Shock in obstetric pdf - د. وسن

Dr.Wasan Shock in obstetric

24/3/2015

BY:TAHER ALI TAHER

OBSTETRICS

It is a critical condition & life threating medical emergency.

Results from acute, generalized, inadequate perfusion of tissue below
that needed to deliver oxygen & nutrients for normal cell function.

Etiology :

Hypovolemic shock (most common and important)

Septic shock (common and important)

Cardiogenic shock

Distributive shock

The first &second is the improtant in obstetric

Stages of shock:
Stage 1 (compensated) :

Changes in blood pressure & cardiac output compensated by adjustment
of hemostatic mechanism

Stage 2 (de compensated) :

Maximum compensatory mechanism is acting but tissue perfusion is
reduced.

Vital organ (cerebral, renal, myocardial) function becomes impaired.

Stage 3 irreversible :

Vital organ perfusion is impaired. Acute tubular necrosis , severe
acidosis, decreased myocardial perfusion & decreased myocardial
contractility occur.

Dr.Wasan Shock in obstetric

24/3/2015

BY:TAHER ALI TAHER

Initial management:

Resuscitation

Dealing with underlying cause

Resuscitation :

 Airways: a patent airway should be assured & high flow oxygen

(15 l/min)

 Breathing: ventilation should be checked

 Circulation: insert 2 wide bore peripheral i.v cannula, restore

circulating volume with crystalloid .

 Blood sample for Hb, FBC, coagulation screen,RFT, & prepare 6

pints of blood

 Vital sign monitoring

 Left lateral position to avoid aorta caval compression which lead

to hypotension

 Emergency O –ve blood may need in massive bleeding

Treatment underlying cause :

• Hemorrhage&hypovolemic shock:

• Is absolute reduction in intravascular volume. Cardiac output is

reduce producing a low perfusion state.

• Is the commonest cause in obst.

Dr.Wasan Shock in obstetric

24/3/2015

BY:TAHER ALI TAHER

Causes of hypovolumic shock :

Antenatal causes:

  Placenta previa
  Abruptio
  Rupture uterus
  Incomplete abortion
  Rupture ectopic pregnancy

Postnatal (postpartum):

  Uterine atony
  laceration of genital tract
  acute uterine inversion
  puerperal sepsis

Uterine rupture :

• Incidence 0.05% of all pregnancy

• Occur in association with previous scar on uterus ( C/S ,

Myomectomy)

• May occur in the absence of knowledge of previous scar (after un

recognized perforation of uterus)

• It occurs in early labor but can develop in late pregnancy.

Clinical feature :

  Continuous abdominal pain
  Vaginal bleeding (slight)
  Fetal distress
  Uterine scar tenderness
  Contraction cease

Dr.Wasan Shock in obstetric

24/3/2015

BY:TAHER ALI TAHER

Treatment :

1 - Resuscitation :

 Airways: a patent airway should be assured & high flow oxygen

(15 l/min)

 Breathing: ventilation should be checked

 Circulation: insert 2 wide bore peripheral i.v cannula, restore

circulating volume with crystalloid .

 Blood sample for Hb, FBC, coagulation screen,RFT, & prepare 6

pints of blood

 Vital sign monitoring

 Left lateral position to avoid aorta caval compression which lead

to hypotension

 Emergency O –ve blood may need in massive bleeding

2 – specific treatment :

 Stop oxytocin infusion &continuous fetal and maternal monitoring
 Emergency laparotomy with rapid operative delivery because

chance of death of baby with in 15minutes.

 Repair of uterus or Caesarean hysterectomy if bleeding is

uncontrollable (massive bleeding or if the uterus unrepaired the
scar opened and descend down ward to the broad ligament and
vagina)

 Repair of the uterus if the patient is young and the scar only

opened not extend we can repair with chance of recurrence of
rapture so to avoid recurrent rupture we should do tubal ligation.

Dr.Wasan Shock in obstetric

24/3/2015

BY:TAHER ALI TAHER

Uterine inversion :

o Part of uterus indents towards the dilated cervix & passing

through the vagina

o Rare complication of pregnancy that can be associated with

massive bleeding (patient shock hypovolemic shoch and the pain
is due to vasovagal pain)

o Nullipara being at higher risk

Predisposing factors :

Short umbilical cord

Excessive traction on umbilical cord

Fundal implantation of placenta

Excessive fundal pressure

Chronic endometritis

Previous uterine inversion

Retained placenta & abnormal adherence of placenta

Vaginal birth after previous C/S

Clinical feature :

 Vaginal mass

 ppH (slight vaginal bleeding)

 Pain (vasovagal pain)

 Cardiovascular collapse

 The diagnosis is confirmed by un felling the fundus of uterus

abdominally

Dr.Wasan Shock in obstetric

24/3/2015

BY:TAHER ALI TAHER

Treatment :

1 - Resuscitation :

 Airways: a patent airway should be assured & high flow oxygen

(15 l/min)

 Breathing: ventilation should be checked

 Circulation: insert 2 wide bore peripheral i.v cannula, restore

circulating volume with crystalloid .

 Blood sample for Hb, FBC, coagulation screen,RFT, & prepare 6

pints of blood

 Vital sign monitoring

 Left lateral position to avoid aorta caval compression which lead

to hypotension

 Emergency O –ve blood may need in massive bleeding

2 – specific treatment :

Replacement of uterus quickly (if we delayed the replacement the
dilated cervix may close on the inverted uterus)

Administer tocolytic as MgSo4, terbutline to relax the uterus

Replacement is under taken and we have three method :

1. If the placenta still attach not delivered and adherent to the

uterus we manually and slowly pushing upward the uterus by
boxing method(by the right hand push the uterus upword until
the fundus) without trying to tract the placenta .

