RU2349261C1 - Method of water balance disorder diagnostics and treatment for pregnant women - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine, obstetrics and rehabilitation and can be applied in diagnostics and treatment of water balance disorder for pregnant women. Water balance disorder type is defined for patient. For I type characterised by 'empty' vessels and hydropic interstition, hypokinetic blood circulation type, average venous hematocrit indicators of 39% or over, low average peripheral hematocrit indicators of 34% or lower and hematocrit indicator difference over 3%, differentiated infusion therapy is performed, with infusion therapy volume calculated with account of circulation blood volume (CBV) increase expected for healthy woman at second or third trimester, equal to 40% or 30% respectively, and of indicators of dependency between original body weight before pregnancy and infusion therapy volume rated per 1 kg of body weight by nomogram No 3. Infusion therapy includes 10% refortan in dosage selected for each pregnant woman with account of her original body weight and pregnancy term by nomogram No 2 and glucose and magnesium mix in amount of 400 ml: 325 ml of 20% glucose solution and 75 ml of 25% magnesium sulfate solution. Infusion therapy volume is calculated so as liquid volume combined with water consumed in one day time comprises normal CBV increase for second or third trimester. For II type characterised by 'empty' vessels and 'dry' interstition, transsudate presence in peritoneal cavity, uterus and parenchymic tissue edema, hyperkinetic blood circulation type, venous and peripheral hematocrit indicators of over 43% and 42% respectively and their difference not larger than 2%, infusion therapy similar to that of I type is performed, with addition of saline solution in volume corresponding to water-binding properties of 10% refortan. For III type characterized by total hyperhydration, hypo- or hyperkinetic blood circulation type, average venous and peripheral hematocrit indicators of under 35% and 33% respectively and their difference not larger than 2%, dehydration therapy by lasiks and euphillin microdosage is performed, III type is transformed into I type, and infusion therapy corresponding to I type is performed with a single difference in total liquid volume administered in one day time, reduced in connection to hypervolemia by value equal to water amount, which can be drawn to vessel course by refortan.

EFFECT: improved treatment results for pregnant patients with water balance disorder by development of differentiated infusion therapy with account of pathological water and original body weight redistribution type both before and after labour, thus reducing number of lethal outcome.

6 tbl, 3 dwg, 3 ex

Description

The invention relates to medicine, obstetrics and resuscitation, can be used in the diagnosis and treatment of water balance disorders in pregnant women.

The closest solution is the method of diagnosis and treatment, proposed in the dissertation for the degree of candidate of medical sciences Nazarova B.F. “Violations of the water sectors and ways of their correction in puerperas with preeclampsia”, which provides for the implementation of a set of diagnostic measures, including bioimpedance spectrometry to diagnose disturbances in the water sectors in puerperas and develop appropriate treatment tactics. The use of the bioimpedance method allowed the authors to identify the leading links in water-sector disorders and to develop infusion therapy algorithms, which contributed to an improvement in treatment outcomes and a 14% reduction in the duration of puerperas in the intensive care unit.

However, this technique has been developed for women who have already given birth, in whom the fact of childbirth has already interrupted the main pathogenetic process of the disease. Infusion therapy was developed without taking into account the initial body weight and the type of water balance imbalance, which does not allow to apply a differentiated treatment method. In addition, not every clinic has the ability to use the bio-impedance spectrometry method, since the corresponding apparatus is not cheap.

The objective of the invention is to improve the treatment of pregnant women with impaired water balance by developing differentiated infusion therapy taking into account the type of pathological redistribution of water and initial body weight both before delivery and after delivery, which in turn will reduce the number of complications and deaths.

The problem is solved by the fact that the difference between the hematocrit in the blood taken from the finger and the blood taken from the vein is determined, the type of water balance disturbance is identified, which determines the further treatment tactics taking into account the initial body weight before pregnancy. I type of water balance disturbance involves “empty” vessels and edematous interstitium, hypokinetic type of blood circulation, high venous hematocrit - an average of 39% or more (40.5 + -1.5) and low peripheral hematocrit - an average of 34% and less (31.5 + -2.5), the difference between venous and peripheral hematocrit is> 3%; in type II disorders of the water balance, there are so-called “empty” vessels and “dry” interstitium, but transudate in the abdominal cavity, edema of uterine tissue and parenchymal organs are detected, the type of central hemodynamics is initially hyperkinetic, and after treatment it becomes hypokinetic, indicators venous and peripheral hematocrit exceed 43 and 42%, respectively, the difference in hematocrit is 2% or <2%; in type III, total hyperhydration occurs, which is usually iatrogenic in nature, when the compensation of the initial hypovolemia was accelerated, the type of central hemodynamics can be both hyperkinetic and hypokinetic, low venous hematocrit - an average of 35% or less (32 , 5 + -2.5%), low peripheral hematocrit - on average 33% or less (31.3 + -1.7%), hematocrit difference 2% or <2%.

