This handout is for cardiogenic shock — amniotic fluid embolism (afe). Your care team identified this based on: sudden cardiovascular collapse + hypoxemia + coagulopathy during labor or within 30 min postpartum / d&c / amnioinfusion — afe clinical diagnosis per smfm 2016 + hui 2022 consensus.
Other reasons your team may use this plan: 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; sudden severe dic (fibrinogen <150 mg/dl + ↑d-dimer + thrombocytopenia + ↑pt/aptt) in peripartum woman with cardiopulmonary collapse — afe-pattern hyperfibrinolytic coagulopathy; bedside echo: acute rv failure + dilated rv + flattened septum (d-shaped lv) + acute pulmonary htn in peripartum woman with shock — afe phase 1 differential.
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| norepinephrine | 0.05–0.5 µg/kg/min titrate MAP ≥65 | IV | continuous | SOAP-II PMID 20200382 — NE first-line in CS; preferred vasopressor in pregnancy / postpartum (less reflex bradycardia than phenylephrine; minimal uterine vasoconstriction at typical doses) |
| phenylephrine | 40–360 µg/min IV | IV | continuous | Pure α-pressor; alternative in pregnant patients per ASA / OB anesthesia guidelines |
| milrinone | 0.125–0.5 µg/kg/min (consider skipping bolus to avoid hypotension) | IV | continuous | PDE3 inhibitor reduces PVR + SVR + improves RV function in acute pulmonary HTN; preferred for RV failure phase 1 of AFE per SCAI 2022 + ACC/AHA 2022 HF Guideline |
| dobutamine | 2.5–10 µg/kg/min | IV | continuous | DOREMI PMID 33704937 — non-inferior to milrinone; preferred for LV failure phase 2 of AFE |
| inhaled nitric oxide | 5–40 ppm inhaled | inhaled | continuous | Selective pulmonary vasodilator; rapidly reduces PVR without systemic hypotension; case series support in AFE phase 1 |
| oxytocin | 10–40 U in 1 L crystalloid IV infusion (avoid bolus — hypotension) | IV | continuous | ACOG 2017 postpartum hemorrhage practice bulletin — first-line uterotonic; AVOID bolus given hypotension risk |
| methylergonovine | 0.2 mg IM q2–4 h (max 5 doses) | IM | q2–4 h PRN | ACOG 2017; CONTRAINDICATED in HTN / preeclampsia / coronary disease |
| carboprost (15-methyl PGF2α) | 0.25 mg IM q15 min (max 8 doses = 2 mg) | IM | q15 min PRN | ACOG 2017; CONTRAINDICATED in asthma (bronchospasm) |
| misoprostol | 800–1000 µg PR or sublingual | PR/SL | single dose | ACOG 2017; useful when IV access limited or other uterotonics CI |
| tranexamic acid | 1 g IV over 10 min within 3 h of hemorrhage onset; may repeat once after 30 min | IV | q30 min × 2 if ongoing | WOMAN trial Lancet 2017 PMID 28456510 — TXA reduces death from PPH when given within 3 h; logical fit for AFE hyperfibrinolytic DIC pattern |
| fibrinogen concentrate (or cryoprecipitate) | cryoprecipitate 10 U bolus (≈ 2 g fibrinogen) OR fibrinogen concentrate 4 g IV; target ≥150 mg/dL | IV | PRN to target | AFE hyperfibrinolytic DIC + ongoing obstetric hemorrhage — fibrinogen target higher than typical trauma (≥150 vs ≥100) per SMFM 2016 + Hui 2022 |
| recombinant factor VIIa | 90 µg/kg IV (LAST RESORT — thromboembolic risk) | IV | single dose; rarely repeated | SMFM 2016 — last-resort for refractory hemorrhage; thromboembolic risk; not first-line; not routine |
| epoprostenol (inhaled) | 50 ng/kg/min inhaled | inhaled | continuous | Inhaled prostacyclin — selective pulmonary vasodilator; alternative to inhaled NO when not available |
Plan: AFE-associated CS — biphasic resuscitation: phase 1 RV failure (NE + milrinone + pulmonary vasodilators) → phase 2 LV failure + DIC (NE + dobutamine + MTP 1:1:1 + cryoprecipitate + TXA + uterotonics)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
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
Guideline: AHA 2024 maternal arrest scientific statement; SMFM 2016 AFE consensus (Pacheco PMID 26987420); Hui 2022 AFE international consensus / classification; ACOG 2014 Committee Opinion #582 perimortem cesarean delivery