Management of Peripartum Cardiomyopathy and Cardiac Arrest

Immediate Resuscitation and Stabilization

The American College of Cardiology recommends immediate aggressive resuscitation with oxygen therapy, invasive hemodynamic monitoring, inotropic support, and rapid escalation to mechanical circulatory support if the patient remains hemodynamically unstable, with urgent consideration for cardiac transplantation if recovery does not occur within hours to days 1
Target arterial oxygen saturation ≥95% using supplemental oxygen, as recommended by the European Society of Cardiology 1
Apply non-invasive ventilation with PEEP 5-7.5 cmH2O if hypoxemia persists without cardiac arrest, according to the European Society of Cardiology 1
Establish continuous invasive hemodynamic monitoring immediately upon stabilization, as suggested by the European Journal of Heart Failure 2, 1
Place continuous urinary catheter for strict fluid balance monitoring, as recommended by the European Journal of Heart Failure 2, 1

Initiate dobutamine or levosimendan if signs of hypoperfusion persist or congestion continues despite vasodilators and diuretics, as recommended by the European Heart Journal 3, 1
Consider intra-aortic balloon pump counterpulsation as first-line mechanical support, according to the European Heart Journal 3, 1
LVAD may serve as bridge to recovery or transplantation, particularly important given the 50% spontaneous recovery rate in PPCM, as suggested by the European Heart Journal 3, 1

Initiate therapeutic anticoagulation with unfractionated heparin or low-molecular-weight heparin once post-delivery bleeding has stopped, due to the pro-thrombotic nature of PPCM and increased risk of ventricular thrombi and cerebral embolism, as recommended by the European Heart Journal and European Journal of Heart Failure 3, 2, 1
Monitor anti-Xa levels if using LMWH, as suggested by the European Heart Journal 3
Proceed with immediate delivery regardless of gestational age if the patient presents with advanced heart failure and hemodynamic instability, according to the European Heart Journal 3
Transition immediately to standard heart failure therapy including ACE inhibitors or ARBs once bleeding has stopped, as recommended by the European Heart Journal and American College of Cardiology 3, 1
Initiate beta-1 selective beta-blockers, such as metoprolol, as recommended by the European Heart Journal and American College of Cardiology 3, 1, 4

LV end-diastolic diameter >60 mm predicts poor recovery, as suggested by the American College of Cardiology 1
LVEF <30% indicates worse prognosis, according to the American College of Cardiology 1
Recognize that 50% of PPCM patients show spontaneous recovery within 6 months, which must factor into transplant timing decisions, as recommended by the European Heart Journal and American College of Cardiology 3, 1
Urgent cardiac transplantation should be considered if weaning from mechanical circulatory support is unsuccessful, as suggested by the American College of Cardiology 1
Reserve transplantation for patients where mechanical support is not possible, not desirable, or who fail to recover after 6-12 months on mechanical support, according to the European Heart Journal 3

Never use ergometrine for third-stage labor management as it is absolutely contraindicated, as recommended by the European Journal of Heart Failure and American College of Cardiology 2, 1
Never use atenolol as the beta-blocker of choice, according to the European Heart Journal and American College of Cardiology 3, 4
Do not delay mechanical circulatory support if inotropes are required beyond the first hour, as suggested by the European Heart Journal and American College of Cardiology 3, 1
Do not underestimate the thrombotic risk—anticoagulation is essential once bleeding is controlled, as recommended by the European Heart Journal, European Journal of Heart Failure, and American College of Cardiology 3, 2, 1

Supervise newborns for 24-48 hours after delivery to exclude hypoglycemia, bradycardia, and respiratory depression if mother received beta-blockers, as recommended by the European Heart Journal and American College of Cardiology 3, 4
Most pregnancy-related deaths occur in the first 4 weeks postpartum, requiring intensive monitoring during this period, according to the American College of Cardiology 1
Defer ICD placement for at least 6 months given the high spontaneous recovery rate, as suggested by the American College of Cardiology 1