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, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC