Extracorporeal membrane oxygenation (ECMO) during pregnancy and postpartum

Maternal-Fetal Results of COVID-19-Infected Pregnant Women Treated with Extracorporeal Membrane Oxygenation: A Descriptive Report

OBJECTIVE

COVID-19 infection may produce severe pneumonia, mainly in the adult population. Pregnant women with severe pneumonia are at high risk of developing complications, and conventional therapy sometimes fails to reverse hypoxemia. Therefore, extracorporeal membrane oxygenation (ECMO) is an option in cases with refractory hypoxemic respiratory failure. This study aims to evaluate the maternal-fetal risk factors, clinical characteristics, complications, and outcomes of 11 pregnant or peripartum patients with COVID-19 treated with ECMO.

STUDY DESIGN

This is a retrospective descriptive study of 11 pregnant women undergoing ECMO therapy during the COVID-19 pandemic.

RESULTS

In our cohort, four patients underwent ECMO during pregnancy (36.3%) and 7 during the postpartum period. Initially, they started on venovenous ECMO, and three patients were required to change modality due to clinical conditions. In total, 4/11 pregnant women (36.3%) died. We established two periods that differed in the implementation of a standardized care model for reducing associated morbidities and mortality. Neurological complications were responsible for most deaths. Regarding fetal outcomes at early-stage pregnancies on ECMO (4), we report three stillbirths (75%), and one newborn (twin pregnancy) survived and had a favorable evolution.

CONCLUSION

At later-stage pregnancies, all newborns survived, and we did not identify any vertical infection. ECMO therapy is an alternative for pregnant women with severe hypoxemic respiratory failure due to COVID-19, and may improve maternal and neonatal results. Regarding fetal outcomes, the gestational age played a definitive role. However, the main complications reported in our series and others are neurological. It is essential to develop novel, future interventions to prevent these complications.

Contemporary Management of Cardiomyopathy and Heart Failure in Pregnancy

Cardiovascular disease is the primary cause of pregnancy-related mortality and morbidity in the United States, and maternal mortality has increased over the last decade. Pregnancy and the postpartum period are associated with significant vascular, metabolic, and physiologic adaptations that can unmask new heart failure or exacerbate heart failure symptoms in women with known underlying cardiomyopathy. There are unique management considerations for heart failure in women throughout pregnancy, and it is imperative that clinicians caring for pregnant women understand these important principles. Early involvement of multidisciplinary cardio-obstetrics teams is key to optimizing maternal and fetal outcomes. In this review, we discuss the unique challenges and opportunities in the diagnosis of heart failure in pregnancy, management principles along the continuum of pregnancy, and the safety of heart failure therapies during and after pregnancy.

Peripartum Abdominal Compartment Syndrome Following Extracorporeal Hemodynamic Support

In massive pulmonary embolism (PE), anticoagulation and thrombolytics may increase the risk of retroperitoneal bleeding following vascular cannulation for extracorporeal hemodynamic support resulting in abdominal compartment syndrome (ACS). A 27-year-old women at 33 weeks of gestation presented with acute chest pain and shortness of breath. Massive PE was diagnosed. Intravenous unfractionated heparin was started together with catheter-directed tissue plasminogen activator (tPA) infusion and mechanical thrombectomy. During the procedure, cardiac arrest developed. Cardiopulmonary resuscitation, intravenous tPA, and urgent perimortem cesarean delivery were performed. After return of spontaneous circulation, profound right ventricular failure required venoarterial membrane oxygenation. Six hours afterward, ACS secondary to retroperitoneal bleeding developed, requiring surgical intervention. ACS may result from retroperitoneal bleeding following cannulation for extracorporeal hemodynamic support.

