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Trends in Emergency Management of Obstetrical Shock

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SHOCK:

Prof.G. Muthamilselvi, M.Sc (N), MHRM,DALL, P.hD, Principal, Mrs. M. Amutha Shoba, M.Sc (N), Lecturer Vinayaka Mission’s College of Nursing, Puducherry. SHOCK

INTRODUCTION:

INTRODUCTION Uterine bleeding associated with an obstetric complication can lead to severe hemorrhage, hypovolemic shock, infection and coagulation disorders. Not only is the pregnant patient at risk for increased morbidity and mortality, but the fetus may also be adversely affected.

DEFINITION OF SHOCK :

DEFINITION OF SHOCK It’s critical and life threatening medical emergency / complex syndrome results from acute, generalized, inadequate perfusion involving reduction in blood flow to the tissues below that needed level to deliver the oxygen and nutrition for normal tissue function leading to dysfunction of organs and cells.

AETIOLOGY:

AETIOLOGY The Major Classes of Shock Include: Hypovolaemic shock Septic shock Cardiogenic shock and Distributive shock

Hypovolaemic shock :

Hypovolaemic shock Hemorrhage – Associated with postpartum/ postabortal hemorrhage, ectopic pregnancy, placenta previa, abruptio placenta, rupture of uterus and obstetric surgery Fluid loss shock – Associated with excessive vomiting, diarrhea, diuresis or rapid removal of amniotic fluid. Supine hypotensive syndrome- associated with compression of inferior vena cava due to pregnant uterus Shock associated with DIC- intrauterine dead fetus syndrome and amniotic fluid embolism. Burns Peritonitis Diabetic Keto-acidosis

Septic shock :

Septic shock Endotoxic shock associated with Septic abortion, chorio amnionitis, pylonephritis, and rarely postpartum endometritis.

CARDIOGENIC SHOCK:

CARDIOGENIC SHOCK Massive pulmonary embolus Cardiomyopathies- myocardial infarction, hypertrophic obstructive cardio myopathy, cardiac amyloid, myocarditis. Obstructive non-structural- pulmonary embolism, cardic tamponade, pulmonary hypertention, constructive pericarditis

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Obstructive structural- valvular aortic stenosis, valvular mitral stenosis,coarctation of the aorta, left atrial myxoma. Regurgitant lesions- mitra l regurgitation, aortic regurgitation, ventricular septal defect, left ventricular aneurysm, ventricular wall rupture. Blunt cardiac trauma - contusion Dysrhythmias Cont’d

Distributive shock :

Distributive shock Neurogenic shock- spinal injury Drug induced-reginal anesthesia anaphylaxis Chemical injury- associated with aspiration of gastrointestinal contents during general anesthesia specially in caesarean section (Mendelson’s syndrome )

PATHOPHYSIOLOGY :

PATHOPHYSIOLOGY If untreated shock progress through three stages. Inadequate management allows shock to progressively worsen passing through these stages until death occurs.

Stage 1- compensated :

Stage 1- compensated Changes in blood pressure and cardiac output compensated by adjustment of homestatic mechanism. In healthy patients this category of shock may not require fluid replacement if the cause is removed.

Stage 2- decompensated :

Stage 2- decompensated Maximal compensatory mechanism is acting but tissue perfusion is reduced . Vital organ (cerebral, renal, and myocardial) function becomes impaired.

Stage 3-irreversible:

Stage 3-irreversible Vital organ perfusion is impaired. Acute tubular necrosis, severe acidosis, decreased myocardial perfusion and decreased myocardial contractility occurs. The profound decrease in perfusion leads to cellular damage and death.

CLINICAL FEATURES OF SHOCK :

CLINICAL FEATURES OF SHOCK Hypovolaemic shock Early phase ( compensatory phase) Normal blood pressure Tachycardia Diaphoresis Extremities remain warm Patient appears restless and anxious. This phase can easily managed with fluid replacement.

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Intermediate phase (Reversible phase ) Patient progressively becomes pale Tachycardia persists Periphery becomes cold Sweating –may be there Patient remains conscious Urine output within normal limit Still adequate management shock state may be reversed. Cont’d

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Late stage- irreversible Hypotension continues Extremities becomes cold and clammy Color of the skin becomes ashen gray Metabolic acidosis Coagulopathy and thrombocytopenia are associated Oliguria and mental confusion –expected Treatment of any kind is practically useless in this phase and mortality varies between 3% to 100% Cont’d

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Neurogenic shock Compensatory phase- Transient Irreversible phase pallor is absent Flushed face Temperature remains normal Cont’d

Septic shock:

Septic shock Initial phase Patient remains alert Marked flushing of the face The skin feels warm Temperature->38°C (or) <36°C Bounding pulse Heart rate >100beats/mt Respiratory rate >20 breaths/mt WBC >12000/ml 3 If state of shock persists Intense constriction of sphincters at either end of capillary bed Pale and profuse sweating Extremities are cold and clammy Urine output is reduced

DIAGNOSIS :

DIAGNOSIS No laboratory Test -but high index suspicion and physical signs of inadequate tissue perfusion and oxygen are base to initiate treatment.

