2026 SOAP Annual Meeting

Peripartum Cardiovascular Collapse Following Cesarean Delivery in a Parturient with Severe Biventricular Failure and Pulmonary Hypertension

Emily Breland Edwards, MD, Jessicca Merrill, MD, Maitri Shah, MD

University of Arkansas for Medical Sciences

•Severe cardiomyopathy + pulmonary HTN → high maternal mortality risk

•Peripartum physiology:

◦Autotransfusion after delivery ↑ preload

◦Relief of aortocaval compression → ↑ venous return

•In pHTN:

◦↑ preload → RV overload → septal shift → ↓ LV filling

◦→ risk of acute biventricular failure & collapse

•Even with support, rapid decompensation can occur

35F, G8P4 at 31 Weeks — Cesarean for Decompensation

Cardiac History:

•Dilated CM, EF 20%, severe MR, mod TR

•Chronic thromboembolic pHTN (PA ~70s/30s)

•Factor V Leiden, recurrent DVT/PE, MI ×2, stroke ×2

Pre-op Status:

•Milrinone infusion, escalating O₂ needs

•Cesarean indicated for maternal decompensation

Anesthetic Approach

General anesthesia: ketamine + propofol + remifentanil + rocuronium

Invasive Monitoring (Pre-induction)

•A-line, PA catheter, large-bore access

•Groin prepped for VA ECMO

Intraoperative Course

Rising PA pressures, tachycardia (120→150s), progressive hypotension. During closure: global hypokinesis → PEA arrest. ROSC after 3 rounds ACLS.

Outcome

Acute BiV failure from postpartum preload surge → VA ECMO + Impella → CVICU

Key Lessons from This Case

Autotransfusion is the Trigger

Postpartum preload surge is potentially catastrophic in pHTN — anticipate before delivery.

Cardiovascular Collapse

Acute BiV failure → RV failure → septal bowing → LV underfilling → worsening of pulmonary hypertension

Monitoring Alone is Not Enough

Invasive lines and echo are essential — but do not prevent decompensation.

Plan for MCS Before the Crisis

Immediate ECMO/Impella availability must be confirmed pre-incision.

GA Preferred in Unstable Patients

Anticoagulation + MCS risk makes neuraxial contraindicated. General anesthesia is the safer choice.

Peripartum Cardiovascular Collapse Following Cesarean Delivery in a Parturient with Severe Biventricular Failure and Pulmonary Hypertension