Delivery decision in pregnant women rescued by ECMO for severe ARDS: a retrospective multicenter cohort study

Abstract

Background Although rarely addressed in the literature, a key question in the care of critically pregnant women with severe acute respiratory distress syndrome (ARDS), especially at the time of extracorporeal membrane oxygenation (ECMO) decision, is whether delivery might substantially improve the mother’s and child’s conditions. This multicenter, retrospective cohort aims to report maternal and fetal short- and long-term outcomes of pregnant women with ECMO-rescued severe ARDS according to the timing of the delivery decision taken before or after ECMO cannulation. Methods We included critically ill women with ongoing pregnancy or within 15 days after a maternal/child-rescue-aimed delivery supported by ECMO for a severe ARDS between October 2009 and August 2021 in four ECMO centers. Clinical characteristics, critical care management, complications, and hospital discharge status for both mothers and children were collected. Long-term outcomes and premature birth complications were assessed. Results Among 563 women on venovenous ECMO during the study period, 11 were cannulated during an ongoing pregnancy at a median (range) of 25 (21–29) gestational weeks, and 13 after an emergency delivery performed at 32 (17–39) weeks of gestation. Pre-ECMO PaO2/FiO2 ratio was 57 (26–98) and did not differ between the two groups. Patients on ECMO after delivery reported more major bleeding (46 vs. 18%, p = 0.05) than those with ongoing pregnancy. Overall, the maternal hospital survival was 88%, which was not different between the two groups. Four (36%) of pregnant women had a spontaneous expulsion on ECMO, and fetal survival was higher when ECMO was set after delivery (92% vs. 55%, p = 0.03). Among newborns alive, no severe preterm morbidity or long-term sequelae were reported. Conclusion Continuation of the pregnancy on ECMO support carries a significant risk of fetal death while improving prematurity-related morbidity in alive newborns with no difference in maternal outcomes. Decisions regarding timing, place, and mode of delivery should be taken and regularly (re)assess by a multidisciplinary team in experienced ECMO centers.

Extracorporeal Membrane Oxygenation in Pregnant and Postpartum Women With Critical Coronavirus Disease 2019 (COVID-19) Acute Respiratory Distress Syndrome

“…After the elimination of studies not relevant to the subject of interest and meeting abstracts, 25 were retrieved for complete analysis. 4,6,[21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39] Four studies were excluded: three for including duplicate patients published in other included articles [40][41][42] and one because of the inability to determine from published information the number of women with maternal mortality. 43 The corresponding authors for the latter study were contacted and indicated that they could not provide the additional information requested.…”

“…Eight corresponding authors from included studies were contacted, with all providing additional supplementary data for inclusion in either the primary or secondary analyses. 6,25,32,33,[35][36][37]39 The study by Barrantes et al 38 included two patients who were also included in the study by Byrne et al 6 These two patients' clinical information was excluded from the reported outcomes of the Barrantes et al 38 study when analyzed for the pooling of results. In total, 21 studies with 386 pregnant individuals who had critical COVID-19 managed with ECMO were included in the review.…”

“…In total, 21 studies with 386 pregnant individuals who had critical COVID-19 managed with ECMO were included in the review. 4,6,[21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39] Study characteristics and results were summarized and verified for accuracy independently by two authors. Features of the included studies are shown in Table 1.…”

Extracorporeal membrane oxygenation in pregnancy during the SARS-CoV-2 pandemic

“…In the authors’ experience, timing of delivery is dictated if the fetal prognosis is favorable based on gestational age and after a multidisciplinary consensus that delivery can improve maternal respiratory status. Pregnant patients on ECMO are more likely to delivery via cesarean delivery in nearly two thirds of cases 18 . Vaginal delivery is not contraindicated but if delivery is indicated but the patient may be too critically ill to undergo an induction of labor leaving cesarean delivery as the safest option.…”

“…Vaginal delivery is not contraindicated but if delivery is indicated but the patient may be too critically ill to undergo an induction of labor leaving cesarean delivery as the safest option. 18 Considerations include the patient’s pulmonary and cardiovascular stability and their ability to tolerate an induction of labor. If delivery is indicated for maternal or fetal reasons, allowing time for induction of labor may not be optimal.…”