The author of the article is A.V. Sozinova, a practicing obstetrician-gynecologist. Professional experience since 2001
The last, final trimester of pregnancy begins from the 29th week and continues until delivery (normally up to 38-42 weeks).
List of dangerous conditions
Topping the list of threatened conditions of the third trimester is such a dangerous complication of pregnancy as preeclampsia. According to various authors, it occurs in 8% to 21% of all pregnancies that ended in childbirth.
Gestosis begins to manifest itself in the second half of pregnancy, but the higher the gestational age, the higher the risk of its occurrence.
In second place is placental insufficiency, which develops in 30-50% of cases against the background of preeclampsia.
The third place is taken by premature placental abruption - a very formidable complication of the gestation period. Its frequency is 0.5-1.5% of the total number of births.
Symptoms
Signs of preeclampsia
The symptomatology of gestosis is determined by a triad of signs:
- increased blood pressure (mainly diastolic),
- proteinuria (appearance of protein in the urine),
- the occurrence of edema of the lower leg, arms, anterior abdominal wall and face (dropsy).
The preclinical picture is characterized by pathological weight gain (more than 300 g per week) and changes in the blood coagulation system (decrease platelets, increasing hematocrit).
Severe manifestations of preeclampsia are preeclampsia and eclampsia. With preeclampsia due to microcirculation disorders in the brain, the following symptoms appear: headache and dizziness, tinnitus and flutter of "flies" before the eyes, pain in the right hypochondrium, nasal congestion, nausea and vomiting, drowsiness or insomnia. If untreated, preeclampsia very quickly turns into eclampsia, which is characterized by the development of seizures and loss of consciousness.
Signs of placental insufficiency
Placental insufficiency can be acute, for example, against the background of placental abruption, and chronic.
Chronic fetoplacental insufficiency does not have pronounced clinical manifestations, a woman can only note a decrease in fetal movements. The diagnosis is confirmed by ultrasound with Doppler ultrasound, cardiotocography (CTG), placentography, which reflect the degree of disturbance of the uteroplacental blood flow. FPN leads to the development of intrauterine fetal hypoxia.
Signs of placental abruption
Premature placental abruption is defined as a very formidable complication of pregnancy, when the detachment of the child's place happened either during pregnancy or in the first or second stage of labor (normally the placenta is separated in the third period).
This condition is manifested by the development of external (less often) and internal bleeding, hemorrhagic shock, acute intrauterine hypoxia, pain syndrome and hypertonicity of the uterus.
Placental abruption can be marginal (more favorable prognosis) and central, when the placenta is attached to the uterine wall only along the circumference, along the edges. Also, depending on the area of the exfoliated area, the detachment of the child's place can be mild (less?), Moderate (1/3 or more) and severe (1/2 or more).
Causes
The causes of gestosis are still not exactly known, therefore this condition is a disease of theories. Gestosis is caused by the inadequacy of the processes of adaptation of the woman's body to new living conditions during gestation and the inability to fully meet the needs of the growing fetus. The predisposing factors for this complication include:
- the woman's age (under 18 and over 30);
- multiple pregnancy;
- first pregnancy;
- heredity;
- preeclampsia in past pregnancies;
- chronic somatic diseases (hypertension, overweight, hormonal pathology, diabetes mellitus).
Fetoplacental insufficiency is most often caused by the development of gestosis, but it can also develop in the presence of the following factors:
- mother's age (under 18 and over 30);
- unfavorable living conditions;
- malnutrition;
- bad habits and industrial hazards;
- stress, emotional instability;
- complications of this pregnancy (few and polyhydramnios, gestosis, prolongation, Rh-conflict, threat of interruption and premature birth);
- chronic somatic pathology (cardiovascular diseases, pathology of the kidneys and endocrine glands, chronic and acute infections, blood pathology);
- multiple pregnancy;
- anomalies in the development of the uterus, infertility, history of isthmic-cervical insufficiency, etc.
Premature placental abruption is also a multifactorial complication, and the risk of its occurrence increases against the background of the following conditions:
- gestosis;
- Rh-conflict pregnancy;
- antiphospholipid syndrome;
- endocrine pathology;
- short umbilical cord;
- "Walking";
- mechanical trauma to the abdomen;
- allergy to some intravenous fluids;
- diseases of the blood coagulation system;
- myomatous nodes and attachment in their area of the placenta;
- multiple pregnancy, etc.
