Hemorrhagic Shock In Pregnant Women

Presented by: Jayatheeswaran. VijayakumarGroup: 88

Definition

Hemorrhagic shock is the clinical syndrome that results from inadequate tissue perfusion (poor blood flow) which leads to hypoxia and ultimately cellular dysfunction which manifests as lactic acidosis.

Body Fluid Compartments? Approximately 2/3 of the bodies water is located

intracellularly. The remaining 1/3 is located in the extracellular

compartment which is distributed between the interstitial compartment and the intravascular compartments in a ratio of 3:1.

Hypovolemic Shock vs. Hemorrhagic Shock

Blood loss has two effects on the body:1. First, there is a loss of volume within blood vessels to be

pumped (hypovolemic shock).2. Second, a reduced oxygen carrying capacity occurs

because of the loss of red blood cells (hemorrhagic shock).

As such, hemorrhagic shock is a subset of hypovolemic shock and it typically occurs when there is significant bleeding that ensues relatively quickly.

Hemorrhagic Shock Etiology Blood Loss

Trauma Retroperitoneal bleed Obstetric hemorrhage:

1. Antepartum hemorrhage 2. Postpartum hemorrhage3. Ectopic pregnancy

Hypovolemic Shock Etiology Fluid Loss

Hyperemesis Gravidarum Diarrhea Keto-acidosis

Plasma Loss Severe burns

Compensatory Mechanisms In Hemorrhagic Shock1. Plasma refill 2. RAS and the HPAA - Renin converts angiotensinogen to angiotensin 1

which is than metabolized in the liver to angiotensin 2, which is a potent vasoconstrictor that stimulates aldosterone secretion, along with the pituitary release of ADH, promoting sodium and water retention.

3. Norepinephrine and epinephrine are locally and systemically released. Catecholamine mediated effects are inotropic (force of contraction) and chronotropic (rate of contraction) resulting in increased cardiac output. They also increase the systemic vascular resistance leading to an increased diastolic pressure and therefore narrow pulse pressure. Vasoconstriction enhances venous return which also increases cardiac output and stroke volume.

Typical Signs & Symptoms Pallor Sweating Confusion Hypotension Rapid weak pulse Oliguria or anuria Cold clammy extremities

Stages of Hemorrhagic Shock1. Compensated2. Uncompensated 3. Irreversible

Compensated Defense mechanisms are successful in

maintaining perfusion. Presentation

TachycardiaDecreased skin perfusionAltered mental status

Uncompensated Defense mechanisms begin to fail. Presentation

Hypotension Marked increase in heart rate Rapid & thready pulse Agitation, restlessness & confusion

Irreversible Complete failure of compensatory

mechanisms. Marked loss of tissue perfusion cause

cellular damage and death even in the presence of resuscitation.

Initial Treatment In ShockRecommended

Oxygenate: 6-8 liters of oxygen is given (high concentration of oxygen).

Secure & maintain the airway. Apply assisted ventilation if needed.

Restore circulatory volume (transfusion).

Drug therapy. Evaluate response to the current therapy.

Remedy the underlying causes.

Control obvious bleeding.

Not Recommended 1. Place patient in the Trendelenburg

Position

In the past, Trendelenburg position was used for patients in hypovolemic shock, with the thought that it would help maintain blood flow to the brain. This is no longer recommended because studies have shows this to be counterproductive.

Restoration of Circulatory Volume1. Firstly, insert at least two large pore IV catheters.2. Next, begin crystalloid solution (recommended for initial resuscitation – should be

delivered through a fluid warmer).3. After, rapidly infuse 5% of dextrose into the lactated Ringer’s solution while the

blood products are being obtained.4. Order at least 6 units of red cells. Do not insist on cross matched blood if

transfusion is urgently needed.5. Colloid solutions/ packed red blood cells (PRBC’s) can than be initiated to replace

blood loss (if the patient becomes coagulopathic after several transfusions platelet transfusion is also recommended).

6. Apply a compression cuff to the infusion pack in order to further monitor the central venous pressure (CVP) and arterial pressure respectively.

Inpatient & Outpatient Medications Patients with hemorrhagic shock are often unable to mount an appropriate

bone marrow response in the acute setting with regard to red blood cell production. Using erythropoietin (40,000 U/week) in combination with supplemental iron and vitamin C to boost production is useful. This strategy has been used successfully to decrease red blood cell transfusions in a large multicenter trial in Canada.

Thank You