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Preeclampsia with Hypovolemic Shock Due To

Post Partum Haemmorhage Shock
Step Wise On Fluid Management And The most common types of shock:
Type of shock Aetiology
Resuscitation Hypovolaemic shock Acute loss of at least 20% of the
circulating volume

Cardiogenic shock Acute disease of the heart, e.g.

severe myocardial infarction

Septic shock Septic condition caused by infectious

agents and their toxic products

Ali Sungkar Neurogenic shock Head trauma, spinal cord injury

Divisi Fetomaternal
Departemen Obstetri dan Ginekologi FKUI / RSUPN - CM Anaphylactic shock Repeated contact with or injection of
antigenic substances

Shock Shock
Hemorrhagic Shock Pathophysiology Hemorrhagic (Classic) shock Pathophysiology
Stage 1: Compensated Stage Stage 2: Progressive Stage

Mechanism: Volume depletion due to bleeding

Mechanism: Kidneys release anti-diuretic hormone which increases
vasoconstriction by closing the capillary sphincters, greatly reducing
peripheral circulation
Body detects decrease in cardiac output

Sympathetic Nervous System is stimulated releasing Epinephrine and Increased hypo-perfusion causes increase in metabolic acid build up
Norepinehrine to stimulate Alpha and Beta Receptors

Alpha = Vasoconstriction Beta = Bronchodilation and

Cardiac Stimulation

Shock Shock
Hemorrhagic (Classic) shock Pathophysiology The Course of Hypovolaemic Shock in Absence of Therapy
Stage 3: Irreversible Stage Blood Pressure Heart Rate
Blood Pressure (mm Hg)
Heart rate (min)
Mechanism: Compensatory mechanisms fail
150 Bleeding

Pre-capillary sphincters open releasing metabolic acids, micro-emboli

100
and other wastes into circulation

50
Cell damage, organ failure and death occur

0 (Time)
Compensation Decompensation Irreversibility

Shock Phases

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Shock
The Influence of Volume Replacement on Tissue Perfusion and Organ Function
Cellular Response to Shock
Cerebral Function
Tissue
(Body Control)
Perfusion
Pulmonary Function Blood Inadequat
(O2 Supply) Acidosis
Loss e
Perfusion

Cellular
Cellular
Edema
Hypoxia
Volume Replacement

Liver Lactic
Function Aerobic
Heart (metabolism) Acid Anaerobic
Function Metabolism
(cardiac output) Renal Function Metabolism
(Diuresis)

HAEMATOLOGICAL CHANGES IN PREGNANCY Physiologic volume change

Characteristic
Normal Adult
Women
32-34 Weeks
Gestation
Increased /
Decreased
of Pregnancy
Plasma volume (ml) 2600 3850 1250 in

Red cell mass (ml) 1400 1640-1800* Increased

Haemoglobin (g/dl) 12-14 11-12 Decreased

Red Blood Cells (10*6 /mm*3) 4-5 3-4-5 Decreased

Packed cell volume 0.36-0.44 0.32-0.36 Decreased

Mean corpuscular volume 80-97 70-95 Decreased

Mean corpuscular haemoglobin (pg) 27-33 26-31 Decreased

Mean corpuscular haemoglobin concentration (%) 32-36 30-35 Decreased

Serum Iron (g/dl) 60-175 60-75 Decreased

Total Iron Binding Capacity (g/100ml) 300-350 350-400 Increased

Percentage Saturation (%) 30 15 Decreased

Requirements of iron (mg/day) 1.5-2.0 4.0 Increased

Mean corpuscular haemoglobin = MCH Packed cell volume = PCV
Mean corpuscular haemoglobin concentration = MCHC Mean corpuscular volume = MCV
Total iron binding capacity = TIBC

Summary in Preeclampsia
Hypertriglyceridemia Insulin resistance
Hyperinsulinemia
sfu ine

Reduced HDL
ion

Ab
Dy ndocr

n Hypertriglyceridemia
nct

Predominance of small, dense LDL Me or m

E

tab al L
cholesterol oli ipi
sm d

Reduced Placental Perfusion

Maternal Endothelial
Abnormal vascular Damage Maternal Fetal
remodeling of spiral arteries Stage 1 VASOSPASM Stage 2 Disease
Effects
Release of toxic factors

n
tio
ma
Ox
ida

am
Infl
tiv
eS
tr e
ss

Increased production of free radicals and lipid

Inflammatory cytokines + endothelial damage peroxides
+endothelial cell damage

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Maternal complications of severe preeclampsia The obstetric ICU patient

