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cardio.cardiogenic-shock.amniotic-fluid-embolism.v1PRODUCTION
cardio.cardiogenic-shock.amniotic-fluid-embolism.v1

Cardiogenic shock — amniotic fluid embolism (AFE)

cardiologyacuteadultpregnancy
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Encounter flow

11/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm AFE clinical diagnosis per SMFM 2016 + Hui 2022 consensus criteria — sudden cardiovascular collapse + acute hypoxemia + coagulopathy / DIC during labor or within 30 min of delivery / D&C / amnioinfusion + no other identifiable cause; clinical diagnosis with no confirmatory lab test

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AFE diagnostic criteria met clinically + alternative causes ruled out (PE, MI, peripartum CMP, sepsis, amniotic fluid infection)

Patient inputs (15)

Maternal age — AFE risk increases with maternal age >35 (Knight 2010 UKOSS PMID 21068427)

Bradycardia / asystole / PEA in cardiac arrest; sinus tachycardia in compensated phase

End-organ damage marker; AKI common in AFE; dose adjustment for resuscitation drugs

Temporal proximity to labor / delivery / D&C / amnioinfusion is a core diagnostic criterion per SMFM 2016 + Hui 2022

Hypoxemia is core diagnostic criterion per SMFM 2016 + Hui 2022

Fibrinogen <150–200 mg/dL is the most sensitive AFE coagulopathy marker; cryoprecipitate target ≥150 mg/dL given hyperfibrinolytic DIC + ongoing obstetric blood loss

Coagulopathy + DIC documentation per ISTH DIC score; informs FFP transfusion strategy

Thrombocytopenia in DIC; platelet transfusion target ≥50–75K with ongoing hemorrhage

Markedly elevated in AFE-DIC; ISTH DIC scoring component

May be elevated due to RV strain or LV failure phase; trend tracks recovery

Phase 1: acute RV failure + dilated RV + D-shaped LV + acute pulmonary HTN; Phase 2: LV failure; rules out other CS etiologies (PE, MI, peripartum CMP)

RV strain pattern (S1Q3T3, RBBB), sinus tach, often non-specific; rules out MI

Gestational age determines perimortem cesarean indication (≥20 wks = uterus impedes IVC → benefit) per AHA 2024 maternal arrest and ACOG 2014 #582

SCAI 2022 staging baseline + maternal arrest threshold

Tissue perfusion / SCAI 2022 staging; CardShock prognostication (Harjola PMID 26333869)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningmaternal_cardiac_arrest_with_perimortem_cesarean_indication
    Maternal cardiac arrest + viable gestation >20 wks + no ROSC within 4 min — perimortem cesarean within 4–5 min from arrest improves maternal survival (decompresses IVC + facilitates resuscitation) and may save the fetus
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningdic_with_hyperfibrinolysis_and_obstetric_hemorrhage
    Fibrinogen <150 mg/dL + ↑D-dimer + thrombocytopenia + ↑PT/aPTT in peripartum woman with ongoing obstetric hemorrhage — AFE hyperfibrinolytic DIC pattern; activate MTP + cryoprecipitate / fibrinogen concentrate to target ≥150 mg/dL + TXA 1 g IV within 3 h
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_rv_failure_with_acute_pulmonary_hypertension_in_afe_phase_1
    Phase 1 AFE — acute RV failure + dilated RV + flattened septum + acute pulmonary HTN refractory to NE + milrinone — escalate to inhaled NO or epoprostenol; consider VA-ECMO
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningrefractory_hemodynamic_collapse_requiring_va_ecmo
    Refractory CS in AFE despite NE + milrinone / dobutamine + inhaled NO + MTP — VA-ECMO consideration as bridge to recovery (case series + ELSO 2020 obstetric ECMO registry support)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningneonatal_complications_after_perimortem_cesarean_or_predelivery_arrest
    Neonatal anoxic injury / cardiopulmonary depression after maternal arrest or perimortem cesarean — neonatology resuscitation; therapeutic hypothermia for HIE if criteria met (AAP 2014); high perinatal mortality 20–60%
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

