Obstetrical shocks

Background
Shock is defined as a state f tissue under perfusion leading to tissue hypoxia, acidosis.
Should the condition left un treated ultimately will lead to permanent damage to the
kidney and heart leading to s state of irreversible shock with inevitable death.
Hemorrhagic shock
By far the most common type of shock seen in the field of obstetrics is hemorrhagic
shock. Primarily caused by severe bleeding leading to hypovolemia.
Etiology
In general there are 4 major causes for primary post partum hemorrhage which leads
to hemorrhagic shock
1- Uterine inertia; Uterine inertia is frequently abused terminology as there exist
inertia before labor and after labor. Before labor inertia is defined as the state
when uterine contractions are weak and infrequent which affects cervical
dilatation. Inertia after labor is defined as failure of the paturient uterus to
contracts strongly to apply shear force which occlude the spiral arterioles so
bleeding start to occur. On examination the uterus is larger than 20 week size
and soft difficult to palpate. Uterine inertia are caused mainly by prolonged
labor, Grand multi para, mal presentation of the fetus, forceps or ventuse
delivery and cesarean section.in addition all causes of overdistension of the
uterus like twin, polyhydramnios and uterus with fibroid are common causes.
2- Laceration of the genital tract; Laceration of the genital tract is usually
suspected when the uterus is well contracted despite the occurrence of vaginal
bleeding. They include vaginal tears, cervical tears as well as laceration of the
uterine wall from obstructed labor. Laceration of the genital tract ias usually
managed by examination in the operating theater with possible spinal or
general anasthesia. Vaginal wall should be examined with Sim’s speculum for
any tears. While stile Sim’s speculum is inserted cervical tears are usually
examined. Vaginal tears are usually treated by meticulous suture while
cervical angle tears are sutured from angle towards the external os.
3- Retained product of gestation; In pregnancy one of the placental abnormalities
is placenta succenturia or accessory lobe of the placenta. Frequently this small
lobe is retained after delivery of the olacenta. In such cases the uterus is felt
 soft and larger than 20 weeks in size on abdominal examination. Frquently the
condition is discovered at time of exploration of the uterus under general
anesthesia. That is when vaginal bleeding persist despite administration of
oxytocin drip. After exploration of laceration of the uterus the uterine cavity
may be exlored with insertion of whole hand if the cervix remains open or
with sponge forceps after extremely careful introduction of it into the uterine
cavity. Blunt currettage is mandatory after sponging to avoid Asherman’s
syndrom.
4- Disseminated intravascular coagulation syndrome; DIC as a cause of primary
post partum hemorrhage is usually rare and difficult to treat. They commonly
follow severe preeclampsia or advanced concelled placental abruption.
Screening is done by platelet count and serum fibrinogen. Treatment is usually
by fresh frozen plasma and cryoprecipitate in addition to fresh blood.

Presentation

Signs of hypovolaemic shock include:

 Altered mental status

 Dizziness
 Sweating, with cold clammy extremities
 Fast, thready pulse
 Oliguria

Treatment of Hemorrhagic shock

1- immediate insertion of 2 wide bore cannula

2- insertion of foley's catherter
3- insertion of central venous pressure line
4- immediate replacement with crystalloids solution initially and with blood. In
severe cases non cross matched O –ve blood may be given
5- The development of disseminated intravascular coagulation (DIC) is a risk and
may require corrective fresh frozen plasma (FFP), platelets and clotting
factors, as indicated by haematocrit, coagulation tests, platelet count and
clinical features. Seek haematological advice. Serial monitoring is essential.

For uterine atony:

 Syntocinon and ergometrine are the first-line agents for the treatment of
uterine atony in the UK. IM Syntometrine® should be given immediately after
delivery where there is a high risk of postpartum haemorrhage (PPH), e.g.
prolonged labour, 2nd stage hysterectomy.
 Syntocinon infusion and prostaglandin (carboprost 250 micrograms, given by
deep IM injection and repeated as necessary) may also be required.
 Rubbing up contractions and bimanual compression are widely used.
 The use of sublingual misoprostol may be as effective as the use of IV
oxytocin and easier to use, particularly in resource-poor countries, but this
remains controversial.
Surgical intervention is required for traumatic bleeding:

 Ligation of the uterine, ovarian and internal iliac arteries will usually control
uterine bleeding.
 Arterial embolisation is another option where interventional radiology
expertise is available.Uterine packing is a conservative option that can be
applied.
 Where bleeding is not controlled, hysterectomy can be life-saving and should
not be delayed.

Septic shock
Unlike hemorrhagic shock, septic shock is primarily mediated by extreme vaso
dilatation to the extent that whole body blood can not fill. The primary cause is
gram negative septicemia. All gram negative bacterial contain complex lipo poly
sacharides in their wall. Should the bacteria die during the phase of septicemia,
this complex is released freely into the blood stream. It acts as a strong vaso
dilator as well as strong activator of blood coagulation cascade, leading to
disseminated intra vascular coagulation syndrome.

Etiology
In the field of obstetrical practice septic shock is primarily seen following septic
abortion mediated by midwife termination of pregnancy. The retained product of
gestation forms a nidus for gram negative bacteria. Later on they will shed into the
blood stream. Rarely septic abortion follows acute pyelonephritis.

Treatment
The treatment of septic abortion is more complicated than hemorrhagic shock. The
followings are the main points

1- Admission to intensive care unit with full monitoring of vital signs,

urine output and electrolyte assessment.
2- Antibiotic are usually given initially which should cover a broad
spectrum of bacteria. However in cases of low urine output the dose
should be modulated accordingly. Third generation cephalosporins are
usually chosen.
3- Crystalloids are usually given in large amount to fill the circulation.
4- Blood transfusion is sometimes required.
5- Hydrocorisone in high dose should be given, 1 gm/ 6 hours to restore
blood vessels dilatation.
6- Sodium bicarbonate infusion may be indicated to combat metabolic
acidosis. The amount given is calculated a cording to a formula
depending on the blood pH and bicarbonate serum levels.
7- Dopamin is usually given in slow IV infusion in 5- 8 ug/ min/ kg to
dilate the renal blood vessels and improve urinary output.
 8- In cases of DIC platelets, fresh frozen plasma and cryoprecipitate may
be given to combat and reverse the hematological abnrmalities.
Heparin in low dose may be given also.
9- Furesemide (Lasix), may be given to prompt urinary output.
10- Finally septic nidus in the uterus should ve evacuated by dilatation and
curettage after correction of shock.

Vasovagal shocke
Vasovagal shock is mediated primarily by over stimulation to the vagus nerve.
Over stimulation to the vagus nerve lead to extreme vaso dilatation mediated by
para sympathetic discharge. The only condition in obstetrics which may cause it is
uterine inversion. The treatment of this condition is by reversion of the uterus.

Cardiogenic shock
Cardio myo pathy of pregnancy is a disease of unknown etiology in which rapidly
developing heart failure arises shortly after birth. There exist two types of this
disorder the dilating type and the hypertrophic type. The condition arise shortly
after birth as rapidly developing heart failure in the form of dyspnea, ascites and
leg edema. Digoxin is the main treatment with careful correction of the blood
volume. Vitamin B6 is sometimes helpful.