Edema in late pregnancy

Introduction Pregnancy edema can be divided into two major categories of physiological and pathological. In the second half of pregnancy, mild edema of the lower extremities often occurs in the lower limbs. After the rest, the physiology is reduced, and the rest is not regressed. If it is getting worse, the pathology should be considered.

Cause

Simple lower extremity edema is very common in late pregnancy. The main reasons are: blood reflux is blocked, blood protein content is insufficient, plasma colloid osmotic pressure is reduced; endocrine gland function changes, causing sodium retention in the body and edema.

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Obstetric B Ultra Urine Protein Test (PRO) Urine Estradiol NST Test Pregnancy Test

The three major clinical characteristics of patients with pregnancy-induced hypertension syndrome are hypertension, proteinuria and edema. The increase in body weight in patients with gestational edema should take into account the factors that lead to weight gain in pregnancy itself. To determine the presence or absence of gestational edema, a standard must be established for weight gain. The currently accepted standard is: weight gain over 0.5 kg in a week, over 1 kg in 2 weeks or more than 2 kg in a month, all of which are abnormal weights. increase. If there is no other reason, pregnancy edema can be considered.

Differential diagnosis

According to the history of the disease, the performance of edema and the above-mentioned examinations, the identification of general edema determines which type of edema or what causes edema will not be very difficult. Individual cases may be atypical or mixed for a variety of reasons, which may also cause difficulty in diagnosis. The characteristics and main diagnostic criteria of several common systemic edema and localized edema are summarized as follows:

First, systemic edema

(a) cardiogenic edema

Refers to the primary disease of heart disease, edema caused by cardiac dysfunction. Mild cardiogenic edema can only show some edema in the ankle. In severe cases, not only the lower extremities have edema, but also upper limbs, chest, back, face, and even pleural, abdominal and pericardial effusions. Because of heart dysfunction, patients with heart disease often appear to sit and breathe and are forced to take a sitting or a semi-sitting position. Therefore, cardiogenic edema occurs in the foot, ankle, humerus and scrotum of the lower limbs, and the influence of the receptor position is obvious.

(two) renal edema

The manifestations and mechanisms of edema caused by kidney disease vary greatly. When nephrotic edema starts, the edema in the low-pitched area is often not as pronounced as in the eyelids or face. Patients often find swelling or swelling of the eyelids or face in the morning, and then spread to the whole body. Unlike cardiogenic edema, it has no obvious circulatory dysfunction, no systemic venous congestion, and there is no significant increase in hydrostatic pressure in peripheral capillaries. Patients can generally lie flat without obvious sag and position. When edema, excessive body fluids retained in the body are first distributed in areas where the subcutaneous tissue is loose and the skin is soft. Experiments have shown that the eyelids are the areas where the interstitial pressure is very low and the skin is stretched.

(3) Hepatogenic edema

Hepatogenic edema is often characterized by ascites, while the lower extremities are not obvious.

The most common cause of hepatic ascites is cirrhosis, and it is more common in patients with cirrhosis who are in a decompensated period. At this time, due to obstruction of hepatic venous return and portal hypertension, especially the pressure in the hepatic sinus is obviously increased, the filtered liquid mainly exudes through the hepatic capsule and drops into the abdominal cavity; in addition, the liver protein synthesis disorder reduces plasma albumin, aldosterone Inactivation of the liver and vasopressin can reduce sodium and water retention, which are important factors for the occurrence of hepatic edema.

The diagnosis of hepatic edema is generally not difficult, and there is a history of chronic hepatitis, liver, splenomegaly, hard, abdominal collateral circulation, esophageal varices, and some patients can see spiders and liver palms. Laboratory tests showed significant impairment of liver function and plasma albumin drop.

(four) malnutrition edema

Malnutrition edema, also known as nutritional edema, is caused by a lack of nutrients. Edema occurs slowly, and its distribution usually begins at the loose tissue and then extends down to the whole body. When the edema develops to a certain extent, the edema of the lower limbs, such as the lower extremities, is obvious. The extent of nutritional edema is not consistent with hypoproteinemia, and its mechanism remains to be further explored. In patients with nutritional edema, plasma albumin is reduced, urine is normal, blood pressure is not high, often accompanied by anemia and fatigue, edema should be resolved after nutritional improvement. Vitamin B1; lack of can cause beriberi. Wet beriberi is often accompanied by systemic edema. The amount of vitamin B1 in the blood and urine of the patient is reduced, and the amount of urine is reduced when edema, but there is no proteinuria. The main symptoms are loss of appetite, numbness of hands and feet, exercise inability to train intestinal muscle tenderness, and knee reflexes disappear. In severe cases, symptoms of cardiac insufficiency may occur.