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)
axis: afe_cs_phenotype
Selected axis "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)" by default fallback (first axis)
  • norepinephrine
    first line
    vasopressor_alpha
    0.05–0.5 µg/kg/min titrate MAP ≥65 • IV • continuous
    triggers: afe_with_sbp_lt_90, cs_scai_c_or_higher
    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)
    rxcui 7512
  • phenylephrine
    second line
    vasopressor_pure_alpha
    40–360 µg/min IV • IV • continuous
    triggers: need_pure_alpha_if_tachycardia_limiting_NE, maternal_hypotension_with_intact_LV
    Pure α-pressor; alternative in pregnant patients per ASA / OB anesthesia guidelines
    rxcui 8163
  • milrinone
    first line
    pde3_inhibitor
    0.125–0.5 µg/kg/min (consider skipping bolus to avoid hypotension) • IV • continuous
    triggers: afe_phase_1_rv_failure_with_pulmonary_hypertension, rv_predominant_failure
    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
    rxcui 52769
  • dobutamine
    first line
    inotrope_beta1
    2.5–10 µg/kg/min • IV • continuous
    triggers: afe_phase_2_lv_failure, low_cardiac_output_with_preserved_systemic_pressure
    DOREMI PMID 33704937 — non-inferior to milrinone; preferred for LV failure phase 2 of AFE
    rxcui 3616
  • inhaled nitric oxide
    add on
    pulmonary_vasodilator_inhaled
    5–40 ppm inhaled • inhaled • continuous
    triggers: refractory_pulmonary_htn_in_afe_phase_1, rv_failure_not_responding_to_milrinone
    Selective pulmonary vasodilator; rapidly reduces PVR without systemic hypotension; case series support in AFE phase 1
    rxcui 7442
  • oxytocin
    first line
    uterotonic
    10–40 U in 1 L crystalloid IV infusion (avoid bolus — hypotension) • IV • continuous
    triggers: uterine_atony_with_postpartum_hemorrhage, afe_postpartum_hemorrhage
    ACOG 2017 postpartum hemorrhage practice bulletin — first-line uterotonic; AVOID bolus given hypotension risk
    rxcui 1733680
  • methylergonovine
    second line
    uterotonic_ergot
    0.2 mg IM q2–4 h (max 5 doses) • IM • q2–4 h PRN
    triggers: atony_refractory_to_oxytocin, no_hypertension_or_preeclampsia
    ACOG 2017; CONTRAINDICATED in HTN / preeclampsia / coronary disease
    rxcui 6883
  • carboprost (15-methyl PGF2α)
    second line
    uterotonic_prostaglandin
    0.25 mg IM q15 min (max 8 doses = 2 mg) • IM • q15 min PRN
    triggers: atony_refractory_to_first_line, no_asthma
    ACOG 2017; CONTRAINDICATED in asthma (bronchospasm)
    rxcui 2051
  • misoprostol
    second line
    uterotonic_prostaglandin_e1
    800–1000 µg PR or sublingual • PR/SL • single dose
    triggers: atony_with_no_iv_access_or_contraindications_to_alternatives
    ACOG 2017; useful when IV access limited or other uterotonics CI
    rxcui 42331
  • tranexamic acid
    first line
    antifibrinolytic
    1 g IV over 10 min within 3 h of hemorrhage onset; may repeat once after 30 min • IV • q30 min × 2 if ongoing
    triggers: postpartum_hemorrhage_within_3_hours_onset, afe_with_hyperfibrinolytic_dic
    WOMAN trial Lancet 2017 PMID 28456510 — TXA reduces death from PPH when given within 3 h; logical fit for AFE hyperfibrinolytic DIC pattern
    rxcui 10691
  • fibrinogen concentrate (or cryoprecipitate)
    first line
    coagulation_factor_replacement
    cryoprecipitate 10 U bolus (≈ 2 g fibrinogen) OR fibrinogen concentrate 4 g IV; target ≥150 mg/dL • IV • PRN to target
    triggers: fibrinogen_lt_150_mg_dL_with_ongoing_hemorrhage, afe_with_hyperfibrinolytic_dic
    AFE hyperfibrinolytic DIC + ongoing obstetric hemorrhage — fibrinogen target higher than typical trauma (≥150 vs ≥100) per SMFM 2016 + Hui 2022
    rxcui 4385
  • recombinant factor VIIa
    rescue
    coagulation_factor_recombinant
    90 µg/kg IV (LAST RESORT — thromboembolic risk) • IV • single dose; rarely repeated
    triggers: refractory_hemorrhage_despite_mtp_and_cryoprecipitate, afe_with_uncontrollable_bleeding_after_full_resuscitation
    SMFM 2016 — last-resort for refractory hemorrhage; thromboembolic risk; not first-line; not routine
    rxcui 253149
  • epoprostenol (inhaled)
    add on
    pulmonary_vasodilator_inhaled
    50 ng/kg/min inhaled • inhaled • continuous
    triggers: no_inhaled_no_available, refractory_pulmonary_htn_in_afe_phase_1
    Inhaled prostacyclin — selective pulmonary vasodilator; alternative to inhaled NO when not available
    rxcui 8814

