Shock In Obstetrics

Shock : Means
imperfect tissue perfusion by blood i.e. It is state of circulatory collapse .
Types of Obstetric Shock
1- Hypovolaemic Shock
2- Septic Shock
3- Neurogenic Shock
4- Embolic Shock
5- Cardiogenic Shock
6- Anaesthetic accident
7- Anaphylactic Shock
8- Shock-like state.
e.g. inveitable abortion, Acute disturbed ectopic pregnancy, Antepartum and Postpartum haemorrhages
1) Hypovolaemic Shock:
Haemorrhagic: The commonest cause of shock in obstetrics either opertaining alone or in association with truma.
With difficult forceps
Rupture uterus
Abruptio placenta
1) Hypovolaemic Shock:(B) : Truma:
(C ): Fluid Loss:
Hyperemesis gravidarum
Prolonged labour (dehydration, starvation, acidosis)
1) Hypovolaemic Shock:(C ): Fluid Loss:
(2) Septic Shock:
Septic abortion esp. criminal one “Commonest”
Pyelitis with pregnancy
Chorioamnionitis following PROM
Puerperal sepsis .
(3) Neurogenic Shock
Acute inversion of the uterus.
Crede’s expression of the placenta without anaesthesia .
Manual removal of the placenta without anaesthesia.
Forcible manual cervical dilatation.
(4) Embolic Shock
Pulmonary embolism (dislodged blood thrombus from the infected placental sinus , pelvic veins or leg veins)
Amniotic fluid embolism (Pulmonary oedema, DIC, Collapse and finally death)
Cardiogenic Shock
With severe Preeclampsia , acute HF and pulmonary oedema develop.
Associated heart disease with pregnancy particularly at third stage.
Anaesthetic accidents
Mendelson’s syndrome (inhalation Pneumonia)
Prolonged or deep general anaesthesia.
With spinal analgesia.
Anaphylactic Shock:-
Mismatched blood transfusion.
Oxytocin injection esp. if repeated …may lead also to coronary spasm
With drugs as antibiotics.
Shock like State: i.e.
Supine hypotension syndrome. Immediate recovery when the patient turned to on her side.
Pathogenesis
Hypovolaemic Shock
(Heg> 1 Liter or excessive fluid loss)
early reversible
late reversible
irreversible
Septic Shock (how)
(Virulent organisms release Endotoxias)
The circulating organism causing high fever, rigors .
The circulating endotoxins : Causing vascular endothelial damage resulting in:
* Vasodilation …… Hypotension and shock
* DIC Haemolysis of RBCS
* Toxic nephrosis (Acute renal failure).
Clinical Diagnosis
(A) Hypovolaemic Shock
Excessive thirst (earlist)
Anxious look (very weak patient , cold skin, excessive sweating)
Dimness of vision
Pallor around the mouth at first, then spreads to whole face, then to whole body.
Pulse weak, rapid, thready .
6- Shallow rapid respiration and irregular
7- Subnormal temperature
8- Diminished BP either slowly or rapidly
9- Oliguria or anuria develops
10- Consciousness is retained until late and pupils is dilated but reactive
(B) Septic Shock:- c/p
Early Stage (Septicaemia):
1- High fever 3- Flushed face
2- Chills 4- Mudy look /earthy look
5- Tachycardia out of preparation of fever
Late Stage (Septic Shock):
1- Hypotension 3- Pallor
2- Fever 4- Delerium /Confusion
5- Thready pulse.
Prevention of Obstetric Shock
(1) Good antenatal care (correction of anaemia and malnutrition)
(2) Proper intrapartum care (giving sedatives, nourishment, correction of any dehyration and acidosis)
(3) Conduction of labour in equiped places where the antishock measures are available.
(4) Proper postnatal care.
Work up management of hypovolaemic shock
Establish IV line and CVP (Blood group and save)
Patient will be resuscitated in flat position
Keep the patient warm
Oxygen administered continuously
Foley’s catheter and assessment of UOP
Blood transfusion and fluid therapy (Plasma volume expanders).
Corticosteroids might help.
Vasoppressors might needed.
Deal with the actual cause.
Work Up of Septic Shock
A- Investigations:-
Culture and sensitivity (aerobics and anarobics) from blood, uterine discharge, cervical swab.
CBC, coagulation profile, FDP
Renal functions test
Serum electrolytes
Pelvic U/S to detect pelvic collection.
Work Up of Septic Shock :Active management:
General measures + Antibiotics + Removal of septic focus+ correct complications.
Work Up of Septic Shock :Active management:General measures:-
CVP, cardic monitoring, and ABG
Fluid therapy
Fresh blood transfusion (correct haemolysis and DIC)
High dose of steroid therapy
NaHCO3 to correct metabolic acidosis.
Work Up of Septic Shock :Active management:Antibiotics:-
Started immediately after sampling for CFS. Triple therapy: Penicillin G or Cephalosporin’s + gentamycint metronidazole
Work Up of Septic Shock :Active management:Removal of septic focus:-
1- removal of remnants.
2- Hysterectomy if the uterus is ganaerenous.
Work Up of Septic Shock :Active management:
Correct complication as:-
1-acute renal faliure 2- DIC
predisposing causes
severe anemia and ill health
tixaemia of preg
antepartum hge
prolonged labour, starvation, dehydration, acidosis
retained placenta for a long time
actual cause hge causes
hypovolemia
actual cause of non hgic
trauma
prolonged labour
fluid liss in hyperemesis gravida
septic shock
htn and toxaemia
anaesthetic drugs
pul embolism
supine hypotension S
obstetric shock
shock following normal labour