Cardiogenic Shock and Late Pregnancy
OVERVIEW
Major issues:
- Two patients
- High mortality
- Planned delivery
- Diagnose and treat cause
MANAGEMENT
- Declare an Emergency
- Call for help – neonates, anaesthesia, ICU, obstetrics, OT, blood bank, cardiology
Resuscitation
Airway
- assess for intubation: high risk induction (difficult airway and haemodynamically instability)
- may be able to support with NIV
Breathing
- assess for severity of pulmonary oedema
- FiO2 titrated to SpO2 99% -> increase O2 availability to baby
- NIV
- if intubated: lung protective ventilation strategy
Circulation
- obtain history and examination
- diagnose cause: pre-existing valvular abnormality with pregnancy related decompensation, peripartum cardiomyopathy
- risk factors: older age, twin gestation, PET, dissection
- assess whether she has biventricular or univentricular failure
- supportive with appropriate vasoactives
- 12 lead ECG
- will need urgent ECHO: TOE or TTE
- diagnose mechanism of cardiogenic shock: systolic dysfunction, diastolic dysfunction, valves, pericardium, arrhythmia
- maintain sinus rhythm
- cautious use of fluid
Electrolytes and Acid-base
- ensure normal Mg2+ and K+
- metabolic component should resolve with heart failure treatment
Specific Therapy
Heart failure
- treatment will depend on contraindications in pregnancy
- decrease preload: fluid restriction, diuretics, spironolactone
- decrease afterload: GTN, hydralazine, SNP, IABP, AC-I’s contraindicated
- optimise contractility: milrinone, dobutamine (but reduces placental blood flow in animal models), adrenaline, VAD
- increase coronary oxygenation + perfusion: O2, Hb, stents, CABG, IABP
- decrease myocardial work: IABP, VAD, VA ECMO, beta-blockers once stable
Mother
- GORD prophylaxis
- family liaison
Baby
- doesn’t require steroids
- left lateral tilt
- planned urgent delivery (under epidural or haemodynamically stable GA)
- CTG monitoring
- O2
- tocolytics if distressed
- optimize perfusion to uterus
Underlying Cause
- dependent on cause
- PE: delivery + embolectomy, thrombolysis, anticoagution, IVC filter
- peripartum cardiomyopathy: anti-failure treatment
- MI: revascularisation
- valvulopathy: surgery
- arrhythmia: cardioversion, anti-arrhythmics
- pericardial tamponade: drain
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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