Cardiovascular disease has become a major cause of death in the peripartum period, accounting for 16%–25% of all pregnancy-related deaths.1,2 When faced with severe hemodynamic instability in the peripartum period, the differential diagnosis is complex and includes cardiogenic, obstructive, hypovolemic, and distributive shock.
The use of focused cardiac ultrasound (FOCUS) as a rescue tool in the clinical assessment of the hemodynamically unstable patient has been described previously, and several studies have demonstrated the utility of FOCUS in establishing a diagnosis during clinical emergencies in critical care, perioperative settings and in pregnant patients.3–5 We describe use of FOCUS using a parasternal long-axis view and an apical 4-chamber view to obtain a diagnosis of cardiogenic shock and to direct medical management toward inotropic support and venoarterial extracorporeal membrane oxygenation (VA ECMO).
Written consent was obtained from the patient for publication of this report. The host institution does not consider case reports to be human subject research, so no Institutional Review Board approval was deemed necessary.
A 27-year-old generally healthy primigravida, 40 weeks + 6 days gestation presented for labor and delivery in our tertiary medical institution.
The third stage of labor was complicated by a retained placenta and postpartum hemorrhage, which was assessed approximately as 1.5 L. She was transferred to the operating room for manual removal of the placenta.
After a negative test dose of 4 mL of 1% lignocaine in the epidural catheter, an additional 6 mL of 1% lignocaine was administered for analgesia. The gynecologist performed manual removal of placenta; however, bleeding continued and a uterine atony was diagnosed. She received 10 units of oxytocin intravenously (IV) and 0.2 mg of methylergometrine intramuscularly (IM), and uterine massage was performed. A large-bore peripheral IV access was instituted, and fluid resuscitation with Ringer’s lactate was initiated. Tracheal intubation was performed with an endotracheal tube of 7.5 mm internal diameter after administration of etomidate 0.2 mg/kg and succinylcholine 1.5 mg/kg. Invasive blood pressure (BP) was instituted in the radial artery. Simultaneously, 2 packed red blood cell units were administered and the massive transfusion protocol was initiated.
A second dose of methylergometrine 0.2 mg IM was administered 30 minutes after the first one. Surgical control of the atony was attempted using a B-lynch suture for uterine compression, and a third dose of IM methylergometrine was administered 60 minutes after the second dose. Misoprostol 1000 µg per rectum was administered also at that time. She had received 6 units of packed red blood cells, 4 fresh frozen plasma units, and 3 L Ringer’s lactate at this stage.
Ninety minutes after the start of surgery, her BP decreased to 40/20 mm Hg, Spo2 decreased to 83%, heart rate was 90 beats/min without evidence of electrocardiogram ST-T segment changes according to the anesthesia monitor, and her Etco2 decreased from 44 to 15 mm Hg (Table 1). Adrenaline 100 μg was administered, increasing her BP to 140/90 mm Hg and heart rate to 130 beats/min.
At this time, FOCUS was performed by the senior anesthesia resident, trained in both FOCUS and transthoracic echocardiography (TTE). FOCUS revealed severely reduced biventricular function with relatively preserved left ventricle contraction in the basal segments. There was no evidence of hypovolemia, intracardiac masses, air, or significant pericardial effusion during the FOCUS examination (Supplemental Digital Content, Video 1, http://links.lww.com/AACR/A225). A central venous line was inserted in the right internal jugular vein, and inotropic support with adrenaline 0.02 μg·kg−1·minute−1 was initiated. The surgical team performed a laparotomy and hysterectomy, and over the next 90 minutes, she remained hemodynamically unstable, supported by increasing doses of adrenaline up to 1 μg·kg−1·minute−1. Signs of active bleeding were not apparent during this surgery period. She developed severe pulmonary edema (Figure). Due to increasing concern regarding oxygenation and cardiac function, the ECMO team was summoned. An ad hoc interdisciplinary discussion (anesthesiologists, gynecologists, ECMO team directed by a senior cardiac surgeon) led to the decision to initiate VA ECMO support. This decision was based on her need for intermittent cardiopulmonary resuscitation (CPR), hemodynamic instability despite high-dose inotropic support, inefficient oxygenation, and severe metabolic acidosis (Tables 1 and 2). Cannulation was performed through the femoral artery and vein. VA ECMO was initiated with the initial flow 4 L/min and was associated with improved hemodynamics and oxygenation, allowing gradual decrease of inotropic support and transfer to the intensive care unit.
