Acute cardiac failure during pregnancy is an uncommon but time-critical event. Pregnancy increases circulating volume, cardiac output and oxygen demand, while labour and the immediate postpartum period cause abrupt haemodynamic shifts. Decompensation may reflect peripartum cardiomyopathy, valvular disease, pre-existing cardiomyopathy, hypertensive pulmonary oedema or another cardiac cause. The 2025 European Society of Cardiology guidance recommends a pregnancy heart team for women at increased cardiovascular risk and provides a framework for urgent management when cardiac failure develops [1]. A multidisciplinary statement on peripartum heart failure likewise describes coordinated diagnosis, treatment and delivery planning as central to care [2].

The obstetric presentation may initially resemble normal pregnancy, pneumonia, pulmonary embolism or pre-eclampsia. Severe dyspnoea, hypoxaemia, pulmonary oedema, poor perfusion and shock require rapid assessment without delaying maternal resuscitation. Contemporary maternal-fetal medicine guidance distinguishes left from right heart failure, advises evaluation of alternative causes before diagnosing peripartum cardiomyopathy and outlines pregnancy-specific therapeutic considerations [3]. Early-recognition literature highlights that diagnosis can be delayed when symptoms are attributed to ordinary pregnancy or postpartum recovery [4]. Diagnostic uncertainty is particularly consequential when gestational age, fetal condition and medication exposure must be considered at the same time.

Intensive-care admission represents a clinically selected high-risk population. Peripartum cardiomyopathy can recover, deteriorate or present after delivery; echocardiographic severity and systemic perfusion influence the need for organ support [5]. In a contemporary series of critically ill pregnant women, cardiac disease formed part of the non-obstetric admission burden and neonatal outcomes depended on the wider obstetric context [6]. Karachi data on valvular disease show why local care pathways require attention to anaesthesia, delivery and neonatal complications [7]. Recent Pakistani work on peripartum cardiomyopathy also reports meaningful fetal and neonatal losses alongside maternal complications [8].

The emergency physician, obstetrician, cardiologist, intensivist and paediatrician have connected but distinct responsibilities. Emergency medicine recognizes shock and pulmonary oedema, initiates oxygenation and resuscitation and mobilizes the team. Obstetrics assesses gestational age, fetal condition and delivery urgency. Cardiology clarifies ventricular and valvular disease. Intensive care manages respiratory and circulatory support. Paediatrics prepares neonatal resuscitation and postnatal monitoring. Regional data from the Philippines [9], Oman [10] and a Nigerian decompensated-heart-failure cohort [11] illustrate that both maternal and neonatal risks matter. Neonatal resuscitation guidelines emphasize preparation, trained personnel and reliable transition to post-resuscitation care [12]. This study examined acute cardiac failure requiring intensive care in a Karachi hospital setting with particular attention to coordination and neonatal outcomes.

