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Shock in Obstetrics

Objectives

Define shock and its different categories

Describe management of shock

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Definition of Shock

Inadequate perfusion (blood flow) leading to inadequate oxygen delivery to tissues

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What is needed to maintain perfusion?

Pump Pipes Fluid

Heart

Blood VesselsBlood

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Types of Shock

Hypovolemic Shock

Cardiogenic Shock

Neurogenic and Anaphylactic Shock Septic Shock

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In Obstetric cases shock is most commonly due to either hemorrhage or sepsis

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Hypovolemic Shock

Causes of hypovolemic shock

Obstetric Causes of hpovolemic shock

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Blood loss (obstetric haemorrhage) Bleeing in early pregnancy Antepartum hemorrhage Post partum hemorrhage Fluid loss e.g Hyperemesis

gravidarum,Diarrhea, keto-acidosis. Plasma loss e.g Severe burns Supine hypotension syndrome. Splanchnic shock: sudden drop in intrauterine

pressure eg Hydramnios

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The most common form of hypovolemic shock in obstetrics is hemorrhagic shock due to massive obstetric hemorrhag

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Obstetrical Hemorrhage

Blood loss associated with pregnancy or parturition that

- causes maternal or perinatal death - requires blood transfusion

- decreases Hct by 10 points - triggers emergency therapeutic

response

Categorization of Acute Hemorrhage

Class 1Class 1 Class 2Class 2 Class 3Class 3 Class 4Class 4

Blood loss Blood loss

(% blood volume)(% blood volume)15%15% 15%-30%15%-30% 30%-40%30%-40% >40%>40%

Pulse ratePulse rate <100<100 >100>100 >120>120 >140>140

Pulse pressurePulse pressure NormalNormal DecreasedDecreased DecreasedDecreased DecreasedDecreased

Blood pressureBlood pressure Normal or Normal or increasedincreased

DecreasedDecreased DecreasedDecreased DecreasedDecreased

Stages of Shock

*Compensated*Uncompensated*Irreversible

Compensated Shock

#Defense mechanisms are successful in maintaining perfusion

#Presentation Tachycardia Decreased skin perfusion Altered mental status

Uncompenstated Shock

#Defense mechanisms begin to fail#Presentation

Hypotension Marked increase in heart rate Rapid, thready pulse Agitation, restlessness, confusion

Irreversible Shock

#Complete failure of compensatory mechanisms

#Marked loss of tissue perfusion cause cell damage and death even in presence of resuscitation

Shock: Signs and Symptoms

Hypotension Rapid weak pulse Pallor Sweating Cold clamy extremities Oliguria or anurea confusion

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Initial Treatment in Shock

Secure, maintain airway Apply high concentration oxygen Assist ventilations as needed Place patient in the Trendelenburg position Control obvious bleeding Prevent loss of body heat

Restoration of CirculationVolume – Fluid Choices

Insert at least two large pore IV catheters

Crystalloids for initial resuscitation

Rapidly infuse 5% dextrose in lactated Ringer’s solution while blood products are obtained

Colloids/PRBC’s to replace blood loss

Blood

• Order at least 6 units of red cells. Do not insist on cross matched blood if transfusion is urgently needed

• Apply compression cuff to infusion pack. Monitor central venous pressure (CVP) and arterial pressure.

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Complications of Hypovolemic shock

1) Acute renal failure.

2) Pituitary necrosis (Sheehan‟s syndrome).

3) Disseminated intravascular coagulation

Neurogenic Shock

Abnormal vessel toneDue to truma and tissue

damage as in painful conditions

Causes of hypovolemic shock

Obstetric Causes of neurogenic shock

Disturbed ectopic pregnancy

Concealed accidental hemorrhage

Manual removal of placenta without anathesia

Difficult forceps or breech extraction Rapid evacuation of uterus poly

hydramninous 25

Neurogenic shock Hemorrhagic shock

Pt is quiet &apatheic Irritable ,anxious,air hunger

No hemorrhage External or internal hemorrhage

Superficial veins are fill Periferal collapse

Hemoconcentration Hemodiluation

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Septic Shock

Results from body’s response to bacteria in bloodstream

Vessels dilate, become “leaky”

Causes of hypovolemic shock

Obstetric Causes of Septic shock

Septic abortion (usually illegal) . Acute pyelonephritis.

Chorioamnionitis . Retained placental tissue.

Puerperal sepsis. Postoperative infections.

Recognition of Septic Shock

Early – warm shock – similar to neurogenic shock

Late – Cold shock – similar to cardiogenic shock

Cardiogenic Shock

Pump failure/malfunction(decreased contractility)

Causes of hypovolemic shock

Obstetric Causes of Cardiogenic shock

Coronary spasm

Cardiomyopathy

Pulmonary embolisn

Amniotic fluid embolism

Mendelson’s syndrome

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Cardiogenic ShockSymptoms

Tachycardia Tachypnea Respiratory distress Mental status change Cool extremities Poor perfusion Signs of dehydration

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Thank you