Peripartum Cardiogenic Shock and Mechanical Circulatory Support

Despite remarkable improvements in the past two decades, the annual cardiovascular mortality rate has remained higher for women than for men. Pregnant women represent an underinvestigated population in clinical research, and the mechanisms of long-term cardiovascular complications in women with obstetric complications remain to be elucidated. Regarding advanced heart failure during pregnancy, interventional approaches are effective but still underutilised. Percutaneous mechanical circulatory support is a valuable option for peripartum cardiogenic shock, although its use during pregnancy is still limited. Survival rates have improved in recent years, but further emphasis on the importance of early recognition and initiation of heart failure treatment in this patient group is warranted. The aims of this review are to summarise the current literature on the implementation of mechanical circulatory support in cardiogenic shock during pregnancy and delivery and to understand the role of percutaneous ventricular assist devices in the management of such conditions.

A case of cardiac arrest due to postpartum hemorrhage treated with hysterectomy and extracorporeal membrane oxygenation

Although extracorporeal membrane oxygenation is relatively contraindicated in patients with severe disseminated intravascular coagulation (DIC), it can be safely introduced by providing adequate anti-DIC therapy.

Extracorporeal Membrane Oxygenation During Pregnancy

In the last 2 decades, the use of venovenous (VV) and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) during pregnancy and the postpartum period has increased, mirroring the increased utilization in nonpregnant individuals worldwide. VV ECMO provides respiratory support for patients with acute respiratory distress syndrome (ARDS) who fail conventional mechanical ventilation. With the COVID-19 pandemic, the use of VV ECMO has increased dramatically and data during pregnancy and the postpartum period are overall reassuring. In contrast, VA ECMO provides both respiratory and cardiovascular support. Data on the use of VA ECMO during pregnancy are extremely limited.

Use of Extracorporeal Membrane Oxygenation Therapy During Pregnancy and COVID-19: A Case Study

Extracorporeal membrane oxygenation is emerging as a vital resource for survival of patients with acute respiratory distress syndrome related to COVID-19. Although recent research provides much insight into the advantages of extracorporeal membrane oxygenation in this patient population, little has been published on its use in pregnancy. This case study describes the use of venovenous extracorporeal membrane oxygenation in a young pregnant woman with acute respiratory distress syndrome due to COVID-19. It illustrates the benefits of a multidisciplinary approach to this treatment modality, allowing time for a fetus to become viable while preserving the life of the mother. In this case, the mother was able to return home after receiving this therapy and resume normal activities of daily living independently.

Veno-venous Extracorporeal Membrane Oxygenation for pregnant women with Acute Respiratory Distress Syndrome: a narrative review

Acute respiratory distress syndrome remains an uncommon condition during pregnancy. In patients with severe acute respiratory distress syndrome, when oxygenation or ventilation cannot be supported sufficiently using best practice conventional mechanical ventilation and additional therapies, veno-venous extracorporeal membrane oxygenation may be considered. In the past two decades, there has been increasing adoption of this technique to support adult patients with refractory acute respiratory distress syndrome. However, its use for the management of pregnant women is rare and remains a challenge. This narrative review addresses acute respiratory distress syndrome and its management during pregnancy, and then focuses on indications, contraindications, challenges, potential complications, and outcomes of the use of veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome in the pregnant patient.

Pulmonary Embolism and Amniotic Fluid Embolism

Venous thromboembolism (VTE) as well as other embolic events including amniotic fluid embolism (AFE) remain a leading cause of maternal death in the United States and worldwide. The pregnant patient is at a higher risk of developing VTE including pulmonary embolism. In contrast, AFE is a rare, but catastrophic event that remains incompletely understood. Here the authors review the cause of VTE in pregnancy and look at contemporary and evidence-based practices for the evaluation, diagnosis, and management in pregnancy. Then the cause and diagnostic difficulty of AFE as well as what is known regarding the pathogenesis are reviewed.