(5) Pregnancy edema

Pregnancy edema can be divided into two major categories of physiological and pathological. In the second half of pregnancy, mild edema of the lower extremities often occurs in the lower limbs. After the rest, the reduction is mostly physiological; after the break does not subside, and the worse, the pathological should be considered. The three major clinical characteristics of patients with pregnancy-induced hypertension syndrome are hypertension, proteinuria and edema. The increase in body weight in patients with gestational edema should take into account the factors that lead to weight gain in pregnancy itself. To determine the presence or absence of gestational edema, a standard must be established for weight gain. The currently accepted standard is: weight gain over 0.5kg in a week, over 1kg in 2 weeks or more than 2kg in a month, all of which are abnormally increased in weight. . If there is no other reason, pregnancy edema can be considered.

(6) edema caused by disease

Connective tissue diseases include many types, and the condition is often delayed and repeated. Most of them are currently considered to be autoimmune diseases. Among them, the main manifestations of edema are:

1, disseminated lupus erythematosus

Mild edema may occur in this disease, which is more common in the face and ankle. Its edema formation is associated with systemic vascular disease and decreased serum albumin. If accompanied by lupus nephritis, the formation of edema is related to the factors of the kidney. This disease has a typical characteristic rash, blood test for lupus cells positive, anti-nuclear antibody positive and titer >1:80, can be diagnosed.

2, scleroderma and adult scleredema

Scleroderma includes systemic sclerosis, localized scleroderma, etc. The former is divided into two types: diffuse sclerosis and acromegaly. Their lesions are characterized by degenerative and inflammatory changes, fibroblasts over-generating collagen and eventually developing fibrosis. The early changes in the skin are swelling of the skin and non-depressed edema. The skin is thick, the tension is increased, and the hardness is increased. Start with the hands and/or feet, gradually with the neck, face and trunk. The degree of fibrosis gradually increased in the later stage, and the skin, subcutaneous tissue and muscles all shrank and the hair fell off. According to the performance characteristics of skin sclerosis, skin biopsy and immunological tests such as anti-nuclear antibodies, anti-scleroderma-70 antibody (anti-Scl-70 antibody) and other positive, can be clearly diagnosed. The symptoms of adult scleredema are similar to those of scleroderma. However, its onset, duration and prognosis are different, and there is often a history of upper respiratory tract infection several weeks before onset. Skin symptoms often start from the head, face, neck, and back, and develop to a peak within 2-4 weeks. They can resolve spontaneously in months to years, and most of the prognosis is good.

3, dermatomyositis

It is a subacute or chronic connective tissue disease that not only invades the skin, under the skin, but also invades the striated muscle. The disease is characterized by non-infectious diffuse inflammation with extensive vasculitis. Most patients have slow onset, lack of appetite, general discomfort, fatigue, mild fever. Symptoms of the skin may have edema, which is non-depressed edema. Edema can occur on the back of the face and limbs, but edema around the eyelid is typical of it. The skin is often diffuse or spotted erythema, urticaria, pleomorphic or nodular erythema. In the later stage, skin atrophy may occur, and the joints of the fingers, elbows, and knees may be infringed, the activity is limited, muscle atrophy or contracture deformity. Laboratory tests for Glutamine aminotransferase (GOT), lactate dehydrogenase (LDH), creatine phosphokinase (CPK) and creatinine were significantly increased, EMG was significantly altered, and muscle biopsy was confirmed.

(7) allergic edema

This type of edema often has a history of allergies, and edema often occurs suddenly. Urine tests can have transient proteinuria and a few casts, but kidney function is normal. The edema usually subsides rapidly after symptomatic treatment.

(8) Endocrine edema

Endocrine edema refers to edema caused by too much or too little endocrine hormone to interfere with water salt metabolism or body fluid balance.

1, anti-diuretic hormone secretion syndrome: patients with excessive secretion of anti-profit, can lead to sodium, water retention and hyponatremia. This sign can be found in malignant tumors such as lung cancer and pancreatic cancer; central nervous system diseases such as brain abscess, brain tumor, cerebral thrombosis, skull fracture, subdural and subarachnoid hemorrhage, tuberculous meningitis and purulent meningitis. And pneumonia, tuberculosis, lung abscess and so on.

2, anterior pituitary dysfunction: this disease is caused by postpartum hemorrhage. Domestic reports of this disease 45% of patients with edema, and skin thickening, dry and scaly, hair loss.