After 24 hours on ECMO, a wake-up test was performed, during which she opened her eyes and followed commands. During the next 4 days, cardiac function was assessed by TTE and remained poor. Left ventricular stroke volume obtained by TTE was 30 mL on ECMO flow 4 L/min and 19 mL when ECMO flow was gradually reduced to 1.5 L/min. On the fifth day of hospitalization, TTE assessment revealed normal right ventricle systolic function and improved left ventricle systolic function. Calculated left ventricular stroke volume on ECMO flow 1.5 L/min was 30 mL. She was weaned from ECMO in the operating room under intraaortic balloon pump and inotropic support; extubated on day 7, and, on day 9, TTE revealed normal left and right ventricular function (Supplemental Digital Content, Video 2, http://links.lww.com/AACR/A226). She was discharged from the hospital to the rehabilitation center on the 25th day of hospitalization without significant neurological and cognitive deficit.
This case illustrates the diagnosis and management of a critically ill obstetric patient in the peripartum period. The FOCUS examination was used as a diagnostic tool in this case; a transesophageal echocardiography machine was not readily available in the delivery room. FOCUS aided our deliberation of the differential diagnoses for our patient. First, we excluded acute hypovolemia as the immediate cause of ongoing hemodynamic instability. Second, images obtained by FOCUS were suggestive of cardiac insufficiency due to a coronary artery event, Takotsubo cardiomyopathy, or peripartum cardiomyopathy. Finally, FOCUS did not reveal any intracardiac masses, air, right ventricle enlargement, or systolic dysfunction in conjunction with an underfilled hyperdynamic left ventricle—findings that may indicate an embolic event. Use of FOCUS is supported by international guidelines5 and has been incorporated into perioperative clinical practice.4,6
VA ECMO and venovenous ECMO in critically ill patients have become an established life-saving therapy.7 Within the urgent time frame, a number of obstacles regarding initiation of VA ECMO were considered for our patient. First, the ECMO device had never been transferred to the labor ward. Second, ECMO is contraindicated in patients with prolonged CPR without adequate tissue perfusion and unclear neurological prognosis.7 Severe acidosis, hypoxemia, and lactatemia were present after prolonged CPR and a shocked state. Third, our patient had a relative contraindication for anticoagulation after her laparotomy and hysterectomy. Anticoagulation was initiated despite the risk of bleeding, after performing surgical control of hemorrhage and administration of blood products, with target activated clotting time that was not decreased below 180 seconds. The ad hoc interdisciplinary consult facilitated the risk-benefit decision to connect her to ECMO.
The exact cause of the cardiac insufficiency is still not known in our patient. Acute myocardial infarction can complicate 2.8–6.2 pregnancies per 100,000.8,9 Acute myocardial infarction can be caused by coronary atherosclerosis in 40% of pregnant women, by spontaneous coronary artery dissection in 27%, and may be associated with normal coronary artery anatomy in 13% of all cases.10 Takotsubo stress cardiomyopathy, secondary to peripartum and perioperative stress, accompanied by catecholamine surge is another possibility. Echocardiographic images obtained by FOCUS demonstrated regional left ventricle motion variation. Specifically, there was relatively preserved function of the basal anteroseptal, inferoseptal, inferolateral, and anterolateral segments. This finding may be suggestive of Takotsubo cardiomyopathy, although our patient is relatively young for classic Takotsubo syndrome. Nevertheless, Takotsubo syndrome managed by ECMO in young peripartum patients has been previously described.11 We did not perform coronary angiography to exclude coronary artery ischemia. In our patient, peripartum cardiomyopathy is a less probable diagnosis because this pathology of cardiac dysfunction typically persists.12 Ergot alkaloids are frequently administered for prevention and treatment of postpartum hemorrhage and may be administered IM or IV. Although ergot alkaloids (contraindicated in hypertension) are regularly used in obstetric patients, their administration may cause severe cardiovascular complications, including vasoconstriction, hypertension, myocardial ischemia, and coronary vasospasm myocardial infarction.13 There are several case reports of cardiogenic shock in gynecology-obstetric patients due to use of ergot alkaloids,14,15 such as used in our patient.
