Pregnant and Peripartum Women with COVID-19 Have High Survival with Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Analysis

OʼNeil, Erika R; Lin, Huiming; Shamshirsaz, Amir A.; Naoum, Emily E.; Rycus, Peter R; Alexander, Peta; Ortoleva, Jamel; Li, Meng; Anders, Marc

doi:10.1164/rccm.202109-2096le

Cited by 31 publications

(66 citation statements)

References 8 publications

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“…Early in the pandemic, ECMO was identified as having a role in managing refractory hypoxemia unresponsive to conventional care. In a retrospective cohort study, the Extracorporeal Life Support Organization Registry reported outcomes of pregnant or peripartum women with covid-19 supported with veno-venous ECMO (VV-ECMO) 79. The primary outcome was survival to hospital discharge, and secondary outcomes were complications related to ECMO in the pregnant or peripartum cohort.…”

Section: Managementmentioning

confidence: 99%

Diagnosis and management of covid-19 in pregnancy

Nana

Hodson

Lucas

et al. 2022

BMJ

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Pregnant women with covid-19 are at greater risk of severe disease than their non-pregnant peers, and yet they are frequently denied investigations or treatments because of unfounded concerns about risk to the fetus. The basic principles of diagnosing and managing covid-19 are the same as for non-pregnant patients, and a multidisciplinary, expert team approach is essential to ensure optimal care. During pregnancy, treatment with corticosteroids should be modified to use non-fluorinated glucocorticoids. Il-6 inhibitors and monoclonal antibodies, together with specific antiviral therapies, may also be considered. Prophylaxis against venous thromboembolism is important. Women may require respiratory support with oxygen, non-invasive ventilation, ventilation in a prone position (either awake or during invasive ventilation), intubation and ventilation, and extracorporeal membrane oxygenation (ECMO). Pregnancy is not a contraindication for any of these supportive therapies, and the criteria for providing them are the same as in the general population. Decisions regarding timing, place, and mode of delivery should be taken with a multidisciplinary team including obstetricians, physicians, anesthetists, and intensivists experienced in the care of covid-19 in pregnancy. Ideally these decisions should take place in consultation with centers that have experience and expertise in all these specialties.

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Section: Managementmentioning

confidence: 99%

Diagnosis and management of covid-19 in pregnancy

Nana

Hodson

Lucas

et al. 2022

BMJ

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“…High survival with ECMO has been reported in pregnant and peripartum women with COVID-19 in the Extracorporeal Life Support Organization Registry [ 20 ]. Among 1180 adult female patients supported with VV-ECMO for COVID-19, the 100 pregnant or peripartum women were more likely to survive hospital discharge (84% vs. 51.5%; overlap propensity score weighted OR 1.18; 95% CI 1.10–1.27) and had fewer renal complications related to ECMO.…”

Section: Discussionmentioning

confidence: 99%

“…Among 1180 adult female patients supported with VV-ECMO for COVID-19, the 100 pregnant or peripartum women were more likely to survive hospital discharge (84% vs. 51.5%; overlap propensity score weighted OR 1.18; 95% CI 1.10–1.27) and had fewer renal complications related to ECMO. However, the proportion of active pregnancies or postpartum patients, obstetrical terms, the fetal loss rate on ECMO, birth terms and neonatal outcomes according to gestational age or preterm delivery decision at cannulation were not reported in this large cohort [ 20 ]. Current consensus recommendations from the UK suggest that ECMO indication should be undertaken with the same criteria as for non-pregnant patients [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

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

James¹,

Guervilly

Lesouhaitier

et al. 2022

Crit Care

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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.

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“…36 Several reports and studies demonstrated the use of PP with reservations. Some researchers subjected patients to extracorporeal membrane oxygenation (ECMO) without previous PP attempts [37][38][39] and others performed cesarean section before PP. 40 In a study on ECMO in pregnant and puerperal women with ARDS, PP was attempted before ECMO in only 2 of the 7 pregnant women with respiratory failure.…”

Section: Discussionmentioning

confidence: 99%

“…38 A more recent publication showed a greater tendency to use PP before ECMO in pregnant women with COVID-19; nevertheless, it was not attempted in 42% of the 100 pregnant and postpartum women in the study. 39 Case reports and series have shown the successful use of PP in pregnant women with COVID-19. 6,7,41,42 In our series, of the 16 intubated patients, 11 (69%) required PP according to the criterion used, which is similar to that described by Guérin et al, 10 except for the stabilization time in MV before its indication, which sometimes was < 12 hours.…”

Section: Discussionmentioning

confidence: 99%

Treatment of pregnant and early postpartum women with severe and critical COVID-19: experience at a tertiary center

Barbosa¹,

Braga²,

Costa³

et al. 2022

Preprint

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Background: The management of acute respiratory failure during pregnancy is a poorly defined issue in the literature, especially regarding the use of the prone position and the appropriate time for delivery. This study describes our experience in treating pregnant and postpartum women with severe or critical coronavirus disease 2019 (COVID-19). Materials and Methods: This descriptive retrospective study included 25 pregnant and 4 postpartum women admitted to an ICU due to respiratory complications from COVID-19 from June 2020 to August 2021. Results: The mean maternal age was 33.6 years, and the median gestational age (GA) at admission was 33 weeks. Obesity was the most common comorbidity. The median time between symptom onset and ICU admission was 10 days, while the median length of ICU stay was 14 days. Invasive mechanical ventilation (IMV) was required in 16 (55.2%) patients for a median time of 16.5 days. Prone positioning (PP) was performed in 68.7% of the patients on IMV, and resulted in an expressive increase in arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2 ratio). Eleven (44%) pregnant women delivered during their ICU stay for obstetric or fetal reasons: of these, 2 (18%) developed postpartum hemorrhagic shock and 1 (9%) developed abdominal wall infection. None of the 25 pregnant women underwent delivery due to acute respiratory failure or in an attempt to avoid intubation. There were 2 fetal deaths, but no maternal or neonatal deaths. Conclusion: We observed favorable outcomes in pregnant and postpartum women with severe and critical COVID-19 admitted to our institution. This finding reinforces the effectiveness of PP in the treatment of hypoxemic respiratory failure secondary to COVID-19 in pregnant women undergoing IMV, and suggests that gestation should only be interrupted in cases of obstetric and fetal complications, provided the patient is stable, or when hypoxemia is refractory to PP.

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Pregnant and Peripartum Women with COVID-19 Have High Survival with Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Analysis

Cited by 31 publications

References 8 publications

Diagnosis and management of covid-19 in pregnancy

Diagnosis and management of covid-19 in pregnancy

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

Treatment of pregnant and early postpartum women with severe and critical COVID-19: experience at a tertiary center

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