Study design, setting and duration A hospital-based retrospective observational cohort design was used. The setting was a tertiary-care hospital in Karachi with emergency, obstetric, cardiology, adult intensive-care and neonatal services. The study interval was January 2022 through December 2025. The unit of analysis was one maternal admission and its linked index pregnancy. When a patient crossed services, the first emergency assessment, subsequent critical-care course and birth outcome were treated as one episode. Participants and sampling The analytic cohort included 120 women who were pregnant or within 42 days postpartum and met a clinical diagnosis of acute cardiac failure requiring adult intensive care. All linked pregnancies had a delivery outcome available. An episode was eligible when acute dyspnoea or pulmonary oedema with objective cardiac dysfunction, significant valvular disease or a clinician-documented cardiac decompensation led to ICU admission. Purely noncardiac respiratory failure and isolated arrhythmia without cardiac failure were outside the target population. One episode per pregnancy was used. The cohort was analysed as a census of eligible episodes rather than as a sample powered to detect a prespecified treatment effect. Operational definitions Acute cardiac failure meant a new or acutely worsened syndrome of congestion or low cardiac output supported by clinical assessment and echocardiography. Peripartum cardiomyopathy was classified when heart failure with left ventricular systolic dysfunction developed toward the end of pregnancy or in the months after delivery and no other clear aetiology explained it. Cardiogenic shock required sustained hypotension or vasopressor support with evidence of hypoperfusion. Severe left ventricular dysfunction was ejection fraction below 35%. Preterm birth was delivery before 37 completed weeks; low birth weight was below 2,500 g. Stillbirth was fetal death before or during birth. Neonatal death meant death of a liveborn infant within seven days. The primary neonatal composite was stillbirth or admission of a liveborn infant to a neonatal intensive-care unit (NICU). Death after NICU admission remained within the same composite event and was not counted twice. Emergency and multidisciplinary pathway Emergency physicians initiated airway and oxygenation assessment, electrocardiography, haemodynamic monitoring, bedside evaluation for pulmonary oedema and a differential diagnosis that included pulmonary embolism, sepsis and pre-eclampsia. The obstetrics and gynaecology team assessed fetal viability, gestational age, placental or hypertensive complications and the safety and timing of delivery. Cardiology interpreted echocardiography and identified ventricular, valvular or rhythm pathology. Intensivists directed ventilatory support, vasoactive therapy, fluid balance and escalation for shock. Anaesthesia supported delivery planning when an operative birth was required. Paediatric and neonatal clinicians were informed before delivery when feasible, prepared resuscitation equipment, attended higher-risk births and determined NICU admission and follow-up. These were role definitions used to describe the pathway; the timing variable did not establish the quality of every individual consultation. Exposure, outcomes and measurements Early coordinated review was defined as emergency, obstetric, intensive-care and cardiac input documented within 60 minutes of recognition, with paediatric notification before delivery for undelivered women. Later review meant that this threshold was not met. Timing was measured from first recognition of cardiac failure rather than from hospital arrival. Maternal variables included age, parity, cardiac diagnosis, antepartum or postpartum onset, ejection fraction, shock, non-invasive and invasive ventilation, vasopressor use, ICU stay, mode of delivery and in-hospital death. Neonatal variables included gestational age, birth weight, stillbirth, NICU admission and death within seven days. The primary endpoint was the neonatal composite. Maternal mortality and individual neonatal outcomes were secondary endpoints. Statistical analysis Categorical variables were summarised as n (%). Age was presented as mean ± standard deviation. Gestational age, ejection fraction and ICU stay were expressed as median (interquartile range). Fisher exact tests compared the composite across binary exposures. Crude odds ratios and Wald 95% confidence intervals were calculated from two-by-two tables. An exploratory logistic model included early review, shock, ejection fraction below 35% and antepartum onset. Preterm birth was excluded from that model because it may lie on the pathway from maternal decompensation and delivery decisions to neonatal admission. Two-sided p<0.05 was used as the descriptive threshold. Python and SciPy were used for calculation. Missingness was absent for the endpoints and model covariates in the analytic dataset; no imputation was performed. Interpretive safeguards The early-review comparison was observational. More severely ill women may trigger faster response yet also have worse neonatal outcomes. Referral time, fetal condition before arrival, treatment selection and clinical reasons for delivery can influence both timing and outcome. The model therefore estimates association within the specified variables and was not interpreted as the causal effect of team activation. The adverse-neonatal composite combines different events with different clinical meanings, so its components were also reported separately. Paired maternal and neonatal denominator Maternal admissions and pregnancies each contributed one observation. Stillbirth and preterm birth used all 120 births as the denominator. NICU admission and seven-day neonatal death used only 115 live births. The composite retained all 120 pregnancies. This denominator plan prevented a neonatal death following NICU admission from becoming a second event and kept postpartum maternal presentations linked to their already completed delivery. Treatment categories were allowed to overlap because escalation from non-invasive to invasive ventilation or from diuresis to vasoactive support could occur within one ICU episode. Figure 1: Study flow and neonatal outcome definition

The cohort contained 120 maternal-neonatal pairs. Mean maternal age was 30.0 ± 4.8 years and 38 (31.7%) women were nulliparous. Acute failure began before or during delivery in 74 (61.7%) and postpartum in 46 (38.3%). Peripartum cardiomyopathy accounted for 48 (40.0%) episodes, valvular disease for 26 (21.7%), hypertensive pulmonary oedema for 20 (16.7%), pre-existing cardiomyopathy for 18 (15.0%) and other cardiac causes for eight (6.7%). Median ejection fraction was 36% (IQR 28–47%) and 54 (45.0%) had ejection fraction below 35%. Twenty-seven (22.5%) developed shock. Baseline and diagnostic distributions appear in Table I.

