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cardio.post-arrest.peripartum-arrest.v1

Post-cardiac-arrest care — peripartum maternal arrest

cardiologyacuteadultacuteinpatienttransitionoutpatient
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Phase E variant of cardio.post-arrest.core.v1 — narrowed to peripartum maternal cardiac arrest cohort (pregnant ≥20 wks GA or within 48-72h post-partum). Etiologic differential = AFE (highest mortality), PPCM, massive PE, hemorrhage, eclampsia, anesthetic complication. Resuscitation modifications: continuous left uterine displacement (manual → tilt board); perimortem cesarean within 4-5 min if no ROSC + viable GA per AHA 2024 Class I; multidisciplinary activation of OB + anesthesia + NICU + cards. TTM still indicated in comatose ROSC; pregnancy is NOT a contraindication. Fetal monitoring continues during cooling. Drug constraints: avoid warfarin / ACEi / ARB / NSAIDs / DOAC during pregnancy; LMWH preferred for AC. ICD pathway deferred to ≥6 mo PPCM recovery window. Inherits manifest + design-brief pointer from parent. 5 setting playbooks (ed, icu, inpatient, transition, outpatient). 5 severity triggers: no ROSC by 4 min + viable GA, AFE classic triad, massive PE, severe PPH, eclampsia. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute Phase E wave 8.

Entry points (3)

  • symptom
    ROSC after maternal cardiac arrest in pregnant patient (typically ≥20 wks GA) or within 48-72h post-partum (AHA 2024 maternal arrest)
    rosc_after_peripartum_maternal_arrest
  • symptom
    Sudden CV collapse during labor / cesarean / immediate post-partum — AFE differential top of list (Hui 2022 consensus)
    sudden_cv_collapse_during_labor_or_immediate_postpartum
  • history
    Comatose pregnant patient post-ROSC — TTM candidate; pregnancy not a contraindication (TTM2; AHA 2024)
    comatose_pregnant_post_rosc

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Maternal age affects PPCM risk + obstetric complications; advanced maternal age ≥35 → higher PE/preeclampsia risk
  • gestational_age_weeksrequired
    history • used at RED_FLAGS
    Drives perimortem cesarean decision (>20 wks viable for maternal hemodynamics; >24 wks viable fetus) per AHA 2024 maternal arrest
  • arrest_witnessedrequired
    history • used at CONTEXT
    Witnessed arrest + bystander CPR → favorable neuro prognosis; CAHP/OHCA score inputs (AHA 2020)
  • initial_rhythmrequired
    history • used at CONTEXT
    PEA most common in AFE / hemorrhage; VF/pVT raises ischemic / channelopathy / PE differential
  • low_flow_time_minrequired
    history • used at CONTEXT
    CPR duration → ECPR eligibility (ARREST PMID 33308475 — <60 min low-flow); neuro prognosis weighting; perimortem cesarean if no ROSC by 4-5 min
  • pregnancy_complications
    history • used at CONTEXT
    Preeclampsia / placenta accreta / PPCM history / prior cardiac history — drives etiologic differential (AHA 2024)
  • sbprequired
    vital • used at TREATMENT
    Hemodynamic stability post-ROSC; SCAI staging if shock; supine pregnant SBP confounded by aortocaval compression — measure with left lateral tilt
  • core_temprequired
    vital • used at TREATMENT
    TTM target 33-37.5 °C × 24h (TTM2 PMID 34133859); pregnancy not contraindication; fetal monitoring during cooling
  • spo2required
    vital • used at TREATMENT
    Avoid hyperoxia: SpO2 92-98% (AHA 2020 Class IIa); profound hypoxemia + sudden onset → AFE classic feature
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Ischemic changes (rare in pregnancy but spontaneous coronary artery dissection / SCAD increased peripartum); right heart strain → PE / AFE; electrolyte / Mg toxicity if obstetric Mg gtt running
  • troponinrequired
    lab • used at INITIAL_WORKUP
    SCAD + PPCM + AFE-related myocardial injury workup (4th UDMI 2018); peripartum SCAD highest in immediate postpartum period
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Tissue hypoperfusion; AFE / hemorrhage / sepsis-arrest cascades all elevate lactate (SCAI 2022 PMID 35718438)
  • creatininerequired
    lab • used at CONTEXT
    Pregnancy normally lowers Cr (~0.5); rising Cr post-arrest → AKI + preeclampsia spectrum + drug renal-adjustment (AHA 2020)
  • fibrinogen_dimer_plateletsrequired
    lab • used at INITIAL_WORKUP
    AFE classic triad includes DIC — fibrinogen <200 + platelets dropping + D-dimer rising in setting of sudden CV collapse + hypoxemia (Hui 2022 consensus)
  • echo_post_roscrequired
    imaging • used at INITIAL_WORKUP
    PPCM (dilated LV + EF <45) vs AFE (acute RV failure + pulmonary HTN) vs PE (acute RV strain + McConnell sign) — guides MCS + AC decisions

12-phase flow (12)

