Treatment of cardiogenic shock in peripartum cardiomyopathy: Case series from a tertiary ECMO center

Extracorporeal membrane oxygenation during pregnancy and peripartal. An international retrospective multicenter study

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.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Anesthetic management of peripartum cardiomyopathy

INTRODUCTION

Peripartum cardiomyopathy (PPCM) is a rare idiopathic cardiomyopathy frequently presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery. Within the published literature, there are case reports extolling the safety of both regional and general anesthetic interventions in PPCM. However, there is an absence of high-quality evidence to define a suitable paradigm for peri-operative care. In the absence of a large prospective case series or clinical trials, the synthesis of clinical data from published case reports provides an opportunity to distil published clinical data and explore the effect of clinical interventions.

EVIDENCE ACQUISITION

A systematic search of English articles English language case reports published between 1986 and 2020 within multiple databases. Clinical data was extracted and aggregated into a database for analysis.

EVIDENCE SYNTHESIS

Gestational hypertension and pre-eclampsia were pre-partum risk factors. 403 case reports provided 466 individual cases from 48 countries. Neither regional nor general anesthetic interventions in the peripartum period have a discernible impact on the outcome of patients with PPCM. Rapid unpredictable deterioration in the peripartum period, requiring mechanical cardiac support or heart transplantation is described. The mortality of PPCM is 5-6%.

CONCLUSIONS

Patients with PPCM are at risk of rapid unpredictable decline. Management within specialist centers should be considered. Although the data is unsuitable to provide a comprehensive paradigm for the anesthetic and critical care management of PPCM, the observations provide a direction for future clinical audits and trials.