Coordinated review met the 60-minute definition in 70 (58.3%) episodes; 50 (41.7%) were later. Forty-nine (40.8%) women received non-invasive ventilation, 30 (25.0%) received invasive ventilation and 34 (28.3%) received vasopressor support. These treatments could overlap. Median ICU stay was four days (IQR 3–5). Emergency caesarean delivery occurred in 67 (55.8%), planned caesarean delivery in 25 (20.8%) and vaginal delivery in 28 (23.3%). Eight mothers (6.7%) died during admission. Six of the eight deaths occurred among the 27 women with shock.

Forty-eight of 120 births (40.0%) were preterm and 42 (35.0%) infants weighed less than 2,500 g. There were five stillbirths (4.2%) and 115 live births. Fifty of the 115 liveborn infants (43.5%) required NICU admission and five (4.3%) died by day seven. All five neonatal deaths followed NICU admission. The primary composite therefore occurred in 55 of 120 pregnancies (45.8%): five stillbirths plus 50 NICU admissions. Table II aligns the emergency and specialty pathway with these maternal and neonatal outcomes.

The composite occurred in 25 of 70 (35.7%) episodes with early coordinated review and 30 of 50 (60.0%) with later review (Fisher exact p=0.010). Its crude odds ratio was 0.37 (95% CI 0.18–0.78) for early versus later review. Among women with shock, 19 of 27 (70.4%) had the composite compared with 36 of 93 (38.7%) without shock (p=0.004). It occurred in 30 of 54 (55.6%) with ejection fraction below 35% and 25 of 66 (37.9%) with higher ejection fraction (p=0.066). Antepartum onset was not associated with the composite (33/74 [44.6%] versus 22/46 [47.8%]; p=0.851).

In the exploratory four-variable model, early coordination remained associated with lower odds of the neonatal composite (adjusted OR 0.36, 95% CI 0.17–0.80; p=0.012), while shock was associated with higher odds (adjusted OR 3.71, 1.41–9.75; p=0.008). Ejection fraction below 35% (adjusted OR 1.85, 0.84–4.05; p=0.125) and antepartum onset (adjusted OR 0.82, 0.37–1.83; p=0.627) had imprecise associations. Maternal death did not differ detectably by review timing (6/70 versus 2/50; Fisher p=0.466). Table III gives the component counts, crude comparisons and adjusted estimates; Figure 2 displays the main composite contrasts.

Preterm birth and low birth weight were frequent but addressed different dimensions of infant risk. A child could meet both definitions and subsequently enter the NICU, so these rows in Table II should not be added together. The ICU interventions also overlapped, reflecting the fact that respiratory and circulatory support may be escalated during one admission. The descriptive distributions therefore indicate workload across emergency, obstetric, adult critical-care and neonatal services rather than independent groups of women.

The direction of the early-review association was unchanged by adjustment for shock, reduced ejection fraction and onset before delivery. Its confidence interval remained broad, consistent with a modest number of events and a narrowly defined process measure. Shock showed a larger absolute difference: 70.4% of pregnancies in that subgroup reached the composite compared with 38.7% without shock. In contrast, the observed difference by reduced ejection fraction did not meet the specified p-value threshold. The model was restricted to four predictors to avoid an unstable analysis of 55 endpoint events.

Table I: Maternal baseline and cardiac characteristics (n=120)

Table II: Specialty-linked emergency care and maternal-neonatal outcomes

Table III: Factors associated with the neonatal composite

Reference categories: later review, no shock, LVEF ≥35% and postpartum onset. The model included all four exposures.