In type I, infusion therapy is used, calculated taking into account the normal increase in circulating blood volume (BCC) in a healthy pregnant woman by the II trimester or by the III trimester of pregnancy (40% BCC or 30% BCC, respectively) and the initial body weight before pregnancy. We calculate the qualitative and quantitative composition of infusion therapy for the II and III trimesters of pregnancy in case of violation of the water balance of type I.

The BCC determination formula is taken from the textbook Anesthesiology-Resuscitation. Bunyatyan A.A., Ryabov G.A., Manevich A.Z., 1977. Table No. 5. "Blood volume in healthy adults." Sex, physique,% of body weight
Body weight Men Women Norma (7%) Fat (6%) Thin (6.5%) Muscular (7.5%) Norm (6.5%) Fat (5.5%) Thin (6%) Muscular (7%) 40 2800 2400 2600 3000 2600 2200 2400 2800 45 3150 2700 2920 3370 2920 2470 2700 3150 fifty 3500 3000 3250 3750 3250 2750 3000 3500 55 3850 3300 3570 4120 3570 3020 3300 3850 60 4200 3600 3900 4500 3900 3300 3600 4200 65 4550 3900 4220 4870 4220 3570 3900 4550 70 4900 4200 4550 5250 4550 3850 4200 4900 75 5250 4500 4870 5620 4870 4120 4500 5250 80 5600 4800 5200 6000 5200 4400 4800 5600 85 5950 5100 5520 6380 5520 4670 5100 5950 90 6300 5400 5850 6750 5850 4950 5400 6300 95 6650 5700 6170 7120 6170 5220 5700 6650 one hundred 7000 6000 6500 7500 6500 5500 6000 7000

For a woman with a body weight of 50 kg (we will conditionally classify her as “thin”):

BCC = body weight × 60 ml / kg (3000 ml).

For a woman with a body weight of 100 kg (we will conditionally attribute it to "obese"):

BCC = body weight × 55 ml / kg (5500 ml).

If the initial body weight of the pregnant woman is 50 kg, then her bcc, according to this formula, will be 3000 ml. Thus, 40% of the bcc, which she should add in the norm in the II trimester will be 1200 ml, and 30% of the bcc, which she should add in the III trimester, will be 900 ml. Graphically, these calculations are provided on nomogram No. 1 (figure 1).

In type I, there will be a lack of circulating blood volume as a result of redistribution of fluid from the vascular bed to interstitium (intravascular hypovolemia with interstitial edema) and the corresponding clinical manifestations: swelling, decreased urine output, etc. According to our point of view, it is necessary to compensate for the lack of bcc by differentiated infusion therapy in the amount, which, together with the interstitial water attracted by 10% reforman and the liquid drunk per day, will be equal to the debt of BCC (40% or 30% of BCC II and III trimesters, respectively).

Infusion therapy should make up for the deficiency of bcc during the day and include components that ensure the normalization of the water balance in a pregnant woman. The reverse transfer of fluid from interstitium to blood vessels is carried out due to the ability of hydroxyethylated starch (HES) molecules, which is part of infusion therapy, to bind water and hold it for a long time in the lumen of the vessels. So, 10% of rephtan has a volumetric effect equal to 140%, that is, when 1000 ml of 10% of the reptan is introduced into the vascular bed, the bcc increases by 1400 ml (1 gram of dry matter of HES binds 14 ml of water) by attracting interstitial water (Shifman E. M. “Infusion-transfusion therapy in obstetrics”, Petrozavodsk, 2001; Russian Medical Journal, Volume 3, No. 14, 2006. “Plasma-replacement preparations based on hydroxyethyl starch and their clinical use,” Prof. V.Yu. Selchuk, MD M.P. Nikulin, Prof. S. S. Chistyakov, State Russian Cancer Research Center named after N.N. Blokhin RAMS, Moscow, Moscow State Medical University named after N.A.Semashko). In addition, Reftan increases colloid osmotic blood pressure. The differentiation of infusion therapy lies in the fact that a certain dose of HES is selected (for example, 10% reformed) for each pregnant woman, taking into account her initial body weight and gestational age (see nomogram No. 2) (figure 2).

For a woman with an initial weight of 50 kg in the II trimester, 400 ml of 10% reforthan is recommended (such an amount of reptan will draw 260 ml of water from the interstitium into the vascular bed), and for a woman with an initial body weight of 100 kg in the II trimester - 1000 ml of 10% reforthan ( he will attract 650 ml of interstitium water into the vascular bed). For a woman with an initial body weight of 50 kg in the III trimester, 300 ml of 10% reforthan is recommended (it will attract 195 ml of water into the vascular bed), and for a woman with an initial mass of 100 kg in the III trimester - 750 ml of 10% reforthan (will attract 488 ml of interstitial water into the vascular bed). In the III trimester, the dose of reformed is 25% less than in the II trimester, since the proper increase in bcc in the III trimester is 25% less than the increase in bcc in the II trimester. Doses of 10% of reforman were selected taking into account the experience gained in the treatment of more than 150 pregnant women with diagnoses of moderate to severe gestosis.