INITIAL MANAGEMENT:

INITIAL MANAGEMENT Successful management of shock patient requires team work . Senior team of anesthetist, obstetrician, hematologist, and midwife other support staff like neonatologist, radiologist, theatre team and dedicated porter. To be in contact. Maternity unit must have established protocol

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Management should start once diagnosis made aiming for prompt restoration of tissue perfusion and oxygenation. Management of underlying etiology is next step until resuscitation is initiated. Cont’d

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ABC AIRWAY Airway-high flow oxygen (15lts/min by mask with reservoir bag) Protected by tracheal intubation if there is potential compromise BREATHING ventiation should be checked and supported if inadequate CIRCULATION insert two widebore peripheral intravenous canulas Initial circulatory management aims to restore circulating volume and reverse hypotension with crystaliod. keep ready blood for transfusion (6 units) Samples can be drawn for full blood count, coagulation screen, urea, electrolytes and cross matching. Continues monitoring the response. Cont’d

SPECIFIC MANAGEMENT:

SPECIFIC MANAGEMENT Hemorrhagic shock: Infusion and transfusion Blood transfusion is must Crystalloids- Normal saline has to be infused initially for immediate volume replacement. colloids- polygelatin solutions ( Heamaccel) are iso-osmotic with plasma maintenance of cardiac efficiency. 6liters of crystalloids may be needed for loss of 1liter of plasma volume. Hemodynamic monitoring should be aimed to maintain systolic BP>90mmhg, mean arterial pressure > 60mmNg, CVP 12-15mm H2O and pulmonary capillary wedge pressure 14-18 mmHg.

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Administration of oxygen to avoid metabolic acidosis In the later phases, ventilation by endo- tracheal intubation may be necessary. Oxygen delivery should be continued to maintain O2 saturation>92%, PaCO2 30-35mmHg and PH<7.35 Cont’d

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Control of hemorrhage Specific surgical and medical treatment for control of hemorrhage should start along with the general management of shock. 1. Management of uterine atony Optimise uterine tone- bimanual massage of the uterus, oxytocin bolus followed by infusion, ergometrine bolus and carboprost (15-methyl prostaglandin F2) Surgery- removal of retained products of conception, intra-uterine balloon tamponade, B-Lynch suture, hysterectomy and arterial embolisation Cont’d

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2. Lacerations of genital tract (Cervix, Vagina & perineum)- Repair of genital tract, vaginal pack. 3. Uterine rupture Stop oxytocin infusion if running. Continues maternal fetal monitoring Emergency laparotomy with rapid operative delivery. Caesarean hysterectomy- if hemorrhage is impossible to control. Cont’d

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4. Uterine inversion Replacement of the uterus quickly Administer tocolytics (nitroglycerin, terbutaline, magnesium sulphate) to allow uterine relaxation. General anaesthesia is usually necessary. Manual removal of placenta by slowly and steadily pushing upwards, with hydrostatic pressure. Cont’d

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Monitoring Clinical parameters like skin temperature, visible peripheral veins can be helpful to assess the degree of tissue perfusion. Urine output (> 30ml/hr) Arterial blood pressure Central venous pressure (CVP) Pulse oximeter and blood gas analysis are useful to assess tissue perfusion. Measurement of left aterial pressure Cont’d

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Pharmacologic agents Vasopressor drugs Vasoactive drugs and corticosteroids Cont’d

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Antibiotics Ampicillin (1g I.V.every 6 hours,) gentamicin (2mg/I.V loadingdose followed by 1.5mg/kg I.V every 8 hours) and metronidazole (500mg I.V every 8 hours) is good combination. Alternative regimen is to give ceftazidine 1g I.V. every 8 hours combined with gentamicin. Clindamycin 600mg I.V. infusion (single dose) is an alternative to metronidazole. Intravenous fluids and electrolytes Liberal infusion and blood transfusion Cont’d

