12-phase flow (12)

1. 1FRAME
   Confirm PPCM diagnosis (HF developing last month of pregnancy through 5 mo postpartum + EF < 45 % on echo + no other identifiable cause per Pearson 2000 NHLBI; ESC HF 2021 PMID 34447992); distinguish from pre-existing cardiomyopathy, valvular / coronary / congenital disease, severe pre-eclampsia with pulmonary edema, amniotic fluid embolism, pulmonary embolism, sepsis-induced cardiomyopathy, hypertensive emergency with HF
   inputs: peripartum_interval, echo_ef, family_history_cardiomyopathy
   advance: Peripartum window confirmed + EF < 45 % documented + alternative causes considered
2. 2ENTRY
   Capture trigger (acute dyspnea / orthopnea / PND in peripartum window, progressive edema disproportionate to expected, echo EF < 45 % incidentally found, cardiogenic shock at delivery, NT-proBNP elevation, palpitations + presyncope for VT/VF concern, LV thrombus on echo, subsequent pregnancy after prior PPCM) per ESC HF 2021 + ESC Pregnancy 2018 + IPAC 2015
   inputs: peripartum_interval
   advance: Trigger documented; multidisciplinary team activated (cardiology + OB + anesthesia + neonatology if undelivered)
3. 3CONTEXT
   Capture peripartum interval (antepartum / intrapartum / early postpartum / postpartum 1 wk – 5 mo), gestational age if antepartum, baseline BP / HR / SpO2, NYHA class, family history of cardiomyopathy (TTN / MYH7 per Ware 2016 NEJM), prior PPCM, pre-eclampsia history, current medications including teratogen check (ACEi/ARB/ARNI/renin inhibitor/atenolol), breastfeeding status for lactation-compatible drug selection (ESC Pregnancy 2018 PMID 30165544)
   inputs: peripartum_interval, gestational_age, nyha_class, family_history_cardiomyopathy, prior_ppcm, prior_pe_or_chronic_htn, current_meds, breastfeeding_status, severe_headache
   advance: Timing tier + NYHA class + risk-factor profile + current medications documented
4. 4RED_FLAGS
   Cardiogenic shock (SBP < 90 + end-organ hypoperfusion + rising lactate) → ICU + inotropes + MCS evaluation (ESC HF 2021); decompensated pulmonary edema antepartum → IV diuretic + nitrate + early-delivery consideration; eclamptic seizure overlap → magnesium + delivery (Magpie 2002 PMID 12057549); LV thrombus on echo → therapeutic anticoagulation; VT/VF or sustained ventricular arrhythmia → antiarrhythmics + wearable defibrillator + EP consult
   inputs: sbp, dbp, spo2, lactate
   advance: Life-threatening overlays assessed; shock pathway / pulmonary edema pathway / arrhythmia pathway activated as needed; delivery indication evaluated if antepartum
5. 5INITIAL_WORKUP
   Transthoracic echocardiography (EF, LV size, regional wall motion, valvular function, LV thrombus); 12-lead ECG (LBBB, QRS duration, arrhythmia); NT-proBNP (diagnostic + trajectory); troponin (rule out concurrent ACS / SCAD); CBC + CMP + LFT + magnesium + lactate; consider CXR for pulmonary congestion (ESC HF 2021 PMID 34447992 + AHA/ACC/HFSA 2022 PMID 35379503)
   inputs: echo_ef, echo_lv_thrombus, ecg, nt_probnp, troponin, creatinine, lft, platelets
   actions: panel.cbc, panel.renal, panel.lft
   advance: Diagnostic workup complete; EF documented; LV thrombus screened; ECG interpreted; alternative-cause workup advanced
6. 6BRANCHING_WORKUP
   D-dimer + CT-PA if PE differential strong (peripartum baseline VTE risk + PPCM LV stasis); MRI cardiac if echo equivocal or for genetic-cardiomyopathy assessment; ADAMTS13 / smear if TTP differential (overlap with pre-eclampsia / HELLP); genetics referral if family history of cardiomyopathy (TTN / MYH7 / MYH6 per Ware 2016 NEJM); right heart catheterization if pulmonary hypertension or refractory shock; viral myocarditis workup if equivocal (CMV, parvovirus, adenovirus)
   inputs: d_dimer
   advance: Differential workup complete or branched; alternative-cause specific dossiers triggered as needed
7. 7DIFFERENTIAL
   Phenotype: PPCM (Pearson 2000 NHLBI confirmed) vs pre-existing cardiomyopathy vs takotsubo / stress cardiomyopathy vs viral myocarditis vs pulmonary embolism vs amniotic fluid embolism vs pre-eclampsia with pulmonary edema vs sepsis-induced cardiomyopathy vs peripartum AMI / SCAD vs hypertensive emergency with HF; assign timing tier (antepartum < 32 wk / antepartum ≥ 32 wk / intrapartum / early postpartum < 1 wk / postpartum 1 wk – 5 mo); assign severity tier (mild-moderate EF 35–44 / severe EF < 35 / cardiogenic shock)