Successful Application of Argatroban During VV-ECMO in a Pregnant Patient Complicated With ARDS due to Severe Tuberculosis: A Case Report and Literature Review

Severe tuberculosis during pregnancy may progress to acute respiratory distress syndrome (ARDS), and venovenous (VV) extracorporeal membrane oxygenation (ECMO) should be considered if conventional lung-protective mechanical ventilation fails. However, thrombocytopenia often occurs with ECMO, and there are limited reports of alternative anticoagulant therapies for pregnant patients with thrombocytopenia during ECMO. This report describes the first case of a pregnant patient who received argatroban during ECMO and recovered. Furthermore, we summarized the existing literature on VV-ECMO and argatroban in pregnant patients. A 31-year-old woman at 17 weeks of gestation was transferred to our hospital with ARDS secondary to severe tuberculosis. We initiated VV-ECMO after implementing a protective ventilation strategy and other conventional therapies. Initially, we selected unfractionated heparin anticoagulant therapy. However, on ECMO day 3, the patient’s platelet count and antithrombin III (AT-III) level declined to 27 × 103 cells/μL and 26.9%, respectively. Thus, we started the patient on a 0.06 μg/kg/min argatroban infusion. The argatroban infusion maintenance dose ranged between 0.9 and 1.2 μg/kg/min. The actual activated partial thromboplastin clotting time and activated clotting time ranged from 43 to 58 s and 220–260 s, respectively, without clinically significant bleeding and thrombosis. On day 27, the patient was weaned off VV-ECMO and eventually discharged. VV-ECMO may benefit pregnant women with refractory ARDS, and argatroban may be an alternative anticoagulant for pregnant patients with thrombocytopenia and AT-III deficiency during ECMO.

Clinical Characteristics and Outcomes of COVID-19 During Pregnancy-a Retrospective Cohort Study

The course of COVID-19 has been shown to be worse in pregnant women compared with their non-pregnant counterparts. The aim of this study is to share our experience treating pregnant women with COVID-19 and to establish a cohort for future studies of the long-term effects of the disease. We reviewed medical records of all SARS-CoV-2-positive pregnant women who were treated at our hospital for any reason, be it COVID-19 related or not, between April 2020 and February 2021. We extracted data regarding medical history, course of pregnancy, delivery, and neonatal outcomes. A total of 193 SARS-CoV-2-positive pregnant women were treated at our establishment during the study period, half of which were asymptomatic. Sixteen were hospitalized for COVID-19 symptoms, the most common being fatigue/malaise (58%) and cough (48%). Three women required mechanical ventilation and extracorporeal membrane oxygenation treatment. One hundred forty-four SARS-CoV-2-positive women were delivered during the study period. Of them, 24 (17%) underwent induction of labor, and four (17%) were due to symptomatic COVID-19. One hundred fifteen (80%) experienced vaginal delivery, and 29 (20%) underwent cesarean delivery. Neonatal outcomes were favorable; only 2% of 5-min Apgar scores were < 7, and all umbilical cord pH levels were > 7.1. Six infants tested positive for SARS-CoV-2; they were all asymptomatic, and none required treatment for viral infection. COVID-19 during pregnancy is a disease with potential substantial adverse maternal and neonatal outcomes. There is still much unknown regarding the long-term effects of the disease on parturients and their offspring.

What's new on the management of obstetric patients who tested positive for Covid-19?

To date, there is still partial data on the effects of COVID-19 on pregnant women. The constant collection of information results in a continuous updating of the knowledge about the best management of pregnant patients affected by COVID-19. This work aims to summarize the state of the art on prevention and management of SARSCoV-2 infection in obstetric patients. This was enabled by a comprehensive literature search for the most recent and relevant publications on the subject, including guidelines and recommendations. Management of these women by a multidisciplinary team is of crucial importance, given the extreme clinical complexity of this condition. Every health worker involved must put in place all possible procedures to protect themselves from contagion. Neuraxial anesthesia should be favored in the management of labor and caesarean section over other modalities, unless there are contraindications based on the patient's status. There is still no standardized drug treatment in pregnant women with COVID-19 due to their exclusion from studies conducted to evaluate pharmacological therapies. Nevertheless, various drugs have been used to treat this disease in pregnancy, although the data at our disposal are still few. As regards mRNA vaccines, it seems that their immunogenicity, safety and tolerability in pregnant women are comparable to those of non-pregnant women of the same age. More studies are certainly needed in infected pregnant women to establish treatment and prevention protocols for this special category of patients.