Focusing on the BCC required for a specific gestational age, the volume of another component of infusion therapy, the glucose-magnesia mixture, is selected so that, in the aggregate, the volume of fluid injected per day is equal to the debt of the BCC (the amount of interstitial water, which attracts 10% of reformed and attracted into the vascular bed, is also taken into account the amount of fluid drunk per day). The composition of the glucose-magnesia mixture includes: 20% glucose solution, which increases the oncotic pressure of the blood, and 25% sulfate magnesia, which has a vasodilating and sedative effect. The recommended daily volume of the glucose-magnesia mixture is 400 ml (325 ml of a 20% glucose solution and 75 ml of a 25% magnesium sulfate solution). The amount of glucose and sulfuric acid magnesia in the composition of this mixture may vary depending on the oncotic blood pressure and blood pressure, however, the total volume of the glucose-magnesia mixture should correspond to the recommended one (the amount of glucose-magnesia mixture is constant for all types of water imbalance and for any gestational age).

Thus, differentiated infusion therapy of water balance disturbance in a pregnant woman with an initial body weight of 50 kg in the second trimester of pregnancy will include: 400 ml of 10% reformed and 400 ml of glucose-magnesia mixture, which will be 800 ml. In terms of 1 kg of woman's weight, this will be 16 ml / kg. This daily volume of infusion is administered evenly at a rate of 11 cap / min. With such infusion therapy, the deficiency of bcc in a pregnant woman (and it is 1200 ml, according to the above) will be completely compensated, since the amount of 160 ml of water drawn from interstitium and the amount of 240 ml of liquid drunk per day will be added to the 800 ml injected. For a woman with an initial weight of 100 kg in the second trimester of pregnancy, infusion therapy will include: 1000 ml of 10% reformed and 400 ml of glucose-magnesia mixture, which will be 1400 ml. In terms of 1 kg of a woman's weight, this will be 14 ml / kg. The infusion rate is 19 drops / min. With such infusion therapy, the deficiency of BCC in a pregnant woman (and it is 2200 ml according to the above) will be fully compensated, since the amount of 400 ml drawn from interstitium will be added to the administered 1400 ml and 400 ml of drunk liquid. Using the same principle, we calculated the volume of infusion therapy for women with different initial body weight in the range from 50 to 100 kg. In addition, the rate of infusion and the ratio of the volume of infusion therapy to the initial body weight of the pregnant woman were calculated. A pattern was obtained: with an increase in the initial body weight, the number of milliliters administered as part of the fluid infusion therapy decreases by 1 kg of weight. This pattern is presented on the nomogram No. 3 (figure 3) and in tables 1 and 2.

Table 1 Quantitative and qualitative composition of differentiated infusion therapy, taking into account the initial body weight in pregnant women with a violation of the water balance of type I in the II trimester of pregnancy Weight (kg) Due increase in bcc in the second trimester of pregnancy (ml) 10% Reformed (ml) Glucose-magnesia mixture (ml) Volume of infusion therapy (ICU) (ml) Infusion rate (cap / min) The ratio of ICU to the original body mass in the second trimester of pregnancy (ml / kg) Water interstitium, attracted by reformed into a vessel. riverbed (VIPSR) (ml) Drunk per day (VZS) (ml) ICU, VIPPS and VZS (ml) fifty 1200 400 400 800 eleven 16 160 240 1200 56.25 1324 475 400 875 12 15,556 190 259 1324 62.5 1450 551 400 951 13 15,216 220 279 1450 68.75 1575 625 400 1025 fourteen 14,909 250 300 1575 75 1700 700 400 1100 fifteen 14,667 280 320 1700 81.25 1825 774 400 1174 16 14,449 310 341 1825 87.5 1950 850 400 1250 17 14,286 340 360 1950 93.75 2075 925 400 1325 eighteen 14,133 370 380 2075 one hundred 2200 100 0 400 1400 19 fourteen 400 400 2200 Notes: 1. Drinking water is given only when adequate diuresis appears (at least 100 ml / h). 2. In the table. Figures 1-6 show exact numbers that are not always convenient for practical use, and therefore the authors recommend rounding them (the number of drops per minute is rounded to the nearest whole number).

table 2 Quantitative and qualitative composition of differentiated infusion therapy, taking into account the initial body weight in pregnant women with a violation of the water balance of type I in the III trimester of pregnancy Weight (kg) Due increase in bcc in the III trimester of pregnancy (ml) 10% Reformed (ml) Glucose-magnesia mixture (ml) Volume of infusion therapy (ICU) (ml) Infusion rate (cap / min) The ratio of ICU to the original body mass in the III trimester of pregnancy (ml / kg) Water interstitium, attracted by reformed into a vessel. riverbed (VIPSR) (ml) Drunk per day (VZS) (ml) ICU, VIPPS and VZS (ml) fifty 900 300 400 700 10 fourteen 120 80 900 56.25 994 356 400 756 eleven 13.44 142 96 994 62.5 1088 413 400 813 eleven 13,008 165 110 1088 68.75 1181 469 400 869 12 12.64 188 124 1183 75 1275 525 400 925 13 12,333 210 140 1275 81.25 1369 581 400 981 fourteen 12,074 232 156 1369 87.5 1463 638 400 1038 fourteen 11,863 255 170 1463 93.75 1556 694 400 1094 fifteen 11,669 278 184 1556 one hundred 1650 750 400 1150 16 11.5 300 200 1650