Figure 2: Neonatal composite by coordination and shock status

The study examined maternal decompensation severe enough to require ICU care and placed neonatal outcomes within the emergency response pathway. Nearly half of the pregnancies met the neonatal composite, chiefly through NICU admission, while shock was a clear marker of elevated risk. Earlier documented team review was associated with fewer neonatal composite events, although the comparison cannot establish benefit from timing alone. The findings reinforce that acute cardiac failure is a dual-patient emergency requiring maternal stabilization, obstetric decision-making and neonatal preparation in parallel. Population data on peripartum cardiomyopathy have shown substantial maternal, delivery and neonatal morbidity [13]. An international registry found that social and economic circumstances influence maternal and neonatal outcomes, indicating that physiology alone does not explain variation [14]. A nationwide study of congenital heart disease in pregnancy likewise demonstrated that the type and severity of cardiac disease matter for neonatal risk [15]. The high preterm and NICU burden here is consistent with a tertiary ICU case mix, where women enter the cohort only after clinically important decompensation. It should therefore not be extrapolated to all women with heart disease in pregnancy. For local services, Karachi evidence on valvular heart disease supports coordinated obstetric, anaesthetic and critical-care management, especially when operative delivery is needed. The current cohort added peripartum cardiomyopathy and hypertensive pulmonary oedema to that clinical spectrum. A western Indian hospital series found a similarly broad mix of cardiac lesions and adverse fetomaternal events [16]. Differences in referral severity, access to echocardiography, timing of delivery and ICU thresholds may explain why proportions across hospitals vary. The relevant service question is whether teams recognize decompensation early enough to align maternal support and neonatal readiness. The early-review variable captured documented coordination, not a single intervention. A retrospective study following the establishment of a multidisciplinary maternal heart-disease pathway reported changes in obstetric care and outcomes [17]. Practical guidance on forming a pregnancy heart team stresses agreed referral criteria, shared records and availability when an emergency occurs [18]. The association in this cohort is compatible with the value of those structures but remains vulnerable to selection and documentation bias. A faster consultation may coincide with a better resourced shift, an earlier referral or a less compromised fetus rather than itself producing the observed difference. A core outcome set for cardiac disease in pregnancy encourages consistent maternal and infant outcome definitions [19]. The present composite included stillbirth and NICU admission because both require planning, but NICU admission can reflect local precautionary policy and not solely biological injury. Reporting its components showed that five stillbirths and 50 liveborn admissions contributed without double counting. Future hospital studies should separately record delivery-room resuscitation, respiratory support, neonatal length of stay, death and neurodevelopment, as well as the indication for ICU transfer. This would reduce the ambiguity of a broad composite. Emergency medicine has a decisive role at first recognition. Point-of-care ultrasound can help identify left ventricular dysfunction in pregnancy and postpartum when dyspnoea has several possible causes [20]. Hypertensive pulmonary oedema requires simultaneous assessment of blood pressure, fluid balance and obstetric disease because treatment differs from uncomplicated cardiomyopathy [21]. An emergency pathway should specify oxygenation, ECG, focused echocardiography, laboratory testing and urgent consultation while avoiding indiscriminate fluid loading. Critical-care clinicians then titrate diuresis, vasodilators, vasoactive agents and ventilation in response to haemodynamics and fetal considerations. The 22.5% shock frequency identifies a subgroup in which escalation planning should begin before refractory organ failure. National experience with extracorporeal membrane oxygenation in obstetric patients shows that advanced support is feasible in highly selected cases [22]. A newer dual-cohort analysis also describes pregnancy-associated extracorporeal support across a broader population [23]. Such resources cannot replace earlier recognition or definitive management of valvular obstruction, pulmonary hypertension or myocardial dysfunction. In a Karachi pathway, the immediate priority is to define transfer arrangements and cardiac-critical-care escalation before an emergency occurs. Obstetrics and gynaecology must assess whether continuing pregnancy, expediting delivery or stabilizing before delivery offers the safest balance. Antepartum