Peripartum cardiomyopathy in an intensive care unit setting

Table 1 Suggested intensive care unit hemodynamics order set

Suggested ICU hemodynamics order set
Insert an arterial line and central venous catheter for unstable patients
Start norepinephrine if MAP < 65 mmHg with signs of hypoperfusion
Initiate inotrope for low-output states:
Dobutamine 2-5 μg/kg/minute, titrated every 30-60 minutes based on invasive measures
OR Milrinone 0.25-0.5 μg/kg/minute, titrate every 30-60 minutes based on invasive measures
Avoid nitroprusside or hydralazine in the presence of hypotension
Daily ECG
Daily electrolytes:
Maintain K+ > 4.0 mmol/L
Maintain Mg2+ > 2.0 mg/dL
Escalation checklist:
Persistent hypotension despite inotrope → Add vasopressor
Cardiac index < 2.0 L/minute/m2 after 2 hours → Consider mechanical circulatory support (see section E)
Lactate > 4 mmol/L or worsening acidosis → Activate advanced heart failure consult

ICU: Intensive care unit; MAP: Mean arterial pressure; ECG: Electrocardiogram.

Table 2 Suggested intensive care unit respiratory order set

Suggested ICU respiratory order set
Oxygen via nasal cannula or HFNC; titrated to target saturation
NIV (CPAP 5-10 cm H2O) if hemodynamically stable and cooperative
Early intubation if PaO2/FiO2 < 150 or signs of fatigue
Daily chest X-ray and ABG for ventilated patients
Avoid high PEEP in preload-dependent patients
Escalation checklist
SpO2 < 88% despite HFNC/NIV → Prepare for intubation
Worsening pulmonary edema → Intensify diuresis and evaluate for MCS
Signs of ventilator-induced hypotension → Adjust PEEP and fluids cautiously

HFNC: High flow nasal cannula; NIV: Non-invasive ventilation; CPAP: Continuous positive airway pressure; ABG: Arterial blood gas; PEEP: Positive end expiratory pressure; MCS: Mechanical circulatory support.

Table 3 Suggested intensive care unit fluid order set

Suggested ICU fluid order set
Furosemide IV bolus (20-40 mg), repeat or switch to infusion if inadequate diuresis
Strict input/output monitoring; daily weights
CVP-guided diuresis in invasive monitoring patients
Hold diuretics if MAP < 60 mmHg or rising creatinine
Escalation checklist
Persistent volume overload despite high-dose loop diuretics → Add thiazide synergy
Rising creatinine > 0.3 mg/dL in 48 hours → Reassess fluid goals
CVP < 5 cmH2O and hypotension → Stop diuretics and reassess preload

ICU: Intensive care unit; CVP: Central venous pressure; MAP: Mean arterial pressure.

Table 4 Suggested intensive care unit anticoagulation order set

Suggested ICU anticoagulation order set
Initiate unfractionated heparin infusion; target PTT 60-80 seconds
Daily CBC and coagulation profile
Transition to warfarin postpartum if stable and no planned procedures
Escalation checklist
New embolic event → Evaluate anticoagulation adequacy
Active bleeding → Hold anticoagulant and reverse if indicated

ICU: Intensive care unit; CBC: Complete blood count; PTT: Partial thromboplastin time.

Table 5 Suggested intensive care unit mechanical circulatory support order set

Suggested ICU MCS order set
Early heart team consult if escalating inotropes/pressors > 24 hours
Prepare femoral access for urgent IABP or ECMO
Daily echocardiographic monitoring while on support
Escalation checklist
MAP < 60 mmHg and lactate rising despite inotropes → Initiate MCS
Multiorgan failure progression → Reassess goals of care

ICU MCS: Intensive care unit mechanical circulatory support; ECMO: Extracorporeal membrane oxygenation; MAP: Mean arterial pressure; MCS: Mechanical circulatory support.

Table 6 Suggested intensive care unit pharmacotherapy order set

Suggested ICU pharmacotherapy order set
Furosemide IV as above
Metoprolol succinate 125-25 mg daily once off inotropes for 24 hours
Lisinopril 25-5 mg daily postpartum if SBP > 90 mmHg
Bromocriptine with concurrent anticoagulation (UFH or LMWH)
Levosimendan 6-12 μg/kg over 10 minute (loading) 0.05-0.2 μg/kg/minute for 24 hours (maintenance). Limited data available in pregnancy. Not advisable during lactation
Escalation checklist
Hypotension after beta-blocker → Hold and reassess
Worsening renal function after ACEi → Stop and monitor

ACEi: Angiotensin converting enzyme inhibitor; UFH: Unfractionated heparin; LMWH: Low molecular weight heparin.