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cardio.post-arrest.peripartum-arrest.v1PRODUCTION
cardio.post-arrest.peripartum-arrest.v1

Post-cardiac-arrest care — peripartum maternal arrest

cardiologyacuteadult
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12/12 authored

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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

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peripartum status confirmed + multidisciplinary team (OB + anesthesia + NICU + cards) activated

Patient inputs (15)

Maternal age affects PPCM risk + obstetric complications; advanced maternal age ≥35 → higher PE/preeclampsia risk

Witnessed arrest + bystander CPR → favorable neuro prognosis; CAHP/OHCA score inputs (AHA 2020)

PEA most common in AFE / hemorrhage; VF/pVT raises ischemic / channelopathy / PE differential

CPR duration → ECPR eligibility (ARREST PMID 33308475 — <60 min low-flow); neuro prognosis weighting; perimortem cesarean if no ROSC by 4-5 min

Pregnancy normally lowers Cr (~0.5); rising Cr post-arrest → AKI + preeclampsia spectrum + drug renal-adjustment (AHA 2020)

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

SCAD + PPCM + AFE-related myocardial injury workup (4th UDMI 2018); peripartum SCAD highest in immediate postpartum period

Tissue hypoperfusion; AFE / hemorrhage / sepsis-arrest cascades all elevate lactate (SCAI 2022 PMID 35718438)

AFE classic triad includes DIC — fibrinogen <200 + platelets dropping + D-dimer rising in setting of sudden CV collapse + hypoxemia (Hui 2022 consensus)

PPCM (dilated LV + EF <45) vs AFE (acute RV failure + pulmonary HTN) vs PE (acute RV strain + McConnell sign) — guides MCS + AC decisions

Drives perimortem cesarean decision (>20 wks viable for maternal hemodynamics; >24 wks viable fetus) per AHA 2024 maternal arrest

Hemodynamic stability post-ROSC; SCAI staging if shock; supine pregnant SBP confounded by aortocaval compression — measure with left lateral tilt

TTM target 33-37.5 °C × 24h (TTM2 PMID 34133859); pregnancy not contraindication; fetal monitoring during cooling

Avoid hyperoxia: SpO2 92-98% (AHA 2020 Class IIa); profound hypoxemia + sudden onset → AFE classic feature

Preeclampsia / placenta accreta / PPCM history / prior cardiac history — drives etiologic differential (AHA 2024)

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Severity triggers (5)