outpatient playbook — drug actions (2)

  1. 1. continue or up-titrate GDMT if persistent EF<40
    lisinopril or sac/val + carvedilol + MRA + SGLT2i • PO • daily/BID
    trigger: Persistent EF<40
    AHA/ACC/HFSA 2022 HF Guideline (PMID 35363499)
  2. 2. discontinue VTE prophylaxis at 6 wks postpartum if no other VTE risk
    per ACOG 2018 • n/a • n/a
    trigger: No persistent risk factors
    ACOG 2018

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Sudden cardiovascular collapse + hypoxemia + coagulopathy during labor or within 30 min postpartum / D&C / amnioinfusion — AFE clinical diagnosis per SMFM 2016 + Hui 2022 consensus; 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.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiogenic shock — amniotic fluid embolism (AFE)** (cardio.cardiogenic-shock.amniotic-fluid-embolism.v1).
Scope: Confirm AFE clinical diagnosis per SMFM 2016 + Hui 2022 consensus criteria — sudden cardiovascular collapse + acute hypoxemia + coagulopathy / DIC during labor or within 30 min of delivery / D&C / amnioinfusion + no other identifiable cause; clinical diagnosis with no confirmatory lab test

No severity triggers fired against current inputs.

Plan

Regimen axis: **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)**.
1. norepinephrine 0.05–0.5 µg/kg/min titrate MAP ≥65 IV continuous (vasopressor_alpha, first line) — 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)
2. phenylephrine 40–360 µg/min IV IV continuous (vasopressor_pure_alpha, second line) — Pure α-pressor; alternative in pregnant patients per ASA / OB anesthesia guidelines
3. milrinone 0.125–0.5 µg/kg/min (consider skipping bolus to avoid hypotension) IV continuous (pde3_inhibitor, first line) — 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
4. dobutamine 2.5–10 µg/kg/min IV continuous (inotrope_beta1, first line) — DOREMI PMID 33704937 — non-inferior to milrinone; preferred for LV failure phase 2 of AFE
5. inhaled nitric oxide 5–40 ppm inhaled inhaled continuous (pulmonary_vasodilator_inhaled, add on) — Selective pulmonary vasodilator; rapidly reduces PVR without systemic hypotension; case series support in AFE phase 1
6. oxytocin 10–40 U in 1 L crystalloid IV infusion (avoid bolus — hypotension) IV continuous (uterotonic, first line) — ACOG 2017 postpartum hemorrhage practice bulletin — first-line uterotonic; AVOID bolus given hypotension risk
7. methylergonovine 0.2 mg IM q2–4 h (max 5 doses) IM q2–4 h PRN (uterotonic_ergot, second line) — ACOG 2017; CONTRAINDICATED in HTN / preeclampsia / coronary disease
8. carboprost (15-methyl PGF2α) 0.25 mg IM q15 min (max 8 doses = 2 mg) IM q15 min PRN (uterotonic_prostaglandin, second line) — ACOG 2017; CONTRAINDICATED in asthma (bronchospasm)