In type II, infusion therapy is used, which is qualitatively and quantitatively similar to type I infusion therapy. It is also calculated taking into account the proper increase in bcc and initial body weight before pregnancy, however, it must be borne in mind that in such patients it is impossible to draw “dry” and endogenous water from it into the vessels, therefore it is necessary to increase the volume of infusion therapy administered during the day by introducing exogenous water (160 ml of 0.9% sodium chloride solution for women with a mass of 50 kg and 400 ml of 0.9% sodium chloride solution for women with an initial weight of 100 kg in the second trimester of pregnancy). It should be noted that the amount of 0.9% sodium chloride injected is equal to the amount of water that is able to bind and retain in the vascular bed 10% of reformed in the dose that is administered in accordance with the initial body weight and gestational age. In the III trimester for a woman with an initial body weight of 50 kg this will be 120 ml of 0.9% sodium chloride, and for a pregnant woman with an initial weight of 100 kg - 300 ml of 0.9% sodium chloride (see nomogram No. 3 and table 3 and four).

With type III, it is necessary to transfer the course of the disease into type I using dehydration therapy: microdoses of Lasix (5-10 mg) and 2.4% aminophylline (3-5 ml). Further infusion therapy differs from that described above for type I only in that, due to the total hyperhydration characteristic of type III, it is necessary to reduce the volume of fluid introduced during the day. This will prevent even greater hypervolemia. In the II trimester, we recommend that the doses of 10% of refortan and the glucose-magnesia mixture be left unchanged, but the amount of liquid drunk per day is reduced by an amount equal to the amount of water that the reptan can attract, and in the III trimester - due to its complete exclusion during the day and reducing the amount of glucose-magnesia mixture (for reducing the amount of 20% glucose). The data obtained are reflected in table. 5 and 6.

Table 3 Quantitative and qualitative composition of differentiated infusion therapy, taking into account the initial body weight in pregnant women with a violation of the water balance of type II in the II trimester of pregnancy Weight (kg) Due increase in bcc in the second trimester of pregnancy (ml) 10% Reformed (ml) Glucose-magnesia mixture (ml) 0.9% sodium chloride solution (ml) Volume of infusion therapy (ICU) (ml) Infusion rate (cap / min) The ratio of ICU to ref. body weight in the second trimester of pregnancy (ml / kg) Drunk per day (VZS) (ml) ICU and VZS (ml) fifty 1200 400 400 160 960 13 19.2 240 1200 56.25 1324 475 400 190 1065 fifteen 18,933 259 1324 62.5 1450 551 400 220 1171 16 18,736 279 1450 68.75 1575 625 400 250 1275 eighteen 18,545 300 1575 75 1700 700 400 280 1380 19 18,4 320 1700 81.25 1825 774 400 310 1484 21 18,265 341 1825 87.5 1950 850 400 340 1590 22 18,171 360 1950 93.75 2075 925 400 370 1695 24 18.08 380 2075 one hundred 2200 1000 400 400 1800 25 eighteen 400 2200

Table 4 Quantitative and qualitative composition of differentiated infusion therapy, taking into account the initial body weight in pregnant women with a violation of the water balance of type II in the III trimester of pregnancy Weight (kg) Due increase in bcc in the III trimester of pregnancy (ml) 10% Reformed (ml) Glucose-magnesia mixture (ml) 0.9% sodium chloride solution (ml) Infusion rate (cap / min) Infusion rate (cap / min) The ratio of ICU to ref. body weight in the third trimester of pregnancy (ml / kg) Drunk per day (VZS) (ml) ICU and VZS (ml) fifty 900 300 400 120 820 eleven 16,4 80 900 56.25 994 356 400 142 898 12 15,964 96 994 62.5 1088 413 400 165 978 fourteen 15,648 110 1088 68.75 1181 469 400 188 1057 fifteen 15,374 124 1181 75 1275 525 400 210 1135 16 15,133 140 1275 81.25 1369 581 400 232 1213 17 14,929 156 1369 87.5 1463 638 400 255 1293 eighteen 14,777 170 1463 93.75 1556 694 400 278 1372 19 14,635 184 1556 one hundred 1650 750 400 300 1450 twenty 14.5 200 1650

Thus, for a woman with an imbalance in water balance of type III and an initial weight of 50 kg in the second trimester, 400 ml of 10% reformed and 400 ml of glucose-magnesia mixture are recommended. The total infusion volume will be 800 ml, which is equal to the infusion volume for type I women with the same weight and gestational age (respectively, the number of milliliters per 1 kg and the infusion rate will also be similar). However, the total volume of fluid injected during the day will be 160 ml less due to less water consumed. Recall that it is precisely 160 ml of water that is able to bind 10% reformed in a dose of 400 ml.

