Management of Obstetric Shock

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1 : Shock in Obstetrics Moderator : Prof. Dr. Biswajith Chakarawarthy Dr. Surakshith
2 : Classification of Shock1
3 : Hemorrhagic Shock (Etiology) Antepartum Abruptio placenta(.5-1.2%8) Placenta previa(37%-54%8) Postpartum Ruptured uterus(.2- 1%8) Postparetem hemorrhage (3-6%8) Atonic uterus(2-3%8) Traumatic(6-15% of PPH8) Retained placenta
4 : Hemorrhage(considerations) Pregnant woman/Predisposing factors Classification of Hemorrhage 2
5 : Classical Signs/Sym. of Shock Altered mental state Breathlessness / Hyperventilation Oliguria <60ml/hr 3 Sweating Pulse rate >100 beats/min Systolic BP <60 mmHg Pyrexia Pallor
6 : Hemorrhagic Shock(Phases1) Phase of Compensation <25% – pallor/tachycardia/tachypnea Arterioles – vasoconstriction Venules – increased tone/autotransfusion (Catecholamines) Redistribution of blood Cushing reflex Phase of Decompensation 25% – classical shock signs/treatment + Tissue hypoxia/Metabolic acidosis Loss of capillary memb. integrity(leak) and platelet aggregation NA+ H2o / K+ shifts Phase of Cellular damage >25% – death imminent Arteriolar dilation/damage(thromboplastin) DIC/CF
7 : Treatment Goals Treat hypovolumic state Find the cause and arrest bleeding. Achieve urine output of greater than 60ml/hr 2 CVP to be maintained at 7-12 mmHg 3 MAP at 65-95 mmHg 3
8 : Monitoring CVP/BP/PR/Tilt test +(>30% blood loss) Urine Output (60ml/hr) PCWP (6-18 Torr.) 4 Continuous AbG Signs of clinical response Investigations – CBC(platelets 12k-1l)/ PT(11-16 sec)/PTT(22-37 sec) /RFT/LFT 4 B/L compression duplex USG 4
9 : Hemorrhagic Shock treatment Life Line- 2 or more large bore iv lines Establish airway for O2 delivery Elevate legs Maintain CVP -Crystalloids(rl/ns/5%d) /colloids(dextran 40) /WB Detect cause , arrest hemorrhage- (Clinical ex/Investigations CBC/Thyroid/GCT/USG/sr. Progesterone/P. Smear) Drug Therapy (analgesics/Sodium bicarb 100mEq/ isoprenaline 1mg slow IV/CS?/Dopamine 2.5mg/kg/min /Digoxin) DIC treatment (heparin/FFP/platelets/clotting factors) Delivery of foetus
10 : Delivery(APH)
11 : Delivery (PP)
12 : Uterine atony Inability of myometrium to adequately contract after delivery 1 Oxytocin (upto 100U in 1L NS) /IM methergine (0.2mg every 2hrs) Prostaglandin F2a250?g IV upto 8 doses Mesoprostol ( upto 1 mg pr) Gauze packing/Baloon tamponade( 30cc baloon foleys/S-B tubular b) Surgical Arterial embolisation with gelfoam Compresion sutures( B-lynch stich/Perira) Ligation uterine /ovarian /internal illiac arteries Hysterectomy
13 : B-Lynch5
14 : Complications Foetus -Hypoxia/acidosis/abruption/death Maternal – ARF/Sheehan’s syndrome/DIC/CF
15 : Septic Shock(Causes) Septic Abortion PROM Trauma Post operative endomyometritis Retained placenta Puerperal sepsis Pyelonephritis Ogranisms E.Coli 0157/proteus/pseudomonas/bacteroids
16 : Septic Shock(Phases2) Endotoxin – activates kinin/coagualation system-fibrinolytic state- selective vasodialation/leucocyte,plt aggregation-VEI (c.leak)- SSS Early(warm) Hypotension/tachycardia/pyrexia/rigors/elevated CO Late(cold) Cold skin/cyanosis/purpura/jaundice/decreased CO Irreversible Coma/Metab. Acidosis/ARF/CF/Adrenal failure/DIC/minimal CO
17 : Septic Shock treatment Restoration of circulatory functions/oxygenation Eradication of infection Investigations (mentioned earlier + Culture swab/Urine cs/Blood cs) Broad spectrum AB until C/S reports (table 7)/ Role of CS Removal of infected tissue
18 : Neurogenic shock(Causes) Disturbed ectopic pregnancy. Concealed accidental hemorrhage. Difficult forceps delivery or breech extraction Difficult internal version Rupture of the uterus or cervical tears extending into the lower uterine segment. Acute inversion of the uterus. Rapid evacuation of the uterus as in precipitate labor and polyhydramnios Retained placenta especially for more than 2 hours. Differences- apathetic pt./hemoconcentration/slow pulse/shallow resp.
19 : Anaphylactic Shock IgE- mediated type 1 hypersensitivity rx to proteins 6 Parenteral exposure to antigen cause immediate rx. Some of agents Antibiotics/NSAIDS/Insulin/ACE Inhibitors Insect bites/seafoods/peanuts Sulfiting agents/Immunotherapy injections Blood products/Latex
20 : Anaphylactic Shock Symptoms/Signs6 Skin – itching / flushing/urticaria Psychologic – sense of impending doom Respiratory – shortness of breath,hoarseness,wheezing,stridor CVS – faintness,palpitations, discomfort,bradycardia GIT – metallic taste mouth, vomiting,diarhoea ,abd. Bloating Fetal – decreased movements,decelerations,bradycardia
21 : Anaphylactic Shock Diagnosis6 Criteria 1 (any one) Mucosa or skin involvement Resp compromise or reduced BP Criteria 2 (any two) Mucosa or skin involvement Resp compromise GIT involvement Hemodynamic instability Criteria 3 Drop in BP <90mmHg or >30 mmHg drop from baseline after exposure of allergen
22 : Management serum levels of histamine and tryptase, both of which will be elevated in anaphylaxis + Monitoring vitals/FHS Provide O2/Intubation Aqueous epinephrine .5mg IM – hypotension/bronchospasm relief 2 large bore iv lines for colloids/crystalloids Remove the inciting agent/tourniquet- obstruct venous return Diphenhydramine 25mg IV+ Ranitidine 1mg/kg IV Role of CS – prevent biphasic anaphylaxis ? Albuterol 5mg for wheezing
23 : Amniotic Fluid Embolism Passage of amniotic fluid into the maternal circulation1(rare) Onset acute sudden collapse, cynosos ,dyspnea – Convusions ,Right heart failure ,pulmonary oedema , frothy sputum Two Phases1 Shortness of breath + hypotension – cardiac arrest – coma Rarely progress to this stage- haemorrhagic phase – shivering, coughing, vomiting
24 : AFE 1
25 : AFE investigations/ treatment ECG- Right heart failure X-ray - mottled chest Coagulation profile (for DIC) Treatment is similar to Hypovolemic shock+ Aminophilline .5g Role of CS – suggested because process may be immune med.
26 : Newer Modalities Anti-shock garments(NASG) Low tech first aid device Red cell substitutes
27 : References 1 2 Obstetric Shock – James W. Van Hook 3 William‘s Obstetrics 4 5 6 Critical Care Obstetrics – 5th ed 7 8 High-risk pregnancy - 3rd ed


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Management of Hemorrhagic , Septic , Anaphylactic Neurogenic shock
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