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cardio.acute-hf.peripartum-cmp.v1

Acute HF — Peripartum cardiomyopathy (PPCM)

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Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.acute-hf.core.v1 — peripartum cardiomyopathy (PPCM): HFrEF (LVEF <45%) developing in last month of pregnancy through 5 months postpartum, with no other identifiable cause. Risk factors: African ancestry (4× higher), age >30, multiparity, pre-eclampsia, multiple gestation. Specializes pregnancy-aware drug selection (AVOID ACEi/ARB/ARNI/MRA/warfarin/DOAC/SGLT2i antepartum; substitute hydralazine + nitrate; LMWH for AC); bromocriptine 2.5 mg PO BID × 8 weeks postpartum per IPAC RCT (Sliwa 2017 PMID 28637825) for LVEF recovery; future-pregnancy counseling (recurrence rate 30-50% if LVEF did not normalize). Pregnancy heart team (cardiology + MFM + anesthesia + neonatology) essential. Manifest pointer reuses cardio.acute-hf.core.v1 manifest. Design-brief pointer reuses parent (PPCM-specific differences documented inline). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled.

Entry points (4)

  • symptom
    New dyspnea/orthopnea/PND in last month of pregnancy through 5 months postpartum
    late_pregnancy_or_postpartum_dyspnea_orthopnea
  • imaging
    Echo LVEF <45% in peripartum window with no prior cardiac history (PPCM diagnostic criterion)
    echo_lvef_below_45_in_peripartum_window
  • lab_abnormality
    BNP/NT-proBNP elevated in peripartum patient with dyspnea (BNP elevation NOT physiologic in pregnancy)
    elevated_bnp_or_nt_probnp_peripartum
  • history
    History of PPCM with subsequent pregnancy — recurrence risk 30-50% if LVEF did not normalize
    prior_ppcm_with_subsequent_pregnancy

Required inputs (11)

  • agerequired
    demographic • used at CONTEXT
    Age >30 increases PPCM risk; affects future-pregnancy counseling
  • gestational_age_or_postpartum_dayrequired
    history • used at CONTEXT
    PPCM defined window: last month pregnancy through 5 months postpartum; trimester drives ACEi/ARB/warfarin teratogenicity decisions
  • parity_and_prior_obstetric_historyrequired
    history • used at CONTEXT
    Multiparity + multiple gestation + pre-eclampsia are PPCM risk factors
  • self_identified_ancestry
    demographic • used at CONTEXT
    African ancestry confers 4× higher PPCM incidence and worse recovery profile
  • sbprequired
    vital • used at RED_FLAGS
    Hemodynamic stratification — pre-eclampsia overlap common; SBP guides afterload reduction choice (hydralazine peripartum)
  • spo2required
    vital • used at RED_FLAGS
    Hypoxemia from pulmonary edema; guides NIPPV vs intubation decision in late pregnancy
  • echo_lvef_and_chamber_sizerequired
    imaging • used at INITIAL_WORKUP
    Echo LVEF <45% is the diagnostic criterion; LV chamber size + RV function + valvular assessment
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    NT-proBNP elevation in peripartum dyspnea is sensitive for PPCM; trends response to therapy
  • creatininerequired
    lab • used at CONTEXT
    Cardiorenal screen + LMWH dosing + ACEi-postpartum dose adjustment
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Rules out ischemic CMP differential; mildly elevated in PPCM but high values prompt SCAD/MI workup
  • pre_existing_cardiac_or_valvular_diseaserequired
    history • used at INITIAL_WORKUP
    PPCM is diagnosis of exclusion — must rule out pre-existing CMP, valvular, ischemic, viral myocarditis

12-phase flow (10)