For the same woman in the third trimester of pregnancy, the composition of the infusion therapy will include 300 ml of 10% reftan and 360 ml of glucose-magnesia mixture (285 ml of a 20% glucose solution and 75 ml of 25% magnesium sulfate). In this case, the total infusion volume will be 660 ml, and the total amount of injected fluid will be 120 ml less than the total amount of injected fluid for type I women with the same weight and gestational age by eliminating drinking water and reducing the amount of 20% glucose in the composition of the glucose-magnesia mixture (for comparison: it is 120 ml of water that is able to bind 10% reformed in a dose of 300 ml).

Thus, infusion therapy for type III disorders of the water balance in pregnant women is similar in quality, volume and pace to infusion therapy for type I. The difference in the management of pregnant women with type III is that microdoses of lasix and aminophylline are initially used, and the amount of fluid introduced per day is also reduced (see nomogram No. 3 and tables 5 and 6).

Case Study No. 1

Pregnant K-th, 25 years old, was admitted to the ward of the City Clinical Maternity Hospital in Kursk on January 21, 2007 with complaints of headache and nausea. The above symptoms appeared 3 hours before admission. The woman turned to the antenatal clinic at the place of residence, where she was diagnosed with: Pregnancy 38 weeks. Severe gestosis. A woman was sent to the City Clinical Maternity Hospital for hospitalization and treatment. At the time of the examination by a medical consultation, the condition was regarded as serious. Consciousness is clear. The skin is dry, warm. Marked swelling of the lower extremities, pasty brushes. The vesicular breathing, no wheezing. NPV 18-20 per min. HELL on the right hand 160/100 mm Hg, on the left 140/100 mm Hg Heart rate 84 beats / min, heart sounds are clear, rhythmic. The abdomen is soft, painless. The uterus is painless. The fetal heartbeats are clear, rhythmic. Feels the fetal movements. There are no discharge from the genital tract. Over the past 12 hours, a woman urinated 3 times with 200 ml of urine (hourly diuresis of 50 ml / h). From the anamnesis: over the past 2 weeks, the prevalence of the drunk liquid over the excreted (weight gain over 2 weeks - 2 kg) is noted. The total weight gain during pregnancy was 20 kg (initial weight - 75 kg). After performing a rheographic study, a hypokinetic type of hemodynamics was revealed. In a biochemical blood test: a decrease in total protein (56 g / l), an increase in urea (12 mmol / l) and creatinine (140 μmol / l). Venous hematocrit 43%, peripheral hematocrit 31%. In the general analysis of urine, proteinuria (1.6 g / l). Diagnosed with Pregnancy 38 weeks. Severe gestosis. A woman was hospitalized in the intensive care unit. A pregnant woman was diagnosed with type I water balance disorders taking into account hematocrit indices (high central hematocrit - 43%, low peripheral hematocrit - 31%, hematocrit difference> 3%), rheography data (hypokinetic type of central hemodynamics), decreased urine output (50 ml / h ), the presence of severe edema. During the day, differentiated infusion therapy was carried out taking into account the type of water balance imbalance and initial body weight. The daily volume of infusion therapy was calculated taking into account the proper increase in bcc for a pregnant woman with an initial weight of 75 kg. The calculation formula: the volume of infusion therapy = 75 kg × 12 333 ml / kg = 925 ml. Coefficient 12333 reflects the ratio of ICU (volume of infusion therapy) to the initial body weight. It can be obtained using calculations similar to ours, or by taking our calculations as a basis and using nomogram No. 3. The composition of the infusion therapy corresponded to type I imbalance of water in pregnant women (taking into account the initial weight and gestational age): 525 ml of 10% reforman, which draws 210 ml of endogenous water from interstitium (52.5 g of dry matter of HES in 525 ml of 10% reformed, and 1 g of dry matter of HES attracts 14 ml of water), 400 ml of glucose-magnesia mixture (325 ml of 20% glucose and 75 ml of 25% magnesium sulfate). In total, infusion therapy amounted to 925 ml per day (525 ml of 10% reftan and 400 ml of glucose-magnesia mixture), in addition, 210 ml of water was drawn from interstitium, which amounted to 1135 ml per day. 2 hours after the start of the infusion, against the background of adequate urine output, the woman began to drink water. 140 ml of water was drunk per day, which, together with the volume of infusion and attracted interstitial water, amounted to 1275 ml. The calculated volume of normal increase in bcc (30%) was also 1275 ml (Table 2). In this pregnant woman, the indicated infusion, compiled taking into account the indicators of nomograms No. 1 and No. 2, as well as table. 2, normalized hematocrit and their difference in 16 hours. 1 hour after the start of the infusion, a decrease in blood pressure to 140/100 mm Hg was noted. on the right hand, 130/100 mmHg on the left and lack of complaints of headache and nausea. After another 2 hours, diuresis (100 ml / h) and blood pressure (120/80 mm Hg on both hands) returned to normal. After 16 hours, normalization of blood urea and creatinine levels, a decrease in proteinuria (0.033 g / l), venous hematocrit 37%, peripheral 34%, which is interpreted as normalization of hematocrit and their difference (normally it is 2-3%) as a result of redistribution, were noted water in the pregnant woman’s body in response to differentiated infusion therapy (fluid transfer from interstitium to blood vessels, their expansion and normalization of peripheral blood circulation, including in the kidneys). 26 hours after hospitalization, a woman in satisfactory condition, against the background of stable hemodynamics (blood pressure in both hands 120/80 mm Hg), a pronounced decrease in edema and normal indicators of urea and creatinine was taken into prenatal due to the onset of labor. The birth was conservative. There were no rises in blood pressure. 16 hours after the onset of labor, a live full-term male baby was born, weighing 3400 g. The early postpartum period without features. Stable hemodynamics (blood pressure on both hands 120/80 mm Hg). The woman was discharged from the hospital on the 7th day after delivery in a satisfactory condition.

