Classification of obstetric shock diagnosis and monitoring

Since 1743 there shock (shock) after the word, people realize that over a long period of shock is not a disease but multiple diseases and life-threatening allergic reactions and damage and pathological process. Shock due to acute circulatory dysfunction, body tissue and organ perfusion deficiency, caused by ischemia, hypoxia, metabolic disorders and various important organs of serious disorder syndrome. Shock can occur in the course of various diseases, if not adequately addressed, the body tissues and organs will be irreversible damage caused by death. Obstetric shock that occurred in the maternal-specific shock, and pregnancy, is directly related to childbirth. Obstetric shock is one of the most prominent obstetric emergency, a threat of maternal and perinatal life, a major reason children. 1 Classification of obstetric shock and shock are generally divided into five categories: hypovolemic shock (including hemorrhagic shock and traumatic shock), cardiogenic shock, neurogenic shock, septic shock and anaphylactic shock. Obstetric shock to hemorrhagic shock, followed by septic shock or other special causes of shock, so people usually divided into obstetric shock and non-hemorrhagic shock hemorrhagic shock [1]. 1.1 1.1.1 obstetric hemorrhagic shock hemorrhagic shock in pregnancy abortion or ruptured ectopic pregnancy, intrauterine pregnancy, incomplete abortion, missed abortion, placenta previa, placental abruption, pregnancy, clotting mechanism and so can be causes bleeding and shock. 1.1.2 hemorrhagic shock during childbirth vagina, cervix, uterine injury or rupture, rupture of cervical venous plexus adjacent broad ligament hematoma, fan-shaped placenta causing bleeding leading to shock. 1.1.3 postpartum hemorrhagic shock after the fetus or the placenta due to uterine contractions remain poor, residue, such as caused by the implantation of postpartum hemorrhage, coagulopathy, wound dehiscence after cesarean section, also can cause bleeding leading to shock . <! - Picture in Picture PIP start --><!-- end -> 1.2 1.2.1 obstetric hemorrhagic shock in non-septic shock Septic shock is a serious infection in obstetric complications, abortion or puerperal infection prone to bacterial infection. Common pathogenic bacteria are anaerobic bacteria, such as anaerobic Lactobacillus, Bacteroides, Escherichia coli, Pseudomonas aeruginosa, etc.; streptococci are divided into A, B, C Category 3 to Category B hemolytic streptococcus virulence most powerful and easy to cause the spread of infection and sepsis; aureus, into gold, white, lemon three categories, in order to most Staphylococcus aureus virulence, easy transfer of abscesses caused by multiple, easy to produce drug resistance. 1.2.2 traumatic shock in the placenta when the uterus caused by repeatedly squeezing the uterus turn, hand to take the placenta, curettage, and other medium-term surgical abortion cavity injection during the operation, careless operation may result in traumatic shock. 1.2.3 obstructive shock amniotic fluid embolism, thromboembolism, air embolism and more by the uterine blood Douzhi Jing vein thrombosis, pulmonary hypertension, can also be small if the embolus to the lungs through the pulmonary capillary cerebral venous thrombosis, or even disseminated intravascular coagulation, shock. 1.2.4 supine hypotension syndrome due to change thy blood less, resulting in tissue, organ hypoperfusion, causing tissue ischemia, hypoxia, shock may occur. 1.2.5 anaphylactic shock applied during the operation allergic narcotic drugs, resulting in anaphylactic shock [2-3]. 1.2.6 Others such as spinal or epidural anesthesia caused by straying into the spinal cord cavity neurogenic shock, cardiac insufficiency during pregnancy and timely treatment is not caused by cardiogenic shock. 2, the diagnosis of obstetric shock and the nature of shock, microcirculatory blood perfusion is drastically reduced, the shock occurs, hemodynamic changes, the release of various humoral factors on changes in the microcirculation plays a regulatory role. According to changes in microcirculation, the progress can be divided into three shock, that shock of early shock and the shock of late. The diagnosis of shock in the past based on the degree of blood pressure lowering, in fact, reduced blood pressure was diagnosed shock therapy has lost a good opportunity at this time is often shock or shock of late, so you obstetrics in the

