Shock in Pregnancy – Recommendations of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI – Section Shock) and the Working Group on Obstetrics and Prenatal Medicine (AGG – Section on Maternal Disorders)

Abstract

Objective The recommendations of the Shock Section of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI) and the Maternal Disorders Section of the Working Group on Obstetrics and Prenatal Medicine (AGG) aim to improve the diagnosis and management of pregnant patients in shock. In 2018, the DIVI Shock Section published a revised classification of shock types. Given that pregnancy involves extensive physiological changes affecting all organ systems – with direct implications for the development and progression of shock – specific characteristics of shock in pregnancy were analyzed.

Methods A selective literature review and iterative consensus process were conducted within the DIVI Shock Section and the Maternal Disorders Section of the AGG.

Results Shock, defined as a state of circulatory failure characterized by a critical mismatch between oxygen delivery (DO₂) and consumption (VO₂), is common to all shock types, including in pregnant women. Unique features of pregnancy include altered sensitivity to triggering factors, modified classical shock symptoms, and specific diagnostic and therapeutic approaches to optimize outcomes for both mother and child.

Conclusions The statements and recommendations facilitate the identification of underlying causes across the different forms of shock (hypovolemic, distributive, cardiogenic, and obstructive) and support the initiation of appropriate management strategies.

Keywords

pregnancy - shock - emergency medicine - obstetrics - intensive care medicine

^* Michael Abou-Dakn, Thorsten Annecke, Christopher Beynon, Matthias Emmel, Dietmar Fries, Stefan Geiger, Axel R. Heller, Jan Kähler, Franz Kainer, Sven Kehl, Janett Kreutziger, Lorenz Lampl, Christoph Menzel, Udo Rolle, Anton Sabashnikov, Andreas Schaper, Bertram Scheller, Silvia Schönenberger, Frank Siemers, Thomas Standl, Wolfram Teske, Stefan Topp