  1. 1FRAME
    Peripartum maternal cardiac arrest (pregnant ≥20 wks GA or within 48-72h post-partum); etiologic differential = AFE (highest mortality), PPCM, PE, hemorrhage, eclampsia, anesthetic complication; resuscitation modified for aortocaval compression + perimortem cesarean window; route to parent cardio.post-arrest.core.v1 for TTM + neuroprog
    inputs: gestational_age_weeks
    advance: peripartum status confirmed + multidisciplinary team (OB + anesthesia + NICU + cards) activated
  2. 2ENTRY
    Continuous left uterine displacement (manual → Cardiff/tilt board); chest compressions hand-position 2-3 cm cephalad standard; activate maternal arrest team; prepare for perimortem cesarean within 4-5 min if no ROSC + viable GA
    inputs: age, arrest_witnessed, gestational_age_weeks
    advance: modified ACLS + obstetric team mobilized
  3. 3CONTEXT
    Pregnancy history, prior cardiac disease, antenatal complications (preeclampsia, GDM), current obstetric meds (Mg gtt → check level, oxytocin gtt, anesthesia type)
    inputs: age, arrest_witnessed, initial_rhythm, low_flow_time_min, pregnancy_complications, sbp, core_temp, spo2, creatinine
    advance: context complete + GOC documented with family + maternal advance directive reviewed
  4. 4RED_FLAGS
    Failure to achieve ROSC by 4 min + viable GA → emergent perimortem cesarean (AHA 2024 Class I); AFE classic triad (sudden collapse + hypoxemia + DIC); massive PE; refractory shock; severe preeclampsia / HELLP
    inputs: gestational_age_weeks, sbp, spo2, fibrinogen_dimer_platelets
    actions: cardiogenic_shock
    advance: red flags screened + perimortem cesarean decision made
  5. 5INITIAL_WORKUP
    ECG + serial troponin + BMP + lactate + ABG + CBC + DIC panel (PT/PTT/fibrinogen/D-dimer/platelets) + CXR (avoid CT abdomen if pregnant unless indicated; CTPA acceptable for PE) + bedside echo + obstetric ultrasound for fetal status
    inputs: ecg_12_lead, troponin, lactate, fibrinogen_dimer_platelets, echo_post_rosc
    actions: post_arrest_care, panel.cardiac, panel.renal
    advance: workup complete + AFE/PPCM/PE/hemorrhage etiology working diagnosis
  6. 6BRANCHING_WORKUP
    AFE → supportive (cryoprecipitate + FFP + platelets for DIC; ECMO if refractory); PPCM → GDMT + bromocriptine controversial; PE → systemic thrombolysis Class I despite peripartum bleeding risk if hemodynamically unstable; hemorrhage → MTP + uterotonics + interventional radiology
    actions: acs_pathway, wide_complex_tach
    advance: etiology-specific bundle delivered
  7. 7DIFFERENTIAL
    AFE (sudden + hypoxemia + DIC) / PPCM (subacute dyspnea progressing to arrest) / PE (sudden + RV strain on echo) / SCAD (postpartum chest pain + STEMI) / preeclampsia-eclampsia (HTN + seizure + HELLP) / anesthetic complication (high spinal post-epidural; LAST after local) / hemorrhagic shock (placental abruption, accreta, atony)
    advance: etiology established + family + obstetric team aligned
  8. 8RISK_STRATIFICATION
    CAHP score (PMID 26491110) + OHCA score (PMID 16424733) for neuro prognosis; SCAI shock stage; AFE mortality estimate (~20-60% with modern care per Hui 2022); PPCM prognosis per LVEF + recovery trajectory
    inputs: initial_rhythm, low_flow_time_min, sbp, lactate
    actions: calc.map, calc.heart, calc.ckd_epi_2021, calc.cha2ds2vasc
    advance: risk class + maternal-fetal prognosis documented
  9. 9TREATMENT
    TTM 33-37.5 °C × 24h with continuous fetal monitoring (if undelivered); etiology-specific therapy (cryo/FFP for AFE-DIC; thrombolysis for PE; GDMT for PPCM; MTP for hemorrhage); avoid NSAIDs + ACEi/ARB if pregnant or breastfeeding
    inputs: sbp, core_temp, spo2, creatinine
    actions: protocol.cardiogenic_shock
    advance: reperfusion + TTM + etiology-specific bundle delivered
  10. 10DISPOSITION
    CICU vs MFM-co-managed ICU per local pathway; cardiology + MFM + OB + anesthesia + neonatology multidisciplinary team
    advance: unit + service-line ownership assigned + lactation + bonding plan if delivered
  11. 11MONITORING
    Continuous telemetry + arterial line + central line + Foley; lactate q2-4h; BMP q6-12h; serial troponin; multimodal neuroprog ≥72h post-rewarm (Sandroni ERC-ESICM 2021 PMID 33745427); fetal heart monitoring if undelivered; postpartum hemorrhage surveillance if delivered
    inputs: creatinine
    actions: panel.renal, panel.cardiac
    advance: monitoring + neuroprog timeline documented
  12. 12FOLLOWUP
    Cardiology follow-up at 1-2 weeks for PPCM EF surveillance; MFM follow-up for any pregnancy continuation; counseling re: future pregnancy risk (PPCM with EF <30 — strong recommendation against future pregnancy); contraception planning; mental health (postpartum + post-arrest PTSD risk very high); AVID-style ICD pathway only for definite cardiac arrhythmic etiology unrelated to reversible peripartum cause
    advance: cardiology + MFM + mental health + contraception + ICD/WCD plan booked