3, the renal function of hyperthyroidism: glucocorticoids are represented by cortisol, and the syndrome of excessive secretion of cortisol is Cushing's syndrome. Cortisol can promote the reabsorption of sodium by the distal convoluted tubules and intestinal wall, and thus excessive secretion can cause edema. The aldosterone of mineralocorticoid is representative. Primary aldosterone increase (Conn syndrome) is mainly seen in adrenal cortical tumors, only a small number of patients with edema; and secondary aldosterone secretion is often many systemic edema (such as cardiogenic edema, renal edema, etc.) One of the important factors in the onset.

4, thyroid dysfunction: thyroid dysfunction and hyperthyroidism can both edema, and are mucinous edema. When the thyroid function is low, the complex of water, sodium and mucin accumulates in the interstitial space. The patient often shows facial and edema of the hands and feet, and the skin is thick and pale. Patients with hyperthyroidism may have swelling of the tissues around the eyelids and orbits, widened eyeballs, and prominent eyeballs. The combined membrane may have edema, and the local skin in the anterior temporal region is thickened, which is called liquid edema in the anterior temporal region.

5, premenstrual edema: women in the early menstrual period periodically appear edema, accompanied by mental symptoms (such as irritability, headache, insomnia) and breast pain, said premenstrual edema. Edema mostly begins 7-15 d before menstrual cramps, increases within one week, and can increase body weight by 2-3 kg. The edema subsides after menstruation. The duration of the duration varies, and the most common in 1-5 years.

(9) Egg self-losing gastrointestinal disease

This disease is a syndrome in which a large amount of plasma protein infiltrates the gastrointestinal tract, and causes hypoproteinemia and edema, which is common in gastrointestinal tumors, gastric mucosal hypertrophy, intestinal lymphangioma, chronic enteritis, malabsorption syndrome. and many more.

(10) Edema caused by drugs

Clinically, edema caused by the application of drugs is common, which is characterized by edema occurring after medication, and edema disappears after stopping the drug. Such as the application of adrenocortical hormone, testosterone, estrogen, insulin, thiophene, potassium perchlorate, licorice, Rauvolfia and so on.

(11) idiopathic edema

Idiopathic edema is a systemic edema of unknown cause. Idiopathic edema is almost exclusively seen in women, with a majority of middle-aged women. The influence of edema receptor position and periodic fluctuations in day and night. The patient showed only slight eyelids, facial and edema in the morning. With the rise and daytime, the edema will migrate to the lower part of the body, and the foot and ankle have obvious edema, usually edema in the evening. Most obvious. The weight gain and loss of a day and night can exceed 1.4 kg, so weighing the body multiple times a day is one of the important criteria for diagnosis. The mechanism of idiopathic edema has not yet been elucidated, but it has been found that patients have microvascular changes, and electron microscopic observations have shown that the microvascular basement membrane of the skin and muscle is thickened. This change leads to increased permeability of the blood vessel wall; some scholars have found that many humoral factors play a role in the occurrence of this disease, and more studies include catecholamine, renin-angiotensin-aldosterone system, vasopressin and slow Kinin and the like. The diagnosis of idiopathic edema must exclude diseases such as heart, kidney, liver and nutrient deficiencies. The vertical position water test is helpful for the diagnosis of this disease. The urine volume at the standing position is lower than 50% of the urine volume in the lying position, which can be considered abnormal and has diagnostic significance.

(12) Systemic edema caused by other causes

It is also seen in daily life that some edema does not fall into the above categories. For example, if there is mild edema in a high temperature environment, obese people are prone to edema, and there is a so-called "traveler edema". The latter suffers from edema in the lower limbs after long-distance trekking, but the phenomenon of edema after exercise can be Disappeared, in addition to senile edema.

Second, localized edema

(a) inflammatory edema

Inflammatory edema is the most common localized edema in the clinic. In particular, acute inflammation usually has edema in the area of inflammation. Red, heat and pain are the four characteristics of acute inflammatory foci, so they are easily differentiated from other localized edema. The edema fluid in the inflammatory zone does not only increase the body fluid, but also contains a large amount of protein and inflammatory cells, so the edema fluid of inflammatory edema is exudate, not leakage.

(two) venous obstructive edema

This type of edema often occurs in tumor compression or tumor metastasis. Venous thrombosis, thrombophlebitis, etc. The extent of edema and its consequences vary depending on where it occurs and how long it lasts. The more common venous obstructive edema in bed is:

1. Superior vena cava obstruction syndrome

The early symptoms of superior vena cava obstruction are headache, dizziness and edema of the eyelids. Later, the distribution of the superior vena cava in the facial hair group such as the head, neck, upper limbs and upper part of the chest wall is dilated, and edema is the main sign of the superior vena cava obstruction syndrome. This syndrome is mostly caused by malignant tumors. According to statistics, lung cancer is the most common cause, accounting for 50%-80%, followed by lymphoma, aortic aneurysm, chronic fibrular mediastinum, benign or malignant tumor in the chest, and thrombosis. Venous phlebitis.