Extracorporeal Membrane Oxygenation for Pregnant and Postpartum Patients

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.

Pulmonary Hypertension Complicating Pregnancy

Purpose of review

This study aims to describe the pathophysiology of pregnancy in pulmonary hypertension (PH) and review recent literature on maternal and fetal outcomes.

Recent findings

There is an increasing number of pregnant women with PH. Maternal mortality in pulmonary arterial hypertension (PAH) ranges from 9 to 25%, most commonly from heart failure and arrythmias. The highest risk of death is peri-partum and post-partum. Fetal/neonatal morbidity and mortality are also substantial. There are high rates of prematurity, intrauterine growth retardation, and preeclampsia. Women should be referred to expert centers for management. Combination PAH therapy with parenteral prostacyclin and a phosphodiesterase type V inhibitor is recommended. Induced vaginal delivery is preferred, except in cases of severe heart failure or obstetric indications for cesarean section.

Summary

Despite advances in management, pregnancy in PAH remains a high-risk condition and should be prevented.

Timing of delivery with coronavirus disease 2019 pneumonia requiring intensive care unit admission

Approximately 4% of pregnant patients with coronavirus disease 2019 require intensive care unit admission. Given the practical implications of advanced ventilatory and circulatory support techniques, urgent or emergent delivery for nonreassuring fetal status frequently presents a logistical impossibility. This article proposes a protocol for obstetrical management of patients in these situations, emphasizing coordinated preparation among obstetrical, anesthesiology, and intensivist teams for planned preterm delivery at gestational ages when neonatal outcomes are likely to be favorable.

Management of life-threatening acute respiratory syndrome and severe pneumonia secondary to COVID-19 in pregnancy: A case report and literature review

Evidence-based treatment involving multidisciplinary decision making is warranted to treat COVID-19 in pregnancy. This case presents the management of a critically ill pregnant women infected with SARS-CoV-2.

Extracorporeal membrane oxygenation in pregnant and postpartum patients: a systematic review

PURPOSE

Information on the use of extracorporeal membrane oxygenation (ECMO) in obstetric patients is scarce. The objective was to conduct a systematic review examining ECMO use in pregnant and postpartum patients in order to identify indications leading to ECMO use and to assess mortality rates.

MATERIALS AND METHODS

PubMed, EMBASE, Cochrane Library, and SCOPUS were searched using the terms "extracorporeal membrane oxygenation" and "pregnancy" up to 1 November 2020. Case reports and case series reporting the use of ECMO in pregnancy were eligible. Data about maternal age, gestational age, diagnosis, type of ECMO, time on ECMO, pregnancy outcomes, and maternal survival were extracted from studies.

RESULTS

The search yielded 1696 citations, of which 125 were included. There were 213 obstetric patients treated with ECMO over a 30-year period. The frequency of reports increased considerably over the last decade. The majority of patients were treated in their third trimester (28.2%) or postpartum (32.9%). Most common etiologies included influenza-induced ARDS (27.7%), pulmonary embolism (13.6%), peripartum cardiomyopathy (11.7%), and infection (11.7%). Pregnancy outcomes ended with live births, either on ECMO (15.5%, 95% CI 10.6-20.4) or not on ECMO (58.3%, 95% CI 51.7-64.9), in fetal demise (8.9%, 95% CI 5.1-12.7), or in spontaneous or induced abortion on ECMO (4.2%, 95% CI 1.5-6.9) or not on ECMO (4.2%, 95% CI 1.5-6.9). Maternal survival was 79.3%.

CONCLUSION

Although women placed on ECMO had a high mortality rate, this is likely an indication of the severity of illness. Overall, ECMO appears to be a valid therapy for the temporary support of vital organs in severely ill pregnant women.

