Factors precipitating hemorrhagic shock, class of hemorrhage and its management

1. HAEMORRHAGIC SHOCK

3. SHOCK: DEFINITION
• Shock is the clinical syndrome that results from
inadequate tissue perfusion. *
• The cellular injury created by hypoperfusion also
induces the production and release of damage-
associated molecular patterns (DAMPs or "danger
signals") and inflammatory mediators that further
compromise perfusion.
• The effects of shock are initially reversible, but rapidly
become irreversible, resulting in multiorgan failure
(MOF) and death.
* Harrisons Principle of Internal Medicine, 19th edition

4. SHOCK: ETIOLOGY
SHOCK
HYPOVOLEMIC
NON HAEMORRHAGIC
HAEMORRHAGIC
BURNS, DIARRHOEA
DISTRIBUTIVE
SEPTIC
NEUROGENIC
ANAPHYLACTIC
CARDIOGENIC
METABOLIC /
RESPIRATORY
OBSTRUCTIVE
TENSION
PNEUMOTHORAX
CARDIAC
TAMPONADE
PULMONIC
EMBOLISM

5. SHOCK: ETIOLOGY
• Haemorrhage is the most common aetiology driving a
patient in a state of shock in obsterics.
• The Hemorrhage accounts for nearly one-quarter of all
maternal deaths and for almost half of all postpartum deaths
in low-income countries.*
• Obstetric haemorrhage is the world’s leading cause of
maternal mortality and accounts for an estimated 127,000
deaths each year.
*Global causes of maternal death: a WHO systematic analysis Lale et al.The Lancet
Global Health June 2014 , Volume 2 , Issue 6 , e323 - e333

6. HAEMORRHAGIC SHOCK
• Massive haemorrhage may be defined as loss
of total Blood Volume within a 24-hour period,
or loss of half of the EBV in a 3-hour period.
• To help guide volume replacement,
haemorrhage can be divided into four classes
Class I is a nonshock state, such as occurs when
donating a unit of blood, whereas class IV is a
preterminal event requiring immediate therapy.
*
* Committee on Trauma . Advanced Trauma Life Support Manual. Chicago: American College
of Surgeons; 1997. pp. 103–112

7. Class of Haemorrhage

8. NORMAL PHYSIOLOGICAL
CHANGES IN PREGNANCY

9. PATHOPHYSIOLOGY OF SHOCK
• Approximately 70 percent of total blood volume is contained in
venules.
• Catecholamine release during haemorrhage causes a
generalized increase in venular tone that provides an auto
transfusion from this capacitance reservoir.
• There is redistribution of cardiac output and blood volume to
brain, heart and adrenals by selective, centrally mediated
arteriolar constriction or relaxation—autoregulation.
• When the blood volume deficit exceeds approximately 25
percent, compensatory mechanisms usually are inadequate to
maintain cardiac output and blood pressure.

10. PATHOPHYSIOLOGY OF SHOCK
• Following an initial increased total oxygen extraction by
maternal tissue, maldistribution of blood flow results in local
tissue hypoxia and metabolic acidosis. This creates a vicious
cycle of vasoconstriction, organ ischemia, and cellular death.
• There is activation of lymphocytes and monocytes, which in
turn cause endothelial cell activation and platelet
aggregation.
• These cause release of vasoactive mediators with small vessel
occlusion and further impairment of microcirculatory
perfusion

12. SHOCK: CLINICAL STAGES
• Stage 1:Compensated - Fall in BP and cardiac output is
compensated by adjustment of homeostatic mechanism, if
cause is removed and iv fluid therapy i s g i v e n , i t is
reversible.
• Stage 2:Decompensate - Maximal compensatory
mechanism are acting but tissue perfusion is reduced.
Vital organ(cerebral , renal, myocardial)function reduced.
• Stage 3:Irreversible - Vital organ perfusion badly impaired.
Acute tubular necrosis , severe acidosis, decreased
myocardial perfusion and contractility the profound
decrease in perfusion leads to cellular death & Organ
failure.

