TEACHING ON

OBSTETRICAL
SHOCK

Guided by: Presented

by:
Mam Mrs. Nidhi Sagar Neha Singla
Associate Professor, M.Sc. 1st
year
DMC&H, Ldh. Roll no. 5
 Definition of Shock
 Shock is a life-threatening condition
that is characterized by failure of the
circulatory system to maintain
adequate perfusion of the vital
organs, resulting in cellular hypoxia
and organ damage.
 Contd…
 Shock during pregnancy is one of the most
difficult problems faced by the obstetrician.
Ninety percent of hemorrhage in obstetrics is due
to placental abnormalities or alteration in the
uterine tonus.
 the remaining 10% are associated with tears and
laceration of the birth canal.
 It requires immediate and intensive
treatment to prevent morbidity and
mortality of both the mother and the
foetus during pregnancy.
Classification of OB shock
Obstetrical shock
Hypovolemic shock

Hemorrhagic shock

Fluid loss shock

Shock associated with DIC

Septic shock

Neurogenic shock

Cardiogenic shock
 Hemorrhagic Shock
 the normal pregnant woman can withstand blood
loss of 500ml and even up to 1000ml during
delivery without obvious danger due to
physiological, cardiovascular, and hematological
adaptations during pregnancy.
 But an excessive blood loss can results in
Hemorrhagic shock.
 Common causes of OB
hemorrhage
ANTEPARTUM POSTPARTUM
 Abruptio Placenta  Retained Placenta
 Trauma  Uterine Atony
 Placenta Previa  Uterine Rupture
 Lacerations
 Coagulopathy
 Clinical Features
Patients usually present with
• Low blood pressure
• A rapid and thready pulse

• Pallor, cold, clammy extremities

• Air hunger
• Oliguria
• Anuria
Phases of hemorrhagic
shock

Phases of hemorrhagic shock

Phase of
Phase of decompensatio
Phase of
compensation cellular damage
n
 Phase of compensation
 Mild- blood loss is <15 percent. No change in vital
signs is there. Postural hypotension is noted.
 Sympathetic stimulation- it is the initial response
to blood loss leading to peripheral vasoconstriction
to maintain blood supply to vital organs.
 S/S: tachycardia, tachypnoea, sweating and
normal blood pressure.
 Phase of Decompensation
 Moderate: blood loss is 20-25%. It is associated with cold
and clammy skin, tachycardia, tachypnoea, pulse
pressure <30mm Hg, low systolic pressure and delayed
capillary filling.
 Due to diversion of blood to vital organs, the patient
remains conscious and the urine output is within normal
limits.
 Adequate treatment at this phase improves the condition
rapidly without residual adverse effects.
 Phase of Cellular Damage and
Danger of Death
 Severe- blood loss is more than 40 percent. It is
associated with profound hypotension with only the
carotid pulse being palpable. Oliguria and anuria is
noted.
 Inadequately treated hemorrhagic shock results in
prolonged tissue hypoxia and damage with the following
effects:
 Metabolic acidosis
 Arteriolar dilatation
 Disseminated intravascular coagulation
 Cardiac failure
 Contd..
 Multisystem failure and cell destruction are
irreparable. Treatment of any kind is practically
useless in this phase. Mortality varies between
3%-100%.
 Categorization of Acute
Hemorrhage
Class 1 Class 2 Class 3
Blood loss
(% blood volume) 15% 15-30% 30-40%
Pulse rate <100 >100 >200
Pulse pressure Normal Decreased Decreased
Blood Pressure Normal Decreased Decreased
OB HEMORRHAGE - TREATMENT

First step in treatment is recognition

• Pregnant patients may have modified
or
attenuated response to moderate
blood loss.
• Blood loss may not be noted at
vaginal
delivery due to distraction.
Treatment - Hemorrhagic Shock

• Recognize and treat underlying condition!