5 need judgement
  • informationallife_threateningno_rosc_by_4_min_with_viable_gestation
    Failure to achieve ROSC within 4 minutes of arrest in pregnant patient with viable gestational age (>20 wks) — perimortem cesarean indicated immediately (AHA 2024 Class I)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningamniotic_fluid_embolism_classic_triad
    Sudden CV collapse + profound hypoxemia + DIC (fibrinogen <200, dropping platelets, rising D-dimer) during labor / cesarean / immediate post-partum — AFE classic triad (Hui 2022 international consensus)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningmassive_pe_in_pregnancy_with_arrest
    Hemodynamic collapse + RV strain on echo + risk factors (postpartum, cesarean, immobility) — massive PE with arrest; thrombolysis Class I despite peripartum bleeding risk if hemodynamically unstable (AHA 2020)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningsevere_postpartum_hemorrhage_with_arrest
    Massive postpartum hemorrhage (>1500 mL) with arrest — atony, accreta, placental abruption; massive transfusion + uterotonics + IR / surgical intervention
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningeclampsia_seizure_with_arrest_or_post_rosc
    Generalized seizure with maternal arrest in setting of preeclampsia (HTN + proteinuria + new-onset seizure) — Mg loading + control of HTN per ACOG
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Peripartum maternal post-arrest phenotype — modified ACLS pharmacotherapy + obstetric resuscitation + AFE/PPCM/PE/hemorrhage etiology bundles (AHA 2024 maternal arrest + Hui 2022 AFE consensus)
axis: peripartum_post_arrest_phenotype
Selected axis "Peripartum maternal post-arrest phenotype — modified ACLS pharmacotherapy + obstetric resuscitation + AFE/PPCM/PE/hemorrhage etiology bundles (AHA 2024 maternal arrest + Hui 2022 AFE consensus)" by default fallback (first axis)
  • norepinephrine
    first line
    vasopressor_alpha1_beta1
    0.05-0.5 µg/kg/min titrate MAP ≥65 (≥70-75 if undelivered for uteroplacental flow) • IV • continuous
    triggers: post_rosc_vasoplegia, afe_with_shock, ppcm_with_shock
    SOAP-II PMID 20200382; first-line in pregnancy per AHA 2024 maternal arrest (no vasopressor contraindicated in pregnancy when arrest)
    rxcui 7512
  • amiodarone
    first line
    class_iii_antiarrhythmic
    300 mg IV bolus → 150 mg if recurrent → 1 mg/min × 6h → 0.5 mg/min × 18h • IV • continuous taper
    triggers: recurrent_vf_pvt_post_rosc
    AHA 2020 ACLS Class IIb; pregnancy concern (fetal thyroid) but life-saving so used per AHA 2024 maternal arrest
    rxcui 703
  • magnesium sulfate
    add on
    electrolyte_anti_arrhythmic
    1-2 g IV bolus + 1-2 g/h infusion (eclampsia loading 4-6 g IV bolus then 1-2 g/h) • IV • bolus + continuous
    triggers: torsades_de_pointes, eclampsia_seizure_prevention
    AHA 2020 ACLS Class IIa for TdP; ACOG-WHO Class I for eclampsia seizure prophylaxis (Magpie PMID 12057549)
    rxcui 6585
  • tranexamic acid
    first line
    antifibrinolytic
    1 g IV over 10 min within 3h of bleeding onset; repeat 1g if bleeding continues • IV • one-time + repeat
    triggers: postpartum_hemorrhage, afe_with_dic
    WOMAN trial PMID 28456510 — TXA reduces death from PPH if given <3h; CRASH-2 PMID 20554319
    rxcui 10691
  • oxytocin
    first line
    uterotonic
    10 U IM + 10-40 U in 1L NS infusion • IV/IM • continuous post-delivery
    triggers: postpartum_hemorrhage_atony
    ACOG Class I uterotonic first-line for atony PPH
    rxcui 7824
  • propofol
    first line
    sedative_iv_anesthetic
    5-50 µg/kg/min • IV • continuous; titrate RASS
    triggers: post_rosc_intubation_ttm
    PADIS 2018; pregnancy category B; propofol crosses placenta but standard ICU sedation post-delivery
    rxcui 8782
  • warfarin
    contraindication substitute
    vitamin_k_antagonist
    AVOID during pregnancy (teratogenic 6-12 wks; fetal hemorrhage); switch to LMWH if AC needed • PO • AVOID
    triggers: contraindicated_pregnancy_ac_indication
    ACOG + AHA 2024 — warfarin teratogenic and fetal bleeding risk; LMWH preferred during pregnancy
    rxcui 11289
  • enoxaparin
    first line
    lmwh
    1 mg/kg SC BID (treatment); 40 mg SC daily (prophylaxis) • SC • BID/daily
    triggers: pe_post_arrest, vte_prophylaxis_pregnancy
    ACOG / RCOG / CHEST 2018 — LMWH first-line AC during pregnancy + breastfeeding
    rxcui 67108

outpatient playbook — drug actions (2)

  1. 1. continue PPCM GDMT 4 pillars if HFrEF persistent
    rxcui 1656328
    sacubitril-valsartan max tolerated (post-breastfeeding); carvedilol; spironolactone; SGLT2i • PO • as scheduled
    trigger: PPCM HFrEF persistent post-breastfeeding
    ACC/AHA 2022 HF 4-pillar; PIONEER-HF PMID 30403955; EMPULSE PMID 35347356
  2. 2. continue contraception (avoid pregnancy if EF <40)
    LARC preferred • IUD/implant • as scheduled
    trigger: PPCM EF <40
    Future pregnancy contraindicated until full EF recovery (Sliwa ESC PPCM)

Auto-drafted A&P note

outpatient

Subjective

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

Objective

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

Assessment

**Post-cardiac-arrest care — peripartum maternal arrest** (cardio.post-arrest.peripartum-arrest.v1).
Phenotype framing: 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)
Scope: 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

No severity triggers fired against current inputs.

