Extracorporeal membrane oxygenation in pregnant and postpartum women: a ten-year case series

Abstract

Objective tExtracorporeal membrane oxygenation (ECMO) is a life-saving therapy for severe, reversible cardiopulmonary failure, but data regarding its use in pregnancy and the postpartum period are limited. We sought to quantify survival of pregnant and postpartum women necessitating ECMO in a contemporary cohort at a single tertiary institution. Study Design All women of reproductive age (14–44 years), who underwent ECMO at our institution between January 1, 2008, and December 31, 2017, were identified using a query of hospital encounters for ECMO-related CPT codes. We manually reviewed all charts of women of reproductive age; women who were pregnant or <6 weeks postpartum at the time of ECMO initiation were included. Clinical characteristics and maternal and fetal outcomes are described. Results In this study, 54 women of reproductive age underwent ECMO for cardiopulmonary failure. Of those, 9 (17%) were pregnant or <6 weeks postpartum at the time of ECMO initiation: 4 antepartum, 1 intraoperative at the time of cesarean delivery, and 4 postpartum (including 2 in whom ECMO was initiated on postpartum day 0 or 1). Overall, maternal survival was 33%. The median maternal age was 24 years (range 19–39 years); most women were nonsmokers without underlying medical comorbidities. The most common indication for ECMO use in pregnant and postpartum women was acute respiratory distress syndrome, which was present in 7 cases (78%), including 5 cases that were due to infectious etiologies and 2 cases that were attributed to preeclampsia. The median number of days on ECMO was 6 (range 1–14). There were no cases of obstetric hemorrhage. Venovenous ECMO was utilized in all but 1 case, in which emergent attempted venoarterial ECMO was unsuccessful in resuscitating a postpartum patient with cardiac arrest and a massive pulmonary embolism. A total of 4 women were initiated on ECMO during pregnancy: their gestational ages at ECMO initiation were 21, 22, 29, and 30 weeks; maternal survival was 50%, and fetal mortality was 50%. A case of ECMO initiated during cesarean section at 29 weeks’ gestation resulted in both maternal and fetal survival. Among 4 mothers with ECMO initiation after childbirth, none survived. Finally, we found a tendency toward survival in those patients for whom ECMO was initiated soon after mechanical ventilation, earlier in the disease process. In contrast, in this study, 23 of 45 women of reproductive age (51%) who were not pregnant but underwent ECMO survived. Conclusion When ECMO was initiated during pregnancy or during childbirth, 60% of mothers and fetuses survived, supporting current use of ECMO as a salvage therapy in pregnant and intrapartum women. In this generally young and healthy population, ECMO has the potential to increase the survival rates of both mother and fetus and should be considered a salvage therapy for peripartum women with reversible forms of cardiorespiratory failure.

Severe acute respiratory distress syndrome in coronavirus disease 2019–infected pregnancy: obstetric and intensive care considerations

“…Therapeutic anticoagulation is often required, and the postpartum period appears to be a potentially tenuous time point for initiation of ECMO with 100% maternal mortality in a recent case series. 18 In summary, this case of rapid clinical decompensation and development of Research Letter severe (PaO 2 :FiO 2 <150) COVID-19e related ARDS in a woman at 31 weeks' gestation highlights many physiologic and management considerations for the care of critically ill pregnant women with COVID-19. Few contemporary resources exist to guide the multidisciplinary team through decisions regarding optimal maternal-fetal surveillance, intensive care procedures, and delivery timing.…”

“…Finally, veno-venous ECMO is a proven life-saving salvage therapy for severe, reversible respiratory failure, and its benefit among critically ill pregnant women has been reported. 18 Consideration for ECMO cannulation should be entertained among a multidisciplinary team of experienced providers in situations where the patient's oxygenation is so severely compromised as to require maximal ventilatory support early in the disease process (less than 7 days of mechanical ventilatory support). Therapeutic anticoagulation is often required, and the postpartum period appears to be a potentially tenuous time point for initiation of ECMO with 100% maternal mortality in a recent case series.…”

Successful management of severe acute respiratory distress syndrome due to COVID-19 with extracorporeal membrane oxygenation during mid-trimester of pregnancy

“…In a ten-year study of ECMO in pregnancy, only 60% of mothers and fetuses survived. 10 Long-term follow-up of our patient and detailed evaluation of future cases can help evaluate efficacy and safety of ECMO in pregnancy.…”

Severe COVID-19 in Third Trimester Pregnancy: Multidisciplinary Approach

“…Pregnancy is also a contraindication for prone ventilation per our institutional policy. Thus, venovenous ECMO was considered as a life-saving salvage therapy in the event of worsening oxygenation and hemodynamic compromise during and after the delivery [ 19 ]. Cardiothoracic surgeon placed central venous access in the internal jugular and femoral veins prior to the cesarean delivery, in anticipation of ECMO.…”