2. Inferior vena cava obstruction

It is characterized by edema of the lower extremities, and its symptoms and signs are related to the location or level of obstruction of the inferior vena cava. If the obstruction occurs in the upper segment of the inferior vena cava, above the hepatic vein population, there is obvious ascites, while the lower extremity edema is relatively insignificant; if the obstruction occurs in the middle of the inferior vena cava, above the renal vein population, the lower extremity edema with low back pain Obstruction, as in the lower segment of the inferior vena cava, is limited to the lower extremities. Causes of inferior vena cava obstruction are tumor or abdominal mass compression, pelvic inflammatory or traumatic waves and thrombosis of the inferior vena cava.

3, limb venous thrombosis and blood stasis phlebitis in the body surface, that is, the difference between superficial tissue venous thrombosis and thrombophlebitis is the latter in addition to edema and local inflammation. Deep tissue phlebitis and venous thrombosis are difficult to identify, because both have edema and pain and tenderness, but the former often have fever, while the latter rarely have fever.

4, chronic venous insufficiency Chronic venous insufficiency generally refers to chronic inflammation of the vein, varicose veins, venous insufficiency of the valve and arteriovenous fistula caused by venous return or obstruction. Edema is one of the important clinical manifestations of chronic venous insufficiency. Edema often appears in the early afternoon, and can resolve after bed rest at night. After long-term development, it can also cause subcutaneous tissue fibrosis. Some patients have pigskin-like sclerosis in the skin of the ankle and lower leg. Due to venous congestion, the area may be bluish, pigmented, and may be combined with eczema or ulcers.

(c) lymphedema

Lymphedema is an edema caused by obstruction of lymphatic drainage. According to different causes, it can be divided into two major categories: primary and secondary. The cause of primary lymphedema is unknown, so it is also called idiopathic lymphedema, which can occur in one side of the lower limbs, but also in other parts. The skin and subcutaneous tissue in which this edema occurs are thickened, the surface of the skin is rough, and there is significant pigmentation. There are dilated and variegated lymphatic vessels in the subcutaneous tissue. Secondary lymphedema is caused by lymphatic compression or obstruction caused by tumors, surgery, infection, etc. The cause of the infection can be either bacteria or parasites. The most common in bacteria is recurrent lymphangitis and cellulitis caused by hemolytic streptococcus. Most of the parasites are found to be parasitic in the lymphatic system causing lymphangitis and lymphadenitis, called filariasis. Filariasis is most common in the lower extremities, and eventually evolves into elephantiasis. The skin of the skin is thickened and the skin is rough like leather and wrinkled. According to the patient's clinical manifestations, microfilaria and blood lesions were detected in the blood for a tissue examination. The general diagnosis is not difficult.

(D) allergic edema

Allergic edema is caused by allergic localized edema, and urticaria is more common in clinic. Allergic edema is actually an allergic reaction and is a form of immediate reaction to antigen-antibody reactions. It mainly releases histamine through mast cells, activates the kinin-producing system to release kinins and promotes the combination, release and release of prostaglandins, causing arterial congestion and increased permeability of microvascular walls, leading to the formation of edema. Allergic edema can occur quickly and can be accompanied by abnormal sensations such as itching and pain.

(5) Angioedema

It is currently believed that there are two types. One is a loose hair style. The patient often has a history of allergies. It can be induced by emotional impulses or mental stimulation. It occurs in the face and has a round or oval bulge. If the position is deeper, the red or swollen skin surface may not be obvious. The rapid development and the elimination of the knife is faster. The other type is a family type, which is autosomal dominant, and the pathological changes and manifestations of local tissue edema are similar to those of sporadic, but not related to allergy, mainly due to defects in complement CI esterase. Serum CI esterase inhibitors in the serum of such patients were significantly lower than normal. The CI esterase inhibitor is also an inhibitor of plasma kallikrein, which will increase plasma kallikrein activity, causing an increase in the concentration of a bradykinin in the plasma, resulting in increased permeability of the microvascular wall and edema. This type of patient may have a wheal-like rash, and may also have acute abdominal symptoms such as abdominal pain and vomiting. The consequences of angioedema depend mainly on where it occurs. If the lesion occurs in the larynx, the rapid edema of the throat can cause death due to asphyxia.

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