Pregnancy-Associated Extracorporeal Membrane Oxygenation in the United States

Abstract

Objectives: The use of extracorporeal membrane oxygenation (ECMO) therapy has increased in the adult population. Studies from the H1N1 influenza pandemic suggest that ECMO deployment in pregnancy is associated with favorable outcomes. With increasing numbers of pregnant women affected by COVID-19 and potentially requiring this life-saving therapy, we sought to compare comorbidities, costs, and outcomes between pregnancy and non-pregnancy associated ECMO therapy among reproductive-aged female patients. Study Design: We used the 2013-2019 National Readmissions Database. Diagnosis and procedural coding were used to identify ECMO deployment, potential indications, comorbid conditions, and pregnancy outcomes. The primary outcome was in-hospital mortality during the patient’s initial ECMO stay. Secondary outcomes included length of stay and hospital charges/costs, occurrence of thromboembolic or bleeding complications during ECMO hospitalization, and mortality and readmissions up to 330 days following ECMO stay. Univariate and multivariate regression models were used to model the associations between pregnancy status and outcomes. Results: The sample included 324 pregnancy-associated hospitalizations and 3,805 non- pregnancy associated hospitalizations, corresponding to national estimates of 665 and 7,653 over the study period, respectively. Pregnancy-associated ECMO had lower incidence of in-hospital death (adjusted odds ratio (AOR): 0.56, 95% confidence interval (CI): 0.41-0.75) and bleeding complications (AOR: 0.67, 95% CI: 0.49-0.93). Length of stay was significantly shorter (adjusted rate ratio (ARR): 0.86, 95% CI: 0.77-0.96) and total hospital costs were less (ARR: 0.83, 95% CI: 0.75-0.93). Differences in the incidence of thromboembolic events (AOR: 1.04, 95% CI: 0.78-1.38) were not statistically significant. Conclusion: Pregnancy-associated ECMO therapy had lower incidence of in-hospital death, bleeding complications, total inpatient cost, and length of stay when compared to non-pregnancy associated ECMO therapy without increased thromboembolic complications. Pregnancy-associated ECMO therapy should be offered to eligible patients.

Outcomes Following Extracorporeal Membrane Oxygenation for Severe COVID-19 in Pregnancy or Post Partum

“…8,24 Previous studies of thromboembolic events in pregnant patients on ECMO before the COVID-19 pandemic have reported ranges between 2.8% to 33.0%. 6,9 However, a more recent report of pregnant patients receiving ECMO with COVID-19 infection noted a rate of 40%, similar to the current analysis. 24 In the current study, we cannot determine the degree of anticoagulant therapy when the thromboembolic event occurred in patients receiving ECMO therapy.…”

“…In a systematic review and meta-analysis reviewing ECMO use for ARDS secondary to H1N1 infection in pregnant and postpartum patients, the pooled survival rate was as high as 74.6% . When compared with all etiologies for ECMO use in pregnancy or the peripartum period, systematic reviews or analysis of large administrative data sets have reported survival rates ranging from 69.5% to 79.3% . In the current investigation of COVID-19 ARDS, the maternal survival rate was higher at 84%.…”

“…ranging from 69.5% to 79.3%. 5,6,9,22 In the current investigation of COVID-19 ARDS, the maternal survival rate was higher at 84%. This survival rate is greater than the 61% that has been reported for in-hospital patients receiving ECMO.…”

“…However, current evidence has advocated that the use of ECMO should be considered due to superior outcomes in pregnant or postpartum patients compared with nonpregnant patients. 8,9 Reports of pregnant patients with COVID-19 who require ECMO are emerging. Several case reports and one large series of pregnant or peripartum patients with COVID-19 ARDS undergoing ECMO reported variable to no adverse outcomes for the maternal-fetal dyad.…”

“…They concluded that due to a limited number of well-designed prospective studies, there is an uncertain benefit of using ECMO for maternal and neonatal survival. However, current evidence has advocated that the use of ECMO should be considered due to superior outcomes in pregnant or postpartum patients compared with nonpregnant patients …”