Consequences
All of the listed dangerous conditions that can develop in the last trimester contribute to the development of the following complications and consequences:
- development of intrauterine fetal hypoxia;
- intrauterine growth retardation;
- premature birth and premature effusion of water;
- pulmonary edema, coma or acute renal failure against the background of preeclampsia;
- hemorrhagic shock and posthemorrhagic anemia on the background of detachment;
- DIC syndrome against the background of preeclampsia and / or detachment;
- low and polyhydramnios against the background of FPN;
- anomalies of the birth forces;
- antenatal fetal death.
Treatment
With the development of all of the listed threatened conditions, the pregnant woman is subject to immediate hospitalization, where the question of whether it is advisable to prolong the pregnancy or to deliver is decided.
When chronic placental insufficiency occurs,
- drugs that improve uteroplacental blood flow (actovegin, vitamin E, hofitol, instenon, piracetam, etc.),
- antispasmodics (papaverine, euphyllin, no-shpa),
- drugs that normalize blood rheology: antiplatelet agents (courantil, aspirin) and anticoagulants (trental, troxevasin),
- also shown tocolytics (ginipral, partusisten, magnesium sulfate) to relax the uterus and normalize blood circulation in it,
- in the case of an identified intrauterine infection, antibiotics (macrolides: erythromycin, sumamed) and other anti-inflammatory drugs (metronidazole, antifungal agents, and others) are prescribed.
With gestosis, therapy begins with the creation of a therapeutic and protective regime and the appointment diets (foods rich in protein, moderately undersalted, moderate or reduced fluid intake), fasting days 1 time per week, herbal teas.
Gestosis requires the appointment of antihypertensive drugs (nifedipine, methyldopa, labetolol), which reduce the tone of the uterus and lower blood pressure funds (ginipral, magnesium sulfate), normalization of uteroplacental circulation (courantil, trental, piracetam, actovegin and etc.).
Also, with gestosis, infusion therapy is indicated to restore the volume of circulating blood and normalize its rheology (infukol, rheopolyglucin, albumin, fresh frozen plasma). Additionally, antioxidants are prescribed (tocopherol, glutamic and ascorbic acid). In the case of the development of preeclampsia during full-term pregnancy, the question of labor induction or operative delivery is decided, eclampsia at any time is an indication for caesarean section.
Moderate or severe placental abruption is a direct indication for operative delivery regardless of the timing of pregnancy (in the interests of the mother). With a mild degree, treatment of placental insufficiency, intrauterine fetal hypoxia, anemia and uterine hypertonicity is prescribed.
Forecast
The prognosis for premature placental abruption is extremely unfavorable and depends on the duration of pregnancy, the timeliness of treatment and the degree of detachment of the child's place. Maternal mortality due to the development of hemorrhagic shock and bleeding ranges from 1.5-10%. Fetal death reaches 100% antenatally, 85.7% during contractions, 35.7% during attempts.
With the development of chronic FPI, intrauterine fetal growth retardation is observed in 23-44%, and fetal hypoxia is observed in 28-51%.
Perinatal mortality with gestosis is 79%, and maternal mortality reaches 3.5%. The development of intrauterine growth retardation syndrome with mild gestosis is 16%, with moderate gestosis 22% and with severe gestosis 62%.
Prevention of complications of the third trimester of pregnancy consists in a balanced diet, taking multivitamins, giving up bad habits, and taking regular walks in the fresh air. You should also avoid stressful and conflict situations, heavy lifting and heavy physical activity, industrial hazards.
Some studies during pregnancy
- Pregnancy smears.
- Tests during pregnancy by trimester.
- Ultrasound during pregnancy.
- General analysis of urine during pregnancy.
- Coagulogram.
- Pessary installation.
- Glucose tolerance test.
- Homocysteine during pregnancy.
- Amniocentesis.
- Anesthesia during labor.
- Fetal CTG (cardiotocography)
- Cordocentesis.
- Epidural anesthesia during labor.
