Obstetric Shock Beyond Hemorrhage: Microcirculatory Shunting, Endothelial Glycocalyx Injury, and Mitochondrial Failure in Pregnancy—A Narrative Review
5 affiliations
- 1Department of Anesthesiology and Intensive Care, Faculty of Medicine, Maranatha Christian University, Bandung, West Java 40164, Indonesia
- 2Fetomaternal Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Maranatha Christian University, Bandung, West Java 40164, Indonesia
- 3Department of Anesthesiology and Intensive Care, Faculty of Medicine, Padjadjaran University, Bandung, West Java 45363, Indonesia
- 4Fertility Division, Department of Obstetrics and Gynecology, Faculty of Medicine, Maranatha Christian University, Bandung, West Java 40164, Indonesia
- 5Department of Obstetrics and Gynecology, Faculty of Medicine, Maranatha Christian University, Bandung, West Java 40164, Indonesia
Abstract
Obstetric shock has traditionally been conceptualized within the framework of hemorrhage and macrocirculatory collapse. However, clinical deterioration may occur despite preserved blood pressure and cardiac output, indicating that disturbances in tissue perfusion and cellular metabolism can precede overt hemodynamic instability. This narrative review synthesizes current evidence examining the contributions of microcirculatory dysfunction, endothelial glycocalyx injury, mitochondrial impairment, immune–metabolic dysregulation, and placental signaling to the development and progression of obstetric shock beyond conventional hemodynamic paradigms. A literature review was conducted using PubMed/MEDLINE and PubMed Central, focusing on studies in obstetrics, critical care, endothelial biology, microcirculatory physiology, and mitochondrial function, with articles selected for their mechanistic, translational, and clinical relevance. Available evidence suggests that disruption of the microcirculation, endothelial injury, and impaired cellular energy metabolism may interact to produce tissue hypoperfusion despite preserved systemic hemodynamics, a phenomenon described as hemodynamic incoherence. These mechanisms may contribute to diverse clinical phenotypes, including normotensive hypoperfusion, endothelial dysfunction–associated shock, microthrombotic states, and impaired cellular oxygen utilization. Although much of the supporting evidence derives from studies of preeclampsia, sepsis, and non-obstetric critical illness rather than obstetric shock itself, these findings provide biologically plausible mechanistic insights that may improve understanding of unexplained maternal deterioration. Emerging physiologic monitoring techniques may facilitate earlier recognition of occult tissue hypoperfusion, although their validation and routine clinical application in obstetric practice remain limited. Overall, obstetric shock should be considered a heterogeneous syndrome that extends beyond hemorrhage alone, and an integrated framework incorporating microvascular, endothelial, metabolic, and placental processes may improve understanding of its pathophysiology while informing future diagnostic and therapeutic research. Further obstetric-specific studies are required to validate these concepts and define their clinical implications.
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BibTeX
@article{rahardjo2026obstetric,
title = {{Obstetric Shock Beyond Hemorrhage: Microcirculatory Shunting, Endothelial Glycocalyx Injury, and Mitochondrial Failure in Pregnancy—A Narrative Review}},
author = {Theresia Monica Rahardjo and Aloysius Suryawan and Wiku Andonotopo and Reza Widianto Sudjud and Ridwan Abdullah Putra and Arief Setiawan and Rizna Tyrani Rumanti and Roland Frederik Lengkey},
journal = {Maternal-fetal medicine (Wolters Kluwer Health, Inc.)},
year = {2026},
month = jul,
doi = {10.1097/fm9.0000000000000373},
url = {https://europepmc.org/article/PMC/PMC13706211},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Obstetric Shock Beyond Hemorrhage: Microcirculatory Shunting, Endothelial Glycocalyx Injury, and Mitochondrial Failure in Pregnancy—A Narrative Review
AU - Theresia Monica Rahardjo
AU - Aloysius Suryawan
AU - Wiku Andonotopo
AU - Reza Widianto Sudjud
AU - Ridwan Abdullah Putra
AU - Arief Setiawan
AU - Rizna Tyrani Rumanti
AU - Roland Frederik Lengkey
PY - 2026
DA - 2026/07/29
JO - Maternal-fetal medicine (Wolters Kluwer Health, Inc.)
DO - 10.1097/fm9.0000000000000373
UR - https://europepmc.org/article/PMC/PMC13706211
AB - Obstetric shock has traditionally been conceptualized within the framework of hemorrhage and macrocirculatory collapse. However, clinical deterioration may occur despite preserved blood pressure and cardiac output, indicating that disturbances in tissue perfusion and cellular metabolism can precede overt hemodynamic instability. This narrative review synthesizes current evidence examining the contributions of microcirculatory dysfunction, endothelial glycocalyx injury, mitochondrial impairment, immune–metabolic dysregulation, and placental signaling to the development and progression of obstetric shock beyond conventional hemodynamic paradigms. A literature review was conducted using PubMed/MEDLINE and PubMed Central, focusing on studies in obstetrics, critical care, endothelial biology, microcirculatory physiology, and mitochondrial function, with articles selected for their mechanistic, translational, and clinical relevance. Available evidence suggests that disruption of the microcirculation, endothelial injury, and impaired cellular energy metabolism may interact to produce tissue hypoperfusion despite preserved systemic hemodynamics, a phenomenon described as hemodynamic incoherence. These mechanisms may contribute to diverse clinical phenotypes, including normotensive hypoperfusion, endothelial dysfunction–associated shock, microthrombotic states, and impaired cellular oxygen utilization. Although much of the supporting evidence derives from studies of preeclampsia, sepsis, and non-obstetric critical illness rather than obstetric shock itself, these findings provide biologically plausible mechanistic insights that may improve understanding of unexplained maternal deterioration. Emerging physiologic monitoring techniques may facilitate earlier recognition of occult tissue hypoperfusion, although their validation and routine clinical application in obstetric practice remain limited. Overall, obstetric shock should be considered a heterogeneous syndrome that extends beyond hemorrhage alone, and an integrated framework incorporating microvascular, endothelial, metabolic, and placental processes may improve understanding of its pathophysiology while informing future diagnostic and therapeutic research. Further obstetric-specific studies are required to validate these concepts and define their clinical implications.
SN - 2096-6954
SN - 2641-5895
ER -