Extracorporeal Membrane Oxygenation for Pregnant and Postpartum Patients

Abstract

Extracorporeal membrane oxygenation (ECMO) has seen increasing use for critically ill pregnant and postpartum patients over the past decade. Growing experience continues to demonstrate the feasibility of ECMO in obstetric patients and attest to its favorable outcomes. However, the interaction of pregnancy physiology with ECMO life support requires careful planning and adaptation for success. Additionally, the maintenance of fetal oxygenation and perfusion is essential for safely continuing pregnancy during ECMO support. This review summarizes the considerations for use of ECMO in obstetric patients and how to address these concerns.

Extracorporeal Membrane Oxygenation for Obstetric Patients: A New Era

“…Provision of effective education through strategies that address both the challenges of interprofessional teamwork and consequences of staff shortages and resource allocation necessitated by each surge of the COVID-19 pandemic is key to safe patient care. Wong et al 9 underline the importance of this by stressing involvement of a multidisciplinary team before cannulation. Simulation education has been a crucial component for preparation of multiprofessional teams in unfamiliar environments during the COVID-19 pandemic.…”

“…To maximize any benefit of ECMO for the obstetric population, clinicians need a clear understanding of the physiology of pregnancy, birth, and postpartum recovery, as well as interactions with the physiological changes that ECMO precipitates. To this end, Wong et al 9 provide a comprehensive narrative review of ECMO use in peripartum and postpartum women, setting the authors' experience against the currently published literature and physiological considerations of the peripartum patient. 9 There is robust discussion of maternal, delivery and fetal aspects that need to be considered when placing a pregnant patient on ECMO support.…”

“…To this end, Wong et al 9 provide a comprehensive narrative review of ECMO use in peripartum and postpartum women, setting the authors' experience against the currently published literature and physiological considerations of the peripartum patient. 9 There is robust discussion of maternal, delivery and fetal aspects that need to be considered when placing a pregnant patient on ECMO support. The authors recommend early referral to a specialist center with ECMO capabilities well before physiological decompensation mandates the intervention.…”

“…While optimal ventilation parameters during ECMO are unknown, the authors suggest peak inspiratory pressure of 20 to 25 cm H 2 O, positive end expiratory pressure of 10 to 15 cm H 2 O, respiratory rate of 10, and fraction of inspired oxygen (Fio 2 ) of 30% to 40%, based on previously published data. 9 During pregnancy, cardiac output increases from 30% to 50% by the third trimester; the effect of this physiological change on ECMO physiology can be pronounced with the potential for venous blood to bypass the drainage cannula and reach the heart without being oxygenated. The Extracorporeal Life Support Organization (ELSO) describes flows through the ECMO circuit in normal adults of 60 to 80 mL/ kg/min, 14 but for obstetric patients, values of 100 to 120 mL/kg/min may be needed.…”

“…The Extracorporeal Life Support Organization (ELSO) describes flows through the ECMO circuit in normal adults of 60 to 80 mL/ kg/min, 14 but for obstetric patients, values of 100 to 120 mL/kg/min may be needed. Wong et al 9 describe level 4 evidence detailing the use of beta-adrenergic antagonists to limit maternal cardiac output and www.anesthesia-analgesia.org…”