremic form of eclampsia (nephritis, retinitis, etc.), almost do not lend themselves to reverse development, the functional state of the organs for a long time remains disturbed. Therefore, the uremic form of eclampsia often gives relapses both in this and in the next pregnancy. Recurrent forms of eclampsia are extremely difficult. The severity is also determined by the number of seizures, the duration of the intervals between them and the condition of the patient at this time. Other things being equal, eclampsia is harder in cases where the number of seizures becomes larger, when they are longer, the intervals between them are shorter, and the patient outside the seizures is unconscious.

To characterize the condition of the patient is of great importance to assess the tone of the cardiovascular system. Frequent weak filling of the pulse is a sign of the onset of the paralytic stage. Often, this increases the temperature.