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Correction of acidosis Acidosis and hypozaemia depress myocardial contractility. Bicarbonate should be administered to correct persistent metabolic acidosis (pH<7.2) First dose would be 50-100 meq (60-110ml of 7.5 percet) of sodium bicarbonate solution. Further doses will depend on the clinical state of the patient and blood gas analysis result. Cont’d

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Maintenance of blood pressure Inotropes should be used. Adrenaline, noradrenalin, dopamine and tolbutamine have both inotropic and vasoconstrictive effects. Vasodilator therapy Sodium nitroprusside and nitroglycerine could be used. This is done under continuous hemodynamic monitoring Diuretic therapy To reduce fluid over load (pre load) and pulmonary oedema, diuretics should be used. Frusemide is the drug of choice. The dose recommended in septic shock is 50mg of hydrocortisone per kg body weight. Cont’d

Septic shock- management :

Septic shock- management Transfer to a higher level facility Invasive monitoring is mandatory Obtain blood culture as soon as possible (other sites includes wounds, urine, sputum, or other body fluids like amniotic fluid) Start with antibiotics –broad spectrum Removal of infected tissue after initial intubation ,evacuation of uterus, delivery, drainage of abscess and hysterectomy in case high of myometrial micro abscesses . Delivery may not be indicated if sepsis not related to uterus and may depend up on gestational age.

Septic shock- management:

Septic shock- management Treatment of diffuse intravascular coagulation-Heparin therapy - as a prophylaxis, Heparin 5000IU subcutaneous (or) IV at 8 hourly interval H2 blockers -ranitidine IV Nutritional support- oral (or) parentral nutrition to provide 20-30Kcal/kg/day with fat and carbohydrate

Advances in sepsis management :

Advances in sepsis management Goal directed therapy – modify the component of treatment to achieve specific end points (mean arterial pressure>65mmhg, urine output >0.5ml/kg/h, CVP 8-12mmh 2 o , and normal o2saturation ). Insulin therapy- aggressive control of blood sugar has been demonstrated to improve outcome in septic patients. Activated protein C Administration in septic shock has been reported to decrease mortality and reduce organ dysfunction

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Distributive shock 1. basic shock management (ABC) 2. Special aspects in management of high block Support of the cardiovascular system with vasopressor drugs and inotropes to maintain adequate BP. Sedative agents- To reduce the risk of awareness once the initial resuscitation has been effected. Cont’d

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Neurogenic Shock- Management fluid replacement Resuscitation initiation of vasopressor drugs to counteract vasodilatation. Administer atropine if bradycardia occurs Cont’d

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Anaphylactic Shock Management 1 . basic and circulatory management. 2. Specific management. Includes immediate and late. Immediate Stop administering suspected agent and call for help Early intubation Client to be placed immediately in supine or Trendelenburg position with leg elevation to increase venous return. Start epinephrine IM. Repeat every 5-15 min. until improvement occurs in blood pressure. if need IV in severe cases. Cont’d

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Replacement with crystalloids solution for rapid intravascular fluid volume expansion. Advanced life support measures if cardiac arrest occurs. Secondary (late)- Management IV epinephrine if hypotension persist. Atropine in cases with significant bradycardia IV salbutamol if brancho spasm persist. If need Anti histamines preferable Refer to critical care centers Cont’d

Complications :

Complications Haemorrhagic shock Fetal - changes to the uteroplacental blood flow can cause fetal hypoxia, acidosis, placental abruption, intracranial haemorrhage and death Maternal - acute renal failure, Sheehan's syndrome , disseminated intravascular coagulation (DIC), death Septic shock Acute respiratory distress syndrome Arrhythmias DIC Hepatic and renal failure Fetal and maternal death

Prevention:

Prevention PPH is much reduced with an actively managed 3rd stage of labour Women at high risk of haemorrhage should not be delivered in isolated units or facilities without immediate access to specialist consultant care, blood products or intensive care. A woman who declines blood products should have a management plan, in case of haemorrhage, agreed with them before delivery is anticipated. Any problems that may lead to sepsis should be communicated to the community carers at the time of discharge so that appropriate follow-up can be instituted Identification of women with risk factors for venous thromboembolism (VTE) should occur prior to pregnancy or in early pregnancy, with implementation of appropriate thromboprophylaxis. Reassessment of risk should take place prior to delivery . Women with BMIs >35 should be referred for specialist assessment.

NURSING PROCESS:

NURSING PROCESS Nursing diagnosis Ineffective tissue perfusion related to excessive blood loss casing decreased placental circulation to the fetus. Deficit fluid volume in relation to excessive blood loss Anxiety related to unexpected occurrences because of the sudden development of complications. Ineffective individual or family coping related to the transfer of the woman to a tertiary center for more intensive management. Powerlessness related to inability to prevent or control condition and outcomes. Risk for impaired physical mobility related to restriction of movement with monitoring devices.

