1
|
Wong RW, Seasely AR, Gongora E, Hoopes CW, Bellot S, McElwee SK, Rusanov V, Wille K, Kaleekal T, Marshall T, Joly JM, Lenneman A, Tallaj J, Pamboukian SV, Sinkey R, Orozco-Hernandez EJ. Strategies and outcomes of extracorporeal membrane oxygenation use in peripartum patients: a single institution experience. J Matern Fetal Neonatal Med 2024; 37:2355293. [PMID: 38873894 DOI: 10.1080/14767058.2024.2355293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 05/08/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) use in peripartum patients is rare, and there is a gap in the literature on the outcomes and guidance on using ECMO in peripartum patients. This study describes ECMO strategies our institution uses for peripartum patients and reports outcomes of ECMO use in peripartum patients with respiratory and/or cardiac failure. METHODS A case series of all peripartum patients, defined as pregnant or up to 6 weeks after delivery of an infant >20 weeks gestation, from 2018 to 2023 from a single center requiring ECMO support. Patients were included if ECMO was initiated in the setting of cardiac, pulmonary, or combined failure. Patient demographics, operative details, ECMO data, and adverse outcomes for maternal, fetus, and neonates were all collected. RESULTS Eighteen patients met the inclusion criteria. The cohort had a mean maternal age of 30.7 years old and was racially diverse. A majority of this cohort tested positive for COVID-19 (n = 10, 55%). ECMO was a bridge to recovery for all patients, of whom 14 (78%) were discharged out of the hospital alive. No patients received transplantation or a durable mechanical device. The most common complications were infection (25%) and postpartum hemorrhage (22%). CONCLUSIONS ECMO use in peripartum patients in a single tertiary center was associated with a high survival rate. Furthermore, a strong multidisciplinary team, careful reevaluation of clinical trajectory, and consideration of complications and risks associated with using ECMO in peripartum patients are possible frameworks to use when challenged with critically ill peripartum patients.
Collapse
Affiliation(s)
- Ryan W Wong
- Tinsley Harrison Internal Medicine Residency Program, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Angela R Seasely
- Division of Maternal-Fetal Medicine, UAB Department of Obstetrics and Gynecology, Birmingham, AL, USA
| | - Enrique Gongora
- Division of Cardiothoracic Surgery, UAB Department of Surgery, Birmingham, AL, USA
| | - Charles W Hoopes
- Division of Cardiothoracic Surgery, UAB Department of Surgery, Birmingham, AL, USA
| | - Scott Bellot
- Division of Cardiothoracic Surgery, UAB Department of Surgery, Birmingham, AL, USA
| | - Samuel K McElwee
- Division of Cardiovascular Disease, UAB Department of Medicine, Birmingham, AL, USA
| | - Victoria Rusanov
- Division of Pulmonary, Allergy, and Critical Care Medicine, UAB Department of Medicine, Birmingham, AL, USA
| | - Keith Wille
- Division of Pulmonary, Allergy, and Critical Care Medicine, UAB Department of Medicine, Birmingham, AL, USA
| | - Thomas Kaleekal
- Division of Pulmonary, Allergy, and Critical Care Medicine, UAB Department of Medicine, Birmingham, AL, USA
| | - Tammy Marshall
- UAB Department of Mechanical Circulatory Support, Birmingham, AL, USA
| | - Joanna M Joly
- Division of Cardiovascular Disease, UAB Department of Medicine, Birmingham, AL, USA
| | - Andrew Lenneman
- Division of Cardiovascular Disease, UAB Department of Medicine, Birmingham, AL, USA
| | - Jose Tallaj
- Division of Cardiovascular Disease, UAB Department of Medicine, Birmingham, AL, USA
| | - Salpy V Pamboukian
- Division of Cardiovascular Disease, University of Washington, Seattle, WA, USA
| | - Rachel Sinkey
- Division of Maternal-Fetal Medicine, UAB Department of Obstetrics and Gynecology, Birmingham, AL, USA
| | | |
Collapse
|
2
|
Alazmi E, Akbar Z, Aldarweesh M, Almuzayen K, Husain E, Alharmi J. Retrospective Cohort Study Comparing the Clinical Profile and Outcomes of Critically Ill Pregnant Patients in Kuwait during the COVID-19 Pandemic Waves. Med Princ Pract 2024:1-11. [PMID: 38643766 DOI: 10.1159/000539004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 04/16/2024] [Indexed: 04/23/2024] Open
Abstract
OBJECTIVES COVID-19 is an infectious disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2 virus). This virus evolved into several variants, each with different severity. There are surges in the number of infected patients, commonly described as "waves." In Kuwait, three waves occurred. Our study describes and compares the clinical presentation and outcomes of critically ill pregnant patients infected with different variants. METHODS This was a retrospective cohort study in two intensive care units (ICU) dedicated to patients with COVID-19. The wave periods were retrieved from the Kuwait Ministry of Health. RESULTS The total number of ICU admissions during the study period was 74 patients. Most cases occurred during the third wave (n = 47/74, 63.5%). Most patients did not have comorbidities. The most common presenting symptoms were fever 62.2%, dyspnea 71.6%, and dry cough 74.3%. Low oxygen saturation 35.1% and maternal tachycardia 75.7% were observed in most patients. Cesarean section was the most common route of delivery, with maternal indication accounting for most cases 78.84%. Eight patients (13.69%) underwent dialysis, and thirty-one (41.9%) needed extracorporeal membrane oxygenation. Most patients required ventilatory support 66.21%. Almost all patients were unvaccinated 97.01%. Maternal mortality was mainly noted in the third wave (13.23%). CONCLUSIONS In Kuwait, the number of admissions and the rate of maternal complications, morbidity, and mortality increased with successive waves.
Collapse
Affiliation(s)
- Eman Alazmi
- Department of Obstetrics and Gynecology, Maternity Hospital Kuwait, Ministry of Health Kuwait, Kuwait City, Kuwait
| | - Zahraa Akbar
- Department of Obstetrics and Gynecology, Maternity Hospital Kuwait, Ministry of Health Kuwait, Kuwait City, Kuwait
| | - Mariam Aldarweesh
- Department of Obstetrics and Gynecology, Maternity Hospital Kuwait, Ministry of Health Kuwait, Kuwait City, Kuwait
| | - Khalid Almuzayen
- Department of Obstetrics and Gynecology, Maternity Hospital Kuwait, Ministry of Health Kuwait, Kuwait City, Kuwait
| | - Eelaf Husain
- Department of Obstetrics and Gynecology, Maternity Hospital Kuwait, Ministry of Health Kuwait, Kuwait City, Kuwait
| | - Jehad Alharmi
- Department of Obstetrics and Gynecology, College of Medicine, Kuwait University, Kuwait City, Kuwait
| |
Collapse
|
3
|
Yahav-Shafir D, Ilgiyaev E, Galante O, Gorfil D, Statlender L, Soroksky A, Carmi U, Sinai YB, Iprach N, Haviv-Yadid Y, Makhoul M, Fatnic E, Ginosar Y, Einav S, Helviz Y, Fink D, Sternik L, Kogan A. Extracorporeal membrane oxygenation in obstetric patients: An Israeli nationwide study. Artif Organs 2024; 48:392-401. [PMID: 38112077 DOI: 10.1111/aor.14691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 11/19/2023] [Accepted: 11/26/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND The leading causes of maternal mortality include respiratory failure, cardiovascular events, infections, and hemorrhages. The use of extracorporeal membrane oxygenation (ECMO) as rescue therapy in the peripartum period for cardiopulmonary failure is expanding in critical care medicine. METHODS This retrospective observational study was conducted on a nationwide cohort in Israel. During the 3-year period, between September 1, 2019, and August 31, 2022, all women in the peripartum period who had been supported by ECMO for respiratory or circulatory failure at 10 large Israeli hospitals were identified. Indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and complications were collected. RESULTS During the 3-year study period, in Israel, there were 540 234 live births, and 28 obstetric patients were supported by ECMO, with an incidence of 5.2 cases per 100 000 or 1 case per 19 000 births (when excluding patients with COVID-19, the incidence will be 2.5 cases per 100 000 births). Of these, 25 were during the postpartum period, of which 16 (64%) were connected in the PPD1, and 3 were during pregnancy. Eighteen patients (64.3%) were supported by V-V ECMO, 9 (32.1%) by V-A ECMO, and one (3.6%) by a VV-A configuration. Hypoxic respiratory failure (ARDS) was the most common indication for ECMO, observed in 21 patients (75%). COVID-19 was the cause of ARDS in 15 (53.7%) patients. The indications for the V-A configuration were cardiomyopathy (3 patients), amniotic fluid embolism (2 patients), sepsis, and pulmonary hypertension. The maternal and fetal survival rates were 89.3% (n = 25) and 100% (n = 28). The average ECMO duration was 17.6 ± 18.6 days and the ICU stay was 29.8 ± 23.8 days. Major bleeding complications requiring surgical intervention were observed in one patient. CONCLUSIONS The incidence of using ECMO in the peripartum period is low. The maternal and neonatal survival rates in patients treated with ECMO are high. These results show that ECMO remains an important treatment option for obstetric patients with respiratory and/or cardiopulmonary failure.