and postpartum peripartum cardiomyopathy have different clinical profiles and associated conditions [24]. A broad analysis of maternal and neonatal heart-disease outcomes shows that prematurity and low birth weight frequently accompany cardiac complications [25]. The 40.0% preterm birth rate in this cohort may reflect spontaneous labour, planned early delivery for maternal deterioration or other obstetric indications. Those mechanisms require separate documentation before attributing neonatal morbidity to the cardiac condition or to the decision to deliver. The paediatric team contributes before and after birth. It reviews anticipated gestational age and growth, prepares airway support and resuscitation, advises on neonatal transfer and follows infants exposed to prematurity or maternal instability. Contemporary peripartum cardiomyopathy reviews emphasize the need to consider infant outcomes alongside maternal recovery [26]. Studies of subsequent pregnancy after peripartum cardiomyopathy focus largely on recurrence and maternal cardiac function [27], whereas the infant pathway may extend through NICU discharge and later development. The neonatal plan should therefore be a documented part of maternal cardiac discussions rather than an afterthought at delivery. Longer-term evidence from a Norwegian peripartum cardiomyopathy cohort shows that initial survival does not end maternal cardiac follow-up needs [28]. Rural and urban disparities in delivery hospitalizations suggest that transfer access can shape disease detection and outcomes [29]. ICU-focused analyses emphasize the severity of cases that reach critical care [30], while Indian data describe context-specific etiologies and management constraints [31]. These studies provide reasons to interpret the present Karachi model within its local referral environment and to plan follow-up for both mother and child after discharge. Cardiac imaging can refine risk but should not delay treatment of shock. Advanced echocardiographic work has described phenotypic differences when cardiomyopathy is discovered during pregnancy [32]. Long-term valvular-disease series underscore that lesion type and functional class affect pregnancy trajectories [33]. A twin-pregnancy study of acute left heart failure found a high preterm and NICU burden, especially when decompensation preceded birth [34]. A tertiary perinatal cohort also linked maternal cardiac disease with infant outcomes [35]. Together these comparisons support a coordinated dataset capturing lesion, haemodynamics, timing of failure, decisions about delivery and neonatal course rather than a single maternal discharge endpoint. The roles should be written into an emergency handover. The emergency physician can communicate the time of recognition, oxygen and perfusion status, initial differential diagnosis and response to stabilization. Obstetrics can state fetal status, gestational age, likelihood and urgency of delivery. The cardiologist can report ventricular function, valve lesions and rhythm concerns. The intensivist can specify support already initiated and the trigger for transfer or advanced circulatory support. The paediatrician can identify the delivery-room team, expected prematurity risks and NICU capacity. A shared timestamped record makes these responsibilities auditable without assuming that a consultation alone guarantees coordinated care. This study has limitations. The single Karachi tertiary-care setting and ICU-only eligibility select the most severe presentations and limit generalizability. The retrospective observational design cannot determine whether early coordination caused better neonatal outcomes. Documentation time may differ from actual bedside contact. Indications for delivery, fetal status before referral, maternal medications, anaesthetic details and socioeconomic access were not fully represented in the adjusted model. The small number of maternal deaths precluded a reliable mortality model. Neonatal follow-up ended at seven days and did not capture later disability or feeding outcomes. A multicentre prospective registry with standardized definitions and paired maternal-neonatal follow-up would address these limitations.

Acute cardiac failure requiring intensive care was accompanied by substantial maternal shock, preterm birth and neonatal intensive-care use. Early documented coordination was associated with a lower neonatal composite while shock marked increased risk, but these associations require validation in actual prospective cohorts. Emergency physicians, obstetricians, cardiologists, intensivists, anaesthetists and paediatricians should use a shared escalation pathway that stabilizes the mother, guides delivery and prepares neonatal care. Future multicentre work should measure the timing and content of each specialty contribution and follow both mother and infant beyond discharge.

Declarations

Financial support and sponsorship: Nil.

Conflicts of interest: There are no conflicts of interest.