Download ANTEPARTUM HAEMORRHAGE

‫االء ابراهيم‬.‫د‬.‫م‬
2015-2016
Shock in obstetric
 Definitions: acute , generalized , in adequate perfusion below that
needed to deliver the oxygen and nutrition's for the normal cell
function.
 Aetiology: there are 4 major classes1. Hypovolemic shock.
2.Septic shock.
3.Cardiogenic shock, e.g massive pulmonary embolism, dysarthemia
4.Distibutive (neurogenic) shock, spinl cord injury, regional anesthesia
anaphylaxis.
Pathophysiology:
Untreated shock progresses through 3 stages until death occur:A.compensated:-change in bood pressure , cardiac output
compensated by adjustment of haemostatic mechanism, healthy female
not require fluid if cause is removed.
B.Decompensated:- maximum mechanical action is acting but tissue
perfusion is reduced, impaired vital organ function (heart, brain,
kidney).
C.Irreversible:-Acute tubular necrosis.decressed myocardial
perfusion and contractility, cellular damage and death.
-In Obstetric cases shock is most commonly due to either hemorrhage
or sepsis.
Haemodynamic consideration in pregnancy:
In pregnancy , there is hyperdynamic circulation , increase cardiac output
50% and blood volume 45%reach peak at 28-34 weeks—this protect against
hemorrhage at some degree, if >30% of circulatory volume loss ---maternal
tachycardia only with peripheral vasoconstriction , hypotension develop at
this point, and uteroplacental hypo perfusion occur before maternal signs are
evident.
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Hypovolemic shock
 It is absolute reduction in intravenous volume that lead to decreased
cardiac output , tissue perfusion, vasocontraction to perfuse blood for
vital organs.
Causes :
1.massive hemorrhage –
A-obvious cause( External).
B-Occult like peritoneal haematoma, intra abdominal bleeding.
2. Non hemorrhagic--- like extra cellular fluid loss.
-In pregnancy classified into :
Antenatal causes
1.Ruptured ectopic pregnancy
2.Incomplete abortion
3.Placenta abruption
4.Placenta previa
5.Uterine rupture
Postnatal causes
1. Uterine atony
2. Lacerations
3. chorioamnionites
4. Large placental site
5. Acute uterine inversion
6. Puerperial sepsis
Signs and Symptoms:
Hypotension.
Rapid weak pulse.
Pallor.
Sweating.
Cold clamy extremities.
Oliguria or anurea.
confusion.
Complications of Hypovolemic shock :
1) Acute renal failure.
2) Pituitary necrosis (Sheehan‟s syndrome).
3) Disseminated intravascular coagulation.
Management:
 Resusitation.
-maintain airway: apply high concentration oxygen, assist ventilations as
needed .
-Place patient in the Trendelenburg position .
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-Control obvious bleeding.
-Restoration of Circulation Volume – insert at least two large pore IV
catheters , Crystalloids for initial resuscitation.
-Blood-- order at least 6 units , do not insist on cross matched blood if
transfusion is urgently needed.
-Monitor central venous pressure (CVP) and arterial pressure.
 Pelvic artery embolization : by using interventional radiological
technique , success in women who expected to have major hemorrhage
like placental accrete undergoing elective C/S.
 Balloon Tamponade :by using uterine packing or hydrostatic
balloon catheter.
-insert the catheter into the uterine cavity.
-inflation with warm saline then vaginal packing.
-oxytocin infusion to maintain the uterine tone.
-Catheter insitue for 12-24 hours.
-Fluid is removed gradually and catheter removed in high care are (operative
theater)then the vaginal packing.
 treat the cause:
-managment of uterne atony (5% of deliviries)—
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-Optimze the uterine tone by bimanual massage, oxytocine, ergometrine ,
carboprost( 15 methyl prostaglandin F2 alfa)
-Surgery –remove retained placenta, physical methods to stop bleeding at placental
bed like (Intrauterine ballon tamponade, B –lynche suture, Hysterectomy).
-Management of rupture uterus(0-05%) of all pregnancy--



Stop oxytocin if running.
Continous maternal and fetal monitoring.
Emergency lapratomy and rapid delivery.
Caesarean hysterectomy if impossible to control haemohrage.
- Management of acute uterine inversion-