Collapse
Affiliation(s)
- Dana Yahav-Shafir
- Department of Anaesthesiology, Sheba Medical Centre, Tel Hashomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eduard Ilgiyaev
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of General Intensive Care, Shamir Medical Center, Zerifin, Israel
| | - Ori Galante
- Intensive Care Unit, Soroka University Medical Centre, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dan Gorfil
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiothoracic Surgery, Cardiothoracic Intensive Care Unit, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
| | - Liran Statlender
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- General Intensive Care Unit, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
| | - Arie Soroksky
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Intensive Care Unit, Wolfson Medical Centre, Holon, Israel
| | - Uri Carmi
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Anesthesia, Pain and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yitzhak Brzezinski Sinai
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Anesthesia, Pain and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Nisim Iprach
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Anesthesia and Intensive Care, Meir Medical Center, Kfar-Saba, Israel
| | - Yael Haviv-Yadid
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Intensive Care Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Maged Makhoul
- Department of Cardiac Surgery, Rambam Medical Center, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Elena Fatnic
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Hebrew University, Ein Karem Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yehuda Ginosar
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Anesthesiology, Mother & Child Anesthesia Unit, Hadassah Hebrew University, Ein Karem Medical Center, Jerusalem, Israel
| | - Sharon Einav
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Yigal Helviz
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Daniel Fink
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Cardiothoracic Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Leonid Sternik
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiac Surgery, Sheba Medical Centre, Tel Hashomer, Israel
| | - Alexander Kogan
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiac Surgery, Sheba Medical Centre, Tel Hashomer, Israel
- Cardiac Surgery Intensive Care Unit, Sheba Medical Centre, Tel Hashomer, Israel
| |
Collapse
|
4
|
O'Kelly AC, Sarma A, Naoum E, Easter SR, Economy K, Ludmir J. Cardiogenic Shock and Utilization of Mechanical Circulatory Support in Pregnancy. J Intensive Care Med 2024:8850666231225606. [PMID: 38204193 DOI: 10.1177/08850666231225606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Maternal mortality rates are rising in the United States, a trend which is in contrast to that seen in other high-income nations. Cardiovascular disease and hypertensive disorders of pregnancy are consistently the leading causes of maternal mortality both in the United States and globally, accounting for about one-quarter to one-third of maternal and peripartum deaths. A large proportion of cardiovascular morbidity and mortality stems from acquired disease in the context of cardiovascular risk factors, which include obesity, pre-existing diabetes and hypertension, and inequities in care from maternal care deserts and structural racism. Patients may also become pregnant with preexisting structural heart disease, or acquire disease throughout pregnancy (ex: spontaneous coronary artery dissection, peripartum cardiomyopathy), and be at higher risk of pregnancy-related cardiovascular complications. While risk-stratification tools including the modified World Health Organization (mWHO) classification, Cardiac Disease in Pregnancy (CARPREG II) and Zwangerschap bij Aangeboren HARtAfwijking/Pregnancy in Women with Congenital Heart Disease (ZAHARA) have been designed to help physicians identify patients at increased risk for adverse pregnancy outcomes and who may therefore benefit from referral to a tertiary care center, the limitation of these scores is their predominant focus on patients with known preexisting heart disease. As such, identifying patients at risk for pregnancy complications presents a significant challenge, and it is often patients with high-risk cardiovascular substrates prior to or during pregnancy who are at a highest risk for adverse pregnancy outcomes including cardiogenic shock.
Collapse
Affiliation(s)
- Anna C O'Kelly
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy Sarma
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emily Naoum
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Rae Easter
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Katherine Economy
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Ludmir
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
5
|
Greer OYO, Anandanadesan R, Shah NM, Price S, Johnson MR. Cardiogenic shock in pregnancy. BJOG 2024; 131:127-139. [PMID: 37794623 DOI: 10.1111/1471-0528.17645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 08/06/2023] [Accepted: 08/20/2023] [Indexed: 10/06/2023]
Abstract
Cardiac disease complicates 1%-4% of pregnancies globally, with a predominance in low and middle-income countries (LMICs). Increasing maternal age, rates of obesity, cardiovascular comorbidities, pre-eclampsia and gestational diabetes all contribute to acquired cardiovascular disease in pregnancy. Additionally, improved survival in congenital heart disease (CHD) has led to increasing numbers of women with CHD undergoing pregnancy. Implementation of individualised care plans formulated through pre-conception counselling and based on national and international guidance have contributed to improved clinical outcomes. However, there remains a significant proportion of women of reproductive age with no apparent comorbidities or risk factors that develop heart disease during pregnancy, with no indication for pre-conception counselling. The most extreme manifestation of cardiac disease is cardiogenic shock (CS), where the primary cardiac pathology results in inadequate cardiac output and hypoperfusion, and is associated with significant mortality and morbidity. Key to management is early recognition, intervention to treat any potentially reversible underlying pathology and supportive measures, up to and including mechanical circulatory support (MCS). In this narrative review we discuss recent developments in the classification of CS, and how these may be adapted to improve outcomes of pregnant women with, or at risk of developing, this potentially lethal condition.
Collapse
Affiliation(s)
- Orene Y O Greer
- Division of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
- Chelsea & Westminster NHS Foundation Trust, London, UK
| | - Rathai Anandanadesan
- Departments of Cardiology and Intensive Care, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- Department of Critical Care, King's College Hospital, London, UK
| | - Nishel M Shah
- Division of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
- Chelsea & Westminster NHS Foundation Trust, London, UK
| | - Susanna Price
- Departments of Cardiology and Intensive Care, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Mark R Johnson
- Division of Reproductive and Developmental Biology, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK
- Chelsea & Westminster NHS Foundation Trust, London, UK
| |
Collapse
|
6
|
Dutta S, Hirani S, Heda A, Shaikh MYD, Washani S, Hirani S, Prasad R, Wanjari M. Extracorporeal Membrane Oxygenation (ECMO): A Lifeline for Pregnant and Postpartum Women. Cureus 2023; 15:e43586. [PMID: 37719551 PMCID: PMC10503783 DOI: 10.7759/cureus.43586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving technology that temporarily supports the heart and lungs in critical care situations. This review article examines the role of ECMO as a lifeline for pregnant and postpartum women facing severe maternal and fetal conditions. The review begins with an overview of the physiology and pathophysiology of ECMO, including its procedure and how it supports cardiopulmonary function. Unique considerations specific to pregnant and postpartum women, such as physiological changes during pregnancy, risks and complications associated with ECMO, and the need to balance maternal and fetal considerations, are discussed. The indications for ECMO in this population are explored, including common maternal indications such as cardiogenic shock, acute respiratory distress syndrome (ARDS), pulmonary embolism, and eclampsia, as well as fetal indications such as fetal distress, hypoxic-ischemic encephalopathy (HIE), and twin-to-twin transfusion syndrome (TTTS). The challenges and considerations in ECMO for pregnant and postpartum women, including ethical considerations and the decision-making process, are highlighted. The review further explores the multidisciplinary care and collaborative approach required, emphasizing the importance of a specialized ECMO team and collaboration between obstetricians, neonatologists, cardiologists, and other specialists. Additionally, patient selection, pre-ECMO assessment, and planning strategies are discussed. The review evaluates existing literature and studies on ECMO in pregnant and postpartum women, analyzing survival rates and maternal and fetal outcomes and comparing different ECMO modalities and strategies. Future directions and research opportunities are presented, including emerging technologies, areas for further research and clinical trials, and improved patient selection and management strategies. The conclusion emphasizes the importance of ECMO as a lifeline for pregnant and postpartum women and the potential impact on maternal and fetal health. The review highlights the need for ongoing research and advancements in ECMO to optimize outcomes and improve care for this unique and vulnerable patient population.
Collapse
Affiliation(s)
- Shaina Dutta
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shoyeb Hirani
- Department of Medicine, Mahatma Gandhi Mission (MGM) Medical College and Hospital, Aurangabad, IND
| | - Arjun Heda
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Mohammed Yusuf D Shaikh
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Shona Washani
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sajid Hirani
- Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Roshan Prasad
- Department of Internal Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Mayur Wanjari
- Department of Research and Development, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| |
Collapse
|
7
|
Severe COVID-19 Infection during Pregnancy Requiring ECMO: Case Report and Review of the Literature. J Pers Med 2023; 13:jpm13020263. [PMID: 36836497 PMCID: PMC9961195 DOI: 10.3390/jpm13020263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/18/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The risk of developing severe COVID-19 that requires admission to an intensive care unit (ICU) and invasive ventilation is increased in pregnant women. Extracorporeal membrane oxygenation (ECMO) has been successfully used to manage critical pregnant and peripartum patients. CASE REPORT A 40-year-old patient, unvaccinated for COVID-19, presented to a tertiary hospital in January 2021 at 23 weeks of gestation due to respiratory distress, cough, and fever. The patient had a confirmed diagnosis of SARS-CoV-2 with a PCR test in a private center 48 h before. She required admission into the ICU due to respiratory failure. High-flow nasal oxygen therapy, intermittent noninvasive mechanical ventilation (BiPAP), mechanical ventilation, prone positioning, and nitric oxide therapy were administered. Additionally, hypoxemic respiratory failure was diagnosed. Thus, circulatory assistance using ECMO with venovenous access was performed. After 33 days of ICU admission, the patient was transferred to the internal medicine department. She was discharged 45 days after hospital admission. At 37 weeks of gestation, the patient presented active labor and underwent an uneventful vaginal delivery. CONCLUSIONS Severe COVID-19 in pregnancy may lead to the requirement for ECMO administration. This therapy should be administered in specialized hospitals using a multidisciplinary approach. COVID-19 vaccination should be strongly recommended to pregnant women to decrease the risk of severe COVID-19.
Collapse
|
8
|
Franquet N, Pierart J, Defresne A, Joachim S, Fraipont V. Veno-venous Extracorporeal Membrane Oxygenation for pregnant women with Acute Respiratory Distress Syndrome: a narrative review. ACTA ANAESTHESIOLOGICA BELGICA 2022. [DOI: 10.56126/73.3.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
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.
Collapse
|
9
|
Wu H, Tang Y, Xiong X, Zhu M, Yu H, Cheng D. Successful Application of Argatroban During VV-ECMO in a Pregnant Patient Complicated With ARDS due to Severe Tuberculosis: A Case Report and Literature Review. Front Pharmacol 2022; 13:866027. [PMID: 35899126 PMCID: PMC9309810 DOI: 10.3389/fphar.2022.866027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 06/06/2022] [Indexed: 12/27/2022] Open
Abstract
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.