9. misoprostol 800–1000 µg PR or sublingual PR/SL single dose (uterotonic_prostaglandin_e1, second line) — ACOG 2017; useful when IV access limited or other uterotonics CI
10. 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 (antifibrinolytic, first line) — WOMAN trial Lancet 2017 PMID 28456510 — TXA reduces death from PPH when given within 3 h; logical fit for AFE hyperfibrinolytic DIC pattern
11. 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 (coagulation_factor_replacement, first line) — AFE hyperfibrinolytic DIC + ongoing obstetric hemorrhage — fibrinogen target higher than typical trauma (≥150 vs ≥100) per SMFM 2016 + Hui 2022
12. recombinant factor VIIa 90 µg/kg IV (LAST RESORT — thromboembolic risk) IV single dose; rarely repeated (coagulation_factor_recombinant, rescue) — SMFM 2016 — last-resort for refractory hemorrhage; thromboembolic risk; not first-line; not routine
13. epoprostenol (inhaled) 50 ng/kg/min inhaled inhaled continuous (pulmonary_vasodilator_inhaled, add on) — Inhaled prostacyclin — selective pulmonary vasodilator; alternative to inhaled NO when not available

Setting playbook (outpatient) — Long-term recovery — cardiology follow-up at 1 mo / 3 mo / 6 mo; neurocognitive rehabilitation if anoxic injury; psychiatric care for PTSD / post-ICU syndrome / perinatal grief; future-pregnancy counseling (recurrence elusive; many uneventful subsequent pregnancies); contraception support; family planning
14. continue or up-titrate GDMT if persistent EF<40 lisinopril or sac/val + carvedilol + MRA + SGLT2i PO daily/BID — Persistent EF<40 (AHA/ACC/HFSA 2022 HF Guideline (PMID 35363499))
15. discontinue VTE prophylaxis at 6 wks postpartum if no other VTE risk per ACOG 2018 n/a n/a — No persistent risk factors (ACOG 2018)

Non-pharmacologic actions:
- Cardiology long-term surveillance
- Neurocognitive rehabilitation if applicable
- Psychiatric care ongoing (PTSD, post-ICU syndrome, perinatal grief)
- Future-pregnancy counseling — recurrence elusive but reported (case reports); many uneventful subsequent pregnancies; high-risk OB management essential
- Family planning support

AVOID / contraindication checks:
- Methylergonovine_AVOID_in_hypertension_or_preeclampsia (vasoconstrictor; ACOG 2017)
- Carboprost_AVOID_in_asthma (bronchospasm risk; ACOG 2017)
- Oxytocin_no_iv_bolus (hypotension; ACOG 2017 — give as infusion only)
- Rfviia_last_resort_thromboembolic_risk (SMFM 2016)
- Perimortem_cesarean_4 5_min_window (AHA 2024 maternal arrest; ACOG 2014 #582 — survival benefit lost beyond ~5 min)
- Left_uterine_displacement_during_cpr (15–30° lateral tilt OR manual displacement; AHA 2024 maternal arrest)
- Dapt_or_full_anticoagulation_HOLD_during_active_dic (resume after coagulopathy resolves)