^** Michael Abou-Dakn, Franz Kainer, Sven Kehl

Publication History

Received: 25 May 2025

Accepted: 27 June 2025

Article published online:
05 September 2025

• References

• 1 Standl T, Annecke T, Cascorbi I. et al. The Nomenclature, Definition and Distinction of Types of Shock. Dtsch Arztebl Int 2018; 115: 757-768
• 2 Schlembach D, Annecke T, Girard T. et al. Peripartum Haemorrhage, Diagnosis and Therapy. Guideline of the DGGG, OEGGG and SGGG (S2k, AWMF Registry No. 015–063, August 2022). Geburtshilfe Frauenheilkd 2023; 83: 1446-1490
• 3 Gänsslen A, Adams HA, Baumann G. et al. Haemostasis in shock Part 4: Special pathophysiological aspects. Anästh Intensivmed 2016; 57: 58-67
• 4 Deitch EA, Condon M, Feketeova E. et al. Trauma-hemorrhagic shock induces a CD36-dependent RBC endothelial-adhesive phenotype. Crit Care Med 2014; 42: e200-e210
• 5 Slaughter AL, Nunns GR, DʼAlessandro A. et al. The Metabolopathy of Tissue Injury, Hemorrhagic Shock, and Resuscitation in a Rat Model. Shock 2018; 49: 580-590
• 6 Pourrat O, Coudroy R, Pierre F. Differentiation between severe HELLP syndrome and thrombotic microangiopathy, thrombotic thrombocytopenic purpura and other imitators. Eur J Obstet Gynecol Reprod Biol 2015; 189: 68-72
• 7 Jackson J, George V, McKinney J. et al. Multimodal postpartum imaging of a severe case of Couvelaire uterus. Case Rep Perinat Med 2022; 11: 20210013
• 8 WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017; 389: 2105-2116
• 9 Singer M, Deutschman CS, Seymour CW. et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315: 801-810
• 10 Shankar-Hari M, Phillips GS, Levy ML. et al. Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315: 775-787
• 11 Antonucci E, Fiaccadori E, Donadello K. et al. Myocardial depression in sepsis: from pathogenesis to clinical manifestations and treatment. J Crit Care 2014; 29: 500-511
• 12 Evans L, Rhodes A, Alhazzani W. et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47: 1181-1247
• 13 Carle C, Alexander P, Columb M. et al. Design and internal validation of an obstetric early warning score: secondary analysis of the Intensive Care National Audit and Research Centre Case Mix Programme database. Anaesthesia 2013; 68: 354-367
• 14 Louie JK, Salibay CJ, Kang M. et al. Pregnancy and severe influenza infection in the 2013–2014 influenza season. Obstet Gynecol 2015; 125: 184-192
• 15 Bowyer L, Robinson HL, Barrett H. et al. SOMANZ guidelines for the investigation and management sepsis in pregnancy. Aust N Z J Obstet Gynaecol 2017; 57: 540-551
• 16 Oseghale O, Vlahos R, OʼLeary JJ. et al. Influenza Virus Infection during Pregnancy as a Trigger of Acute and Chronic Complications. Viruses 2022; 14: 2729
• 17 Allotey J, Stallings E, Bonet M. et al. Clinical manifestations, risk factors, and maternal and perinatal outcomes of coronavirus disease 2019 in pregnancy: living systematic review and meta-analysis. BMJ 2020; 370: m3320
• 18 Vasquez DN, Giannoni R, Salvatierra A. et al. Ventilatory Parameters in Obstetric Patients With COVID-19 and Impact of Delivery: A Multicenter Prospective Cohort Study. Chest 2023; 163: 554-566
• 19 Kalafat E, Prasad S, Birol P. et al. An internally validated prediction model for critical COVID-19 infection and intensive care unit admission in symptomatic pregnant women. Am J Obstet Gynecol 2022; 226: 403.e1-403.e13
• 20 Gotts JE, Matthay MA. Sepsis: pathophysiology and clinical management. BMJ 2016; 353: i1585
• 21 Brunkhorst FM, Weigand MA, Pletz M. et al. [S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2020; 115: 37-109
• 22 Neuhaus S, Neuhaus C, Weigand MA. et al. [Principles of intensive medical care in pregnant patients]. Anaesthesist 2021; 70: 621-630
• 23 Berlit P. [Neurological Disorders and Pregnancy]. Fortschr Neurol Psychiatr 2016; 84: 103-111 quiz 112–113
• 24 Bateman BT, Schumacher HC, Bushnell CD. et al. Intracerebral hemorrhage in pregnancy: frequency, risk factors, and outcome. Neurology 2006; 67: 424-429
• 25 Kowalski A, Brandis D. Shock Resuscitation. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2024
• 26 Stein DM, Knight WA. Emergency Neurological Life Support: Traumatic Spine Injury. Neurocrit Care 2017; 27: 170-180
• 27 Briggs GG, Freeman RK, Tower CV. et al. Briggʼs Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk. Online (Stand: 27.11.2024): https://www.wolterskluwer.com/en/solutions/ovid/briggs-drugs-in-pregnancy-and-lactation-a-reference-guide-to-fetal-and-neonatal-risk-730
• 28 Abboud T, Raya J, Sadri S. et al. Fetal and maternal cardiovascular effects of atropine and glycopyrrolate. Anesth Analg 1983; 62: 426-430
• 29 Banayan J, Rana S, Mueller A. et al. Cardiogenic shock in pregnancy: Analysis from the National Inpatient Sample. Hypertens Pregnancy 2017; 36: 117-123
• 30 Chung E, Leinwand LA. Pregnancy as a cardiac stress model. Cardiovasc Res 2014; 101: 561-570
• 31 Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J. et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J 2018; 39: 3165-3241
• 32 Davis MB, Arany Z, McNamara DM. et al. Peripartum Cardiomyopathy: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 75: 207-221
• 33 James AH, Jamison MG, Biswas MS. et al. Acute myocardial infarction in pregnancy: a United States population-based study. Circulation 2006; 113: 1564-1571
• 34 Prakash S, Pramanik V, Chellani H. et al. Maternal and neonatal effects of bolus administration of ephedrine and phenylephrine during spinal anaesthesia for caesarean delivery: a randomised study. Int J Obstet Anesth 2010; 19: 24-30
• 35 Furer A, Wessler J, Burkhoff D. Hemodynamics of Cardiogenic Shock. Interv Cardiol Clin 2017; 6: 359-371
• 36 Pich H, Heller AR. [Obstructive shock]. Anaesthesist 2015; 64: 403-419
• 37 Pacheco LD, Clark SL, Klassen M. et al. Amniotic fluid embolism: principles of early clinical management. Am J Obstet Gynecol 2020; 222: 48-52
• 38 Tschöp J, Lier H, Annecke T. Anästhesiologisches Management der Fruchtwasserembolie. Anasthesiol Intensivmed Notfallmed Schmerzther 2020; 55: 674-685
• 39 Kaur K, Bhardwaj M, Kumar P. et al. Amniotic fluid embolism. J Anaesthesiol Clin Pharmacol 2016; 32: 153-159