Venovenous Extracorporeal Membrane Oxygenation Combined with Fiberoptic Bronchoscopy-Assisted CO2 Cryotherapy in the Treatment of Massive Hemoptysis in Pregnancy: A Case Report

Background

Massive hemoptysis in pregnancy is very rare but can be life-threatening for both the pregnant woman and fetus. Extracorporeal membrane oxygenation (ECMO) is extremely rare in the treatment of severe hemoptysis in pregnancy. Here we describe the case of massive hemoptysis in the second trimester of pregnancy successfully treated with a combination of venovenous (VV)-ECMO, and bronchial artery embolization combined with fiberoptic bronchoscopy–assisted CO₂ cryotherapy.

Case Presentation

A 34-year-old patient at 28 2/7 weeks gestation with a history of hemoptysis for 3 days was transferred to our care. Massive hemoptysis completely blocked the trachea and main bronchus, and a ventilator could not carry out ventilation. ECMO was performed immediately when oxygenation was not maintained. A right lower bronchial artery hemorrhage was found by bronchial arteriography under ECMO, and embolization with microcoils and gelatin sponge particles was then performed. An emergency bedside carbon dioxide cryo-thrombectomy was performed under fiberoptic bronchoscopy because of obstruction of the trachea and main bronchus. Endotracheal cryotherapy was repeated (for a total three times) until bronchoscopic evaluation confirmed no obstruction of the trachea and no active bleeding in the airway. On day 7, ECMO was successfully evacuated. On day 15, the patient was extubated. On day 17, the tracheotomy was closed and replaced by nasal oxygen inhalation. On day 20, the patient was discharged from hospital. The patient has had no recurrence of hemoptysis in 3-month follow-up.

Conclusion

VV-ECMO combined with carbon dioxide cryotherapy in the treatment of pregnancy complicated with massive hemoptysis is an effective treatment, when massive hemoptysis completely blocked the trachea.

Extracorporeal Membrane Oxygenation Utility in Postpartum Patients

Although extracorporeal membrane oxygenation (ECMO) has been used in many different populations, its use in pregnant or postpartum patients has not been widely studied. This article reviews the ECMO experience in this population at a large urban hospital. Electronic medical records for all pregnant or postpartum patients who required ECMO between 2012 and 2019 were retrospectively reviewed. Data on clinical characteristics, outcomes, and complications were gathered. Comparisons between survivors and nonsurvivors were completed. Ten postpartum patients were identified. The patients presented as follows: four with cardiac arrest, one with a massive pulmonary embolism, three with acute respiratory distress syndrome (ARDS), one with combined ARDS and cardiogenic shock, and one with suspected amniotic embolism. Survival to decannulation was 70%, and survival to discharge was 60%. When comparing survivors vs. nonsurvivors, ECMO survivors tended to have shorter support times vs. nonsurvivors. Otherwise, no differences were noted in age, mechanical ventilation time, or length of stay. Disseminated intravascular coagulation was a common phenomenon in this patient cohort. After initiation of ECMO, elevated serum lactate levels, lower systolic blood pressure, and acute renal failure were predictors of mortality. In a single institution at a large metroplex, we present data regarding the use of ECMO in postpartum patients. ECMO can be successfully used in selected postpartum patients with severe cardiac or respiratory dysfunction. Multidisciplinary collaboration on a regular basis will streamline the ECMO referral in a timely manner. Furthermore, larger studies are indicated to understand the utility of ECMO in larger cohorts.

Survival of Pregnant Coronavirus Patient on Extracorporeal Membrane Oxygenation

A 27-year-old woman presented at 23 weeks’ 6 days’ gestation who tested positive for the coronavirus disease 2019 (COVID-19). Despite mechanical ventilation and paralysis, she remained hypoxic and was emergently cannulated for veno-venous extracorporeal membrane oxygenation (VV-ECMO). The patient ambulated while intubated and on VV-ECMO. She was decannulated and extubated. An ultrasound demonstrated an appropriately grown fetus without abnormalities. She was discharged to home and gave birth to a healthy baby girl at 39 weeks’ gestation. Using VV-ECMO, this patient and her fetus survived acute hypoxemic respiratory failure due to COVID-19.