Monitoring

Regimen monitoring:
- arterial line continuous BP (ACC/AHA 2022 Class I)
- central venous access large bore (ACC/AHA 2022)
- lactate q1-2h (CardShock, Harjola EHJ 2015)
- UOP hourly (SCAI 2019 end-organ perfusion marker)
- serial fibrinogen pt aptt inr platelets q2-4h during MTP (PROPPR JAMA 2015)
- serial echo q24h for cardiac recovery trajectory (RV recovery in phase 1; LV recovery in phase 2)
- continuous telemetry (arrhythmia surveillance)
- neurologic checks q1-2h initially (anoxic injury common in survivors)
- fetal heart rate continuous until delivery (predelivery AFE)

Setting (outpatient) monitoring:
- Echo at 3 mo and 6 mo
- Annual cardiology surveillance if persistent dysfunction
- Annual neurocognitive assessment if anoxic injury

Follow-up plan: 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
- Close-out criterion: Multidisciplinary follow-up booked + psychiatric and bereavement support engaged

Monitoring phase: A-line, central line, foley, possibly PA catheter; lactate q1–2 h; UOP hourly; serial fibrinogen / coags / platelet count q2–4 h during MTP; serial echo q24 h for cardiac recovery trajectory; continuous telemetry; neurologic checks (anoxic injury common in survivors)

Disposition

Current setting: outpatient — Long-term recovery — cardiology follow-up at 1 mo / 3 mo / 6 mo; neurocognitive rehabilitation if anoxic injury; psychiatric care for PTSD / post-ICU syndrome / perinatal grief; future-pregnancy counseling (recurrence elusive; many uneventful subsequent pregnancies); contraception support; family planning

Disposition criteria:
- Complete recovery → routine surveillance only
- Persistent HFrEF → long-term cross-link to cardio.hfref.core.v1 / cardio.hf.core.v1
- Persistent anoxic injury → ongoing neuro / rehab / palliative care coordination

Escalation triggers (move to higher acuity):
- Recurrent symptoms → cardiology urgent
- Persistent severe LV dysfunction beyond 6 mo → transplant evaluation
- New pregnancy → high-risk OB referral immediately

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Maternal cardiac arrest + viable gestation >20 wks + no ROSC within 4 min — perimortem cesarean within 4–5 min from arrest improves maternal survival (decompresses IVC + facilitates resuscitation) and may save the fetus
- [LIFE_THREATENING] Fibrinogen <150 mg/dL + ↑D-dimer + thrombocytopenia + ↑PT/aPTT in peripartum woman with ongoing obstetric hemorrhage — AFE hyperfibrinolytic DIC pattern; activate MTP + cryoprecipitate / fibrinogen concentrate to target ≥150 mg/dL + TXA 1 g IV within 3 h
- [LIFE_THREATENING] Phase 1 AFE — acute RV failure + dilated RV + flattened septum + acute pulmonary HTN refractory to NE + milrinone — escalate to inhaled NO or epoprostenol; consider VA-ECMO

Citations

- 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 [PMID:26987420](https://pubmed.ncbi.nlm.nih.gov/26987420/)
- Cited evidence (PMID 19751694) [PMID:19751694](https://pubmed.ncbi.nlm.nih.gov/19751694/)
- Cited evidence (PMID 21068427) [PMID:21068427](https://pubmed.ncbi.nlm.nih.gov/21068427/)
- Cited evidence (PMID 28456510) [PMID:28456510](https://pubmed.ncbi.nlm.nih.gov/28456510/)
- Cited evidence (PMID 25647203) [PMID:25647203](https://pubmed.ncbi.nlm.nih.gov/25647203/)

Last reconciled with current guidelines: 2026-05-15.
References
  • 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 — PMID:26987420
  • Cited evidence (PMID 19751694) — PMID:19751694
  • Cited evidence (PMID 21068427) — PMID:21068427
  • Cited evidence (PMID 28456510) — PMID:28456510
  • Cited evidence (PMID 25647203) — PMID:25647203