Collapse
Affiliation(s)
| | | | | | | | - He Yu
- *Correspondence: He Yu, ; Deyun Cheng, ,
| | | |
Collapse
|
10
|
Malfertheiner SF, Brodie D, Burrell A, Taccone FS, Broman LM, Shekar K, Agerstrand CL, Serra AL, Fraser J, Malfertheiner MV. Extracorporeal membrane oxygenation during pregnancy and peripartal. An international retrospective multicenter study. Perfusion 2022:2676591221090668. [PMID: 35549557 DOI: 10.1177/02676591221090668] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Extracorporeal Membrane Oxygenation (ECMO) may be used in the setting of pregnancy or the peripartal period, however its utility has not been well-characterized. This study aims to give an overview on the prevalence of peripartel ECMO cases and further assess the indications and outcomes of ECMO in this setting across multiple centers and countries. METHODS A retrospective, multicenter, international cohort study of pregnant and peripartum ECMO cases was performed. Data were collected from six ECMO centers across three continents over a 10-year period. RESULTS A total of 60 pregnany/peripartal ECMO cases have been identified. Most frequent indications are acute respiratory distress syndrome (n = 30) and pulmonary embolism (n = 5). Veno-venous ECMO mode was applied more often (77%). ECMO treatment during pregnancy was performed in 17 cases. Maternal and fetal survival was high with 87% (n = 52), respectively 73% (n = 44). CONCLUSIONS Various emergency scenarios during pregnancy and at time of delivery may require ECMO treatment. Peripartal mortality in a well-resourced setting is rare, however emergencies in the labor room occur and knowledge of available rescue therapy is essential to improve outcome. Obstetricians and obstetric anesthesiologists should be aware of the availability of ECMO resource at their hospital or region to ensure immediate contact when needed.
Collapse
Affiliation(s)
- S Fill Malfertheiner
- Department of Obstetrics and Gynecology, Hospital St. Hedwig of the Order of St. John, Regensburg University, Regensburg, Germany
| | - D Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, 12294Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - A Burrell
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - F S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, ULB, Brussels, Belgium
| | - L M Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - K Shekar
- Critical Care Research Group, 67567The Prince Charles Hospital, Brisbane, Australia
| | - C L Agerstrand
- Division of Pulmonary, Allergy, and Critical Care Medicine, 12294Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - A L Serra
- Division of Pulmonary, Allergy, and Critical Care Medicine, 12294Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - J Fraser
- Critical Care Research Group, 67567The Prince Charles Hospital, Brisbane, Australia
| | - M V Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, University Hospital Regensburg, Regensburg, Germany
| |
Collapse
|
11
|
Fischer J, Gerresheim G, Schwemmer U. Internistische Notfälle bei der schwangeren Patientin. Med Klin Intensivmed Notfmed 2022; 117:239-252. [PMID: 35312817 PMCID: PMC8935102 DOI: 10.1007/s00063-022-00910-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Peripartale Notfälle, die intensivmedizinisch behandelt werden müssen, stellen eine große Herausausforderung an das interdisziplinäre Behandlungsteam dar. Aufgrund physiologischer Veränderungen der Schwangeren können Symptome maskiert und eine Therapieeinleitung verzögert werden. Die peripartale Sepsis weist eine relativ hohe Inzidenz auf. Die antiinfektive Therapie richtet sich nach dem zu erwartenden Keimspektrum. Endokrinologische Notfälle sind selten, können jedoch fulminant und tödlich sein. Die Entstehung einer Ketoacidose wird durch erniedrigte Bikarbonatpuffer und Plazentahormone begünstigt. Im Rahmen einer Thyreotoxikose stehen zur Therapie Propylthiouracil und Thiamazol in Abhängigkeit vom Gestationszeitpunkt zur Verfügung. Das Sheehan-Syndrom ist eine Infarzierung des Hypophysenvorderlappens im Rahmen einer Hämorrhagie. Durch Produktionsausfall lebenswichtiger Hormone kann dieses letal enden. Ebenso akut ist die Entstehung eines Lungenödems. Dieses wird durch physiologische Veränderungen während der Schwangerschaft begünstigt. Kausal ist für die Therapie die Unterscheidung eines hyper- oder hypotensiven Lungenödems von Bedeutung.
Collapse
Affiliation(s)
| | | | - U Schwemmer
- Klinik für Anästhesiologie und Intensivmedizin, Klinikum Neumarkt i.d.OPf., Neumarkt i.d.OPf., Deutschland.
| |
Collapse
|
12
|
Clemenza S, Zullino S, Vacca C, Simeone S, Serena C, Rambaldi MP, Ottanelli S, Vannuccini S, Bonizzoli M, Peris A, Micaglio M, Petraglia F, Mecacci F. Perinatal outcomes of pregnant women with severe COVID-19 requiring extracorporeal membrane oxygenation (ECMO): a case series and literature review. Arch Gynecol Obstet 2022; 305:1135-1142. [PMID: 35262778 PMCID: PMC8905275 DOI: 10.1007/s00404-022-06479-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Purpose Pregnant women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection have a higher risk of hospitalization, admission to intensive care unit (ICU) and invasive ventilation, and of acute respiratory distress syndrome (ARDS). In case of ARDS and critical severe coronavirus disease 2019 (COVID-19), the use of extracorporeal membrane oxygenation (ECMO) is recommended when other respiratory support strategies (oxygen insufflation, non-invasive ventilation [NIV], invasive ventilation through an endotracheal tube) are insufficient. However, available data on ECMO in pregnant and postpartum women with critical COVID-19 are very limited. Methods A case series of three critically ill pregnant women who required ECMO support for COVID-19 in pregnancy and/or in the postpartum period. Results The first patient tested positive for COVID-19 during the second trimester, she developed ARDS and required ECMO for 38 days. She was discharged in good general conditions and a cesarean-section [CS] at term was performed for obstetric indication. The second patient developed COVID-19-related ARDS at 28 weeks of gestation. During ECMO, she experienced a precipitous vaginal delivery at 31 weeks and 6 days of gestation. She was discharged 1 month later in good general conditions. The third patient, an obese 43-year-old woman, tested positive at 38 weeks and 2 days of gestation. Because of the worsening of clinical condition, a CS was performed, and she underwent ECMO. 143 days after the CS, she died because of sepsis and multiple organ failure (MOF). Thrombosis, hemorrhage and infections were the main complications among our patients. Neonatal outcomes have been positive. Conclusion ECMO should be considered a life-saving therapy for pregnant women with severe COVID-19.
Collapse
Affiliation(s)
- Sara Clemenza
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Viale Morgagni 44, 50134, Florence, Italy.
| | - Sara Zullino
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - Chiara Vacca
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - Serena Simeone
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - Caterina Serena
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - Marianna Pina Rambaldi
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - Serena Ottanelli
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - Silvia Vannuccini
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - Manuela Bonizzoli
- Department of Emergency, Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Adriano Peris
- Department of Emergency, Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Massimo Micaglio
- Department of Anesthesia and Intensive Care, Unit of Obstetric and Gynecologic Anesthesia, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Felice Petraglia
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| | - Federico Mecacci
- Division of Obstetrics and Gynecology, Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Viale Morgagni 44, 50134, Florence, Italy
| |
Collapse
|
13
|
Kulkarni S, Futane SS. Cardiopulmonary Resuscitation in Obstetric Patient: Special Considerations. J Obstet Gynaecol India 2022; 72:192-200. [DOI: 10.1007/s13224-021-01568-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/08/2021] [Indexed: 11/29/2022] Open
|
14
|
|
15
|
Imanishi T, Kawabata K, Kanno C, Kanno M, Shimizu M. A 26 week preterm infant delivered by a mother on extracorporeal membrane oxygenation for COVID-19. Pediatr Int 2022; 64:e15229. [PMID: 35831254 PMCID: PMC9350366 DOI: 10.1111/ped.15229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/19/2022] [Accepted: 04/26/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Toshiyuki Imanishi
- Division of Neonatology, Department of Maternal and Perinatal Center, Saitama Children's Medical Center, Chuo, Saitama, Japan
| | - Ken Kawabata
- Division of Neonatology, Department of Maternal and Perinatal Center, Saitama Children's Medical Center, Chuo, Saitama, Japan
| | - Chika Kanno
- Division of Neonatology, Department of Maternal and Perinatal Center, Saitama Children's Medical Center, Chuo, Saitama, Japan
| | - Masayuki Kanno
- Division of Neonatology, Department of Maternal and Perinatal Center, Saitama Children's Medical Center, Chuo, Saitama, Japan
| | - Masaki Shimizu
- Division of Neonatology, Department of Maternal and Perinatal Center, Saitama Children's Medical Center, Chuo, Saitama, Japan
| |
Collapse
|
16
|
Kawamoto Y, Nishihara T, Aono J, Nandate H, Hamada T, Yasuoka T, Matsumoto T, Yamaguchi O, Sugiyama T, Yorozuya T. Perioperative management of emergent cesarean section in a patient with peripartum cardiomyopathy and orthopnea: a case report. J Int Med Res 2021; 49:3000605211063077. [PMID: 34898316 PMCID: PMC8678898 DOI: 10.1177/03000605211063077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Perioperative management of pregnant women with heart failure is difficult. Management of anesthesia in pregnant women is especially difficult because all of the currently available choices present challenges. We report a patient with peripartum cardiomyopathy (PPCM) who required an emergent cesarean section and discuss the possible tactics for managing anesthesia. A 40-year-old primipara with severe cardiac and respiratory failure required an emergent cesarean section at 39+1 gestational weeks. Her left ventricular ejection fraction was between 10% and 15%, and she had orthopnea. General anesthesia was planned after inserting sheaths for percutaneous cardiopulmonary support from the femoral artery and vein. However, when the patient was asked to lie down on the operation bed, she panicked and resisted because of labor pain and dyspnea. Therefore, anesthesia was induced instead of the initial plan. Finally, we successfully managed the anesthesia and delivered the newborn. There are no alternatives to general anesthesia in patients with PPCM presenting with orthopnea. Anesthesia induction in the supine position is impossible in such patients owing to dyspnea. Anesthesia should be started with light sedation in the sitting position, and ketamine or low-dose remifentanil may be an option to maintain maternal hemodynamics and prevent neonatal asphyxia.