Case Study No. 2

Pregnant Guy, 27 years old, was admitted to the admission department of the Kursk City Clinical Maternity Hospital on 02/25/2007 with complaints of headache, flickering “flies” before her eyes, nausea, general weakness. The above symptoms appeared 6 hours before admission. The woman applied to the antenatal clinic at the place of residence, where she was examined by a doctor. Was diagnosed with Pregnancy 38 weeks. Severe gestosis. Scar on the uterus (cesarean section in 2004). The pregnant woman was sent to the City Clinical Maternity Hospital for hospitalization and treatment. At the time of the examination by a medical consultation, the condition was regarded as serious. Consciousness is clear. The skin is pink, dry, warm. No swelling. The vesicular breathing, no wheezing. NPV 18 min HELL on the right hand 170/110 mm Hg, on the left 150/100 mm Hg Heart rate 96 beats / min, heart sounds are clear, rhythmic. The abdomen is soft, painless. The fetal heartbeats are clear, rhythmic. There are no discharge from the genital tract. During the last 12 hours, I urinated 4 times in 200 ml (hourly diuresis 67 ml / h). In the anamnesis, the predominance of the drunk liquid over the excreted within the last 2 weeks is noted (weight gain for 2 weeks - 1.5 kg). The total weight gain during pregnancy was 16 kg. The initial weight when registering for pregnancy is 62.5 kg. After performing a rheographic study, a hyperkinetic type of hemodynamics was revealed. In a biochemical blood test, an increase in urea (10 mmol / L) and creatinine (145 μmol / L), a decrease in total protein (58 g / L). Venous hematocrit 45%, peripheral hematocrit 43%. In the general analysis of urine, proteinuria (1.6 g / l). Diagnosed with Pregnancy 38 weeks. Severe gestosis. Scar on the uterus. A woman was hospitalized in the intensive care unit. A pregnant woman was diagnosed with a II type of water balance disturbance taking into account hematocrit indicators (high venous hematocrit - 45%, high peripheral hematocrit - 44%, hematocrit difference less than 2%), rheography data (hyperkinetic type of central hemodynamics), history of fluid retention, objectively confirmed (excessive weight gain in pregnant normosthenic type). During the day, differentiated infusion therapy was carried out taking into account the type of water balance imbalance and initial body weight before pregnancy. The daily volume of infusion therapy was calculated taking into account the proper increase in bcc for a pregnant woman with an initial weight of 62.5 kg. The calculation formula: the volume of infusion therapy = 62.5 kg × 15.648 ml / kg = 978 ml. The coefficient of 15.648 reflects the ratio of ICU (volume of infusion therapy) to the initial body weight. It was obtained using the above calculations (see table. 4 and nomogram No. 3). The composition of the infusion therapy corresponded to the second type of imbalance in pregnant women’s water balance (taking into account the initial weight and gestational age): 413 ml of 10% reforman, which is able to bind and retain 165 ml of water in the vascular bed, 165 ml of 0.9% sodium chloride solution, which included in the infusion therapy due to the inability to draw water from interstitium in type II water imbalance and 400 ml of glucose-magnesia mixture (325 ml of 20% glucose and 75 ml of 25% magnesium sulfate). In total, infusion therapy amounted to 978 ml per day. 1 hour after the start of the infusion, diuresis was 100 ml / hour, and the woman began to drink water. 110 ml of water was drunk per day, which together with the infusion was 1088 ml. The calculated increase in bcc (30%) also amounted to 1088 ml (see table. 4). The pregnant woman indicated infusion, compiled taking into account nomograms No. 1 and No. 2, as well as table. 4, normalized hematocrit and their differences in 18 hours. 1 hour after the start of the infusion, a decrease in blood pressure to 150/100 mm Hg was noted. on the right hand and 140/90 mmHg on the left and the absence of complaints of headache, flickering "flies" in front of the eyes and nausea. After another 1 hour, hourly diuresis was 100 ml / hour, blood pressure 130/90 mm Hg. and 120/80 mmHg on the right and left hands, respectively. 18 hours after the start of infusion therapy, venous hematocrit 37%, peripheral 35% (their difference is 2%, and normally it is 2-3%), blood pressure 120/80 mm Hg on both hands, a decrease in proteinuria (up to 0.033 g / l), normalization of urea and blood creatinine were noted, with repeated reovasography, a hypokinetic type of central hemodynamics was determined. 24 hours after hospitalization amid a satisfactory condition (normal laboratory parameters and stable hemodynamics - blood pressure of 120/80 mm Hg on both hands), the woman was delivered by cesarean section. At the 4th minute of the operation, a live full-term girl weighing 3300 g was extracted, 8-9 points on the Apgar scale. During the operation, swelling of the uterine tissues and the presence of a clear fluid in the abdominal cavity in the amount of 200 ml were noted, which confirms the disturbances in the water balance of this woman that developed according to type II. The early postoperative period without features. Hemodynamics is stable (symmetrical blood pressure, 120/80 mm Hg). The woman was discharged from the hospital on the 10th day after delivery in a satisfactory condition.

