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Cotton JL, Makinen J, Park SY, Halpern Mungo A, Aftab M, Hoffman JRH, Cain MT. Spontaneous Coronary Artery Dissection, Takotsubo Cardiomyopathy, and Venoarterial Extracorporeal Membrane Oxygenation in Pregnancy. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024:15569845241252443. [PMID: 38828949 DOI: 10.1177/15569845241252443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Affiliation(s)
- Jake L Cotton
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - James Makinen
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sarah Y Park
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alison Halpern Mungo
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Muhammad Aftab
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jordan R H Hoffman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael T Cain
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Schlein SM, Reno EM, Coffey CH, Casper LM, Klein DA, Claypool MS, Wiitala EL, Keyes LE. Environmental Exposures and Risks During Pregnancy. Wilderness Environ Med 2024:10806032241248626. [PMID: 38706212 DOI: 10.1177/10806032241248626] [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: 05/07/2024]
Abstract
The Women in Wilderness Medicine Research Committee of the Wilderness Medical Society conducted a narrative review to address considerations for pregnant individuals in wilderness environments. There is limited evidence behind many opinion-based recommendations on the safety of various environmental exposures in pregnancy. The authors reviewed the literature for the best available evidence, including observational studies, case series, limited controlled trials, and extrapolation from physiological data, as well as evaluating expert consensus statements. The benefits of exposure to natural environments include better pregnancy outcomes and improved maternal mental and physical health. Risks are similar to nonpregnant individuals with the added risks associated with maternal-fetal physiology in wilderness environments and difficulties of evacuation. This narrative review discusses pregnancy-specific concerns in extreme environments, including high altitude, hypothermia, hyperthermia, lightning strikes, envenomations, and common outdoor exposures.
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Affiliation(s)
- Sarah M Schlein
- Larner College of Medicine, University of Vermont, Burlington, VT
| | - Elaine M Reno
- Department of Emergency Medicine, University of Colorado, Aurora, CO
| | | | | | - David A Klein
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Diego, San Diego, CA
| | | | - Ellen L Wiitala
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Linda E Keyes
- Department of Emergency Medicine, University of Colorado, Aurora, CO
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Varvoutis MS, Wein LE, Sugrue R, Darwin KC, Vaught AJ, Meng ML, Hughes BL, Grotegut CA, Federspiel JJ. Pregnancy-Associated Extracorporeal Membrane Oxygenation in the United States. Am J Perinatol 2024; 41:e1248-e1256. [PMID: 36608702 PMCID: PMC10425568 DOI: 10.1055/a-2008-8462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE The use of extracorporeal membrane oxygenation (ECMO) therapy has increased in the adult population. Studies from the H1N1 influenza pandemic suggest that ECMO deployment in pregnancy is associated with favorable outcomes. With increasing numbers of pregnant women affected by COVID-19 (coronavirus disease 2019) and potentially requiring this life-saving therapy, we sought to compare comorbidities, costs, and outcomes between pregnancy- and nonpregnancy-associated ECMO therapy among reproductive-aged female patients. STUDY DESIGN We used the 2013 to 2019 National Readmissions Database. Diagnosis and procedural coding were used to identify ECMO deployment, potential indications, comorbid conditions, and pregnancy outcomes. The primary outcome was in-hospital mortality during the patient's initial ECMO stay. Secondary outcomes included length of stay and hospital charges/costs, occurrence of thromboembolic or bleeding complications during ECMO hospitalization, and mortality and readmissions up to 330 days following ECMO stay. Univariate and multivariate regression models were used to model the associations between pregnancy status and outcomes. RESULTS The sample included 324 pregnancy-associated hospitalizations and 3,805 nonpregnancy-associated hospitalizations, corresponding to national estimates of 665 and 7,653 over the study period, respectively. Pregnancy-associated ECMO had lower incidence of in-hospital death (adjusted odds ratio [aOR]: 0.56, 95% confidence interval [CI]: 0.41-0.75) and bleeding complications (aOR: 0.67, 95% CI: 0.49-0.93). Length of stay was significantly shorter (adjusted rate ratio (aRR): 0.86, 95% CI: 0.77-0.96) and total hospital costs were less (aRR: 0.83, 95% CI: 0.75-0.93). Differences in the incidence of thromboembolic events (aOR: 1.04, 95% CI: 0.78-1.38) were not statistically significant. CONCLUSION Pregnancy-associated ECMO therapy had lower incidence of in-hospital death, bleeding complications, total inpatient cost, and length of stay when compared with nonpregnancy-associated ECMO therapy without increased thromboembolic complications. Pregnancy-associated ECMO therapy should be offered to eligible patients. KEY POINTS · Pregnancy-related ECMO use was compared with nonpregnant use.. · Outcomes were equal or favored pregnancy-related deployment.. · These data may be useful when considering ECMO use in pregnancy..
