Clinical Commander

All dossiers
cardio.cardiogenic-shock.amniotic-fluid-embolism.v1

Cardiogenic shock — amniotic fluid embolism (AFE)

cardiologyacuteadultpregnancyacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to amniotic fluid embolism (AFE)–associated cardiogenic shock per SMFM 2016 consensus (Pacheco PMID 26987420) + Hui 2022 international consensus + AHA 2024 maternal arrest scientific statement. Rare obstetric emergency (1:8,000–80,000 deliveries) with abrupt triad: cardiovascular collapse + hypoxemia + DIC during labor or within 30 min postpartum / D&C / amnioinfusion. Pathophysiology is biphasic: phase 1 (early) — amniotic fluid + fetal squames + tissue factor enter maternal circulation → pulmonary vasoconstriction → acute pulmonary HTN + RV failure + hypoxemia; some cases anaphylactoid reaction (mast cell tryptase elevation in subset). Phase 2 (later) — LV failure + DIC (hyperfibrinolytic pattern) + obstetric hemorrhage from atony + coagulopathy. Diagnosis is CLINICAL — no confirmatory test exists. SMFM 2016 + Hui 2022 criteria: sudden cardiopulmonary collapse during or within 30 min of labor / delivery / D&C + acute hypoxemia + coagulopathy / DIC + no other identifiable cause. Treatment: maternal CPR with LEFT UTERINE DISPLACEMENT (15–30° lateral tilt OR manual displacement) per AHA 2024; PERIMORTEM CESAREAN within 4–5 min if no ROSC + viable gestation >20 wks per AHA 2024 + ACOG 2014 Committee Opinion #582; aggressive volume + vasopressors (NE first per SOAP-II PMID 20200382); inotropes (milrinone for RV failure phase 1; dobutamine for LV failure phase 2); pulmonary vasodilators (inhaled NO, epoprostenol) for refractory pulmonary HTN; MASSIVE TRANSFUSION PROTOCOL 1:1:1 RBC:FFP:platelets per PROPPR JAMA 2015 PMID 25647203; cryoprecipitate or fibrinogen concentrate to target ≥150 mg/dL (higher than typical trauma due to hyperfibrinolytic DIC + obstetric hemorrhage); tranexamic acid 1 g IV within 3 h per WOMAN trial Lancet 2017 PMID 28456510; uterotonics (oxytocin → methylergonovine if no HTN → carboprost if no asthma → misoprostol); recombinant factor VIIa LAST RESORT (thromboembolic risk); VA-ECMO if refractory CS / RV failure (ELSO 2020 obstetric ECMO registry). Mortality 20–60% maternal even with optimal modern care per Conde-Agudelo 2009 PMID 19751694 + Knight 2010 UKOSS PMID 21068427; permanent neurologic injury common in survivors; perinatal mortality 20–60%; neonatal neurologic morbidity high. Inherits parent CS framework (vasopressor / inotrope ladder, MCS escalation, MDT activation); specialises for obstetric pathophysiology — biphasic resuscitation, obstetric hemorrhage management with MTP + TXA + uterotonics + cryoprecipitate target ≥150, perimortem cesarean pathway, maternal arrest team activation, and long-term recovery emphasis on neurocognitive rehabilitation + perinatal bereavement support + future-pregnancy counseling. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 10 etiology variant.

Entry points (5)

  • symptom
    Sudden cardiovascular collapse + hypoxemia + coagulopathy during labor or within 30 min postpartum / D&C / amnioinfusion — AFE clinical diagnosis per SMFM 2016 + Hui 2022 consensus
    sudden_cardiovascular_collapse_during_labor_or_within_30_min_postpartum
  • history
    Maternal cardiac arrest in pregnancy or within 30 min postpartum — activate AHA 2024 maternal arrest pathway with LEFT UTERINE DISPLACEMENT and consider perimortem cesarean within 4–5 min if no ROSC and viable gestation >20 wks
    maternal_cardiac_arrest_pregnant_or_postpartum
  • lab_abnormality
    Sudden severe DIC (fibrinogen <150 mg/dL + ↑D-dimer + thrombocytopenia + ↑PT/aPTT) in peripartum woman with cardiopulmonary collapse — AFE-pattern hyperfibrinolytic coagulopathy
    sudden_severe_dic_in_peripartum_woman
  • imaging
    Bedside echo: acute RV failure + dilated RV + flattened septum (D-shaped LV) + acute pulmonary HTN in peripartum woman with shock — AFE phase 1 differential
    echo_acute_rv_failure_with_pulmonary_hypertension_peripartum
  • symptom
    Sudden fetal bradycardia / non-reassuring tracing followed by maternal cardiopulmonary collapse — sentinel AFE presentation pattern
    fetal_distress_followed_by_maternal_collapse