13. SHOCK : SYMPTOMS
Mild (<20% Blood Volume Moderate (20–40% Blood Volume) Severe (>40% Blood Volume)
Cool extremities Same, plus: Same, plus:
Increased capillary refill time Tachycardia Hemodynamic instability
Diaphoresis Tachypnea Marked tachycardia
Collapsed veins Oliguria Hypotension
Anxiety Postural changes Mental status deterioration (coma)

14. SHOCK: SIGNS

15. SHOCK IN OBSTETRIC CASES
Antenatal:
• Ruptured ectopic pregnancy
• Incomplete abortion
• Uterine perforation during evacuation of H.Mole
• Abruptio placentae
• Uterine rupture
• Non obstetrical intra abdominal bleeding.
Perinatal:
• Uterine rupture
• Acute uterine inversion .
Postnatal : PPH(primary, secondary) Atonic ,
Traumatic, Retained tissue

16. IMMEDIATE MANAGEMENT AND
RESUSCITATION
• The primary treatment of hemorrhagic shock is to
control the source of bleeding as soon as possible and
to replace fluid.
• Maintain airway, breathing and circulation
• Fluid replacement is aimed toward normalization of
hemodynamic parameters.
• Crystalloid is the first fluid of choice for resuscitation.
Immediately administer 2 L of isotonic sodium chloride
solution or lactated Ringer’s solution in response to
shock from blood loss
• PRBCs should be transfused if the patient remains
unstable after 2000 mL of crystalloid resuscitation.
Crystalloids restore
volume in a 3:1 ratio
Colloids restore volume
in a 1:1 ratio
Saline versus Albumin Fluid
Evaluation (SAFE) randomized
trial of almost 7000
nonpregnant patients (Finfer,
2004) found that both are
equally effective.

17. TRANSFUSION GUIDELINES *
• Valid consent should be obtained where possible prior to
administering a blood transfusion.
• In an emergency, where it is not feasible to get consent,
information on blood transfusion should be provided
retrospectively.
• The reason for transfusion and a note of the consent discussion
should be documented in the patient’s case notes
• All women should have their blood group and antibody status
checked at booking and at 28 weeks of gestation..
• Group and screen samples used for provision of blood in
pregnancy should be less than 3 days old.
* RCOG, Green Top Guidelines No. 47, Blood Transfusion in Obstetrics, May 2015

18. TRANSFUSION GUIDELINES*
• FFP at a dose of 12–15 ml/kg should be administered for every 1- 2 units of red cells
during major obstetric haemorrhage aiming to maintain prothrombin time (PT) and
activated partial thromboplastin time (APTT) ratios at less than 1.5 x normal.
• Cryoprecipitate at a standard dose of two 5-unit pools should be administered early
, later guided by fibrinogen results, aiming to keep levels above 1.5 g/l.
• The FFP and cryoprecipitate should ideally be of the same group as the recipient. If
unavailable, FFP of a different ABO group is acceptable.
• No anti-D prophylaxis is required if a RhD-negative woman receives RhD-positive
FFP or cryoprecipitate.
* RCOG, Green Top Guidelines No. 47, Blood Transfusion in Obstetrics, May 2015

19. TRANSFUSION GUIDELINES *
• A platelet transfusion trigger of 75 x 109 /l is recommended
to provide a margin of safety.
• The platelets should ideally be group compatible. RhD-
negative women should also receive RhDnegative platelets.
• The use of rFVIIa may be considered as a treatment for life-
threatening postpartum haemorrhage .
• In Intra or Post partum patients who are not actively
bleeding, PRC should be transfused if Hb is less than 7g/dl.
* RCOG, Green Top Guidelines No. 47, Blood Transfusion in Obstetrics, May 2015

21. NOVOSEVEN
• NovoSeven® is recombinant human coagulation Factor VIIa
(rFVIIa), intended for promoting haemostasis by activating the
extrinsic pathway of the coagulation cascade.
• NovoSeven is a vitamin K-dependent glycoprotein consisting of
406 amino acid residues (MW 50 K Dalton). NovoSeven is
structurally similar to human plasma-derived Factor VIIa.
• rFVIIa assists haemostasis in PPH patients with bleeding
refractory to pharmacologic management and uterus sparing
surgical techniques to prevent OH.
• Recommended administration of rFVIIa is 90 mg/kg rFVIIa as IV
bolus over 3–5 min, per RCOG and Franchini et al.*
* Franchini M, Franchi M, Bergamini V et al. The use of recombinant activated FVII in
postpartum hemorrhage. Clin. Obstet. Gynecol. 53(1), 219–227 (2010).

22. MANAGING POSTPARTUM
HAEMORRHAGE
• Examine the uterus to rule out atony
• Examine the vagina and cervix to ruleout
lacerations; repair if present
• Explore the uterus and perform curettage to
rule out retained placenta
To be undertaken
simultaneouslywith
management of
hypovolemic shock

23. MEDICAL MANAGEMENT OF
ATONIC PPH *
• Intravenous oxytocin is the preferred initial agent in PPH
treatment, regardless of whether a prophylactic dose was
administered.
• If bleeding continues after oxytocin administration or if
oxytocin is unavailable, IV ergometrine, ergometrine-oxytocin
fixed dose (Syntometrine) or a prostaglandin such as
misoprostol 800 mg sublingual and IM Carboprost can be
administered.
• Simultaneous administration of misoprostol with treatment
doses of oxytocin is not recommended.
* World Health Organization. WHO recommendations for the prevention and treatment of
postpartum hemorrhage. (2012).