Collapse
Affiliation(s)
- Yuko Kawamoto
- Department of Anesthesia and Perioperative Medicine, 38050Ehime University Graduate School of Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Tasuku Nishihara
- Department of Anesthesia and Perioperative Medicine, 38050Ehime University Graduate School of Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Jun Aono
- Department of Cardiology, Pulmonology, Hypertension, and Nephrology, 38050Ehime University Graduate School of Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Hideyuki Nandate
- Department of Anesthesia and Perioperative Medicine, 38050Ehime University Graduate School of Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Taisuke Hamada
- Department of Anesthesia and Perioperative Medicine, 38050Ehime University Graduate School of Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Toshiaki Yasuoka
- Department of Obstetrics and Gynecology, 38050Ehime University Graduate School of Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Takashi Matsumoto
- Department of Obstetrics and Gynecology, 38050Ehime University Graduate School of Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Hypertension, and Nephrology, 38050Ehime University Graduate School of Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Takashi Sugiyama
- Department of Obstetrics and Gynecology, 38050Ehime University Graduate School of Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Toshihiro Yorozuya
- Department of Anesthesia and Perioperative Medicine, 38050Ehime University Graduate School of Medicine, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| |
Collapse
|
17
|
Garg R, Hariharan UR, Malik I. Critical Care Management of the Parturient with Cardiac Disease. Indian J Crit Care Med 2021; 25:S230-S240. [PMID: 35615613 PMCID: PMC9108789 DOI: 10.5005/jp-journals-10071-24068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
UNLABELLED Parturient with heart disease forms a challenging group of patients and requires specialized critical care support in the peripartum period. Maternal heart disease may remain undiagnosed till the second trimester of pregnancy, presenting frequently after 20 weeks of gestation, due to increased demands imposed on the cardiovascular system and pose a serious risk to the life of mother and fetus. Management of critically ill parturient with heart disease must be tailored according to individual assessment of the patient and requires a strategic, multidisciplinary, and protocol-based approach. A dedicated obstetric intensive care unit (ICU) and team effort are the need of the hour. HOW TO CITE THIS ARTICLE Garg R, Hariharan UR, Malik I. Critical Care Management of the Parturient with Cardiac Disease. Indian J Crit Care Med 2021;25(Suppl 3):S230-S240.
Collapse
Affiliation(s)
- Rakesh Garg
- Department of Onco-anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
- Rakesh Garg, Department of Onco-anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India, Phone: +91 9810394950, e-mail:
| | - Uma R Hariharan
- Department of Cardiac Anaesthesia, Dr Ram Manohar Lohia Hospital and Atal Bihari Vajpayee Institute of Medical Sciences, New Delhi, India
| | - Indira Malik
- Department of Cardiac Anaesthesia, Pt BD Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
| |
Collapse
|
18
|
Ijuin S, Ishihara S, Maemura S, Fukushima M, Murakami A, Inoue A, Taniguchi Y, Igarashi N, Matsuyama S, Kawase T, Doi T, Nakayama S. Successful interhospital transfer for extracorporeal cardiopulmonary resuscitation of a patient who had a cardiac arrest after cesarean section. Acute Med Surg 2021; 8:e701. [PMID: 34815887 PMCID: PMC8594766 DOI: 10.1002/ams2.701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/04/2021] [Accepted: 10/07/2021] [Indexed: 11/09/2022] Open
Abstract
Background Studies describing the effectiveness of extracorporeal cardiopulmonary resuscitation (ECPR) for peripartum cardiopulmonary arrest are lacking. Case Presentation A 39‐year‐old woman underwent elective cesarean section. Right after surgery, she fell into a cardiac arrest and was promptly transferred to our institute by ambulance. On arrival, we immediately initiated ECPR, within 63 min of the cardiac arrest. Return of spontaneous circulation was achieved 80 min after induction of extracorporeal membrane oxygenation. As the hemodynamics of the patient stabilized, extracorporeal membrane oxygenation was discontinued on day 3 of hospitalization. The patient’s cerebral performance category score was 3 at discharge, which improved to 2 after 3 months. Conclusion This case suggests that prompt interhospital transfer and ECPR might be effective for peripartum cardiac arrest due to nonhemorrhagic events.
Collapse
Affiliation(s)
- Shinichi Ijuin
- Department of Emergency and Critical Care Medicine Hyogo Emergency Medical Center Hyogo Japan
| | - Satoshi Ishihara
- Department of Emergency and Critical Care Medicine Hyogo Emergency Medical Center Hyogo Japan
| | - Saki Maemura
- Department of Emergency and Critical Care Medicine Hyogo Emergency Medical Center Hyogo Japan
| | - Masafumi Fukushima
- Department of Emergency and Critical Care Medicine Hyogo Emergency Medical Center Hyogo Japan
| | - Atsushi Murakami
- Department of Cardiology Japanese Red Cross Kobe Hospital Kobe Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine Hyogo Emergency Medical Center Hyogo Japan
| | - Yayoi Taniguchi
- Department of Cardiology Japanese Red Cross Kobe Hospital Kobe Japan
| | - Nobuaki Igarashi
- Department of Cardiology Japanese Red Cross Kobe Hospital Kobe Japan
| | - Shigenari Matsuyama
- Department of Emergency and Critical Care Medicine Hyogo Emergency Medical Center Hyogo Japan
| | - Tetsunori Kawase
- Department of Emergency and Critical Care Medicine Hyogo Emergency Medical Center Hyogo Japan
| | - Tomofumi Doi
- Department of Cardiology Japanese Red Cross Kobe Hospital Kobe Japan
| | - Shinichi Nakayama
- Department of Emergency and Critical Care Medicine Hyogo Emergency Medical Center Hyogo Japan
| |
Collapse
|
19
|
Khryshchanovich VY, Skobeleva NY. Prophylaxis and management of venous thromboembolism during pregnancy and postpartum period. OBSTETRICS, GYNECOLOGY AND REPRODUCTION 2021. [DOI: 10.17749/2313-7347/ob.gyn.rep.2021.222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction. Venous thromboembolism (VTE) is one of the lead causes for maternal mortality and morbidity during pregnancy in the majority of developed countries. The incidence rate of VTE per pregnancy-year increases during pregnancy and postpartum period about by 4-fold and at least 14-fold, respectively.Aim: to analyze and summarize current view on risk factors of thrombotic events during gestation and to discuss recent guidelines for the management of venous thromboembolic complications during pregnancy and postpartum, by taking into account a balance between risks and benefits of using anticoagulants.Materials and Methods. The literature search covering the last 10 years was carried out in the electronic scientific databases RSCI, PubMed/MEDLINE, and Embase. While formulating a search strategy for evidence-based information, the PICO method (P = Patient; I = Intervention; C = Comparison; O = Outcome) and the key terms “venous thromboembolism” and “pregnancy” were used.Results. Risk factors were found to include a personal history of VTE, verified inherited or acquired thrombophilia, a family history of VTE and general medical conditions, such as immobilization, overweight, varicose veins, some hematological diseases and autoimmune disorders. VTE is considered being potentially preventable upon prophylactic administration of anticoagulants, but no high confidence randomized clinical trials comparing diverse strategies of thromboprophylaxis in pregnant women have been proposed so far. Because heparins do not cross the placenta, weight-adjusted therapeutic-dose low molecular weight heparins (LMWH) represent the anticoagulant treatment of choice for VTE during pregnancy. Once- and twice-daily dosing regimens are acceptable. However, no evidence suggesting benefits for measurement of factor Xa activities and consecutive LMWH dose adjustments to improve clinical outcomes are available. In case of uncomplicated pregnancy-related VTE, no routine administration of vitamin K antagonists, direct thrombin or factor Xa inhibitors, fondaparinux, or danaparoid is recommended. Lactating women may switch from applying LMWH to warfarin. Anticoagulation therapy should be continued for 6 weeks postpartum with total duration lasting at least for 3 months.Conclusion. VTE is a challenging task in pregnant women expecting to apply a multi-faceted approach for its efficient solution by taking into account updated recommendations and personalized patient-oriented features.
Collapse
Affiliation(s)
| | - N. Ya. Skobeleva
- Belarussian State Medical University;
Clinical Maternity Hospital of Minsk Region
| |
Collapse
|
20
|
Balasundaram P, Louis S, Thompson-Branch A. Preterm neonate delivered to COVID-19 positive mother on ECMO support. J Neonatal Perinatal Med 2021; 15:379-382. [PMID: 34542036 DOI: 10.3233/npm-210845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Despite ongoing research and recent discoveries, there remains a paucity of data regarding COVID-19 and its implications for pregnant women, particularly its effects on the developing fetus. To date, there are a limited number of articles available regarding the utility of Extra Corporeal Membrane Oxygenation (ECMO) for cardio-respiratory support of pregnant women during the perinatal period. Additionally, there are only a few case reports detailing the delivery management of a baby born to a mother on ECMO support. Here, we report a case of a premature, low birth weight neonate delivered by a 32-year-old woman while on ECMO due to severe acute respiratory distress syndrome resulting from COVID-19 infection.