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Maternal age — AFE risk increases with maternal age >35 (Knight 2010 UKOSS PMID 21068427)
  • gestational_agerequired
    demographic • used at RED_FLAGS
    Gestational age determines perimortem cesarean indication (≥20 wks = uterus impedes IVC → benefit) per AHA 2024 maternal arrest and ACOG 2014 #582
  • sbprequired
    vital • used at RED_FLAGS
    SCAI 2022 staging baseline + maternal arrest threshold
  • spo2required
    vital • used at INITIAL_WORKUP
    Hypoxemia is core diagnostic criterion per SMFM 2016 + Hui 2022
  • hrrequired
    vital • used at CONTEXT
    Bradycardia / asystole / PEA in cardiac arrest; sinus tachycardia in compensated phase
  • fibrinogenrequired
    lab • used at INITIAL_WORKUP
    Fibrinogen <150–200 mg/dL is the most sensitive AFE coagulopathy marker; cryoprecipitate target ≥150 mg/dL given hyperfibrinolytic DIC + ongoing obstetric blood loss
  • pt_aptt_inrrequired
    lab • used at INITIAL_WORKUP
    Coagulopathy + DIC documentation per ISTH DIC score; informs FFP transfusion strategy
  • platelet_countrequired
    lab • used at INITIAL_WORKUP
    Thrombocytopenia in DIC; platelet transfusion target ≥50–75K with ongoing hemorrhage
  • d_dimerrequired
    lab • used at INITIAL_WORKUP
    Markedly elevated in AFE-DIC; ISTH DIC scoring component
  • lactaterequired
    lab • used at RISK_STRATIFICATION
    Tissue perfusion / SCAI 2022 staging; CardShock prognostication (Harjola PMID 26333869)
  • creatininerequired
    lab • used at CONTEXT
    End-organ damage marker; AKI common in AFE; dose adjustment for resuscitation drugs
  • troponinrequired
    lab • used at INITIAL_WORKUP
    May be elevated due to RV strain or LV failure phase; trend tracks recovery
  • echorequired
    imaging • used at INITIAL_WORKUP
    Phase 1: acute RV failure + dilated RV + D-shaped LV + acute pulmonary HTN; Phase 2: LV failure; rules out other CS etiologies (PE, MI, peripartum CMP)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    RV strain pattern (S1Q3T3, RBBB), sinus tach, often non-specific; rules out MI
  • recent_labor_delivery_or_dncrequired
    history • used at CONTEXT
    Temporal proximity to labor / delivery / D&C / amnioinfusion is a core diagnostic criterion per SMFM 2016 + Hui 2022

12-phase flow (11)