• Restore intravascular volume
– Blood
– Volume
– Access
• Establishment of an airway and oxygen therapy
• Elevation of the legs to encourage return of blood
from the limbs to the central circulation.
• Prevent/manage hypothermia
 Blood Component Therapy –
Hemorrhagic Shock
 Packed RBC generally more available
than whole blood.
 Fresh frozen plasma (FFP) not indicated
for volume replacement.
 FFP not indicated for “prophylactic
transfusion after arbitrary number of
packed RBC units.
Volume Therapy – Hemorrhagic
Shock
 In addition to volume loss from
hemorrhage
itself, vascular damage produces
pronounced
intravascular volume depletion.
 First choice in treatment is
crystalloid like ringer lactate.
 Colloid solutions like dextran 40 or
70 may be administered.
 Component Therapy –
Hemorrhagic Shock
 Fresh Frozen Plasma (Easy Way)
– replaces all clotting factors to degree found
in normal unit volume of blood
 Cryoprecipitate (Easy Way)
– “best” choice for hypofibrinogenemia (easy=
each unit raises fibrinogen 10 mg% - “target”
level often > 100mg%)
– used for Factor VIII, XIII, fibrinectin
 Drug Therapies-
Hemorrhagic Shock
 Analgesics: 10-15mg morphine IV if
there is pain, irritability.
 Corticosteroids: Hydrocortisone 1gm
or dexamethasone 20mg slowly(IV). It
may be decrease peripheral resistant
and improves tissue perfusion.
 Vasopressors : to increase the blood
pressure so as to maintain renal
perfusion.
 Dopamine: 2.5mg/kg/min. IV is the
drug of choice.
Complications of Haemorrhagic
failure
These are:
 Acute Renal Failure
 Pituitary Necrosis
 Disseminated intravascular coagulation
 Septic Shock
Inroduction:
 There is an over-whelming infection,
commonly from gram negative organisms
such as E. coli , Proteus or Pseudomonas
Pyocyaneus.
 These organisms are common pathogens in
the female genital tract and have
endotoxins present in their cells.
 Endotoxins release components that
trigger body’s immune response.
 Contd…
 The placental site is the main point of
entry for an infection associated with
pregnancy and childbirth.
Causes:
 Septic abortion.
 Prolonged rupture of membranes.
 Obstetric trauma.
 Presence of retained placental tissue.
 Puerperal sepsis.
 Respiratory tract infections.
 Clinical Signs
 Early Phase Late Phase
Irreversible Phase
 Hypotension -Hypotension -
adrenal failure
 Tachycardia -Cyanosis -
Pulmonary
 Tachypnoea -Oliguria
edema
 Flushed skin -Jaundice -
CVS failure
 Patient is alert -Acidemia -
 Management of Septic
Shock
 Management is based on preventing further
deterioration by restoring circulatory volume
and eradication of the infection.
 A full infection screening should be carried
out including a high vaginal swab, midstream
urine and blood cultures.
 Retained products of conception if detected
on ultrasound should be removed.
 Measures of management include IV
administration of antibiotics, IV fluids,
adjustment of acid-based balance, steroids,
administration of oxygen and elimination of
source of infection.
 ANTIBIOTICS
 Broad-spectrum
antibiotics are given
to start with and
after confirming the
sensitivity, Specific
antibiotics are given
intravenously.
INTRAVENOUS FLUIDS &
ELECTROLYTES
 Septic shock
associated
hemorrhagic
hypotension is treated
with liberal infusion
and blood transfusion.
 Impairment of renal
function
contraindicates
administration of
electrolytes.
CORRECTION OF
ACIDOSIS
 Bicarbonate is
administered to correct
metabolic acidosis.
 MAINTENANCE OF
BLOOD PRESSURE
 Agents such as adrenaline,
noradrenaline, dopamine,
and dobutamine are
administered to increase
cardiac contractility.
 Vasodilator drugs such as
sodium nitroprusside,
nitroglycerine and diuretics
are used to reduce the after
load and pulmonary edema.
CORTICOSTEROIDS
 These are given to
exert an anti-
endotoxic effect
and to counteract
anaerobic
oxidative
mechanism.
 HEPARIN

