Clinical Outcomes of Pregnant and Postpartum Extracorporeal Membrane Oxygenation Patients

Abstract

BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) as a rescue therapy for cardiopulmonary failure is expanding in critical care medicine. In this case series, we describe the clinical outcomes of 21 consecutive pregnant or postpartum patients that required venovenous (VV) or venoarterial (VA) ECMO. Our objective was to characterize maternal and fetal survival in peripartum ECMO and better understand ECMO-related complications that occur in this unique patient population. METHODS: Between January 2009 and June 2019, all pregnant and postpartum patients treated with ECMO for respiratory or circulatory failure at a single quaternary referral center were identified. For all patients, indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and anticoagulation and bleeding complications were collected. RESULTS: Twenty-one obstetric patients were treated with ECMO over 10 years. Thirteen patients were treated with VV ECMO and 8 patients were treated with VA ECMO. Six patients were pregnant at the time of cannulation and 3 patients delivered while on ECMO; all 6 maternal and infant dyads survived to hospital discharge. The median gestational age at cannulation was 28 weeks (interquartile range [IQR], 24–31). In the postpartum cohort, ECMO initiation ranged from immediately after delivery up to 46 days postpartum. Fifteen women survived (72%). Major bleeding complications requiring surgical intervention were observed in 7 patients (33.3%). Two patients on VV ECMO required bilateral orthotopic lung transplantation and 1 patient on VA ECMO required orthotopic heart transplantation to wean from ECMO. CONCLUSIONS: Survival for mother and neonate are excellent with peripartum ECMO in a high-volume ECMO center. Neonatal and maternal survival was 100% when ECMO was used in the late second or early third trimester. Based on these results, ECMO remains an important treatment option for peripartum patients with cardiopulmonary failure.

Clinical Characteristics of 10 Pregnant and Postpartum Women With Extracorporeal Membrane Oxygenation: A Retrospective Study

“…Upon further analysis of laboratory tests in Table 3 , it appears that liver enzyme indicators were more sensitive and potentially showed damage from ECMO initiation, whereas renal function indicators remained largely normal due to favorable basic renal function. Similar to other clinical studies ( 17 – 19 ), our data suggest that early application of ECMO obviously improves patient perfusion and leads to more favorable outcomes.…”

“…Continuation of pregnancy is only recommended for fetuses that will survive with a follow-up short-term pregnancy. Mazzeffi et al suggested that general obstetric indications should be retained, but more studies are expected ( 17 ). There are some limitations in our study; for example, the etiologies of cases are relatively scattered and the cases are low in number.…”

Maternal Heart Failure

“… 87 Extracorporeal membrane oxygenation has been shown in small studies to be an effective rescue therapy in pregnant and postpartum mothers. 88 , 89 Cardiac transplantation is only pursued when mechanical circulatory support is not feasible or desired, or for patients who fail to recover 6 to 12 months after onset. 68 …”

Management of high-risk pulmonary embolism in pregnancy

“…The level of evidence for the use of ECMO among pregnant women is very low. ECMO has been mostly used to treat refractory hypoxemia in pregnant women with adult respiratory distress syndrome (ARDS), with a veno-venous circuit [37][38][39], and PE remains a marginal indication (5% of all cases). When considering all indications of VA-ECMO, the reported cases had a high 30-day maternal survival (72.4%), which was similar for the subgroup of patients with PE (11/17, 64.7%) [40].…”

“…There is no consensus on the appropriate obstetrical monitoring in pregnant women on ECMO. Some propose a continuous CTG for the first 24 h after ECMO initiation, and twice daily thereafter in case of hemodynamic stability [46].…”