25. MECHANICAL PROCEDURES FOR
PPH MANAGEMENT
• Uterine Massage : WHO and FIGO strongly recommend the
use of uterine massage for treatment of PPH immediately upon
diagnosis.
• Uterine Packing : Uterine packing is no longer recommended
by the WHO due to concerns around potential harms.
• Uterine Tamponade : The WHO does recommend intrauterine
balloon tamponade (IUB) for atonic PPH unresponsive to
uterotonics.

26. INTRAUTERINE BALLOON
TAMONADE
• Intrauterine balloon tamponade has been suggested as an effective, easily
administered minimally invasive treatment option to control uterine bleeding
while preserving the mother’s ability to bear additional children.
• It is believed to act by exerting inward to outward pressure against the uterine
wall, resulting in a reduction in persistent capillary and venous bleeding from
the endometrium and the myometrium..
• The Bakri postpartum balloon and the BT-cath balloon tamponade catheter are
specifically designed for postpartum intrauterine tamponade, and they are the
only such devices approved by the US Food and Drug Administration for this
application.

27. INTRAUTERINE BALLOON TAMONADE

28. BAKRI BALLOON
• The Bakri® Balloon is a medical device
invented by Dr. Younes Bakri.
• The obstetrical balloon is a 24 French,
54 cm-long, silicone catheter with a
filling capacity of 500 mL. The device is
used for the temporary control and
reduction of postpartum
hemorrhage (PPH).
• Cost RS 53000

29. INTRAUTERINE BALLOON
TAMONADE : INDICATION
• The 2006 ACOG practice bulletin on
postpartum hemorrhage by the American
College of Obstetricians and Gynecologists
states the following: tamponade of the uterus
can be effective in decreasing hemorrhage
secondary to uterine atony.
• Finally, use of IUB in conjunction with B-lynch
or other compression sutures is a technique
referred to as the ‘uterine sandwich’; this joint
method has been successful at avoiding
hysterectomy

30. INTRAUTERINE BALLOON
TAMONADE: CONTRAINDICATION
• Pregnancy
• Heavy arterial bleeding requiring surgical exploration or angiographic
embolization
• Cervical cancer
• Congenital uterine anomaly
• Uterine distorting pathology (leiomyoma)
• Suspected uterine rupture
• Purulent infection of the vagina, cervix, or uterus
• Allergy to balloon material (silicone)
• Disseminated intravascular coagulation (DIC)

31. TEMPORIZING MEASURES
• Temporizing measures recommended for intractable atonic and non-atonic PPH
include:
1. External aortic compression
2. Bimanual uterine compression
3. Non-pneumatic anti-shock garment (NASG)

32. EXTERNAL AORTIC COMPRESSION
• External aortic compression significantly
reduces blood flow to the pelvic organs
while preserving blood supply to
surrounding organs.
• It has traditionally been accomplished
manually, with a provider applying pressure
with a closed fist on the abdominal aorta
slightly to the patient’s left and immediately
above the umbilicus.

33. EXTERNAL AORTIC COMPRESSION
DEVICE
• The external aortic compression device, also known as the EACD,
consists of a strong metal spring, cylindrical in shape, covered with
leather.
• It has a height of 12 cm (5 cm when compressed), diameter of 8
cm, and a net surface area of 22.3 cm2. It is fixed in place by a
leather belt wrapped around the waist. When not in use, it is held
compressed and fixed with Velcro™ straps.
• When the straps are released the spring will open and the desired
pressure (103.5 mm Hg/cm2 (30 kg)) on the abdominal wall is
achieved in order to stop bleeding.
• EACD use was associated with significantly reduced time to
cessation of uterine bleeding in one study; however, additional
research is necessary to determine the effectiveness of this device.
*
* Soltan MH, Sadek RR. Experience managing postpartum hemorrhage at Minia
University Maternity Hospital, Egypt: no mortality using external aortic
compression. J. Obstet. Gynaecol. Res. 37(11), 1557–1563 (2011)

34. NON-PNEUMATIC ANTI-SHOCK
GARMENT
• For women suffering from uncontrollable PPH, a
method to control the bleeding, reverse the shock,
and stabilize the patient for safe transport to a
comprehensive obstetric care facility could be
lifesaving.
• It is a lightweight neoprene garment that is made up
of five segments that close tightly with Velcro.
• The NASG applies pressure to the lower body and
abdomen, thereby stabilizing vital signs and forcing
blood to the essential organs - heart, lungs, and brain.