Collapse
Affiliation(s)
- P Balasundaram
- Division of Neonatology, The Children's Hospital atMontefiore and Albert Einstein College of Medicine, Bronx, NY, USA
| | - S Louis
- Division of Neonatology, The Children's Hospital atMontefiore and Albert Einstein College of Medicine, Bronx, NY, USA
| | - A Thompson-Branch
- Division of Neonatology, The Children's Hospital atMontefiore and Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
21
|
Taha B, Guglielminotti J, Li G, Landau R. Utilization and Outcomes of Extracorporeal Membrane Oxygenation in Obstetric Patients in the United States, 1999-2014: A Retrospective Cross-Sectional Study. Anesth Analg 2021; 135:268-276. [PMID: 34724684 DOI: 10.1213/ane.0000000000005753] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Utilization of extracorporeal membrane oxygenation (ECMO) for adult critically ill patients is increasing, but data in obstetric cohorts are scant. This study analyzed ECMO utilization and maternal outcomes in obstetric patients in the United States. METHODS Data were abstracted from the 1999-2014 National Inpatient Sample (NIS), a 20% US national representative sample. ECMO hospitalizations (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 39.65) in patients ≥15 years of age were categorized into obstetric ECMO and nonobstetric ECMO. Obstetric patients included 4 categories: (1) loss or termination of pregnancy, (2) delivery (term or preterm), (3) postdelivery hospitalization, and (4) pregnancy without an obstetrical outcome. Possible underlying causes for obstetric ECMO were identified by analysis of ICD-9-CM codes in individual records. In-hospital death was abstracted from the NIS, and ECMO complications were identified using ICD-9-CM algorithms. Statistical significance in time-effect was assessed using weighted regression models. RESULTS During the 16-year study period, 20,454 adult ECMO cases were identified, of which 331 occurred in obstetric patients (1.6%; 95% confidence interval [CI], 1.4-1.8). Obstetric ECMO utilization rate was 4.7 per million obstetric discharges (95% CI, 4.2-5.2). The top 3 possible indications were sepsis (22.1%), cardiomyopathy (16.6%), and aspiration pneumonia (9.7%). Obstetric ECMO utilization rate increased significantly during the study period from 1.1 per million obstetric discharges in 1999-2002 (95% CI, 0.6-1.7) to 11.2 in 2011-2014 (95% CI, 9.6-12.9), corresponding to a 144.7% increase per 4-year period (95% CI, 115.3-178.1). Compared with nonobstetric ECMO, obstetric ECMO was associated with decreased in-hospital all-cause mortality (adjusted odds ratio [aOR] 0.78; 95% CI, 0.66-0.93). In-hospital all-cause mortality for obstetric ECMO decreased from 73.7% in 1999-2002 (95% CI, 48.8-90.8) to 31.9% in 2011-2014 (95% CI, 25.2-39.1), corresponding to a 26.1% decrease per 4-year period (95% CI, 10.1-39.3). Compared with nonobstetric ECMO, obstetric ECMO was associated with significantly increased risk of both venous thromboembolism without associated pulmonary embolism (aOR 1.83; 95% CI, 1.06-3.15) and of nontraumatic hemoperitoneum (aOR 4.32; 95% CI, 2.41-7.74). CONCLUSIONS During the study period, obstetric ECMO utilization has increased significantly and maternal prognosis improved.
Collapse
Affiliation(s)
- Bushra Taha
- From the Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Jean Guglielminotti
- From the Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Guohua Li
- From the Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York.,Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Ruth Landau
- From the Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| |
Collapse
|
22
|
Fischer J, Gerresheim G, Schwemmer U. [Internal medical emergencies in the pregnant patient : Peripartum sepsis, metabolic derailment, endocrinological emergencies and pulmonary edema]. Anaesthesist 2021; 70:795-808. [PMID: 34143232 PMCID: PMC8212281 DOI: 10.1007/s00101-021-00944-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 11/28/2022]
Abstract
Peripartale Notfälle, die intensivmedizinisch behandelt werden müssen, stellen eine große Herausausforderung an das interdisziplinäre Behandlungsteam dar. Aufgrund physiologischer Veränderungen der Schwangeren können Symptome maskiert und eine Therapieeinleitung verzögert werden. Die peripartale Sepsis weist eine relativ hohe Inzidenz auf. Die antiinfektive Therapie richtet sich nach dem zu erwartenden Keimspektrum. Endokrinologische Notfälle sind selten, können jedoch fulminant und tödlich sein. Die Entstehung einer Ketoacidose wird durch erniedrigte Bikarbonatpuffer und Plazentahormone begünstigt. Im Rahmen einer Thyreotoxikose stehen zur Therapie Propylthiouracil und Thiamazol in Abhängigkeit vom Gestationszeitpunkt zur Verfügung. Das Sheehan-Syndrom ist eine Infarzierung des Hypophysenvorderlappens im Rahmen einer Hämorrhagie. Durch Produktionsausfall lebenswichtiger Hormone kann dieses letal enden. Ebenso akut ist die Entstehung eines Lungenödems. Dieses wird durch physiologische Veränderungen während der Schwangerschaft begünstigt. Kausal ist für die Therapie die Unterscheidung eines hyper- oder hypotensiven Lungenödems von Bedeutung.
Collapse
Affiliation(s)
| | | | - U Schwemmer
- Klinik für Anästhesiologie und Intensivmedizin, Klinikum Neumarkt i.d.OPf., Neumarkt i.d.OPf., Deutschland.
| |
Collapse
|
23
|
Lankford AS, Chow JH, Jackson AM, Wallis M, Galvagno SM, Malinow AM, Turan OM, Menaker JA, Crimmins SD, Rector R, Kaczorowski D, Griffith B, Kon Z, Herr D, Mazzeffi MA. Clinical Outcomes of Pregnant and Postpartum Extracorporeal Membrane Oxygenation Patients. Anesth Analg 2021; 132:777-787. [PMID: 33591093 DOI: 10.1213/ane.0000000000005266] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) as a rescue therapy for cardiopulmonary failure is expanding in critical care medicine. In this case series, we describe the clinical outcomes of 21 consecutive pregnant or postpartum patients that required venovenous (VV) or venoarterial (VA) ECMO. Our objective was to characterize maternal and fetal survival in peripartum ECMO and better understand ECMO-related complications that occur in this unique patient population. METHODS Between January 2009 and June 2019, all pregnant and postpartum patients treated with ECMO for respiratory or circulatory failure at a single quaternary referral center were identified. For all patients, indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and anticoagulation and bleeding complications were collected. RESULTS Twenty-one obstetric patients were treated with ECMO over 10 years. Thirteen patients were treated with VV ECMO and 8 patients were treated with VA ECMO. Six patients were pregnant at the time of cannulation and 3 patients delivered while on ECMO; all 6 maternal and infant dyads survived to hospital discharge. The median gestational age at cannulation was 28 weeks (interquartile range [IQR], 24-31). In the postpartum cohort, ECMO initiation ranged from immediately after delivery up to 46 days postpartum. Fifteen women survived (72%). Major bleeding complications requiring surgical intervention were observed in 7 patients (33.3%). Two patients on VV ECMO required bilateral orthotopic lung transplantation and 1 patient on VA ECMO required orthotopic heart transplantation to wean from ECMO. CONCLUSIONS Survival for mother and neonate are excellent with peripartum ECMO in a high-volume ECMO center. Neonatal and maternal survival was 100% when ECMO was used in the late second or early third trimester. Based on these results, ECMO remains an important treatment option for peripartum patients with cardiopulmonary failure.
Collapse
Affiliation(s)
| | - Jonathan H Chow
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Amanda M Jackson
- Walter Reed National Military Medical Center, Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Bethesda, Maryland
| | - Marianne Wallis
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Samuel M Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Andrew M Malinow
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Jay A Menaker
- University of Maryland School of Medicine, Department of Surgery, Baltimore, Maryland
| | | | - Raymond Rector
- University of Maryland Medical Center, Department of Surgery, Baltimore, Maryland
| | - David Kaczorowski
- University of Maryland School of Medicine, Department of Surgery, Baltimore, Maryland
| | - Bartley Griffith
- University of Maryland School of Medicine, Department of Surgery, Baltimore, Maryland
| | - Zachary Kon
- New York University School of Medicine, Department of Surgery, New York, New York
| | - Daniel Herr
- University of Maryland School of Medicine, Department of Surgery, Baltimore, Maryland
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| |
Collapse
|
24
|
Douglass KM, Strobel KM, Richley M, Mok T, de St Maurice A, Fajardo V, Young AT, Rao R, Lee L, Benharash P, Chu A, Afshar Y. Maternal-Neonatal Dyad Outcomes of Maternal COVID-19 Requiring Extracorporeal Membrane Support: A Case Series. Am J Perinatol 2021; 38:82-87. [PMID: 33069171 PMCID: PMC7869039 DOI: 10.1055/s-0040-1718694] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE This study aimed to describe two cases of acute respiratory distress syndrome (ARDS) secondary to novel coronavirus disease 2019 (COVID-19) in pregnant women requiring extracorporeal membrane oxygenation (ECMO), and resulting in premature delivery. STUDY DESIGN The clinical course of two women hospitalized with ARDS due to COVID-19 care in our intensive care (ICU) is summarized; both participants provided consent to be included in this case series. RESULTS Both women recovered with no clinical sequelae. Neonatal outcomes were within the realm of expected for prematurity with the exception of coagulopathy. There was no vertical transmission to the neonates. CONCLUSION This case series highlights that ECMO is a feasible treatment in the pregnant woman with severe COVID-19 and that delivery can be performed safely on ECMO with no additional risk to the fetus. While ECMO carries its natural risks, it should be considered a viable option during pregnancy and the postpartum period. KEY POINTS · COVID-19 may present with a more severe course in pregnancy.. · ECMO may be used in pregnant woman with severe COVID-19.. · Delivery can be performed on ECMO without added fetal risk..
