Shock in obstetrics for undergraduate

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Shock in Obstetrics

• Dr Manal Behery
• Assistant professor,Zagazig University
• 2013

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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 Vessels
Blood
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Types of Shock
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• 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
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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

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Categorization of Acute Hemorrhage
Class 1 Class 2 Class 3 Class 4
Blood loss ( blood volume) 15 15-30 30-40 gt40
Pulse rate lt100 gt100 gt120 gt140
Pulse pressure Normal Decreased Decreased Decreased
Blood pressure Normal or increased Decreased Decreased Decreased
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Stages of Shock

• Compensated
• Uncompensated
• Irreversible

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Compensated Shock

• Defense mechanisms are successful in maintaining
  perfusion
• Presentation
• Tachycardia
• Decreased skin perfusion
• Altered mental status

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Uncompenstated Shock

• Defense mechanisms begin to fail
• Presentation
• Hypotension
• Marked increase in heart rate
• Rapid, thready pulse
• Agitation, restlessness, confusion

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Irreversible Shock

• Complete failure of compensatory mechanisms
• Marked loss of tissue perfusion cause cell
  damage and death even in presence of
  resuscitation

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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

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Restoration of CirculationVolume Fluid Choices

• Insert at least two large pore IV catheters
• Crystalloids for initial resuscitation
• Rapidly infuse 5 dextrose in lactated Ringers
  solution while blood products are obtained
• Colloids/PRBCs to replace blood loss

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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

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Neurogenic Shock

• Abnormal vessel tone
• Due to truma and tissue damage as in painful
  conditions

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Causes of hypovolemic shock

• Obstetric Causes of neurogenic shock

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• Disturbed ectopic pregnancy
• Concealed accidental hemorrhage
• Manual removal of placenta without anathesia
• Difficult forceps or breech extraction
• Rapid evacuation of uterus poly hydramninous

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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 bodys response to bacteria in
  bloodstream
• Vessels dilate, become leaky

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Causes of hypovolemic shock

• Obstetric Causes of Septic shock

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• ? Septic abortion (usually illegal)
• .
• ? Acute pyelonephritis.
• ? Chorioamnionitis .
• ? Retained placental tissue.
• ? Puerperal sepsis.
• ? Postoperative infections.

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Recognition of Septic Shock

• Early warm shock similar to neurogenic shock
• Late Cold shock similar to cardiogenic shock

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Cardiogenic Shock

• Pump failure/malfunction
• (decreased contractility)

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Causes of hypovolemic shock

• Obstetric Causes of Cardiogenic shock

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• Coronary spasm
• Cardiomyopathy
• Pulmonary embolisn
• Amniotic fluid embolism
• Mendelsons 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