  1. 1FRAME
    PPCM = HFrEF (LVEF <45%) in last month of pregnancy through 5 months postpartum, no other identifiable cause; pregnancy status drives drug selection (ACEi/ARB/warfarin teratogenic; bromocriptine adjunct)
    inputs: gestational_age_or_postpartum_day, echo_lvef_and_chamber_size
    advance: PPCM diagnosis criteria met or strong suspicion
  2. 2ENTRY
    Bedside echo + NT-proBNP + ECG + obstetric consult if antepartum; multidisciplinary pregnancy heart team activation
    inputs: age, gestational_age_or_postpartum_day
    advance: pregnancy heart team engaged
  3. 3CONTEXT
    Trimester or postpartum day determined; ancestry, parity, multiple gestation, pre-eclampsia, lactation status all documented for drug-selection decisions
    inputs: parity_and_prior_obstetric_history, creatinine
    advance: pregnancy context complete
  4. 4RED_FLAGS
    Cardiogenic shock peripartum (high mortality), pulmonary edema requiring intubation, refractory arrhythmia, fetal distress if antepartum, AC-related obstetric bleeding
    inputs: sbp, spo2
    actions: cardiogenic_shock
    advance: red flags screened + obstetric team aware
  5. 5INITIAL_WORKUP
    Echo (LVEF, chamber size, valvular, RV), NT-proBNP, troponin, BMP, CBC, TSH, viral panel if indicated, ECG, CXR (limited radiation if antepartum); rule out pre-existing CMP / valvular / ischemic / viral myocarditis
    inputs: echo_lvef_and_chamber_size, nt_probnp, troponin, pre_existing_cardiac_or_valvular_disease
    actions: acute_pulm_edema, panel.cardiac, panel.renal
    advance: workup documented + PPCM confirmed by exclusion
  6. 6BRANCHING_WORKUP
    Cardiac MRI postpartum if diagnosis uncertain (LGE pattern); coronary CTA or cath if SCAD/ischemic concern; viral PCR if myocarditis suspected; genetic counseling if family history of CMP
    advance: differential narrowed
  7. 7TREATMENT
    STANDARD ADHF: IV loop diuretic (furosemide 40 mg IV bolus, titrate per DOSE), NIPPV for pulmonary edema, IV inotrope (milrinone preferred over dobutamine in pregnancy — class limited data) if cardiogenic shock. PEPARTUM-SPECIFIC: AVOID ACEi/ARB/ARNI/spironolactone if antepartum (teratogenic) — substitute hydralazine + isosorbide dinitrate for afterload reduction. Bromocriptine 2.5 mg PO BID × 8 weeks per IPAC (Sliwa 2017 PMID 28637825) — postpartum only (suppresses lactation). Beta-blocker (metoprolol succinate or carvedilol) safe in pregnancy and postpartum. POSTPARTUM: full GDMT 4-pillar (ACEi/ARNI + BB + MRA + SGLT2i if eGFR allows). AC: LMWH peripartum if CHA2DS2-VASc ≥2 + LVEF <35%; transition to warfarin or DOAC postpartum.
    inputs: sbp, creatinine
    actions: protocol.cardiogenic_shock
    advance: pregnancy-appropriate regimen active + lactation status documented
  8. 8DISPOSITION
    CICU if hemodynamic instability or delivery imminent; obstetric MFM ward if antepartum and stable; cardiology floor if postpartum and stable; transfer to advanced HF center if MCS need or refractory shock
    advance: unit + multidisciplinary plan documented
  9. 9MONITORING
    Continuous telemetry, daily weight, hourly UOP, fetal monitoring if antepartum, daily BMP, repeat echo at 1 week and at 6 weeks postpartum for LVEF recovery trajectory
    inputs: nt_probnp, creatinine
    actions: panel.cardiac
    advance: monitoring + LVEF surveillance plan booked
  10. 10FOLLOWUP
    PPCM clinic at 2 weeks, 6 weeks, 3 months, 6 months postpartum; serial echo for LVEF recovery; future-pregnancy counseling (recurrence 30-50% if LVEF did not normalize); ICD/WCD evaluation if LVEF still <35% at 3-6 months on full GDMT
    advance: PPCM clinic + future-pregnancy counseling + ICD pathway documented