treatment OF endothermic SHOCK

MMR:--Septic abortion / Criminal abortion/ Backstreet abortion related death was common in the decades of sixties and seventies. Fortunately, this rate (MMR  / mortality due to abortion) however has declined after promulgation of MTP act, 1972.(the yr of my passing MD). Now let us quickly but briefly recapitulate “How to treat a woman ENDOTOXIC (SEPTIC OR BACTERAEMIC) SHOCK” ??  My dear members pl add your comments so that we caN SHARE OUR EXPERINCES.

Obstetric Causes OF SEPTIC SHOCK? ENDOTOXIC SHOCK??

Septic abortion.

Prolonged rupture of membranes.

Manipulations and instrumentations.

Trauma.

Retained placental tissues.

Puerperal sepsis.

Severe acute pyelonephritis.

Causative Organisms

Gram-negative bacilli: E.coli, proteus, pseudomonas and bacteroids. The endotoxin is a phospholipopolysaccharide released by lysis of its cell envelope.

A similar picture is produced from exotoxin of ß-haemolytic streptococci, anaerobic streptococci and clostridia.

Pathology

Release of endotoxin results in increased lysosomal permeability and cytotoxicity. The sequence of events thereafter may occur in few minutes and include:

Stimulation of the adrenal medulla and sympathetic nervous system → constriction of arterioles and venules → local acidosis → arteriolar dilatation but with continuing constriction of the venules → capillary pooling of blood → haemorrhagic engorgement of bowel, liver, kidneys and lungs.

There is associated extensive disseminated intravascular coagulation due to sudden massive plasmin generation with which the antiplasmins cannot cope.

Clinical Features

Endotoxic shock passes with 2 main stages:

Reversible stage

It has 2 phases:

Early (warm) phase: there are;

hypotension,

tachycardia,

pyrexia,

rigors,

flushed skin,

patient is alert,

leucocytosis develops within hours.

Late (cold) phase: there are;

cold and clammy skin,

mottled cyanosis,   

purpura,

jaundice,

progressive mental confusion,

coma.

Irreversible stage

Prolonged cellular hypoxia leads to:

metabolic acidosis,

acute renal failure,   

cardiac failure,

pulmonary oedema,   

adrenal failure and ultimately death.

Differential Diagnosis

Amniotic fluid embolism.

Pulmonary embolism.  

Pulmonary aspiration syndrome.

Myocardial infarction.         

Incompatible blood transfusion.

Management

It includes 3 major lines of treatment:

Restoration of circulatory function and oxygenation

Replacement of blood loss: by whole blood, if not available start with colloids or crystalloids. The CVP measurement is essential to guard against circulatory overload.

Corticosteroids: as;

Hydrocortisone 1gm IV / 6 hours or,

Dexamethasone 20 mg initially followed by 200 mg/day by IV infusion.

β-adrenergic stimulants: as isoprenaline cause arteriolar dilatation, increase heart rate and stroke volume improving tissue perfusion. Blood volume must be normal prior to its administration.

Oxygen: if respiratory function is impaired.

Aminophylline: improves respiratory function by alleviating bronchospasm.

Eradication of infection

Antibiotic therapy:

Swabs for culture and sensitivity are taken first.

Antibiotic therapy is starting immediately till the result of culture and given by IV route. The therapy should cover the wide range of organisms:

	Antibiotic	Acts upon	Dose
Regimen 1	Ampicillin or Cephalosporines	Aerobic gram+ organisms and gram- cocci.	500-1000 mg/6 hours.
	Gentamycin	Aerobic gram- bacilli.	80 mg/ 8 hours. (not to be given in the solutions).
	Metronidazole	Anaerobic.	500 mg/ 8 hours.
Regimen 2	Clindamycin	Aerobic gram + organisms + gram- cocci + anaerobic organisms.	600 mg/ 6 hours.
	Gentamycin	Aerobic gram- bacilli.	80 mg/ 8 hours.

Surgical treatment:

is indicated when there is retained infected tissues as in septic abortion. It should be removed as soon as antibiotic therapy and resuscitative measures have been started by:

suction evacuation,

digital evacuation, or

hysterectomy in advanced infection with a gangrenous (clostridium welchii) or traumatised uterus.