Although our patient did not demonstrate severe coagulopathy or hypoxia with the onset of hemodynamic instability, this does not exclude diagnosis of amniotic fluid embolism. In our case, use of FOCUS enabled us to direct management and crucially impact the patient’s outcome. Therefore, we consider that, without use of FOCUS in this case, the cardiogenic shock may not have been rapidly identified, and ECMO may not have been instituted.
Name: Ilya Lembrikov, MD.
Contribution: This author helped write and edit the manuscript.
Name: Ehud Rudis, MD.
Contribution: This author helped write and edit the manuscript.
Name: Carolyn F. Weiniger, MBChB.
Contribution: This author helped write and edit the manuscript.
This manuscript was handled by: Kent H. Rehfeldt, MD.
1. Hameed AB, Lawton ES, McCain CL, et al. Pregnancy-related cardiovascular deaths in California: beyond peripartum cardiomyopathy. Am J Obstet Gynecol. 2015;213:379.e1–379.e10.
2. Ray P, Murphy GJ, Shutt LE. Recognition and management of maternal cardiac disease in pregnancy. Br J Anaesth. 2004;93:428–439.
3. Breitkreutz R, Price S, Steger HV, et al.; Emergency Ultrasound Working Group of the Johann Wolfgang Goethe-University Hospital, Frankfurt am Main. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation. 2010;81:1527–1533.
4. Jain D, Grejs AM, Bhavsar R, Bang U, Sloth E, Juhl-Olsen P. Focused cardiac ultrasound is feasible in parturients; a prospective observational study. Acta Anaesthesiol Scand. 2017;61:1105–1113.
5. Via G, Hussain A, Wells M, et al.; International Liaison Committee on Focused Cardiac Ultrasound (ILC-FoCuS); International Conference on Focused Cardiac Ultrasound (IC-FoCUS). International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014;27:683.e1–683.e33.
6. Skubas NJ, Rehfeldt KH, Beattie WS. Be FoCUSed: the time is now! Anesth Analg. 2017;124:714–715.
7. ELSO Guidelines for Adult Cardiac Failure, Version 1.3. Extracorporeal Life Support Organization web site. Available at: www.elso.org/Resources/Guidelines.aspx
. Published December 2013. Accessed June 15, 2015.
8. Ladner HE, Danielsen B, Gilbert WM. Acute myocardial infarction in pregnancy and the puerperium: a population-based study. Obstet Gynecol. 2005;105:480–484.
9. James AH, Jamison MG, Biswas MS, Brancazio LR, Swamy GK, Myers ER. Acute myocardial infarction in pregnancy: a United States population-based study. Circulation. 2006;113:1564–1571.
10. Roth A, Elkayam U. Acute myocardial infarction associated with pregnancy. J Am Coll Cardiol. 2008;52:171–180.
11. Crimi E, Baggish A, Leffert L, Pian-Smith MC, Januzzi JL, Jiang Y. Images in cardiovascular medicine. Acute reversible stress-induced cardiomyopathy associated with cesarean delivery under spinal anesthesia. Circulation. 2008;117:3052–3053.
12. Regitz-Zagrosek V, Blomstrom Lundqvist C, Borghi C, et al. ESC guidelines on the management of cardiovascular diseases during pregnancy: the Task Force on the Management of Cardiovascular Diseases during Pregnancy of European Society of Cardiology (ESC). Eur Heart J. 2011;32:3147–3197.
13. Barbara M, Scavone MD. Chestnut DH. Antepartum and postpartum hemorrhage. In: Chestnut’s Obstetric Anesthesia: Principles and Practice. 2014:3rd ed. Philadelphia, PA: Elsevier/Saunders, 890–891.
14. Ko WJ, Ho HN, Chu SH. Postpartum myocardial infarction rescued with an intraaortic balloon pump and extracorporeal membrane oxygenator. Int J Cardiol. 1998;63:81–84.
15. Lee HS, Min JY, Lee Y. Cardiac arrest with pulmonary edema in a non-parturient after ergonovine administration recovered with extracorporeal membrane oxygenation - a case report. Korean J Anesthesiol. 2012;63:559–562.