Resuscitating the Crashing Pregnant Patient

Care of the critically ill pregnant patient is anxiety-provoking for those unprepared, as the emergency physician must consider not only the welfare of the immediate patient, but of the fetus as well. Familiarity with the physiologic changes of pregnancy and how they affect clinical presentation and management is key. Although some medications may be safer in pregnancy than others, stabilizing the pregnant patient is paramount. Emergency physicians should target pregnancy-specific oxygen and ventilation goals and hemodynamics and should be prepared to perform a perimortem cesarean section, should the mother lose pulses, to increase chances for maternal and fetal survival.

Putting It All Together: Clinical Considerations in the Care of Critically Ill Obstetric Patients with COVID-19

Pregnant patients with severe acute respiratory syndrome coronavirus 2, the virus responsible for the clinical condition newly described in 2019 as coronavirus disease 2019 (COVID-19) and illness severity to warrant intensive care have a complex disease process that must involve multiple disciplines. Guidelines from various clinical societies, along with direction from local health authorities, must be considered when approaching the care of an obstetric patient with known or suspected COVID-19. With a rapidly changing landscape, a simplified and cohesive perspective using guidance from different clinical society recommendations regarding the critically-ill obstetric patient with COVID-19 is needed. In this article, we synthesize various high-level guidelines of clinical relevance in the management of pregnant patients with severe disease or critical illness due to COVID-19. KEY POINTS: · When caring for severely ill obstetric patients with COVID-19, one must be well versed in the complications that may need to be managed including, but not limited to adult respiratory distress syndrome with need for mechanical ventilation, approach to refractory hypoxemia, hemodynamic shock, and multiorgan system failure.. · Prone positioning can be done safely in gravid patients but requires key areas of support to avoid abdominal compression.. · For the critically ill obstetric patient with COVID-19, the focus should be on supportive care as a bridge to recovery rather than delivery as a solution to recovery..

Pregnancy-Associated Myocardial Infarction: Prevalence, Causes, and Interventional Management

Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.

Phrenic nerve injury secondary to extracorporeal membrane oxygenation in pregnancy: A case report

Extracorporeal membrane oxygenation (ECMO) is used to provide acute respiratory and/or hemodynamic support to patients with severe, refractory respiratory failure. Phrenic nerve injury with subsequent hemidiaphragm paralysis should be included in the differential diagnosis of pregnant women with persistent hypoxia after ECMO cannulation.

Coronavirus Disease 2019 (COVID-19) and pregnancy: what obstetricians need to know