Collapse
Affiliation(s)
- K. Marie Douglass
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles
| | - Katie M. Strobel
- Division of Neonatology, Department of Pediatrics, University of California, Los Angeles
| | - Michael Richley
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles
| | - Thalia Mok
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles
| | - Annabelle de St Maurice
- Division of Infectious Disease, Department of Pediatrics, University of California, Los Angeles
| | - Viviana Fajardo
- Division of Neonatology, Department of Pediatrics, University of California, Los Angeles
| | - Andrew T. Young
- Division of Critical Care, Department of Anesthesia, University of California, Los Angeles
| | - Rashmi Rao
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles
| | - Lydia Lee
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles
| | - Peyman Benharash
- Divison of Cardiac Surgery, Department of Surgery, University of California, Los Angeles
| | - Alison Chu
- Division of Neonatology, Department of Pediatrics, University of California, Los Angeles
| | - Yalda Afshar
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Los Angeles,Address for correspondence Yalda Afshar, MD, PhD Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, David Geffen School of MedicineUCLA, 200 Medical Plaza, Suite 430, Los Angeles, CA 90095
| |
Collapse
|
25
|
Sebastian NA, Spence AR, Bouhadoun S, Abenhaim HA. Extracorporeal membrane oxygenation in pregnant and postpartum patients: a systematic review. J Matern Fetal Neonatal Med 2020; 35:4663-4673. [PMID: 33345652 DOI: 10.1080/14767058.2020.1860932] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
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.
Collapse
Affiliation(s)
- Natasha A Sebastian
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Andrea R Spence
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada
| | - Sarah Bouhadoun
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Haim A Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada
| |
Collapse
|
26
|
Carlier L, Devroe S, Budts W, Van Calsteren K, Rega F, Van de Velde M, Rex S. Cardiac interventions in pregnancy and peripartum – a narrative review of the literature. J Cardiothorac Vasc Anesth 2020; 34:3409-3419. [DOI: 10.1053/j.jvca.2019.12.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 11/19/2019] [Accepted: 12/12/2019] [Indexed: 12/17/2022]
|
27
|
Chen T, Yao L, Zhu C. Venovenous Extracorporeal Membrane Oxygenation Combined with Fiberoptic Bronchoscopy-Assisted CO 2 Cryotherapy in the Treatment of Massive Hemoptysis in Pregnancy: A Case Report. Int J Gen Med 2020; 13:1291-1296. [PMID: 33273848 PMCID: PMC7708678 DOI: 10.2147/ijgm.s287666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/11/2020] [Indexed: 11/25/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Ting Chen
- Department of Critical Care Medicine, The Second People's Hospital of Hefei, Hefei, Anhui 230009, People's Republic of China
| | - Li Yao
- Department of Critical Care Medicine, The Second People's Hospital of Hefei, Hefei, Anhui 230009, People's Republic of China
| | - Chunyan Zhu
- Department of Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei, Anhui 230032, People's Republic of China
| |
Collapse
|
28
|
Venous Thromboembolism Associated With Pregnancy. J Am Coll Cardiol 2020; 76:2128-2141. [DOI: 10.1016/j.jacc.2020.06.090] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/10/2020] [Accepted: 06/16/2020] [Indexed: 12/23/2022]
|
29
|
Extracorporeal Cardiopulmonary Resuscitation During Cesarean Delivery in a Patient With D-Transposition of the Great Vessels, Years Following Mustard Operation. World J Pediatr Congenit Heart Surg 2020; 12:549-551. [DOI: 10.1177/2150135120948490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patients with surgically repaired complex congenital cardiac anomalies present unique characteristics that can make the implementation of extracorporeal membrane oxygenation (ECMO) support especially challenging. Very few series have reported the outcomes of ECMO support during pregnancy and peripartum. We report a case of successful extracorporeal cardiopulmonary resuscitation during cesarean delivery in a patient with surgically repaired d-transposition of the great arteries, and we discuss particular aspects that contributed to successful implementation of ECMO support and hospital discharge.
Collapse
|
30
|
Tay JH, Goy RWL, Sng BL. Amniotic fluid embolism and management of coagulopathy: A case report with successful outcome. PROCEEDINGS OF SINGAPORE HEALTHCARE 2020. [DOI: 10.1177/2010105820929723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Amniotic fluid embolism (AFE) is a rare and potentially catastrophic condition unique to pregnancy. Presentation may range from subtle clinical events to sudden and fatal maternal cardiorespiratory arrest, with a reported incidence of 2–6 in 100,000 deliveries and mortality of 15–60%. Management should include immediate high-grade resuscitation for AFE presenting as cardiac arrest, involvement of multidisciplinary team, provision of adequate ventilator and circulatory support, treatment of coagulopathy precipitated by AFE, and immediate delivery of the foetus in cases of cardiac arrest. The following case report involves a patient with suspected AFE post-induction of labour with favourable maternal and neonatal outcome in our local setting. The management of coagulopathy in AFE is further discussed, including use of massive transfusion protocols, pharmacological agents and recombinant factor VIIa.
Collapse
Affiliation(s)
- Jun Hoe Tay
- Department of Women’s Anaesthesia, KK Women’s and Children’s Hospital, Singapore
| | - Raymond Wee Lip Goy
- Department of Women’s Anaesthesia, KK Women’s and Children’s Hospital, Singapore
| | - Ban Leong Sng
- Department of Women’s Anaesthesia, KK Women’s and Children’s Hospital, Singapore
| |
Collapse
|
31
|
Extracorporeal Membrane Oxygenation for Amniotic Fluid Embolism-Induced Cardiac Arrest in the First Trimester of Pregnancy: A Case Report. Crit Care Explor 2020; 2:e0162. [PMID: 32766559 PMCID: PMC7368879 DOI: 10.1097/cce.0000000000000162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Amniotic fluid embolism is a rare obstetric emergency that can be accompanied by profound hypoxemia, coagulopathy, hemorrhage, and cardiogenic shock. Extracorporeal membrane oxygenation may provide a rescue strategy in amniotic fluid embolism with cardiopulmonary collapse. Approaches to anticoagulation must be balanced against the risk of hemorrhage with concomitant coagulopathy. Although extracorporeal membrane oxygenation has been described for cardiopulmonary collapse in the setting of amniotic fluid embolism, its initiation as a bridge to hemostasis and cardiopulmonary recovery in amniotic fluid embolism–induced hemorrhagic and cardiogenic shock remains a novel resuscitation strategy.
Collapse
|
32
|
Naoum EE, Chalupka A, Haft J, MacEachern M, Vandeven CJM, Easter SR, Maile M, Bateman BT, Bauer ME. Extracorporeal Life Support in Pregnancy: A Systematic Review. J Am Heart Assoc 2020; 9:e016072. [PMID: 32578471 PMCID: PMC7670512 DOI: 10.1161/jaha.119.016072] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background The use of extracorporeal life support (ECLS) has expanded to include unique populations such as peripartum women. This systematic review aims to (1) quantify the number of cases and indications for ECLS in women during the peripartum period reported in the literature and (2) report maternal and fetal complications and outcomes associated with peripartum ECLS. Methods and Results This review was registered in PROSPERO (CRD42018108142). MEDLINE, Embase, and CINAHL were searched for case reports, case series, and studies reporting cases of ECLS during the peripartum period that reported one or more of the following outcomes: maternal survival, maternal complications, fetal survival, and/or fetal complications. Qualitative assessment of 221 publications evaluated the number of cases, clinical details, and maternal and fetal outcomes of ECLS during the peripartum period. There were 358 women included and 68 reported fetal outcomes in cases where the mother was pregnant at the time of cannulation. The aggregate maternal survival at 30 days was 270 (75.4%) and at 1 year was 266 (74.3%); fetal survival was 44 (64.7%). The most common indications for ECLS overall in pregnancy included acute respiratory distress syndrome 177 (49.4%), cardiac failure 67 (18.7%), and cardiac arrest 57 (15.9%). The most common maternal complications included mild to moderate bleeding 66 (18.4%), severe bleeding requiring surgical intervention 48 (13.4%), and intracranial neurologic morbidity 19 (5.3%). The most commonly reported fetal complications included preterm delivery 33 (48.5%) and neonatal intensive care unit admission 19 (27.9%). Conclusions Reported rates of survival in ECLS in pregnant and postpartum women are high and major complications relatively low.
Collapse
Affiliation(s)
- Emily E. Naoum
- Department of AnesthesiologyUniversity of MichiganAnn ArborMI
| | - Andrew Chalupka
- Department of Anesthesia, Critical Care and Pain MedicineMassachusetts General HospitalBostonMA
| | - Jonathan Haft
- Department of Cardiac SurgeryUniversity of MichiganAnn ArborMI
| | - Mark MacEachern
- Taubman Health Sciences LibraryUniversity of MichiganAnn ArborMI
| | - Cosmas J. M. Vandeven
- Department of Obstetrics and GynecologyMaternal‐Fetal MedicineUniversity of MichiganAnn ArborMI
| | - Sarah Rae Easter
- Division of Maternal‐Fetal MedicineDepartment of Obstetrics and GynecologyBrigham and Women’s HospitalBostonMA
| | - Michael Maile
- Department of AnesthesiologyUniversity of MichiganAnn ArborMI
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and PharmacoeconomicsDepartment of MedicineDepartment of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s HospitalBostonMA
| | | |
Collapse
|
33
|
Madden AM, Meng ML. Cardiopulmonary resuscitation in the pregnant patient. BJA Educ 2020; 20:252-258. [PMID: 33456958 DOI: 10.1016/j.bjae.2020.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- A-M Madden
- St-Paul's Hospital and University of British Columbia, Vancouver, Canada
| | - M-L Meng
- Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
34
|
|
35
|
Sebastian N, Czuzoj-Shulman N, Spence AR, Abenhaim HA. Use of extracorporeal membrane oxygenation in obstetric patients: a retrospective cohort study. Arch Gynecol Obstet 2020; 301:1377-1382. [PMID: 32363547 DOI: 10.1007/s00404-020-05530-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/28/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE There is little information on the use of extracorporeal membrane oxygenation (ECMO) in pregnant women. Our objectives are to estimate the use of ECMO in pregnant patients, identify clinical conditions associated with ECMO use, and assess survival rates by the associated condition. METHODS Using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample, we carried out a retrospective cohort study of all delivery admissions in the United States from January 1, 1999, to October 1, 2015. Within the cohort, women who received ECMO therapy were identified using ICD-9 codes and then survival rates among these women were calculated. RESULTS There were 83 women who underwent ECMO therapy in our cohort of 15,335,205 births, for an overall ECMO use rate of 0.54/100,000 pregnancies. The incidence of ECMO use increased from 0.23/100,000 in 1999 to 2.57/100,000 in 2015. Patients on ECMO were more likely to be older, have a lower income, and have pre-existing medical conditions when compared with the patients not on ECMO. The overall survival rate for the ECMO group was 62.7%. The most common reason for ECMO use was acute respiratory failure. Etiologies associated with the highest survival in those on ECMO were pneumonia and venous thromboembolism, which were found to have survival rates of 75.0% and 81.0%, respectively. CONCLUSION The incidence of ECMO use in the obstetric population increased over the last decade and a half. Although it carries a limited survival rate within this population, it has proven life-saving for many suffering from complications of pregnancy and delivery.
