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cardio.cardiogenic-shock.peripartum-cardiomyopathy.v1

Cardiogenic shock — peripartum cardiomyopathy (PPCM, severe)

cardiologyacuteadultpregnancyacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to severe PPCM with cardiogenic shock physiology (SCAI C+); ~5-10% of PPCM cases progress to shock with very high maternal + fetal mortality. Distinguished from cardio.acute-hf.peripartum-cmp.v1 by FOCUS on shock physiology (LVEF <30 + SBP <90 + lactate ≥2) rather than ADHF decompensation across the full PPCM spectrum (LVEF <45). Treatment ACUTE: standard CS support (NE first per SOAP-II PMID 20200382; milrinone preferred over dobutamine in pregnancy due to better arrhythmia profile despite OPTIME-CHF caution); MCS bridge to recovery — Impella CP per DanGer Shock 2024 PMID 38587234; VA-ECMO for biventricular failure or refractory shock (case series support successful peripartum use); BROMOCRIPTINE 2.5 mg PO BID × 2 wk then daily × 6 wk per IPAC RCT (Sliwa 2017 PMID 28637825) — POSTPARTUM ONLY, suppresses lactation, ADD prophylactic AC due to thrombosis risk. Pregnancy-aware drug selection: avoid ACEi/ARB/ARNI/SGLT2i/DOAC/spironolactone if antepartum (teratogenic); substitute hydralazine + isosorbide dinitrate; LMWH peripartum (warfarin teratogenic 6-12 wks gestation + fetal bleeding third trimester); transition to warfarin (lactation-safe) or DOAC (avoid in lactation) postpartum. Delivery considerations: antepartum shock + fetal distress + maternal compromise → URGENT delivery (often improves maternal hemodynamics by relieving aortocaval compression); vaginal preferred unless obstetric indication; epidural fluid load careful; emergent C-section under regional or general anesthesia if needed. Recovery: ~50% normalize LVEF by 6 mo (better than other dilated CMs per AHA 2020 PPCM PMID 32362133); 30-50% recurrence in subsequent pregnancy if LVEF did not normalize (mortality up to 20% per ESC 2018 PMID 30165544); advanced HF + transplant pathway if no recovery at 6-12 mo (LVAD bridge feasible per HeartMate 3 era); ICD/WCD if LVEF <35% at 3-6 mo on full GDMT. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 19 cardiogenic-shock rare-etiology variant.

Entry points (4)

  • symptom
    Peripartum patient (last month pregnancy through 5 mo postpartum) with SBP <90 + severe LV dysfunction (LVEF <30%) on bedside echo — PPCM-CS clinical pattern (SCAI C+)
    peripartum_shock_with_severe_lv_dysfunction
  • imaging
    Echo LVEF <30% + dilated LV + global hypokinesis in peripartum window with shock physiology — PPCM with cardiogenic shock
    echo_lvef_below_30_in_peripartum_window_with_shock
  • history
    Patient with prior PPCM + persistent LV dysfunction + new pregnancy presenting with shock — recurrence with severe presentation (mortality up to 20%)
    prior_ppcm_with_recurrence_in_subsequent_pregnancy_with_shock
  • symptom
    Postpartum patient (within 5 mo of delivery) with fulminant dyspnea + hemodynamic collapse — fulminant PPCM-CS
    fulminant_postpartum_dyspnea_with_hemodynamic_collapse

Required inputs (14)