early diagnosis of shock diagnosis. Shock depends on early diagnosis of clinical and laboratory tests, for patients with suspected shock, the primary task is to determine whether the patient is in shock, and then judge the extent of the current shock, while in the active rescue shock to find the cause of causes, usually to that shock is not difficult to determine, according to the preliminary conclusion of clinical symptoms. 2.1 shock of early conscious, conscious thirst, pale skin and mucous membranes begin, the skin temperature is normal, cold, pulse <100/min, normal or slightly higher systolic blood pressure, diastolic blood pressure increased, narrowing pulse pressure, peripheral circulation was normal, urine was normal. The decrease of circulating blood volume <20%. 2.2 The shock of the mind is still clear, conscious indifference, slow, thirsty, pale skin and mucous membranes, skin cold, pulse 100 ~ 120/min, thready and weak pulse, systolic blood pressure decreased to 70 ~ 90mmhg, pulse pressure is small, superficial veins collapse, slow capillary filling, oliguria (<30mL / h), then entered decompensated shock. The decrease of circulating blood volume of 20% to 40%, respectively. 2.3 The fuzzy mind late shock and even coma, very thirsty, but may not be the main complaint, pale skin and mucous membranes significantly, acral cyanosis, skin cold to the extremities, systolic blood pressure <70mmHg or undetectable, superficial vein collapse very slow capillary filling, oliguria or even anuria. And shock may occur late circulatory system, digestive system, respiratory system, urinary system and other multi-system dysfunction, induced by multiple system organ failure and even cardiac arrest. The decrease of circulating blood volume> 40%. 3, the majority of obstetric monitoring of obstetric shock shock ferocious, life-threatening within a short time. Therefore, the familiar shock of monitoring methods, early detection of shock, and actively deal with important clinical significance. 3.1 The early clinical manifestations of monitoring the performance of the shock irritability, anxiety or excitement, not with doctors, thirst, blood pressure, rapid thready pulse, pale or mild cyanosis, clammy extremities; shock advanced into suppression, expression of indifference or confusion and even coma, skin color, cyanosis, clammy extremities, peripheral vein and jugular vein collapse, nail fold capillary filling speed rate, blood pressure continued to decline, slow pulse, dilated pupils, facial white swelling, oliguria or anuria and other may suggest a serious degree of shock. 3.2 The monitoring of vital signs the pulse or heart rate monitor is the most simple and easy method to monitor shock [4]. Early changes of blood pressure has not shock, pulse and heart rate has accelerated markedly, such as pulse and heart rate> 100/min, should consider the possibility of early shock, shock pulse in the early fall in blood pressure before, often breakdown, with blood pressure, more for the breakdown; shock later, the thin and slow, suggesting a critical condition. Monitoring blood pressure is an important indicator of shock, but should be closely integrated clinical and pulse rate to judge. Should be considered in shock following occur: systolic blood pressure: <90mmHg, or based on the original lower 20 ~ 30mmHg; DBP: <40mmHg; pulse pressure <20mmHg. Mean arterial pressure (MAP): clinical diagnosis for shock value more, MAP = DBP +1 / 3 pulse pressure, such as <65mmHg should be diagnosed shock. Monitoring of breathing, shock early breath and respiratory acidosis appeared deep and rapid breathing; acidosis deepened, the breathing became deep and slow breathing difficulties, rapid shallow breathing, sighing like tidal breathing or breathing is that shock enter the critical stage. Urine reflects renal perfusion shock, indirectly reflects the perfusion of vital organs the body can reflect the severity of shock, if the urine volume <25mL / h, or 24h urine volume <600mL, that shock has entered the late in the urine and urinary sodium and low enough in patients with sepsis, suggesting that retention of sodium by the kidneys in order to maintain blood volume, this time despite normal urine output should also be fluid. 3.3 Monitoring obstetric hemorrhage the estimated amount of bleeding often with greater subjectivity, not conducive to the shock of the early diagnosis and prompt treatment, the use of shock index (shocindex) estimated blood loss is simple, can be routinely used [4]. 3.4 The monitoring of central venous pressure central venous pressure changes than the early changes in arterial pressure, systemic venous blood volume can accommodate 55% to 60%.

Central venous pressure of the normal 5 ~ 10cmH2O. CVP reflects the blood volume, blood volume and cardiac ejection Rhodobryum functional relationship of dynamic indicators, but also the expansion of clinical treatment [5]. <5cmH2O prompted a serious shortage of blood volume; if> 15cmH2O the prompt cardiac insufficiency, venous bed or excessive contraction of pulmonary vascular resistance increased; if> 20cmH2O suggestive of congestive heart failure. More accurate dynamic observation, but central venous pressure reflects only the right atrium and right ventricle pressure, not directly reflect the pulmonary veins, left atrial and left ventricular pressure. 3.5-invasive cardiovascular hemodynamic monitoring function monitoring: Swan-Gans catheter pulmonary artery flotation method [6]: the catheter from cubital vein into the superior vena cava balloon inflation will make it with the blood flow through the right atrium and right ventricle into the pulmonary artery, pulmonary artery and pulmonary capillary wedge pressure, can understand the pulmonary veins, left atrium and left ventricle end diastolic pressure and volume before the load, in order to reflect the resistance situation in the pulmonary circulation. Normal pulmonary artery pressure was 10 ~ 22mmHg, pulmonary artery wedge pressure of normal for the 6 ~ 15mmHg, increased pulmonary vascular resistance that increase. Central venous pressure did not increase pulmonary edema, and pulmonary artery wedge pressure increased significantly. Therefore, the monitoring of pulmonary artery wedge pressure than central venous pressure monitoring. However, there are some complications catheter application, technically demanding higher catheter longer than 72h, not dynamic observation, it is only in the hospital conditions in patients with acute re-applied when necessary. Noninvasive monitoring of cardiac function requires special equipment, complex operation, and can not be dynamic monitoring, is not yet widely used. 3.6 laboratory monitoring, including blood, arterial blood gas analysis, electrolytes and coagulation and other projects determined. Such as the determination of blood cell count, hemoglobin and hematocrit, hemorrhagic shock occurs when the indicators are low; septic shock, leukocyte and neutrophil counts significantly increased granulocyte poisoning can occur inside the particles. Blood gas analysis: shock, pH, PO2 decreased, PCO2 increased. Considered when there is disseminated intravascular coagulation can be used for three screening tests: platelet count <100 109 / L, fibrinogen <1.5 g / L, prothrombin time> 15s, or more than the normal> ; 3s. Obstetric shock, early diagnosis, timely and correct treatment to reduce maternal mortality and improve perinatal outcome of great significance. Therefore, as obstetricians should fully understand the occurrence of obstetric shock, development, and change the law, familiar with the diagnostic criteria and monitoring methods.

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