Purpose Pregnant women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have a higher risk of hospitalization, admission to intensive care unit (ICU) and invasive ventilation, and of acute respiratory distress syndrome (ARDS). In case of ARDS and critical severe coronavirus disease 2019 (COVID-19), the use of extracorporeal membrane oxygenation (ECMO) is recommended when other respiratory support strategies (oxygen insufflation, non-invasive ventilation [NIV], invasive ventilation through an endotracheal tube) are insufficient. However, available data on ECMO in pregnant and postpartum women with critical COVID-19 are very limited. Methods A case series of three critically ill pregnant women who required ECMO support for COVID-19 in pregnancy and/or in the postpartum period. Results The first patient tested positive for COVID-19 during the second trimester, she developed ARDS and required ECMO for 38 days. She was discharged in good general conditions and a cesarean-section [CS] at term was performed for obstetric indication. The second patient developed COVID-19-related ARDS at 28 weeks of gestation. During ECMO, she experienced a precipitous vaginal delivery at 31 weeks and 6 days of gestation. She was discharged 1 month later in good general conditions. The third patient, an obese 43-year-old woman, tested positive at 38 weeks and 2 days of gestation. Because of the worsening of clinical condition, a CS was performed, and she underwent ECMO. 143 days after the CS, she died because of sepsis and multiple organ failure (MOF). Thrombosis, hemorrhage and infections were the main complications among our patients. Neonatal outcomes have been positive. Conclusion ECMO should be considered a life-saving therapy for pregnant women with severe COVID-19.

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To show feasibility of using indocyanine green (ICG) in endometriosis surgery, especially bowel endometriosis shaving, and to discuss its potential benefits. Design: Stepwise demonstration of this technique with narrated video footage. Setting: Endometriosis is a common benign chronic disorder, characterized by the presence of endometrial tissue outside the uterus. Deep infiltrating endometriosis (DIE) represents the most aggressive presentation. Robot-assisted laparoscopy represents an important innovation and has opened new perspectives for the treatment of endometriosis, offering numerous advantages especially in the most complex procedures, particularly when extragenital endometriosis diffusely involves pelvic structures including the bowel and the urinary tract [1]. Endometriosis affects the bowel in 30% of DIE cases, and it is usually associated with ovarian and ureteral involvement; therefore, a multidisciplinary team with both general and gynecologic surgeons is required. The goal of endometriosis surgery in these cases is to obtain long-term outcomes without compromising intestinal function. One possible treatment is laparoscopic shave excision, which consists of dissection, keeping it as superficial as possible to avoid compromising bowel integrity [2]. Recent studies have shown that ICG can be useful to evaluate the size and depth of penetration of lesions during endometriosis surgery to understand shaving excision and to prevent a major iatrogenic intestinal complication [3−7]. Interventions: Total robot-assisted laparoscopic approach to a DIE case with adnexal, uterine, and intestinal endometriosis, with the presence of a nodular rectal lesion. The excision consisted of several key strategies to minimize iatrogenic rectal injury: Adhesiolysis with adnexal and uterus liberation and pelvic visualization; Endometriosis mapping with an evaluation of adnexal masses, uterus, vesical-uterine septum, pouch of Douglas, sigmoid-rectal wall, and ureters; Endovenous injection of ICG (25 mg of ICG diluted in 10 mL of soluble water and a bolus of 0.25 mg/kg), with visualization of rectal wall vascularization and evaluation of the degree of bowel involvement by endometriosis; Lesion shaving, as superficial as possible, with subsequent reinforcement suture of the rectal serosa. Conclusion: The approach to DIE, particularly rectal endometriotic lesions, could be more accurate with ICG evaluation of vascular pertinence, in attempt to evaluate shaving feasibility of lesions in endometriosis laparoscopic robotic surgery.