  • agerequired
    demographic • used at CONTEXT
    Age >30 increases PPCM risk; informs future-pregnancy counseling and transplant candidacy
  • gestational_age_or_postpartum_dayrequired
    history • used at CONTEXT
    PPCM defined window: last month pregnancy through 5 mo postpartum; trimester drives ACEi/ARB/SGLT2i/DOAC teratogenicity decisions and delivery-decision urgency
  • parity_and_prior_obstetric_historyrequired
    history • used at CONTEXT
    Multiparity + multiple gestation + pre-eclampsia + prior PPCM are risk factors; prior PPCM with recurrence carries up to 20% mortality
  • self_identified_ancestry
    demographic • used at CONTEXT
    African ancestry confers 4× higher PPCM incidence and worse recovery profile per AHA 2020 PPCM Scientific Statement (PMID 32362133)
  • sbprequired
    vital • used at RED_FLAGS
    SCAI 2022 staging baseline; SBP <90 with end-organ hypoperfusion = SCAI C+; preserves uteroplacental perfusion if antepartum
  • spo2required
    vital • used at RED_FLAGS
    Hypoxemia from pulmonary edema; guides NIPPV vs intubation decision in pregnant patient
  • hrrequired
    vital • used at CONTEXT
    Tachycardia + arrhythmia surveillance; PPCM-CS has elevated VT/VF risk if LVEF <35%
  • lactaterequired
    lab • used at RISK_STRATIFICATION
    SCAI 2022 staging; CardShock prognostication (Harjola PMID 26333869); ≥4 = SCAI D-E pattern
  • creatininerequired
    lab • used at CONTEXT
    Cardiorenal screen; LMWH dosing; ACEi-postpartum dose adjustment; renal injury common in shock
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Rules out ischemic CMP differential; mildly elevated in PPCM but high values prompt SCAD/MI workup (postpartum SCAD common)
  • nt_probnprequired
    lab • used at INITIAL_WORKUP
    NT-proBNP markedly elevated in PPCM-CS; trends response to therapy and recovery
  • echo_lvef_and_chamber_sizerequired
    imaging • used at INITIAL_WORKUP
    Echo LVEF <30% + dilated LV + global hypokinesis is the diagnostic pattern; RV function + valvular assessment; rules out other CS etiologies (PE, tamponade, valvular emergency)
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    Rules out SCAD-related ischemia, arrhythmia, conduction disease; documents baseline rhythm
  • 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 (11)