Case Study 3

Pregnant S-th, 22 years old, was transferred to the intensive care unit of the City Clinical Maternity Hospital in Kursk on 04/18/2007 from the Department of Pregnancy Pathology, where from April 15, 2007 she was hospitalized with a diagnosis of Pregnancy 37 weeks. Gestosis of moderate severity. At the time of transfer complains of headache, nausea, general weakness, which appeared 30 minutes before this moment. Consciousness is clear. The skin is pink, dry, warm. Severe swelling of the hands, legs and feet. The vesicular breathing, no wheezing. NPV 18 min HELL 160/100 mm Hg on both hands. Heart rate 92 beats / min, heart sounds are clear, rhythmic. The abdomen is soft, painless. The uterus is painless. The fetal heartbeats are clear, rhythmic. Feels the fetal movements. There are no discharge from the genital tract. Anamnesis. During the last week, the predominance of the drunk fluid over the excreted (weight gain per week 1 kg) is noted. The total weight gain is 18 kg (initially - 87.5 kg). The woman entered the department of pathology of pregnant women on April 15, 2007 from the antenatal clinic, where symptoms of progression of gestosis were revealed: arterial hypertension (140/80 mmHg on both hands; during the previous turnout, 130/80 mmHg) , an increase in edema of the legs and feet (during the previous appearance there was a pasty of the legs and feet). Proteinuria was not observed. In the department of pregnant women’s pathology, she received the following therapy: aminophylline 2.4% 10 ml iv twice a day, intravenous glucose-magnesia mixture (400 ml 10% glucose and 20 ml 25% magnesium sulfate) once a day, Reftan 6% 500 ml iv drip 1 time per day, Dibazole 1% 3 ml IM 3 times a day, papaverine 2% 2 ml IM 4 times a day, Riboxin 10 ml and cocarboxylase 100 mg in 200 ml 0.9% solution of intravenous sodium chloride drip 1 time per day. The total infusion volume was 1100 ml per day. During the first two days in the Department of Pathology of Pregnant HELL 130/80 - 140/80 mm Hg on both hands, hourly diuresis of 60-70 ml / h, urea and creatinine values corresponded to the upper limits of the norm, proteinuria was not observed. On the third day, there was a negative dynamics during the disease in the form of: a rise in blood pressure to 160/100 mm Hg. on both hands, the appearance of complaints of headache, nausea, general weakness, increased swelling of the legs and feet, the appearance of swelling of the hands, decreased hourly urine output to 40 ml / h, increased urea (12 mmol / l) and creatinine (145 μmol / l ), a decrease in total blood protein (52 g / l). In connection with these changes, the pregnant woman was transferred to the intensive care unit and intensive care unit for further treatment. At the time of transfer, venous hematocrit 33%, peripheral hematocrit 32%. Reovasography data is a hyperkinetic type of central hemodynamics. Marked proteinuria 1.2 g / L. Diagnosed with Pregnancy 37 weeks. Severe gestosis. In this pregnant woman, a III type of water balance disturbance was revealed taking into account low venous and peripheral hematocrit values (33 and 32%, respectively), their difference (less than 2%), decreased urine output (40 ml / h), and the presence of severe edema. During the day, differentiated infusion therapy was carried out taking into account the type of water balance imbalance and initial body weight. The daily volume of infusion therapy was calculated taking into account the proper increase in bcc for a pregnant woman with an initial weight of 87.5 kg. The calculation formula: the volume of infusion therapy = 87.5 kg × 10.891 ml / kg = 953 ml. The coefficient 10.891 reflects the ratio of ICU (volume of infusion therapy) to the initial body weight. It was obtained using the calculations given above (see nomogram No. 3 and table 6). The composition of the infusion therapy corresponded to the III type of violation of the water balance in pregnant women (taking into account the initial body weight and gestational age): 638 ml of 10% reformed (it is able to bind 255 ml of water, but in connection with the total hyperhydration in order to prevent even greater hypervolemia, we reduced the amount of fluid introduced during the day by exactly 255 ml due to the exclusion of drinking water during the day and the amount of the glucose-magnesia mixture), 315 ml of the glucose-magnesia mixture (240 ml of 20% glucose and 75 ml of 25% magnesium sulfate ) In total, infusion therapy included 953 ml per day, which, together with water taken from interstitium (255 ml), amounted to 1208 ml (255 ml less than the amount of fluid that a woman with the same weight and type I imbalance would receive and, respectively 255 ml less than the normal increase in bcc to the III trimester in this pregnant woman).