Collapse
Affiliation(s)
- Natasha Sebastian
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada
| | - Nicholas Czuzoj-Shulman
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, QC, Canada
| | - Andrea R Spence
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, QC, Canada
| | - Haim A Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, 3755 Chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1E2, Canada.
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, QC, Canada.
| |
Collapse
|
36
|
Bazan VM, Rodgers-Fischl P, Zwischenberger JB. Supportive Therapy: Extracorporeal Membrane Oxygenation. Crit Care Clin 2020; 36:517-529. [PMID: 32473696 DOI: 10.1016/j.ccc.2020.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute high-risk pulmonary embolism (PE) is characterized by life-threatening hemodynamic instability that may lead to refractory cardiac arrest. Recently, extracorporeal membrane oxygenation (ECMO) has been used to provide primary cardiopulmonary support for select high-risk PE patients or before surgical embolectomy. This article reviews the growing body of literature regarding ECMO support of acute high-risk PE.
Collapse
Affiliation(s)
- Vanessa M Bazan
- College of Medicine, University of Kentucky, Lexington, 800 Rose Street, MN264, Lexington, KY 40536-0298, USA
| | - Peter Rodgers-Fischl
- Division of Cardiothoracic Surgery, Kentucky Clinic, UK Health Care, 740 South Limestone A-301, Lexington, KY 40536, USA
| | - Joseph B Zwischenberger
- Department of Surgery, University of Kentucky, University of Kentucky Medical Center, 800 Rose Street, MN350, Lexington, KY 40536-0298, USA.
| |
Collapse
|
37
|
Bartholomew JR. Pulmonary Embolism in the Intensive Care Unit: Therapy in Subpopulations. Crit Care Clin 2020; 36:547-560. [PMID: 32473698 DOI: 10.1016/j.ccc.2020.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The optimal management of a submassive or massive pulmonary embolism (PE) during pregnancy is unclear because of a lack of large clinical trials. Evaluation of the patient who may be a candidate for more aggressive therapy includes the use of biomarkers and echocardiogram for risk stratification. PE Response teams (PERTs) have gained increasing acceptance by the medical community and are being implemented in hospitals in the United States and worldwide. PERTs bring together a team of specialists from different disciplines to enhance decision-making in the patient with acute submassive and massive PE.
Collapse
Affiliation(s)
- John R Bartholomew
- Vascular Medicine, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue J3-5, Cleveland, OH 44195, USA.
| |
Collapse
|
38
|
Cotter EK, Banayan J, Tung A, Gupta A, Mueller A, Shahul S. Trends and Outcomes of Mechanical Circulatory Support in Peripartum Women, 2002-2014: A Nationwide Inpatient Sample Analysis. J Cardiothorac Vasc Anesth 2020; 34:1198-1203. [DOI: 10.1053/j.jvca.2019.11.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/26/2019] [Accepted: 11/29/2019] [Indexed: 11/11/2022]
|
39
|
Extracorporeal membrane oxygenation in pregnancy and the postpartum period: a systematic review of case reports. Int J Obstet Anesth 2020; 43:106-113. [PMID: 32439296 DOI: 10.1016/j.ijoa.2020.04.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 03/10/2020] [Accepted: 04/13/2020] [Indexed: 11/24/2022]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) as salvage therapy for patients with severe cardiopulmonary failure has increased significantly in the past decade. However, the use of ECMO in pregnant and peripartum patients has received scant attention. We performed a systematic review of case reports in the literature, documenting indications and outcomes of ECMO in pregnancy and postpartum patients. Case reports on ECMO use in pregnant and postpartum patients were retrieved from MEDLINE, EMBASE and SCOPUS databases up to December 2018. Ninety publications reporting on 97 patients met our inclusion criteria. The majority of publications reported peripartum or postpartum ECMO use for cardiovascular failure (60.8%), while the remainder had respiratory failure. Adult Respiratory Distress Syndrome (91.9%) was the most common respiratory indication while pulmonary embolism (23.7%) and peripartum cardiomyopathy (16.9%) accounted for the two most common cardiovascular indications. Hemorrhage was the most common complication of ECMO reported (31.9%). Of 96 documented neonatal outcomes, 80 neonates (83.3%) survived while 88 of 97 (90.7%) mothers survived. Extracorporeal membrane oxygenation appears to be a viable life support modality in pregnant and postpartum women with severe cardiopulmonary failure, but publication bias in our study cohort should be considered.
Collapse
|
40
|
Webster CM, Smith KA, Manuck TA. Extracorporeal membrane oxygenation in pregnant and postpartum women: a ten-year case series. Am J Obstet Gynecol MFM 2020; 2:100108. [PMID: 32835205 PMCID: PMC7362433 DOI: 10.1016/j.ajogmf.2020.100108] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective tExtracorporeal membrane oxygenation (ECMO) is a life-saving therapy for severe, reversible cardiopulmonary failure, but data regarding its use in pregnancy and the postpartum period are limited. We sought to quantify survival of pregnant and postpartum women necessitating ECMO in a contemporary cohort at a single tertiary institution. Study Design All women of reproductive age (14–44 years), who underwent ECMO at our institution between January 1, 2008, and December 31, 2017, were identified using a query of hospital encounters for ECMO-related CPT codes. We manually reviewed all charts of women of reproductive age; women who were pregnant or <6 weeks postpartum at the time of ECMO initiation were included. Clinical characteristics and maternal and fetal outcomes are described. Results In this study, 54 women of reproductive age underwent ECMO for cardiopulmonary failure. Of those, 9 (17%) were pregnant or <6 weeks postpartum at the time of ECMO initiation: 4 antepartum, 1 intraoperative at the time of cesarean delivery, and 4 postpartum (including 2 in whom ECMO was initiated on postpartum day 0 or 1). Overall, maternal survival was 33%. The median maternal age was 24 years (range 19–39 years); most women were nonsmokers without underlying medical comorbidities. The most common indication for ECMO use in pregnant and postpartum women was acute respiratory distress syndrome, which was present in 7 cases (78%), including 5 cases that were due to infectious etiologies and 2 cases that were attributed to preeclampsia. The median number of days on ECMO was 6 (range 1–14). There were no cases of obstetric hemorrhage. Venovenous ECMO was utilized in all but 1 case, in which emergent attempted venoarterial ECMO was unsuccessful in resuscitating a postpartum patient with cardiac arrest and a massive pulmonary embolism. A total of 4 women were initiated on ECMO during pregnancy: their gestational ages at ECMO initiation were 21, 22, 29, and 30 weeks; maternal survival was 50%, and fetal mortality was 50%. A case of ECMO initiated during cesarean section at 29 weeks’ gestation resulted in both maternal and fetal survival. Among 4 mothers with ECMO initiation after childbirth, none survived. Finally, we found a tendency toward survival in those patients for whom ECMO was initiated soon after mechanical ventilation, earlier in the disease process. In contrast, in this study, 23 of 45 women of reproductive age (51%) who were not pregnant but underwent ECMO survived. Conclusion When ECMO was initiated during pregnancy or during childbirth, 60% of mothers and fetuses survived, supporting current use of ECMO as a salvage therapy in pregnant and intrapartum women. In this generally young and healthy population, ECMO has the potential to increase the survival rates of both mother and fetus and should be considered a salvage therapy for peripartum women with reversible forms of cardiorespiratory failure.
Collapse
Affiliation(s)
- Carolyn M. Webster
- Division of Maternal-Fetal Medicine, Departments of Obstetrics & Gynecology, University of North Carolina-Chapel Hill and University of North Carolina Health, Chapel Hill, NC
| | - Kathleen A. Smith
- Anesthesiology, University of North Carolina-Chapel Hill and University of North Carolina Health, Chapel Hill, NC
| | - Tracy A. Manuck
- Division of Maternal-Fetal Medicine, Departments of Obstetrics & Gynecology, University of North Carolina-Chapel Hill and University of North Carolina Health, Chapel Hill, NC
- Corresponding author: Tracy A. Manuck, MD.
| |
Collapse
|
41
|
Aryal SR, Moussa H, Sinkey R, Dhungana R, Tallaj JA, Pamboukian SV, Patarroyo-Aponte M, Acharya D, Bajaj NS, Bhattarai S, Lenneman A, Joly JM, Sibai BM, Rajapreyar IN. Management of reproductive health in patients with pulmonary hypertension. Am J Obstet Gynecol MFM 2020; 2:100087. [PMID: 33345958 DOI: 10.1016/j.ajogmf.2020.100087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 01/04/2020] [Accepted: 01/11/2020] [Indexed: 11/29/2022]
Abstract
Pulmonary hypertension is characterized by elevated pulmonary artery pressure caused by several clinical conditions that affect pulmonary vasculature. Morbidity and death in this condition are related to the development of right ventricular failure. Normal physiologic changes that occur in pregnancy to support the growing fetus can pose hemodynamic challenges to the pregnant patient with pulmonary hypertension that results in increased morbidity and mortality rates. Current guidelines recommend that patients with known pulmonary hypertension be counseled against pregnancy. This review aims to provide clinicians with guidelines for preconception counseling, medication management, and delivery planning.
