This handout is for cardiogenic shock — peripartum cardiomyopathy (ppcm, severe). Your care team identified this based on: 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+).
Other reasons your team may use this plan: echo lvef <30% + dilated lv + global hypokinesis in peripartum window with shock physiology — ppcm with cardiogenic shock; patient with prior ppcm + persistent lv dysfunction + new pregnancy presenting with shock — recurrence with severe presentation (mortality up to 20%); postpartum patient (within 5 mo of delivery) with fulminant dyspnea + hemodynamic collapse — fulminant ppcm-cs.
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; preserves uteroplacental perfusion; preferred vasopressor in pregnancy |
| milrinone | 0.125–0.5 µg/kg/min IV continuous (no bolus to avoid hypotension) | IV | continuous | Inodilator preferred over dobutamine in pregnancy (better arrhythmia profile despite OPTIME-CHF PMID 12759322 caution); ACC/AHA 2022 HF (PMID 35363499) |
| dobutamine | 2.5–10 µg/kg/min | IV | continuous | DOREMI PMID 33704937 — non-inferior to milrinone; used cautiously in pregnancy due to arrhythmogenic potential |
| furosemide | 40 mg IV bolus then 5–10 mg/h infusion or 40–80 mg IV q6–8h | IV | as scheduled | DOSE PMID 21366472 high-dose IV bolus arm; safe in pregnancy and lactation |
| hydralazine | 10–25 mg PO TID OR 5–10 mg IV q4–6h prn | PO/IV | TID | Pregnancy-safe afterload reducer; substitute for ACEi/ARB during pregnancy (ESC pregnancy 2018 PMID 30165544) |
| isosorbide dinitrate | 20–40 mg PO TID | PO | TID | Combine with hydralazine (A-HeFT analog) for pregnancy-safe afterload + preload reduction |
| carvedilol | 3.125 mg PO BID titrate (after off catecholamines ≥24 h) | PO | BID | CAPRICORN PMID 11356436 + COPERNICUS PMID 11386262; preferred postpartum (limited lactation data but acceptable per AAP); start AFTER inotrope wean |
| sacubitril-valsartan | 24/26 mg PO BID titrate to 97/103 BID | PO | BID | PIONEER-HF PMID 30403955; POSTPARTUM ONLY (TERATOGENIC); AAP advises against during lactation |
| enalapril | 2.5 mg PO BID titrate | PO | BID | POSTPARTUM ONLY; enalapril and captopril are AAP-approved during lactation |
| spironolactone | 12.5–25 mg PO daily | PO | daily | POSTPARTUM ONLY (potential antiandrogenic teratogen); RALES PMID 10471456 |
| empagliflozin | 10 mg PO daily | PO | daily | EMPULSE PMID 35347356; POSTPARTUM ONLY; not recommended during pregnancy or breastfeeding |
| bromocriptine | 2.5 mg PO BID × 2 weeks then 2.5 mg PO daily × 6 weeks (8 weeks total) | PO | BID then daily | IPAC RCT (Sliwa 2017 PMID 28637825): 8-wk regimen improved LVEF recovery 27→58% at 6 mo; POSTPARTUM ONLY (suppresses lactation — counsel patient); ADD prophylactic AC during therapy due to thrombosis risk |
| enoxaparin | 1 mg/kg SC q12h (therapeutic) OR 40 mg SC daily (prophylactic) | SC | q12h or daily | LMWH preferred peripartum (warfarin teratogenic 6–12 wks gestation + fetal bleeding third trimester); ESC pregnancy 2018 PMID 30165544 |
| warfarin | 5 mg PO daily; INR target 2-3 | PO | daily | POSTPARTUM transition from LMWH; safe in lactation (no significant breast milk transfer) |
| apixaban | 5 mg PO BID | PO | BID | POSTPARTUM alternative to warfarin; NOT recommended during breastfeeding (limited data) |
Plan: PPCM-CS pregnancy-aware shock regimen — NE first-line + milrinone preferred over dobutamine in pregnancy + bromocriptine 8-wk postpartum per IPAC + LMWH peripartum + MCS bridge to recovery (Impella CP / VA-ECMO)
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
PPCM clinic at 2 wks, 6 wks, 3 mo, 6 mo, 12 mo postpartum; serial echo for heart pumping strength (LVEF) recovery; ICD/WCD evaluation if heart pumping strength (LVEF) <35% at 3–6 mo on full the four foundational heart-failure medications; advanced HF + transplant pathway if no recovery at 6–12 mo; future-pregnancy counseling (recurrence 30–50% if heart pumping strength (LVEF) did not normalize); contraception counseling (avoid combined oral contraceptives — thrombosis risk; prefer progestin-only or IUD)
Guideline: 2022 ACC/AHA/HFSA HF Guideline (Heidenreich PMID 35363499) + AHA 2020 PPCM Scientific Statement (Davis PMID 32362133) + ESC pregnancy 2018 (Regitz-Zagrosek PMID 30165544) + IPAC bromocriptine RCT (Sliwa 2017 PMID 28637825) + SCAI 2022 CS staging (Naidu PMID 35718438)