Infusion, compiled taking into account the indicators of nomograms No. 2 and No. 3, as well as table. 6, normalized hematocrit indices and their differences in 20 hours. In addition to this infusion, dehydration therapy with microdoses of lasix (5-10 mg) and 2.4% aminophylline (3-5 ml) was carried out from the first hours of a pregnant woman in the intensive care unit. 1 hour after the start of infusion therapy, a decrease in blood pressure to 140/90 mm Hg was noted. on both hands and the absence of complaints of headache and nausea. After another 1 hour, diuresis was 150 ml / h. After 20 hours, normalization of urea and creatitinin, an increase in total blood protein relative to the original (up to 58 g / l), a decrease in proteinuria (0.033 g / l) were noted; venous hematocrit 36%, peripheral 34% (hematocrit difference within normal limits - 2%), blood pressure on both hands 125/80 mm Hg, a significant reduction in edema, improvement of well-being (lack of weakness). 25 hours after the start of infusion therapy, the pregnant woman was transferred to the prenatal ward in connection with the onset of labor. The birth was conservative. There were no rises in blood pressure. 14 hours after the onset of labor, a lively female child was born with no signs of prematurity, weighing 3,500 g, with an Apgar score of 8–9 points. The postpartum period without features. Hemodynamics is stable (blood pressure on both hands is 120/80 mm Hg), hourly diuresis is 80-100 ml / hour. On the 3rd day after delivery, the complete disappearance of edema and proteinuria was noted. The woman was discharged from the hospital on the 7th day after delivery in a satisfactory condition.

Thus, the task was achieved by the fact that, through a strictly differentiated approach to infusion therapy for pregnant women with impaired water balance, it was possible, firstly, to avoid iatrogenic hyperhydration that occurs when there is an unreasonable increase in the volume of infusion and accelerate its pace; secondly, to achieve normalization of the water balance in the pregnant woman during the first days of her stay in the intensive care unit and intensive care.

The application of the proposed method ultimately leads to the fact that:

1. The treatment time for pregnant women with impaired water balance is reduced.

2. The probability of developing iatrogenic total hyperhydration is reduced in connection with the development of differentiated infusion therapy, taking into account the type of changes in water balance and initial body weight.

3. The number of perinatal losses due to disruption of the water balance is reduced.

4. The number of fatal complications among pregnant women associated with disturbances in water balance is reduced.

5. Increases the cost-effectiveness of the treatment of pregnant women with impaired water balance.

Claims (1)

A method for the diagnosis and treatment of water balance disorders in pregnant women, characterized in that they determine the type of water balance disturbance, while with type I, characterized by "empty" vessels and edematous interstitium, hypokinetic type of blood circulation and average venous hematocrit of 39% or more and low average peripheral hematocrit indicators of 34% or less, as well as their difference of more than 3%, carry out differentiated infusion therapy, the volume of infusion therapy is calculated taking into account the proper increase in the volume of compasses blood flow (BCC) in a healthy woman by the second or third trimester, which is 40% or 30%, respectively, and indicators of the relationship between the initial body weight before pregnancy and the volume of infusion therapy in terms of 1 kg of body weight according to nomogram No. 3, while infusion therapy includes 10% reformed, the dose of which is chosen for each pregnant woman, taking into account her initial body weight and gestational age according to nomogram No. 2 and glucose-magnesia mixture in an amount of 400 ml: 325 ml of a 20% glucose solution and 75 ml of a 25% solution sulfuric acid magician esia, and the calculation of the volume of infusion therapy is carried out so that, together with the water drunk per day, the volume of fluid will be that volume by which the normal bcc of the woman normally increases in the second or third trimester of pregnancy, with type II, characterized by "empty" vessels and "dry" interstitium, the presence of transudate in the abdominal cavity, edema of uterine tissue and parenchymal organs with a hyperkinetic type of blood circulation and venous and peripheral hematocrit values of more than 43% and 42%, respectively, and their difference of 2% or less, etc. they administer infusion therapy similar to type I, supplementing it with physiological saline in a volume corresponding to the water-binding properties of 10% reformed, with type III, characterized by total hyperhydration, hypo- or hyperkinetic nature of blood circulation, average venous and peripheral hematocrit 35% and less and 33% and less, respectively, as well as their difference of 2% or less, dehydration therapy is carried out with microdoses of lasix and aminophylline, type III is converted into type I and the type I infu is carried out ion therapy with the only difference that the total amount administered during the day in fluid communication with fluid overload is reduced by the amount equal to the amount of water that can attract Refortan bloodstream.

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