Cardiogenic Shock in Pregnancy

The following article was written by Dr. Juliette Power as a CardioNerds Conference Scholar for The 2022 SCAI SHOCK Conference.

In Dr. Anna Bortnick’s review of cardiogenic shock in pregnancy at SCAI Shock 2022, she impressed upon the audience to identify cardiogenic shock and initiate mechanical circulatory support early and often in order to improve outcomes. Specifically, mechanical circulatory support within 6 days of onset of cardiogenic shock is associated with lower mortality.

Dr. Bortnick MD, PhD, MSc, FSCAI is an associate professor at Albert Einstein College of Medicine who began her talk by reviewing that CS in pregnancy is a rare but serious complication, most commonly diagnosed postpartum or postmortem, that dramatically worsens peripartum outcomes. Common etiologies of cardiogenic shock in pregnancy include worsening stenotic valvular disease due to increased cardiac output, hypercoagulable states leading to increased risk of thrombotic events, and hormonal shifts increasing risk of pregnancy-associated SCAD (P-SCAD) and peripartum cardiomyopathy (PPCM).

P-SCAD is the most common cause of pregnancy associate MI. Hormonal effect on the vasculature leads to a tripled risk of acute myocardial infarction in pregnant patients, most often in the 3rdtrimester or postpartum, as compared to non-pregnant patients. Studies have shown that P-SCAD is associated with higher risk features, compared to traditional SCAD, with 75% of women presenting with left main artery and left anterior descending artery and at least 1/4 presenting in cardiogenic shock and needing mechanical circulatory support. When treating P-SCAD consideration should be given to minimizing the risk of coronary angiogram complications. Dr. Bortnick, suggests use of 4 Fr radial catheters, limited and low pressure injections, and percutaneous intervention only if the patients has unstable or high risk features. Her other recommendations include fetal monitoring, IV access above the diaphragm, left lateral tilt positioning, and uterine evacuation within four minutes of a cardiac arrest.

As PPCM is implicated in >50% of all cardiogenic shock cases in pregnant and peripartum women, cardiologists should be familiar with diagnosis and management. PPCM is a diagnosis of exclusion as a nonischemic cardiomyopathy presenting at the end of pregnancy or early postpartum with an LVEF<45%. Aside from non-teratogenic traditional guideline-directed medical therapy, bromocriptine, a dopamine receptor agonist that inhibits prolactin release, can be considered as an adjunct medical therapy (IIB recommendation, ESC guidelines), but requires anticoagulation due to thrombosis risk, although this is less of an issue as most patients cardiogenic shock with mechanical circulatory support will require anticoagulation anyways.

Ultimately pregnant cardiogenic shock patients are complex and require multidisciplinary care to maximize chances for favorable outcomes.

References

  1. Park, K., Bortnick, A., et al. Interventional Cardiac Procedures and Pregnancy. Journal of the Society for Cardiovascular Angiography & Interventions. 2022; 1:5.
  2. Sharma, S., Thomas, S. Management of Heart Failure and Cardiogenic Shock in Pregnancy. Curr Treat Options Cardio Med. 2019; 21:83.