Syok Pada Perdarahan Obstetri

● Syok adalah suatu sindrom dimana terjadi ketidak

seimbangan antara kebutuhan oksigen tissue (VO2)
dengan delivery oksigen (DO2)
● Ditandai tidak adekuatnya oksigenisasi dan perfusi
(aliran darah ke organ) ke jaringan
● Mengancam nyawa ibu dan janin
● Diagnosis dan penatalaksanaan yang tepat menentukan
keberhasilan
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The most common types of shock:
Shock
Type of shock Aetiology

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

Neurogenic shock Head trauma, spinal cord injury

Anaphylactic shock Repeated contact with or injection

of antigenic substances
 Shock
The Course of Hypovolaemic Shock in Absence of Therapy

Blood Pressure Heart Rate

Blood Pressure (mm Hg)
Heart rate (min)

150 Bleeding

100

50

0 (Time)
Compensation Decompensation Irreversibility

Shock Phases
 Tatalaksana Pada Perdarahan Masif
 Airway
 Breathing
 Circulation
 Hemorrhage control
 Shock position
 Stop/ minimize the
bleeding
 Replace blood loss
Menghentikan Perdarahan
 Thrombogenic uterine pack
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
 Menghentikan Perdarahan

Kompresi B-Lynch suture

Bimanual
Kondom
Kateter
 Tatalaksana
Perdarahan pasca Persalinan
The Clinical Use of Blood
Estimasi BB : ... 60 kg
Estimasi Blood Volume : ... 70 ml/kg x 60 = 4200 ml
Estimasi Blood Loss : .... % EBV = ..... ml

Tsyst 120 100 < 90 < 60-70

Nadi 80 100 > 120 > 140 - ttb
Perf hangat pucat dingin basah

NORMO -- 15% -- 30% -- 50%

VOLEMIA
EBV EBV EBV

EBL = perdarahan 600 1200 2000 ml

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

 Kristaloid vs Koloid Sebagai Cairan
Pengganti
Kristaloid Koloid
Merembes ke komponen
ekstraselular Tetap berada di
Mengurangi peningkatan komponen intravaskular
cairan paru volume yang diperlukan
Meningkatkan fungsi organ lebih sedikit
Manfaat
setelah operasi Meningkatkan transpor
Reaksi anafilaktik minimal oksigen ke jaringan,
Kemungkinan dapat kontraktilitas jantung dan
mengurangi angka kematian keluarannya
Lebih murah

Predisposisi untuk terjadinya

Resiko Mahal
edema pulmonal
Choi et al 1999.
 Product Infection Risk Storage Start Infusion Indication Administration

Acute • ABO and RhD

Capable of transmitting • Between +2⁰C Within 30 minutes
Hypovolemia, compatible
Whole Blood any agent present in cells and +6⁰C in of removal from
Exchange • Complete tranfsusion
of plasma refrigerator refrigerator
tranfusion within 4 hours

• Between +2⁰C Anaemic patient, • ABO and RhD

Capable of transmitting Within 30 minutes
and +6⁰C in use crystalloid compatible
Packed RBCs any agent present in cells
refrigerator
of removal from
replacement in • Complete tranfsusion
of plasma refrigerator
• 42 days acute blood loss within 4 hours

• Initial dose of
Multiple
Capable of transmitting • 25⁰C or colder 15ml/kg
coagulation factor
FFP any agent present in cells for up to 1 year As soon as possible
deficiencies, DIC,
• Complete transfusion
of plasma • 12 months within 20 minutes
ITP

Capable of transmitting • 25⁰C or colder Von Willebrand Complete transfusion

Cryoprecipitate any agent present in cells for up to 1 year As soon as possible Diseases, within 20 minutes
of plasma • 12 months Haemophilia A, DIC

Capable of transmitting Trombocytopenia, Complete transfusion

• 20⁰C to 24⁰C
Platelets any agent present in cells
• 5 days
Immediately bone marrow within 20 minutes
of plasma failure
 Estimating Allowable Blood Loss Blood Loss
Clinical condition Equivalent
% Loss of blood Replacement
Healthy Average Poor Adult fluid
Volume Fliud
Percentage Methode Volume

Acceptabel
loss of blood 30% 20% 10%
vol Crystalloid ( e.g.
< 20 % Up to 1 Liter
0,9 % saline )
Haemodilution Method
Lowest
Acceptable 9 mg / dl 10 mg / dl 11 mg / dl
Hb Crystalloid and /
More than 1
> 20 % or Colloid Red
Lowest liter
27% 30% 33% Cell
acceptable Ht
 Starting Transfusion
 Warming of blood is not necessary  Prohibited to addition drugs &
for routine tx . Warming increasing medications to blood bag / set except
metabolism, reduce 2,3-DPG & risk Normal Saline.
bacterial growth  Do not use dextrose 5% / RingerLactate.
 Indication for warming blood:  Use 170 u standard filter.
 Adult receiving over 50
 Transfusion must be completed in 4
ml/kg/hour
hours.
 Child receiving over 15
ml/kg/hour
 Hemodynamically stable 2 hours
 Exchange tranfusion in infants
 Hemodynamically unstable 4 hours
 Rapid infusion CVP lines
 Presence of cold aglutinines
 Autologous Blood
 Pre Operative Blood Donation
 Min Hb 11 gr
 1 Unit ( 10-15% Blood vol) 5-7 days
 35 days-2 days, iron supply
 Acute Normovolemic Haemodilution
 During surgery ( 4 hours )
 Monitoring
 Replace fluid = Crystaloid 1:3, Colloid 1:1
 Blood Salvage
 Direct tranfusion
Don’ts for Blood Transfusion
 Transfusion Reactions

Hemolytic
Transfusion
Reaction
 “Practice Safe Transfusion”

Informed Consent
Standardized Guidelines

Error and Incident

Adverse Event Reporting Reporting
Summary
 Components
 Indications
 Transfusion Reactions
 Rujukan
 Cunningham FG, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL,
Casey BM et al. William Obstetrics. 26th ed. New York Chicago San
Fransisco Lisbon London Madrid Mexico City Milan New Delhi San Juan
Seoul Singapore Sydney Toronto: Mc Graw Hill; 2022. p. 1893-2035.
 ACOG. Hemorrhagic shock. Educational Bulletin #235, 1997.
 Choi PT-L et al. 1999. crystalloid vs. colloids in fluid resuscitation: A
systematic review. Critical Care Medicine 27( 1): 200-210.
 Scheirhout and Roberts 1998. Fluid resuscitation with colloid or crystalloid
in critically ill patients: A systematic review of randomized trials. BMJ
316:961-964.
 MNH Post Partum Hemorrage.
 The Clinical Use of Blood, WHO 2002.
• RN/MD : Registered Nurse/Medical Doctor
• 2,3 DPG (diphosphoglyceric Acid) : salah satu komponen dari sel darah
merah yang berfungsi membantu transportasi oksigen ke sel/jaringan.
• AHTR : Acute Hemolytic Transfusion Reaction
• DHTR : Delay Hemolytic Transfusion Reaction
• IHTR : Immediate Hemolytic Transfusion Reaction
• TRALI :Transfusion Related Acute Lung Injury
• PTP : Post Transfusion Purpura
• GVH :Graft Versus Host Diseases