As a prophylactic
measure for DIC, heparin
may be given. Fresh
frozen plasma or whole
blood transfusion may be
used.
 Surgical Treatment:
It is indicated when there is retained infected
tissues as in septic abortion. It can be done by:
 Suction Evacuation
 Digital Evacuation
 Hysterectomy
 Cardiogenic Shock
 It is defined as circulatory collapse caused by sudden
failure of the heart to pump the blood adequately.
Causes:
 Failure of left ventricular ejection due to
 Cardiac Arrest
 Myocardial infarction
 Failure of ventricular filling
 Pulmonary embolism

 The major cause of cardiogenic shock during pregnancy is

severe valvular disease.
 Clinical Features
Patient presents with:
 Distended neck veins

 Dysnpoea

 Tachypnoea

 Systolic or diastolic murmurs

 If severe, Generalized edema

 Loss of consciousness
 Absence of pulse

 Cyanosis
 MANAGEMENT
 Airway: Clear the airway of vomitus, blood,
teeth and foreign body. Endotracheal
intubation should be done.
 Breathing: Mouth to mouth artificial
respiration should be given or after
inserting a cuffed endotracheal tube
intermittent positive pressure using 100
percent oxygen should be given.
 Cardiac massage: Put the patient on a firm
surface and using heel of one hand, with
the other on top, and with arms extended
apply pressure to lower sternum using full
body weight.
 Contd..
 Drugs:
 Sodium bicarbonate: 8.4% solution
to counteract metabolic acidosis.
Give 100ml initially and further 10ml
for each subsequent minute of
inadequate circulation.
 Cardiac Stimulants can be given IV
or intracardiac e.g. Adrenaline 0.5-
1.0mg, Atropine 0.6mg.
 Direct current defibrillator is used if
required.
NEUROGENIC SHOCK
 Causes
 Disturbed Ectopic pregnancy. Concealed accidental
hemorrhage
 Difficult forceps delivery
 Acute inversion of uterus
 Retained placenta escp. for more than 2 hrs
 Rupture of the uterus or cervical tears extending into the
lower uterine segment
 Management
 Management includes
 Fluid replacement
 Correction of acidosis
 Vasoactive drugs
 Corticosteroids
 Ventilation
 Elimination of the source of neurogenic
stimulus.
 AMNIOTIC FLUID
EMBOLISM
 Passage of amniotic fluid into the maternal circulation
 onset acute sudden collapse, cyanosis, dyspnea,
convulsions, right heart failure, pulmonary edema
 Two phases
 Shortness of breath + hypotension-cardiac arrest-coma
 Rarely progress to this stage- hemorrhagic phase-
shivering, coughing, vomiting.
 AFE Investigations/
treatment
 ECG- right heart failure
 X ray- mottled chest
 Coagulation profile(for DIC)
 Treatment is similar to Hypovolemic
shock + Aminophylline 0.5mg
 Red cell substitutes


THANKyou!
 References
 D.C. Dutta’s “Textbook of Obstetrics”
published by “New Central Book of
Agency” sixth edition Page no. 614-618.
 Annamma Jacob’s “A comprehensive
Textbook of Midwifery” Jaypee
Publications 2nd Edition Page no. 446-448.
 Sudha Salhan “ Textbook of Obstetrics”
Jaypee publications First edition Page no.
715-719.
 Contd…
 Kamini Rao’s “Midwifery Obstetrics For
Nurses” Elsevier Publications First Edition Page
no.475-478.
 Journal on “Obstetrical shock” by James W.
Van Hook, M.D. of University of Texas Medical
Branch, Galveston, Texas
 Topic on “obstetrical shock” from wikipedia.com
 www.google.com