  1. 1FRAME
    Confirm AFE clinical diagnosis per SMFM 2016 + Hui 2022 consensus criteria — sudden cardiovascular collapse + acute hypoxemia + coagulopathy / DIC during labor or within 30 min of delivery / D&C / amnioinfusion + no other identifiable cause; clinical diagnosis with no confirmatory lab test
    inputs: recent_labor_delivery_or_dnc, spo2, fibrinogen
    advance: AFE diagnostic criteria met clinically + alternative causes ruled out (PE, MI, peripartum CMP, sepsis, amniotic fluid infection)
  2. 2ENTRY
    Code activation: maternal arrest pathway per AHA 2024 — LEFT UTERINE DISPLACEMENT + high-quality CPR + perimortem cesarean within 4–5 min if no ROSC and viable gestation >20 wks; immediate massive transfusion protocol activation
    inputs: sbp, spo2, gestational_age
    advance: Code team activated + uterine displacement applied + perimortem cesarean clock started if applicable
  3. 3CONTEXT
    Maternal age, parity, gestational age, mode of delivery, prior obstetric history, allergies, baseline meds, code status; anesthesia / amnioinfusion / D&C exposure as triggers
    inputs: age, hr, creatinine
    advance: Context complete
  4. 4RED_FLAGS
    Maternal cardiac arrest → AHA 2024 maternal arrest pathway with LEFT UTERINE DISPLACEMENT + perimortem cesarean within 4–5 min if no ROSC + viable gestation >20 wks; refractory hemodynamic collapse → MCS / VA-ECMO consideration; massive postpartum hemorrhage → MTP activation; fetal distress → emergency cesarean for fetal indication
    inputs: sbp, spo2, gestational_age
    actions: cardiogenic_shock
    advance: Red flags addressed; perimortem cesarean clock started if applicable; MTP active
  5. 5INITIAL_WORKUP
    Bedside echo (RV failure phase 1 vs LV failure phase 2 vs both); ECG; ABG; CBC; coags (PT/aPTT/INR/fibrinogen/D-dimer); BMP; troponin; lactate; CXR; type & crossmatch (multiple units)
    inputs: echo, ecg, fibrinogen, pt_aptt_inr, platelet_count, d_dimer, lactate, troponin
    actions: cardiogenic_shock, panel.cardiac, panel.renal, panel.abg, panel.cbc, panel.coag
    advance: Workup obtained simultaneous with resuscitation; SCAI stage assigned; DIC score documented
  6. 6BRANCHING_WORKUP
    Differential rule-outs: pulmonary embolism (CT-PA when stable), peripartum cardiomyopathy (echo), MI (cath if focal RWMA + troponin pattern), septic shock, anesthetic complication, eclampsia; mast cell tryptase if anaphylactoid pattern; postpartum hemorrhage source identification (atony, lacerations, retained POC)
    advance: Alternative diagnoses excluded; postpartum hemorrhage source identified
  7. 7RISK_STRATIFICATION
    SCAI 2022 staging; CardShock prognostication; perimortem cesarean clock (4–5 min from arrest); fibrinogen trajectory; lactate trajectory; ISTH DIC score; mortality 20–60% maternal, 20–60% perinatal even with optimal modern care
    inputs: sbp, lactate, fibrinogen
    advance: Risk stratified
  8. 8TREATMENT
    Maternal CPR with left uterine displacement; perimortem cesarean within 4–5 min if no ROSC + viable gestation >20 wks; aggressive volume + vasopressors (NE) + inotropes (milrinone for RV failure phase 1; dobutamine for LV failure phase 2); pulmonary vasodilators (inhaled NO, epoprostenol) for refractory pulmonary HTN; uterotonics (oxytocin → methylergonovine if no HTN → carboprost if no asthma → misoprostol); MTP 1:1:1 (RBC:FFP:platelets per PROPPR PMID 25647203); cryoprecipitate or fibrinogen concentrate to target ≥150 mg/dL; tranexamic acid 1 g IV within 3 h (WOMAN trial PMID 28456510); recombinant factor VIIa LAST RESORT; VA-ECMO consideration if refractory CS / RV failure
    inputs: sbp, fibrinogen, lactate
    actions: cardiogenic_shock
    advance: Resuscitation bundle active + obstetric source controlled + MTP running + TXA given
  9. 9DISPOSITION
    OB-ICU or general ICU at MCS-capable + transfusion-capable + obstetric center; level III/IV maternal care designation per ACOG 2019; multidisciplinary team (maternal-fetal medicine, OB anesthesia, hematology, CT surgery, neonatology if perimortem)
    advance: ICU disposition assigned + multidisciplinary team mobilised
  10. 10MONITORING
    A-line, central line, foley, possibly PA catheter; lactate q1–2 h; UOP hourly; serial fibrinogen / coags / platelet count q2–4 h during MTP; serial echo q24 h for cardiac recovery trajectory; continuous telemetry; neurologic checks (anoxic injury common in survivors)
    inputs: lactate, fibrinogen
    actions: panel.cardiac, panel.renal, panel.coag
    advance: Monitoring cadence set + reassessment cadence scheduled
  11. 11FOLLOWUP
    Cognitive / neurologic rehabilitation (anoxic brain injury common in maternal survivors); psychiatric support (PTSD, post-ICU syndrome, perinatal loss grief); cardiology follow-up at 1 mo + 3 mo + 6 mo; future-pregnancy counseling — recurrence risk elusive (case reports of recurrence; many uneventful subsequent pregnancies); contraception / family planning; perinatal bereavement support if neonatal loss
    advance: Multidisciplinary follow-up booked + psychiatric and bereavement support engaged