   advance: Phenotype assigned; timing tier + severity tier + NYHA class + overlay assessment complete
8. 8RISK_STRATIFICATION
   Stratify by EF tier (< 25 highest risk + bromocriptine consideration / 25–34 severe + wearable defibrillator / 35–44 moderate / ≥ 45 recovered), NYHA class (II / III / IV), NT-proBNP trajectory (> 2000 pg/mL = adverse-event within 30 d), LBBB + LVEDD > 60 mm (poorer recovery prognosis per IPAC 2015 PMID 26293760), MAP target (≥ 65 if shock), arrhythmia overlay (VT/VF/SCD risk), thrombus overlay, recurrence-risk profile for next pregnancy
   inputs: nyha_class, echo_ef, echo_lv_thrombus, nt_probnp, echo_lvedd, hr, ecg
   actions: calc.map
   advance: Severity + EF tier + NYHA + prognosis indicators documented; delivery-timing decision made if antepartum
9. 9TREATMENT
   Timing-tiered GDMT: antepartum → hydralazine + nitrates + carvedilol / metoprolol succinate / bisoprolol + cautious diuresis (furosemide) + antenatal corticosteroids 24+0–33+6 wk per ACOG 713 + Roberts Cochrane 2017 PMID 28321847; postpartum → full GDMT (ACEi enalapril / ARB / ARNI sacubitril-valsartan + beta-blocker + MRA spironolactone / eplerenone + SGLT2i empagliflozin / dapagliflozin per DAPA-HF PMID 31535829 + EMPEROR-Reduced PMID 32865377); anticoagulation if LV thrombus (warfarin postpartum / LMWH antepartum) or EF < 30–35 % with risk factor; bromocriptine 2.5 mg PO BID × 1 wk (short-course) or × 2 wk then 2.5 mg daily × 6 wk (8-wk regimen) per Hilfiker-Kleiner 2018 in select early-postpartum severe cases + lactation cessation + concurrent enoxaparin VTE prophylaxis; wearable defibrillator if EF < 35 % × 3–6 mo; mechanical circulatory support (IABP → Impella → V-A ECMO → durable LVAD) if cardiogenic shock refractory to inotropes; ICD only after ≥ 6 mo optimal medical therapy if EF persistently < 35 % per AHA/ACC/HFSA 2022 PMID 35379503
   inputs: echo_ef, nyha_class, sbp, peripartum_interval
   advance: GDMT initiated per timing tier; delivery plan made if antepartum; MCS / wearable defibrillator / bromocriptine decision made per severity tier
10. 10DISPOSITION
    L&D / cardiac OB / OB ICU for antepartum severe (NYHA III–IV, cardiogenic shock, pulmonary edema, refractory HTN); cardiothoracic OR if MCS placement; postpartum unit for stable postpartum with full GDMT; outpatient cardiology + OB postpartum f/u for stable mild-moderate postpartum on GDMT (ESC HF 2021 + ESC Pregnancy 2018 PMID 30165544)
    advance: Level of care + delivery timing assigned; multidisciplinary team coordinated
11. 11MONITORING
    Serial echocardiography q3 mo × 12 mo (or sooner if worsening); NT-proBNP trajectory q1–2 wk during titration then q3 mo; daily weights + symptom log; renal + K+ q3–5 d during ACEi/MRA titration then q3 mo; LV thrombus surveillance q4–6 wk if on therapeutic anticoagulation; INR weekly if warfarin; lactation-medication review q visit; postpartum BP monitoring if pre-eclampsia overlap (ACOG 222 + AHA 2021); 6-week postpartum comprehensive visit (ACOG 2025)
    inputs: echo_ef, nt_probnp, creatinine, potassium, sbp, hr
    actions: panel.cbc, panel.renal
    advance: Mother stable; recovery trajectory documented; GDMT titrated to maximum tolerated doses; lactation-compatible regimen confirmed if breastfeeding
12. 12FOLLOWUP
    Cardiology q3 mo × 12 mo + thereafter q6 mo if recovered; serial echocardiography q3 mo × 12 mo (or sooner if worsening); GDMT uptitration to maximum tolerated; ICD evaluation only after ≥ 6 mo optimal medical therapy if EF persistently < 35 % per AHA/ACC/HFSA 2022 PMID 35379503; advanced HF / transplant referral if no recovery at 12 mo; preconception MFM + cardiology consultation if planning next pregnancy with recurrence-risk counseling (30–50 % if EF not recovered, 15–20 % if recovered); highly-effective contraception during recovery (IUD, etonogestrel implant; avoid combined estrogen contraceptives in EF < 50 % per WHO MEC); EPDS / PPD screen + perinatal mental health referral as needed (psych.postpartum-depression.v1 overlay); psychosocial + family counseling
    advance: Recovery trajectory documented; GDMT optimized; preconception counseling complete if planning next pregnancy; long-term cardiology surveillance established