Collapse
Affiliation(s)
- Sudeep R Aryal
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL.
| | - Hind Moussa
- Division of Maternal-Fetal medicine, The University of Cincinnati, Cincinnati, OH
| | - Rachel Sinkey
- Department of Obstetrics and Gynecology, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL
| | - Rajat Dhungana
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Jose A Tallaj
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Salpy V Pamboukian
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Maria Patarroyo-Aponte
- Center for Advanced Heart Failure, University of Texas Health Science Center, Houston, TX
| | - Deepak Acharya
- Division of Cardiology, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Navkaranbir S Bajaj
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | | | - Andrew Lenneman
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Joanna M Joly
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| | - Baha M Sibai
- Division of Maternal-Fetal Medicine, University of Texas, Houston, TX
| | - Indranee N Rajapreyar
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|
42
|
Extracorporeal Membrane Oxygenation as Salvage Therapy in the Peripartum Period: A Case Series. ASAIO J 2020; 66:e94-e98. [DOI: 10.1097/mat.0000000000001120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
|
43
|
Foong TW, Ramanathan K, Chan KKM, MacLaren G. Extracorporeal Membrane Oxygenation During Adult Noncardiac Surgery and Perioperative Emergencies: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 35:281-297. [PMID: 32144062 DOI: 10.1053/j.jvca.2020.01.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/03/2020] [Accepted: 01/12/2020] [Indexed: 12/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Theng Wai Foong
- Department of Anesthesia and Surgical Intensive Care Unit, National University Hospital, Singapore.
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, Department of Cardiothoracic and Vascular Surgery, National University Hospital, Singapore
| | - Kevin Kien Man Chan
- Department of Anesthesia and Surgical Intensive Care Unit, National University Hospital, Singapore
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, Department of Cardiothoracic and Vascular Surgery, National University Hospital, Singapore
| |
Collapse
|
44
|
Abstract
Pregnant patients can suffer from the same respiratory diseases as the general population in addition to unique syndromes of pregnancy (such as pre-eclampsia and tocolytic induced pulmonary edema, and pregnancy induced cardiomyopathy). Pregnancy by itself may add certain challenges such as difficult intubation. The critically ill pregnant patient requires a multidisciplinary approach and early inclusion of obstetrical expertise is paramount in managing these patients especially in the third trimester.
Collapse
Affiliation(s)
- Robert C. Hyzy
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
| | - Jakob McSparron
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
| |
Collapse
|
45
|
Zhang JJY, Ong JAH, Syn NL, Lorusso R, Tan CS, MacLaren G, Ramanathan K. Extracorporeal Membrane Oxygenation in Pregnant and Postpartum Women: A Systematic Review and Meta-Regression Analysis. J Intensive Care Med 2019; 36:220-228. [DOI: 10.1177/0885066619892826] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background: Although extracorporeal membrane oxygenation (ECMO) is frequently utilized as a salvage therapy for patients with cardiopulmonary failure, outcomes of its use in peripartum patients have not been clearly established. We aimed to review peer-reviewed publications on the use of ECMO in pregnant and postpartum patients, with analyses of maternal and fetal outcomes. Methods: Data were retrieved from MEDLINE, EMBASE, and Scopus databases from 1972 up to November 2017 for publications on ECMO in peripartum patients. Search terms included “ECMO,” “ECLS,”, “pregnancy,” “postpartum,” and “peripartum.” Publications with 3 or more patients were reviewed for quality using the Joanna Briggs Institute checklist for prevalence studies and case series. Results: After reviewing 143 publications, 9 observational studies met our inclusion criteria. Pooled prevalence of maternal survival was 77.2% (95% confidence interval [CI]: 64.1%-88.4%). Pooled prevalence of fetal survival was 69.1% (95% CI: 44.7%-89.8%). The level of heterogeneity across studies was low for both outcomes. Meta-regression did not reveal any correlation between pregnant women with pulmonary or cardiac indications and maternal survival. Individual patient data meta-regression demonstrated higher odds of survival for patients on venovenous ECMO compared to those on venoarterial ECMO that was close to statistical significance (odds ratio = 3.016, 95% CI: 0.901-11.144; P = .081) after adjusting for pregnancy status. Conclusions: Extracorporeal membrane oxygenation can be considered as an acceptable salvage therapy for pregnant and postpartum patients with critical cardiac or pulmonary illness.
Collapse
Affiliation(s)
- John J. Y. Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jamie Ann-Hui Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas L. Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Center, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Chuen Seng Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Graeme MacLaren
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiac Thoracic and Vascular Surgery, National University Heart Centre, National University Hospital, Singapore
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiac Thoracic and Vascular Surgery, National University Heart Centre, National University Hospital, Singapore
| |
Collapse
|
46
|
Phoophiboon V, Jaimchariyatam N, Srimahachota S, Sirinawin C. Successful multimodality management of severe pulmonary arterial hypertension during pregnancy with VA-ECMO and atrial septostomy using stent. BMJ Case Rep 2019; 12:12/12/e231916. [PMID: 31796462 DOI: 10.1136/bcr-2019-231916] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Vorakamol Phoophiboon
- Division of Pulmonology and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Nattapong Jaimchariyatam
- Division of Pulmonology and Critical Care Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Suphot Srimahachota
- Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University Faculty of Medicine, Bangkok, Thailand
| | - Chayatat Sirinawin
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| |
Collapse
|
47
|
Stiff A, Harrison R, Palatnik A. Case report of massive hemoptysis in pregnancy requiring veno-venous extracorporeal membrane oxygenation. J Obstet Gynaecol Res 2019; 45:2452-2455. [PMID: 31486147 DOI: 10.1111/jog.14110] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/14/2019] [Indexed: 12/01/2022]
Abstract
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.
Collapse
Affiliation(s)
- Alyssa Stiff
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Rachel Harrison
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Anna Palatnik
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
48
|
Abstract
Background: Maternal sepsis accounts for 11% of all maternal deaths worldwide. It is the third most common direct cause of maternal death and is a major contributor to other common causes of maternal death, such as haemorrhage and thromboembolism.
Methods: This review addresses important topics, including the epidemiology, risk factors, prevention, diagnosis, care bundles and management of maternal sepsis, including antibiotic treatment, and critical care interventions such as extracorporeal membrane oxygenation. Preventative measures that have had an impact on maternal sepsis as well as future research directions are also covered in this review. Case studies of maternal sepsis which highlight key learning points relevant to all clinicians involved in the management of obstetric patients will also be presented.
Results: Although, historically, maternal death from sepsis was considered to be a problem for low-income countries, severe obstetric morbidity and maternal death from sepsis are increasing in high-income countries. The global burden of maternal sepsis and the obstetric-related and patient-related risk factors and the likely sources are presented. Recent changes in definition and nomenclature are outlined, and challenges in diagnosis and identification are discussed.
Conclusions: Following maternal sepsis, early diagnosis and early intervention are critical to save lives and prevent long-term adverse sequelae. Dogma surrounding critical care interventions in pregnancy is being challenged, and future research is warranted to maximise therapeutic options available for maternal septic shock.
Collapse
Affiliation(s)
- Amaan Ali
- St Bartholomew's and The London School of Medicine and Dentistry, 4 Newark St, Whitechapel, London, E1 2AT, UK
| | - Ronnie F Lamont
- Department of Gynecology and Obstetrics, University of Southern Denmark, Institute of Clinical Research, Research Unit of Gynaecology and Obstetrics, Kløvervænget 10, 5000 Odense C, Denmark.,Division of Surgery, University College London, Northwick Park Institute for Medical Research Campus, Watford Road, London, HA1 3UJ, UK
| |
Collapse
|
49
|
Nnaoma C, Chika-Nwosuh OZ, Isedeh A, Bustillo J, Al Twal A, Patel P. Venovenous Extracorporeal Membrane Oxygenation in a Gravid Patient with Acute Respiratory Distress Syndrome: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:705-708. [PMID: 31097681 PMCID: PMC6537755 DOI: 10.12659/ajcr.914490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Patient: Female, 22 Final Diagnosis: Acute respiratory distress syndrome Symptoms: Flank pain • urinary frequency Medication: — Clinical Procedure: ECMO Specialty: Critical Care Medicine
Collapse
Affiliation(s)
- Christopher Nnaoma
- Department of Internal Medicine, Newark Beth Israel Medical Center, Newark, NJ, USA
| | | | - Anthony Isedeh
- Department of Internal Medicine, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Jose Bustillo
- Department of Internal Medicine, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Abdullah Al Twal
- Department of Pulmonary and Critical Care Medicine, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Patrik Patel
- Department of Pulmonary and Critical Care Medicine, Newark Beth Israel Medical Center, Newark, NJ, USA
| |
Collapse
|
50
|
Preemptive ECMO Cannulation in a Patient with Severe Left Ventricular Systolic Dysfunction Undergoing Cesarean Delivery. Case Rep Anesthesiol 2019; 2019:2623608. [PMID: 31093376 PMCID: PMC6476149 DOI: 10.1155/2019/2623608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/31/2019] [Accepted: 03/24/2019] [Indexed: 12/01/2022] Open
Abstract
Obstetric patients with heart failure undergoing cesarean delivery are high risk and the perioperative care of these patients poses significant multidisciplinary challenges. In contrast to the nonobstetric patient population the potential role of mechanical circulatory support in parturients with heart failure is not well established and the use of extracorporeal membrane oxygenation (ECMO) has rarely been reported. We report the case of a super morbidly obese patient with decompensated heart failure, pulmonary hypertension, and superimposed preeclampsia undergoing preemptive ECMO cannulation for urgent cesarean delivery.
Collapse
|