Plan

Regimen axis: **Peripartum maternal post-arrest phenotype — modified ACLS pharmacotherapy + obstetric resuscitation + AFE/PPCM/PE/hemorrhage etiology bundles (AHA 2024 maternal arrest + Hui 2022 AFE consensus)**.
1. norepinephrine 0.05-0.5 µg/kg/min titrate MAP ≥65 (≥70-75 if undelivered for uteroplacental flow) IV continuous (vasopressor_alpha1_beta1, first line) — SOAP-II PMID 20200382; first-line in pregnancy per AHA 2024 maternal arrest (no vasopressor contraindicated in pregnancy when arrest)
2. amiodarone 300 mg IV bolus → 150 mg if recurrent → 1 mg/min × 6h → 0.5 mg/min × 18h IV continuous taper (class_iii_antiarrhythmic, first line) — AHA 2020 ACLS Class IIb; pregnancy concern (fetal thyroid) but life-saving so used per AHA 2024 maternal arrest
3. magnesium sulfate 1-2 g IV bolus + 1-2 g/h infusion (eclampsia loading 4-6 g IV bolus then 1-2 g/h) IV bolus + continuous (electrolyte_anti_arrhythmic, add on) — AHA 2020 ACLS Class IIa for TdP; ACOG-WHO Class I for eclampsia seizure prophylaxis (Magpie PMID 12057549)
4. tranexamic acid 1 g IV over 10 min within 3h of bleeding onset; repeat 1g if bleeding continues IV one-time + repeat (antifibrinolytic, first line) — WOMAN trial PMID 28456510 — TXA reduces death from PPH if given <3h; CRASH-2 PMID 20554319
5. oxytocin 10 U IM + 10-40 U in 1L NS infusion IV/IM continuous post-delivery (uterotonic, first line) — ACOG Class I uterotonic first-line for atony PPH
6. propofol 5-50 µg/kg/min IV continuous; titrate RASS (sedative_iv_anesthetic, first line) — PADIS 2018; pregnancy category B; propofol crosses placenta but standard ICU sedation post-delivery
7. warfarin AVOID during pregnancy (teratogenic 6-12 wks; fetal hemorrhage); switch to LMWH if AC needed PO AVOID (vitamin_k_antagonist, contraindication substitute) — ACOG + AHA 2024 — warfarin teratogenic and fetal bleeding risk; LMWH preferred during pregnancy
8. enoxaparin 1 mg/kg SC BID (treatment); 40 mg SC daily (prophylaxis) SC BID/daily (lmwh, first line) — ACOG / RCOG / CHEST 2018 — LMWH first-line AC during pregnancy + breastfeeding

Setting playbook (outpatient) — Long-term cardiology + MFM surveillance; PPCM recovery trajectory + family planning; mental health; ICD decision at 6+ mo only if EF persistently <35 despite GDMT
9. continue PPCM GDMT 4 pillars if HFrEF persistent sacubitril-valsartan max tolerated (post-breastfeeding); carvedilol; spironolactone; SGLT2i PO as scheduled — PPCM HFrEF persistent post-breastfeeding (ACC/AHA 2022 HF 4-pillar; PIONEER-HF PMID 30403955; EMPULSE PMID 35347356)
10. continue contraception (avoid pregnancy if EF <40) LARC preferred IUD/implant as scheduled — PPCM EF <40 (Future pregnancy contraindicated until full EF recovery (Sliwa ESC PPCM))

Non-pharmacologic actions:
- ICD decision at 6+ mo if EF persists <35 despite GDMT (HRS PPCM consensus)
- Family planning counseling — pregnancy contraindicated if EF <40 (high mortality recurrence)
- Cardiac rehab maintenance phase
- Mental health long-term f/u