  1. 1FRAME
    PPCM with cardiogenic shock = HFrEF (LVEF <30% in severe variant) in peripartum window + SCAI C+ shock physiology; pregnancy status drives drug selection (ACEi/ARB/SGLT2i/DOAC teratogenic; bromocriptine postpartum-only adjunct); ~5–10% of PPCM progresses to shock; very high maternal + fetal mortality
    inputs: gestational_age_or_postpartum_day, echo_lvef_and_chamber_size, sbp
    advance: PPCM-CS pattern confirmed (peripartum window + LVEF <30 + SCAI C+ physiology)
  2. 2ENTRY
    Bedside echo + NT-proBNP + ECG + STAT obstetric consult if antepartum; CICU activation; advanced HF + MCS team mobilization; multidisciplinary pregnancy heart team activation
    inputs: age, gestational_age_or_postpartum_day
    advance: CICU + pregnancy heart team + advanced HF / MCS team engaged
  3. 3CONTEXT
    Trimester or postpartum day documented; ancestry, parity, multiple gestation, pre-eclampsia, prior PPCM history, lactation status / desire all collected for drug-selection and delivery-decision context
    inputs: parity_and_prior_obstetric_history, creatinine, hr
    advance: Pregnancy + obstetric + cardiac context complete
  4. 4RED_FLAGS
    Cardiogenic shock SCAI C+ → vasopressor + inotrope + MCS pathway; antepartum shock requiring delivery → emergent C-section vs vaginal delivery decision per fetal/maternal status; refractory shock → MCS escalation; bromocriptine bleed risk if active hemorrhage; recurrent VT/VF storm
    inputs: sbp, spo2
    actions: cardiogenic_shock
    advance: Red flags screened + obstetric + advanced HF teams aware
  5. 5INITIAL_WORKUP
    Bedside echo (LVEF, chamber size, valvular, RV); NT-proBNP; troponin; BMP; CBC; ABG; lactate; coags; TSH (rules out thyroid); viral panel if myocarditis suspected; ECG; CXR with abdominal shielding if antepartum; rule out pre-existing CMP / valvular / ischemic / viral myocarditis / SCAD / PE
    inputs: echo_lvef_and_chamber_size, ecg, troponin, nt_probnp, lactate, pre_existing_cardiac_or_valvular_disease
    actions: cardiogenic_shock, panel.cardiac, panel.renal, panel.abg
    advance: Workup obtained simultaneous with resuscitation; SCAI stage assigned; PPCM confirmed by exclusion
  6. 6BRANCHING_WORKUP
    Cardiac MRI postpartum if diagnosis uncertain (LGE pattern); coronary angiography or CTA if SCAD/ischemic concern (postpartum chest pain + troponin); viral PCR if myocarditis suspected; genetic counseling if family history of CMP; CT-PA if PE suspected (low threshold given peripartum hypercoagulability)
    actions: acs_pathway
    advance: Differential narrowed; alternative shock etiologies excluded
  7. 7RISK_STRATIFICATION
    SCAI 2022 staging (most PPCM-CS = Stage C-E); CardShock score; MAGGIC less calibrated for PPCM (recovery profile differs); fetal status if antepartum (gestational age, fetal viability); transplant candidacy assessment if no recovery anticipated
    inputs: sbp, lactate
    advance: Risk stratified; transplant + MCS pathway considered
  8. 8TREATMENT
    Standard CS support: NE first-line per SOAP-II (PMID 20200382), preserves uteroplacental perfusion; MILRINONE preferred over dobutamine in pregnancy (better arrhythmia profile despite OPTIME-CHF caution); MCS bridge to recovery — Impella CP per DanGer Shock 2024 (PMID 38587234); VA-ECMO for biventricular failure or refractory shock (case series support peripartum use); BROMOCRIPTINE 2.5 mg PO BID × 2 wk then daily × 6 wk per IPAC (Sliwa 2017 PMID 28637825) — POSTPARTUM ONLY, add prophylactic AC, suppresses lactation. Pregnancy-aware substitutions: hydralazine + isosorbide dinitrate for ACEi/ARB if antepartum; LMWH peripartum, transition to warfarin/DOAC postpartum. Delivery decision: urgent if antepartum + fetal distress + maternal compromise (often improves hemodynamics)
    inputs: sbp, creatinine
    actions: protocol.cardiogenic_shock
    advance: Pregnancy-appropriate CS regimen active + MCS pathway considered + delivery decision documented if antepartum
  9. 9DISPOSITION
    CICU mandatory; transfer to advanced HF / MCS-capable + transfusion-capable + obstetric center (level III/IV maternal care per ACOG 2019) if not already there; multidisciplinary pregnancy heart team daily rounds
    advance: CICU at appropriate-level center + MDT mobilized
  10. 10MONITORING
    Continuous telemetry, A-line, central line, possibly PA catheter; lactate q1–2 h; UOP hourly; daily echo for cardiac recovery trajectory; continuous fetal monitoring if antepartum; daily BMP / NT-proBNP / troponin
    inputs: lactate, creatinine
    actions: panel.cardiac, panel.renal
    advance: Monitoring cadence + fetal surveillance plan documented
  11. 11FOLLOWUP
    PPCM clinic at 2 wks, 6 wks, 3 mo, 6 mo, 12 mo postpartum; serial echo for LVEF recovery; ICD/WCD evaluation if LVEF <35% at 3–6 mo on full GDMT; advanced HF + transplant pathway if no recovery at 6–12 mo; future-pregnancy counseling (recurrence 30–50% if LVEF did not normalize); contraception counseling (avoid combined oral contraceptives — thrombosis risk; prefer progestin-only or IUD)
    advance: PPCM clinic + transplant pathway + future-pregnancy + contraception counseling booked