Abstract 11672: A Case of Postpartum Seizure, Cardiac Arrest, and Shock

Cardiogenic shock (CS) in the peripartum period is associated with significant morbidity and mortality. Treatment of CS by specialists in high-volume centers is associated with improved outcomes. A healthy 34-year-old pregnant woman underwent planned cesarian section delivery for placenta previa at a community hospital, which was complicated by postpartum hemorrhage treated with methylergonovine, tranexamic acid, and carboprost. One hour later, she was hypertensive, tachycardic, and had a generalized seizure followed by hypoxemia and pulseless electrical activity. She was persistently hypotensive after resuscitation. An echocardiogram (TTE) demonstrated a left ventricular ejection fraction of 25%. She was transferred to our cardiac intensive care unit (CCU) for consideration of mechanical circulatory support (MCS). The patient arrived at the CCU on multiple vasopressors and inotropes. The advanced HF, CCU, and maternal fetal medicine teams assessed the patient on arrival. Bedside right heart catheterization demonstrated right atrial pressure of 6 mmHg, pulmonary arterial pressure of 22/17 mmHg, pulmonary capillary wedge pressure of 10 mmHg, and Fick cardiac index of 2.5 L/min. BP was improving and vasoactive agents were weaned. The bleeding risk of anticoagulation for MCS after postpartum hemorrhage was thought to outweigh the potential benefit of MCS with normal filling pressures and weaning of vasoactive agents, thus MCS was not deployed. An electroencephalogram revealed status epilepticus, and magnetic resonance imaging of the brain was suggestive of posterior reversible encephalopathy syndrome with hemorrhage secondary to cerebral vasospasm. TTE on hospital day 4 showed normalization of biventricular function, and she made a full neurologic recovery and was discharged home on hospital day 15. Given the normalization of cardiac and neurologic function with supportive care only, her shock was attributed to methylergonovine-induced cerebral vasospasm leading to seizures with subsequent respiratory and cardiac arrest and myocardial stunning. This case demonstrates the importance of rapid team-based diagnostic assessment of peripartum patients presenting in suspected CS to appropriately triage the use of MCS.