Cardiovascular dysfunction (cardiac failure, hypertension)

Renal dysfunction (oliguria, reduced GFR, elevated creatinine, acute tubular

Intensive Care Unit
necrosis, cortical necrosis) Delivery room
Respiratory dysfunction (ARDS, pulmonary edema)

Hepatic dysfunction (elevated liver enzymes, subcapsular hematoma, HELLP

syndrome) Post Anesthesia
Cerebral dysfunction (encephalopathy, ischemia, cortical blindness, retinal Care Unit
detachment, infarction, hemorrhage, eclampsia) Operating room

Pre eclampsia Post partum Haemorrage

Fluid restricted to 80 ml / kg / hour

Contracted intravascular compartment
Decreased colloid pressure
Damaged endothelial surface
PULMONARY EDEMA
Remember!
Oxytocin and Magnesium sulphate infusions
Fluid management in pre-eclampsia, T. Engelhardt, F. M. MacLennan.
International Journal of Obstetric Anesthesia (1999) 8. 253-259

ATLS Classification of
Hemorrhagic Shock
CLASS I CLASS II CLASS III CLASS IV

BloodLoss (ml) <750 750-1500 1500-2000 >2000

% 15% 15%-30% 30-40% >40%

HR <100 >100 >120 >140

BP normal normal decrease decrease

PP normal decrease decrease decrease

RR 14-20 20-30 30-40 >35

UOP >30 20-30 5-15 negligible

CNS slightly mildly anxious confused

anxious anxious confused lethargic

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Response Fluid Resuscitation Controle Bleeding

Rapid Transient No
EVAL Response Response Response Kateter Foley
Vital Signs Return to normal Transient Remain
improvement abnormal Kondom Kateter
Estimated Minimal
(10-20%)
Moderate and
ongoing
Severe (>40%) Tampon uterus
Blood
(20-40%)
Loss Maier RC .Am J Obstet Gynecol 1993 Aug;169(2 pt 1):317-21
Need for more IV Low High High
fluid

Need for Low Moderate Immediate

Blood T&C Type Spec O Pos/Neg Medikamentosa: Metergin, Misoprostol, Prostaglandin
OR Possibly Specific
Likely High

Step wise Controle Bleeding Conserve uterus

B-Lynch suture
Dacus JV, Busowski MT, Busowski JD, Smithson S, Masters K, Sibai BM. J Matern Fetal Med 2000 May-Jun;9(3):194-6
Thrombogenic uterine pack Ferguson JE, Bourgeois FJ, Underwood PB. Obstet Gynecol 2000 Jun;95(6 Pt 2):1020-2
Bobrowski RA, Jones TB. Obstet Gynecol 1995 May;85(5 Pt 2):836-7

Vaginal ligature of uterine arteries

Philippe HJ, d'Oreye D, Lewin D. Int J Gynaecol Obstet 1997 Mar;56(3):267-70

Ligasi a hipogastrika
Histerektomi subtotal

Kristaloid vs Koloid
Fluid Management
Estimasi BB : ... 60 kg
Kristaloid Koloid
Estimasi Blood Volume : ... 70 ml/kg x 60 = 4200 ml
Estimasi Blood Loss : .... % EBV = ..... ml Merembes ke komponen
ekstraselular
Tetap berada di komponen
Tsyst 120 100 < 90 < 60-70 Mengurangi peningkatan
Nadi 80 > 120 > 140 -
intravaskular
100 cairan paru
Perf hangat pucat dingin ttb volume yang diperlukan lebih
basah Meningkatkan fungsi organ
Manfaat sedikit
setelah operasi
Meningkatkan transpor oksigen
-- 15%
-- 30% Reaksi anafilaktik minimal
NORMO -- 50% ke jaringan, kontraktilitas
EBV EBV Kemungkinan dapat
VOLEMIA
EBV
jantung dan keluarannya
mengurangi angka kematian
Lebih murah

Predisposisi untuk terjadinya

Resiko Mahal
edema pulmonal
EBL = perdarahan 600 1200 2000 ml

Infus RL 1200-2000 2500-5000 4000-8000 ml

Choi et al 1999.

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Kristaloid vs Koloid

Kristaloid merupakan pilihan

pertama untuk digunakan, karena:
- Lebih aman
- Lebih murah
- Lebih mudah didapatkan

Transfusion Reactions

Immediate Delayed

Hemolytic Non-hemolytic Infections Allergic

Febrile Allergic Hyper- Kalemia & Hypo-

Acidosis calcemia
Hemolytic
Transfusion Acute Lung Injury
Reaction

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