Coronavirus disease 2019 is an emerging disease with a rapid increase in cases and deaths since its first identification in Wuhan, China, in December 2019. Limited data are available about coronavirus disease 2019 during pregnancy; however, information on illnesses associated with other highly pathogenic coronaviruses (ie, severe acute respiratory syndrome and the Middle East respiratory syndrome) might provide insights into coronavirus disease 2019's effects during pregnancy. Coronaviruses cause illness ranging in severity from the common cold to severe respiratory illness and death. Currently the primary epidemiologic risk factors for coronavirus disease 2019 include travel from mainland China (especially Hubei Province) or close contact with infected individuals within 14 days of symptom onset. Data suggest an incubation period of ∼5 days (range, 2-14 days). Average age of hospitalized patients has been 49-56 years, with a third to half with an underlying illness. Children have been rarely reported. Men were more frequent among hospitalized cases (54-73%). Frequent manifestations include fever, cough, myalgia, headache, and diarrhea. Abnormal testing includes abnormalities on chest radiographic imaging, lymphopenia, leukopenia, and thrombocytopenia. Initial reports suggest that acute respiratory distress syndrome develops in 17-29% of hospitalized patients. Overall case fatality rate appears to be ∼1%; however, early data may overestimate this rate. In 2 reports describing 18 pregnancies with coronavirus disease 2019, all were infected in the third trimester, and clinical findings were similar to those in nonpregnant adults. Fetal distress and preterm delivery were seen in some cases. All but 2 pregnancies were cesarean deliveries and no evidence of in utero transmission was seen. Data on severe acute respiratory syndrome and Middle East respiratory syndrome in pregnancy are sparse. For severe acute respiratory syndrome, the largest series of 12 pregnancies had a case-fatality rate of 25%. Complications included acute respiratory distress syndrome in 4, disseminated intravascular coagulopathy in 3, renal failure in 3, secondary bacterial pneumonia in 2, and sepsis in 2 patients. Mechanical ventilation was 3 times more likely among pregnant compared with nonpregnant women. Among 7 first-trimester infections, 4 ended in spontaneous abortion. Four of 5 women with severe acute respiratory syndrome after 24 weeks' gestation delivered preterm. For Middle East respiratory syndrome, there were 13 case reports in pregnant women, of which 2 were asymptomatic, identified as part of a contact investigation; 3 patients (23%) died. Two pregnancies ended in fetal demise and 2 were born preterm. No evidence of in utero transmission was seen in severe acute respiratory syndrome or Middle East respiratory syndrome. Currently no coronavirus-specific treatments have been approved by the US Food and Drug Administration. Because coronavirus disease 2019 might increase the risk for pregnancy complications, management should optimally be in a health care facility with close maternal and fetal monitoring. Principles of management of coronavirus disease 2019 in pregnancy include early isolation, aggressive infection control procedures, oxygen therapy, avoidance of fluid overload, consideration of empiric antibiotics (secondary to bacterial infection risk), laboratory testing for the virus and coinfection, fetal and uterine contraction monitoring, early mechanical ventilation for progressive respiratory failure, individualized delivery planning, and a team-based approach with multispecialty consultations. Information on coronavirus disease 2019 is increasing rapidly. Clinicians should continue to follow the Centers for Disease Control and Prevention website to stay up to date with the latest information (https://www.cdc.gov/coronavirus/2019-nCoV/hcp/index.html).

Extracorporeal Membrane Oxygenation During Adult Noncardiac Surgery and Perioperative Emergencies: A Narrative Review

Over the last decade, the use of extracorporeal membrane oxygenation (ECMO) has increased significantly. In some centers, ECMO has been deployed to manage perioperative emergencies and plays a role in facilitating high-risk thoracic, airway, and trauma surgery, which may not be feasible without ECMO support. General anesthesiologists who usually manage these cases may not be familiar with the initiation and management of patients on ECMO. This review discusses the use of ECMO in the operating room for thoracic, airway, and trauma surgery, as well as obstetric and perioperative emergencies.

Amniotic fluid embolism: principles of early clinical management

Amniotic fluid embolism is an uncommon, but potentially lethal, complication of pregnancy. Because amniotic fluid embolism usually is seen with cardiac arrest, the initial immediate response should be to provide high-quality cardiopulmonary resuscitation. We describe key features of initial treatment of patients with amniotic fluid embolism. Where available, we recommend performing transthoracic or transesophageal echocardiography as soon as possible because this is an easy and reliable method of identifying a failing right ventricle. If such failure is identified, treatment that is tailored at improving right ventricular performance should be initiated with the use of inotropic agents and pulmonary vasodilators. Blood pressure support with vasopressors is preferred over fluid infusion in the setting of severe right ventricular compromise. Amniotic fluid embolism-related coagulopathy should be managed with hemostatic resuscitation with the use of a 1:1:1 ratio of packed red cells, fresh frozen plasma, and platelets (with cryoprecipitate as needed to maintain a serum fibrinogen of >150-200 mg/dL). In cases that require prolonged cardiopulmonary resuscitation or, after arrest, severe ventricular dysfunction refractory to medical management, consideration for venoarterial extracorporeal membrane oxygenation should be given.