35. SURGICAL MANAGEMENT OF PPH
• Uterine compression sutures
• Systematic pelvic devascularization
• Uterine artery embolization
• Total or sub-total hysterectomy

36. UTERINE COMPRESSION SUTURES
• In 1997, B-Lynch et al described a highly effective
surgical technique for the control of postpartum
bleeding in five women with PPH: compressing
the uterus with two longitudinal sutures along its
long axis and preventing the uterus from relaxing
and filling with blood.
• A woman meets the criteria of compression
sutures if bimanual compression of uterus
controls bleeding by abdominal and vaginal
inspection.
• Vertical sutures like B- lynch, modified B – lynch,
Hayman sutures or square compression sutures
like Cho sutures can be taken.
B – Lynch suture

37. SYSTEMATIC PELVIC DEVASCULARIZATION
• Uterine and utero-ovarian artery ligation
• One of several uterus-conserving techniques
• Relatively simple and effective procedure
should be taught during Obstetric and
Gynaecologic training

38. INTERNAL ILIAC ARTERY LIGATION
• Experiments in the 1960’s by Burchell,
ascertained that ligating the hypogastric artery
turned the pelvic circulation like a venous
system, thereby aiding clotting and controlling
PPH.
• It is effective in Uterine atony, midline
perforation, large broad ligament or lateral
pelvic wall haematoma, multiple cervical tears
and lower segment bleeding.

39. UTERINE ARTERY EMBOLISATION
• Uterine artery embolization (UAE) is a procedure where
an interventional radiologist uses a catheter to deliver small particles
that block the blood supply to the uterine body under fluoroscopic
guidance.
• Can be done electively before a planned a perioperative
hysterectomy or in emergency when bleeding does not stop even
after OH.
• One analysis of 30 women with placenta accreta who underwent
embolization catheter placement reported performing embolization
in 77% of patients, and noted that only 8% required hysterectomy.
The mean estimated blood loss in this report was 2000 ml.*
* Sivan E, Spira M, Achiron R, Rimon U, Golan G, Mazaki-Tovi S, et al. Prophylactic pelvic artery
catheterization and embolization in women with placenta accreta: can it prevent cesarean hysterectomy?
Am J Perinatol 2010;27:455–61

40. OBSTETRIC HYSTERECTOMY
• In most cases, it is a last resort lifesaving procedure,
undertaken when other more conservative method to
control haemorrhage have failed.
• Most common indications are:
1. Placenta accrete
2. Uterine atony
3. Severe couvelaire uterus
4. Uterine rupture
5. Cornual or cervical pregnancy
6. Refractory uterine scar infection
7. Chronic recurrent uterine inversion.

41. CONCLUSION
• Obstetric haemorrhage is the world’s leading cause of
maternal mortality.
• A series of delays in receiving definitive PPH treatment is
associated with much higher mortality rates.
• Continued institutionalization of management protocols,
and simulation efforts will help ensure preparedness for
obstetric haemorrhage when they occur.
• Algorithms for hypovolemic shock resuscitation have
benefited from trauma research, and massive transfusion
protocols are now being implemented on obstetric wards

42. REFERENCES
• Lu M C, Fridman M, Korst L M. et al. Variations in the incidence of postpartum hemorrhage across hospitals in
California. Matern Child Health J. 2005;9:297–306.
• Sivan E, Spira M, Achiron R, Rimon U, Golan G, Mazaki-Tovi S, et al. Prophylactic pelvic artery catheterization and
embolization in women with placenta accreta: can it prevent cesarean hysterectomy? Am J Perinatol 2010;27:455–61
• Harrisons Principle of Internal Medicine, 19th edition
• Global causes of maternal death: a WHO systematic analysis Lale et al.The Lancet Global Health June 2014 , Volume
2 , Issue 6 , e323 - e333
• Committee on Trauma . Advanced Trauma Life Support Manual. Chicago: American College of Surgeons; 1997. pp.
103–112
• RCOG, Green Top Guidelines No. 47, Blood Transfusion in Obstetrics, May 2015
• Soltan MH, Sadek RR. Experience managing postpartum hemorrhage at Minia University Maternity Hospital, Egypt:
no mortality using external aortic compression. J. Obstet. Gynaecol. Res. 37(11), 1557–1563 (2011)
• Franchini M, Franchi M, Bergamini V et al. The use of recombinant activated FVII in postpartum hemorrhage. Clin.
Obstet. Gynecol. 53(1), 219–227 (2010).