AVOID / contraindication checks:
- Warfarin_avoid_pregnancy_first_trimester (ACOG; teratogenic 6 12 wks)
- Ace_inhibitor_arb_avoid_pregnancy (FDA category D; fetal renal injury)
- Nsaid_avoid_third_trimester (ductal closure)
- Doac_limited_pregnancy_data (ACOG — use LMWH instead)
- Bromocriptine_for_ppcm_controversial (no high quality RCT; small ESC pilot)
- Thrombolytic_relative_contraindication_immediate_postpartum_bleeding_but_lifesaving_for_massive_pe (AHA 2020)

Monitoring

Regimen monitoring:
- continuous ecg telemetry (AHA 2020 Class I)
- serial troponin q2-3h x 3 then q6h (4th UDMI 2018)
- BMP q6-12h + Mg + K + coags (DIC panel q4-6h if AFE) (Hui 2022)
- core temperature continuous via bladder or esophageal probe (TTM2)
- continuous EEG for 24-48h (Sandroni 2021)
- NSE at 24h 48h 72h (Sandroni 2021)
- continuous fetal heart monitoring if undelivered (ACOG)
- echo at day 3-5 for lv function trajectory if ppcm (Sliwa 2010 ESC PPCM)
- postpartum bleeding assessment q1h x 24h then q4h (ACOG)

Setting (outpatient) monitoring:
- Quarterly BP + weight + symptom score
- Annual ECG + echo
- Annual mental health

Follow-up plan: 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
- Close-out criterion: cardiology + MFM + mental health + contraception + ICD/WCD plan booked

Monitoring phase: 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

Disposition

Current setting: outpatient — Long-term cardiology + MFM surveillance; PPCM recovery trajectory + family planning; mental health; ICD decision at 6+ mo only if EF persistently <35 despite GDMT

Disposition criteria:
- Long-term continuation; cross-link to cardio.hf.core.v1 for chronic PPCM; cardio.ascvd.chronic.v1 for SCAD secondary prevention

Escalation triggers (move to higher acuity):
- ICD therapy delivered → urgent EP
- EF declining despite GDMT → advanced HF + transplant
- Subsequent pregnancy attempted with EF <50 → high-risk MFM + cards joint program

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Failure to achieve ROSC within 4 minutes of arrest in pregnant patient with viable gestational age (>20 wks) — perimortem cesarean indicated immediately (AHA 2024 Class I)
- [LIFE_THREATENING] Sudden CV collapse + profound hypoxemia + DIC (fibrinogen <200, dropping platelets, rising D-dimer) during labor / cesarean / immediate post-partum — AFE classic triad (Hui 2022 international consensus)
- [LIFE_THREATENING] Hemodynamic collapse + RV strain on echo + risk factors (postpartum, cesarean, immobility) — massive PE with arrest; thrombolysis Class I despite peripartum bleeding risk if hemodynamically unstable (AHA 2020)

Citations

- AHA 2024 maternal cardiac arrest scientific statement + AHA 2020 ACLS / Post-Cardiac-Arrest Care + Hui 2022 AFE international consensus + ACOG hemorrhage / hypertension bundles [PMID:33081530](https://pubmed.ncbi.nlm.nih.gov/33081530/)
- Cited evidence (PMID 26473546) [PMID:26473546](https://pubmed.ncbi.nlm.nih.gov/26473546/)
- Cited evidence (PMID 34133859) [PMID:34133859](https://pubmed.ncbi.nlm.nih.gov/34133859/)
- Cited evidence (PMID 31532382) [PMID:31532382](https://pubmed.ncbi.nlm.nih.gov/31532382/)
- Cited evidence (PMID 33745427) [PMID:33745427](https://pubmed.ncbi.nlm.nih.gov/33745427/)

Last reconciled with current guidelines: 2026-05-14.
References
  • AHA 2024 maternal cardiac arrest scientific statement + AHA 2020 ACLS / Post-Cardiac-Arrest Care + Hui 2022 AFE international consensus + ACOG hemorrhage / hypertension bundles — PMID:33081530
  • Cited evidence (PMID 26473546) — PMID:26473546
  • Cited evidence (PMID 34133859) — PMID:34133859
  • Cited evidence (PMID 31532382) — PMID:31532382
  • Cited evidence (PMID 33745427) — PMID:33745427