Successful multimodality management of severe pulmonary arterial hypertension during pregnancy with VA-ECMO and atrial septostomy using stent

A 30-year-old Thai woman (gravida 1, para 0) at 33 weeks gestation was referred to our hospital due to acute right ventricular failure. Pulmonary vasodilators were gradually administered before delivery. On the verge of sudden postpartum cardiac circulation collapse, she was resuscitated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Abdominal compartment syndrome was developed in the early period of the mechanical support. Knowledge of pathophysiology about pulmonary arterial hypertension during pregnancy was applied. Atrial septostomy was the effective procedure for discontinuing mechanical support (VA-ECMO) corresponding to the suitable timing for maximal effect of pulmonary vasodilators. The patient and her child were safe and discharged in 2 months after the admission.

Successful Use of Extracorporeal Membrane Oxygenation for Status Asthmaticus in a Woman With a Periviable Pregnancy

BACKGROUND

Status asthmaticus is a severe asthma exacerbation with persistent airway obstruction despite standard therapy. Use of extracorporeal membrane oxygenation (ECMO) as rescue therapy in pregnancy is exceedingly rare. We describe a case of ECMO for treatment of status asthmaticus in woman with a periviable pregnancy culminating in a term delivery.

CASE

The patient was a 33-year-old woman, gravida 3 para 1, admitted at 23 2/7 weeks of gestation with respiratory failure secondary to status asthmaticus. Venovenous ECMO was initiated and continued for 6 days. After hospital discharge, she had no further respiratory issues. She ultimately developed fetal growth restriction and gestational hypertension and underwent a repeat cesarean delivery at 38 weeks of gestation.

CONCLUSION

Venovenous ECMO can be used successfully for status asthmaticus during a periviable pregnancy and enable delivery at term.

Case report of massive hemoptysis in pregnancy requiring veno-venous extracorporeal membrane oxygenation

Hemoptysis in pregnancy is rare and can be life-threatening. This case describes management of hemoptysis in pregnancy requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO). The patient presented with massive hemoptysis in respiratory failure at 26 weeks gestation. VV-ECMO was utilized for maternal stability due to severe hypoxia from lung parenchymal damage. An extensive work-up for hemoptysis returned negative except for an elevated Bordetella pertussis IgG antibody. The patient was delivered via cesarean section with a complicated post-partum course. She and the infant were discharged in stable condition after long hospital stays. Prior publications describing VV-ECMO use in pregnancy are limited to treatment of respiratory infections such as influenza or pneumonia. This case is the first in the literature to describe VV-ECMO utilization for hemoptysis in pregnancy, specifically, and demonstrates its significant benefit in cases of respiratory failure due to hemoptysis.

Successful use of VV-ECMO in a pregnant patient with severe ARDS

Introduction

Around 0.1–0.2% of all pregnancies are complicated by respiratory failure. The altered physiology of pregnancy predisposes mother and child to develop hypoxia and respiratory failure more easily than a non-pregnant patient. Respiratory failure in pregnancy may have detrimental fetal complications, therefore extensive knowledge of the range of therapeutic options is necessary. If conventional lung-protective mechanical ventilation strategies fail, alternative approaches such as veno-venous extracorporeal membrane oxygenation (VV-ECMO) should be considered.

Case presentation

A previously healthy 30-year-old P1G2 at 26 weeks and 6 days of gestation was admitted to the emergency department because of a severe respiratory infection. She suffered of severe hypoxic respiratory failure due to an overwhelming pneumonia (influenza type A) with acute respiratory distress syndrome (ARDS). Because long protective ventilation strategies and ventilation in prone positioning were inadequate, and further respiratory deterioration occurred, VV-ECMO was initiated.

Conclusion

In a pregnant patient with severe respiratory failure, when other interventions fail, initiation of VV-ECMO should not be delayed. The use of VV-ECMO in pregnancy is a multi-disciplinary team approach.