2. If boxing method failed we use HYDROSTATIC REDUCTION

(O’SULLIVAN’S TECHNIQUE) :

Hydrostatic reduction is a method of reinverting the uterus by infusing
warm saline into the vagina.
Note: uterine rupture should be exclude prior to this performing
the procedure.

Dr.Wasan Shock in obstetric

24/3/2015

BY:TAHER ALI TAHER

The women may be placed in the reverse Tredelenburg position to assist
gravity and reduce traction on the infundibulo-pelvic ligaments, round
ligaments and the ovaries, in which 500 cc of normal saline with seal of
i.v fluid are needed (technique : Insert the left hand into the vagina
obtain a seal at the vaginal entrance by enclosing the labia around the
wrist/hand to prevent fluid leakage Infuse warmed fluid under gravity to
push the uterus to its normal position, Several litres of fluid may be
required )

 If these two method fail that mean there is contracted cervix on

the inverted uterus so we go to third method

SURGICAL MANAGEMENT :

Laparotomy with open on the cervix 2cm not transverse then by
fingers we try to push the uterus up words by the fingers through the
surgical opening .

Epidural or spinal anesthesia can used in acute state when the
patient condition is cardio vascular stable

Amniotic fluid embolus :

 Is sudden cardio vascular collapse & coagulopathy during labor or

immediately postpartum period after delivery of the baby

 Is rare condition

 Amniotic fluid enter pulmonary circulation produce severe

pulmonary vasospasm & hypertension when ventilation perfusion
mismatch occur lead to hypoxia ( 50% maternal death within first
hour following onset of the symptoms

Dr.Wasan Shock in obstetric

24/3/2015

BY:TAHER ALI TAHER

Clinical feature :

 Dyspnea

 Hypotension

 Seizure ( tonic – clonic)

 Cyanosis as hypoxia/ hypoxemia progress cause peripheral &

central cyanosis

 Fetal bradycardia

 Uterine atony after delivery

 Cardiac arrest

Treatment :

1 - Resuscitation :

 Airways: a patent airway should be assured & high flow oxygen

(15 l/min)

 Breathing: ventilation should be checked

 Circulation: insert 2 wide bore peripheral i.v cannula, restore

circulating volume with crystalloid .

 Blood sample for Hb, FBC, coagulation screen,RFT, & prepare 6

pints of blood

 Vital sign monitoring

 Left lateral position to avoid aorta caval compression which lead

to hypotension

 Emergency O –ve blood may need in massive bleeding

Dr.Wasan Shock in obstetric

24/3/2015

BY:TAHER ALI TAHER

2 – specific treatment :

o Urgent resuscitation & circulation support , intubation with 100%

oxygen

o Treated the coagulopathy

o Delivered by C/S if no response to the treatment even if the

patient in cardic arrest because it will die in ten to fifteen minutes

Septic shock :

It is a significant cause of direct death in pregnancy ( 3% mortality
rate in obstetric)

It is due to inflammation response cause massive vasodilator &
increase capillary permeability & cardiac depression lead to
hypotension which lead decrease tissue perfusion & hypoxia latter
multiple organ failure & death

Dx of septic shock :

Two criteria must be present :

1. Evidence of infection ( positive blood culture)
2. Refractory hypotension despite adequate fluid replacement due

to Microorganism ( E-coli , Group A& B streptococci, Klebsiella)

Predisposing factors for sepsis :

 Post Caesarean endometritis (15-85%)

 Prolong rupture of membrane

 Retained product of conception

 Emergency C/S

Dr.Wasan Shock in obstetric

24/3/2015

BY:TAHER ALI TAHER

 Post vaginal endometritis( 1-4%)

 UTI (1-6%)

 Intra amniotic infection

Clinical feature :

 Abdominal pain

 Vomiting

 Diarrhea

 Signs of septic shock : pallor, tachycardia, hyper then hypothermia

,hyper then hypotension, tachypnea , cold extremities, oliguria,
confusion.

Investigation :

• Leukocytosis

• Platelet count decrease

• Blood urea & creatinine elevated

• CRP increased

• Increase lactic acid ( metabolic acidosis)

• Deranged liver function

• coagulopathy

Dr.Wasan Shock in obstetric

24/3/2015

BY:TAHER ALI TAHER

Management :

1 - Resuscitation to correct hypovolemia :

 Airways: a patent airway should be assured & high flow oxygen

(15 l/min)

 Breathing: ventilation should be checked

 Circulation: insert 2 wide bore peripheral i.v cannula, restore

circulating volume with crystalloid .

 Blood sample for Hb, FBC, coagulation screen,RFT, & prepare 6

pints of blood

 Vital sign monitoring (especially the urine output not less than

20cc/hour)

 Left lateral position to avoid aorta caval compression which lead

to hypotension

 Emergency O –ve blood may need in massive bleeding

2 – specific treatment :

• Monitor the patient by direct arterial ,venous, central

• Blood culture, culture from other site as wound ,amniotic fluid,

urine.

• Broad spectrum AB.

• Monitor vital sigh & urine output

• Corticosteroid (low level of hydrocortisone may improve survival

in patient with septic)

• Removal of the infected tissue (evacuation of uterus, drainage of

abscess, delivery in case of chorioamnitis)

… THE END …

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