Presents as ppH , vaginal mass, collapse, pain
1.quick uterine replacement as any delay make it difficult
2.Tocolysis for uterine relaxation like nitroglycerine, terbutaline.
3. manual replacement with placenta if still attached by slowly and steadly
pushing upwards .
 Developments in management pf hypovolemia:
1. Cell salvage: autologous transfusion with salvaged RBC .
Technique:
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 remove blood from the operative site through heparinized suction
tube.
 Filter into collecting reservoir then processed by centrifugation
washing, to remove debris.
 Resultant RBC , returned to patints quickly.
 So only replace RBC not correct coagulopathy.
Advantage: -avoids hazards with homologous blood.
Disadvantage : Amniotic fluid embolism.
 RH isoimmunization.
 Expensive.
 Require training.
 The unit can only be use for cleaning blood not for PPH.
2.Recombinant activated factor 7-Novoseven:
-is engineered protein promots clot formation.
-Forms complex with exposed tissue factor at the site of endothelial damage
,this initiates haemostasis , production of thrombin, platelets activation.
Septic shock
 Sepsis and hypotension despite adequate fluid resuscitation.
 Mortality rate is 3%.
 Results from body’s response to bacteria in blood stream .Vessels
dilate, become “leaky.
Pathology :
 Most cases of septic shock (approximately 70%) are caused by
endotoxin-producing Gram negative bacteria. However, 5% to 10%
have a fungal cause, and 15% to 20% are polymicrobial. In
emergency patients and the increased use of arterial and venous
catheters, Gram positive cocci are implicated, as well
 Invasion of the microorganism into soft tissue leads in a complex
cascade of events involving monocyte, macrophage and neutrophil
recognition, activation, and initial release of inflammatory
mediators, leads to massive vasodilatation---cause decrease vascular
resistance , increase capillary permability, cardiac depression ,
hypotension ----decrease tissue pressure , hypoxia , impaired oxygen
utilization, ---multiple organ failure , death.
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Obstetric Causes of Septic shock:
 Intra-amniotic infections.
 Invasive procedures for prenatal diagnosis (amniocentesis, chorionic
villous sampling).
 Cervical cerclage placement.
 Postoperative infections.
 Post-partum endometritis
 Puerperal sepsis.
 Retained placental tissue.
 Chorioamnionitis .
 Acute pyelonephritis.
 Septic abortion (usually illegal).
 Wound infection Necrotizing fasciitis.
Symptoms:
 patches of discolored skin
 noticeably lower amounts of urination
 confusion
 problems breathing
 abnormal heart functions, such as palpitations or rapid heart rate
 chills due to fall in body temperature
 extreme weakness or lightheadedness
Criteria for diagnosis :
 Evidence of infection through positive blood culture.
 Refractory hypotension.
 Require vasopressor or inotropic drugs, despite fluid replacement.
Treatment:
the earlier sepsis is diagnosed and treated, the more likely you are to
survive.
1.Once sepsis is diagnosed, call for help and ,you will most likely be
admitted to an Intensive Care Unit (ICU) for treatment.
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2. Oxygen therapy100% through a face mask, a tube inserted into nose, or
an endotracheal tube inserted into mouth. In severe shortness of breath, a
mechanical ventilator may be used.
3. warm the patient and adequate venous access must be ensured for
volume resuscitation. When sepsis is suspected, 2 large-bore (16-gauge)
intravenous (IV) lines should be placed if possible to allow administration of
aggressive fluid resuscitation and broad-spectrum antibiotics. Central venous
access is useful when administering vasopressor agents and in establishing a
stable venous infusion site but is not mandatory. If the hypotension does not
respond to a crystalloid fluid bolus of 30 mL/kg (1-2 L) over 30-60 minutes
or if fluids cannot be infused rapidly enough, a central venous catheter
should be placed in the internal jugular or subclavian vein.
4. Urinary catheterization
An indwelling urinary catheter should be placed. In all patients with sepsis,
urine output (UOP), a marker for adequate renal perfusion and cardiac
output, should be closely monitored, as should renal function; mortality is
greatly increased in patients with urosepsis and severe sepsis or septic shock.
Normal UOP in an adult is 0.5 mL/kg/hr or more, equivalent to about 30-50
mL/hr for most adults.
4. Inotropic medicines (inotropes), such as dobutamine, stimulate the
heart. They increase the strength of heartbeat, which helps get oxygen-rich
blood to tissues and organs where it's needed.
5. intravenous antibiotics to fight infection:The principles of rational
therapy include the following: (1) know the type of microorganisms or
suspected organism being treated; (2) be familiar with resistant organisms
in both the community as well as the hospital; and (3) initiate combination
therapy with a beta-lactam antibiotic plus an aminoglycoside or use
monotherapy selected third generation cephalosporin.
After culture results are known, the antibiotic regimen should be narrowed
to cover the specific infecting microorganism using the least expensive, least
toxic antibiotic available.
The beta-lactam antibiotics include all penicillins, cephalosporins,
carbapenems, and monobactams. Penicillins with extensive gram-negative
coverage include all the carboxy (carbenicillin, ticarcillin, and ticarcillin plus
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clavulanic acid) and ureido (piperacillin, mezlocillin, azlocillin) penicillins.
The third generation cephalosporins (cefoperazone, cefotaxime,
ceftazidime, ceftizoxime, ceftriaxone, and moxalactam) have the broadest
gram-negative coverage within the cephalosporin family
6. vaso pressure medications – drugs that constrict blood vessels and help
increase blood pressure, and flow of blood allow your vital organs to start
functioning properly, like dopamine, adrenaline , noradrenaline.
7.corticosteroids to help with inflammation.
8. In severe cases of sepsis or septic shock, the large decrease in blood
pressure and blood flow can kill organ tissue. If this happens, surgery may
be required to remove the dead tissue.
Cardiogenic shock:
-Pulmonary embolisim.
-cardiomyopathy.
-mmmmmyocardial infarction.
-Obstrective structural—e.g.mitral stenosis, aortic stenosis.
-Obstrective non structural ---cardiac tamponade, pulmonary hypertension.
-Regurgitation, like MR,AR, VSD.
-Dysarrethmia.
-Blunt cardiac truma.
Neurogenic Shock: abnormal vessel tone due to truma and tissue
damage as in painful conditions.
Obstetric Causes of neurogenic:
-Disturbed ectopic pregnancy.
-Concealed accidental hemorrhage.
-Manual removal of placenta, without anathesia.
-Difficult forceps or breech extraction.
-Rapid evacuation of uterus.
-Polyhydramninous.
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