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Nursing diagnosis Risk for impaired parenting related to separation from infant secondary to treatment regimen. Risk for injury maternal related to administration of blood products and operative procedures. Risk for fetal injury related to reduced placental perfusion secondary to vasospasm. Risk for infection related to presence of favourable conditions for infection. Deficit knowledge related to the unexpected emergent nature of care required to ensure maternal and fetal well-being. Cont’d

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Nursing diagnosis: Ineffective tissue perfusion related to excessive blood loss casing decreased placental circulation to the fetus. Expected out come: woman will have stable vital signs, oxygen saturation, arterial blood gases and hemoglobin INTERVENTION RATIONALE Monitor vital signs (pulse, respirations, and blood pressure every 15min; apply pulse oximeter and automatic blood pressure cuff as necessary.) level of consciousness. Provides baseline data on maternal response to blood loss Administer oxygen as necessary at 6-10 L/min by face mask. Provides adequate fetal oxygenation despite lowered maternal circulating blood volume Administer intravenous fluid such as lactated ringer’s Replaces intravascular fluid volume; intravenous line is established if blood replacement will be needed. Place woman flat in bed on her side. Maintains optimal placental and renal function Provide suctioning Clears airway

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Nursing diagnosis: Deficit fluid volume in relation to excessive blood loss Expected outcome: woman will demonstrate fluid balance as evidence by stable vital sing, balanced intake and output. INTERVENTION RATIONALE Monitor vital signs (pulse, respirations, and blood pressure every 15min; apply pulse oximeter and automatic blood pressure cuff as necessary.) level of consciousness. Provides baseline data on maternal response to blood loss Monitor blood hemacrit and HB Provides baseline data on maternal response to blood loss Insert indwelling catheter and measure hourly urine output Provides baseline data on maternal response to blood loss Administer blood (packed cells, fresh frozen plasma) Provides adequate circulating blood volume Administer intravenous fluid such as lactated ringer’s Replaces intravascular fluid volume; intravenous line is established if blood replacement will be needed. Place woman flat in bed on her side. Maintains optimal placental and renal function

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Nursing diagnosis: Anxiety related to unexpected occurrences because of the sudden development of complications. Expected outcome: women well verbalizes that anxious feelings are diminished INTERVENTION RATIONALE Monitor emotional status of client and family members. Provides baseline data Provide calm, competent, attitudes and environment Decreases anxiety Explain all procedures Decreases anxiety Allow the women to verbalize feelings Permits clarification of information Keep family informed of condition. Provides supports

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Nursing diagnosis: Compromised or disabled individual or family coping. Expected outcome: women and family will demonstrate coping as evidenced by accepting the conditions. INTERVENTION RATIONALE Monitor coping status of client and family members. Provides baseline data Provide emotional support to women, her partner and her family. Support woman’s self-esteem. Assists problem solving, which is lessened by poor self-esteem Provide calm, competent, attitudes and environment Decreases anxiety Explain all procedures Decreases anxiety Allow the women to verbalize feelings Permits clarification of information Keep family informed of condition. Provides supports

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Nursing diagnosis: Risk for impaired parenting related to separation from infant secondary to treatment regimen. Expected outcome: women begins to bond with newborn with exposure as evidenced by expression of positive feeling toward newborn increasing participation in care of newborn INTERVENTION RATIONALE promote adequate rest and sleep Ensures adequate energy for interaction. Contact family members to participate in care of the newborn Allows mother to rest and recover from infection. Offer praise and positive reinforcement for caretaking tasks Facilitates bonding and attachment. Encourage mother to care for herself first and then the newborn Ensures adequate energy for newborn’s care. Refer to CHN for follow up care of mother and newborn at home Fosters continued development of maternal- infant relationship.

CONCLUSION :

CONCLUSION The management of emergencies is usually the responsibility of hospital obstetricians. As more maternity care is now given in the community, however, midwives, general practitioners, and paramedics may be involved and must know the outlines of management of emergencies and the possible side effects.

TAKE HOME MESSAGE :

TAKE HOME MESSAGE Successful management of the shocked patient requires team work Obstetric units should have established protocols for dealing with shock and practice ‘fire’ drills regularly Shock management should commence immediately diagnosis is made aiming for prompt restoration of tissue perfusion and oxygenation. The resuscitation follows the familiar ABC pattern.

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Thank you