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Affiliation(s)
- Megan S. Varvoutis
- Department of Obstetrics and Gynecology, West Virginia University, Morgantown, WV, USA
| | - Lauren E. Wein
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Ronan Sugrue
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Kristin C. Darwin
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Arthur J. Vaught
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Brenna L. Hughes
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
| | - Chad A. Grotegut
- Department of Obstetrics and Gynecology, Wake Forest University, Winston-Salem, NC, USA
| | - Jerome J. Federspiel
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, NC, USA
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Pálfi A, Zöllei É, Varga Z, Tomozi LB, Schulcz D, Bari G, Peták F, Kun-Szabó F, Baráth K, Rudas L, Balogh ÁL, Babik B. Venovenous Extracorporeal Membrane Oxygenation for COVID-19 in Postpartum Patients: 1-Year Outcome. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00281-7. [PMID: 38866659 DOI: 10.1053/j.jvca.2024.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/03/2024] [Accepted: 04/18/2024] [Indexed: 06/14/2024]
Affiliation(s)
- Alexandra Pálfi
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Éva Zöllei
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Zoltán Varga
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - László B Tomozi
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Domonkos Schulcz
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Gábor Bari
- Department of Cardiac Surgery, University of Szeged, Szeged, Hungary
| | - Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary.
| | - Fruzsina Kun-Szabó
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Kristóf Baráth
- Department of Pulmonology, University of Szeged, Szeged, Hungary
| | - László Rudas
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Ádám L Balogh
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Barna Babik
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
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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.
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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
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Kakar V, Ahmed I, Ahmed W, Raposo N, Kumar G P. Peripartum veno-venous extracorporeal membrane oxygenation in patients with severe CoViD-19-related-ARDS. Perfusion 2024; 39:426-432. [PMID: 36484202 PMCID: PMC9742351 DOI: 10.1177/02676591221144729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We describe a case series of five pregnant or postpartum women with severe CoViD-19-related ARDS requiring VV ECMO at our centre between Jan 1 and Sep 30, 2021. All patients were cannulated at the referring hospitals by our team before transferring to our centre. None of the women were vaccinated against CoViD-19. All had severe ARDS with Murray's Lung Injury Score of 3-4 and met the severity threshold for ECMO initiation that was used in the EOLIA study. All patients were discharged alive to home, acute rehabilitation, or lung transplant centre. One patient suffered intrauterine death before ECMO initiation and another while on ECMO. VV ECMO for refractory CoViD-19 related ARDS in the peripartum period is safe, and in this small series, it was associated with good maternal survival rates.
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Affiliation(s)
- Vivek Kakar
- Cardiac Critical Care and ECMO, Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Ihab Ahmed
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Walid Ahmed
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Nuno Raposo
- Vascular, and Thoracic Institute, Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Praveen Kumar G
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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Shamshirsaz AA, Byrne JJ, Ramsey PS, Cahill AG, Turrentine MA. Extracorporeal Membrane Oxygenation in Pregnant and Postpartum Women With Critical Coronavirus Disease 2019 (COVID-19) Acute Respiratory Distress Syndrome: A Systematic Review and Meta-analysis. Obstet Gynecol 2024; 143:219-228. [PMID: 37944145 DOI: 10.1097/aog.0000000000005452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 09/21/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE To estimate the maternal survival and live-birth rates in pregnant women with acute respiratory distress syndrome (ARDS) secondary to critical coronavirus disease 2019 (COVID-19) who are treated with extracorporeal membrane oxygenation (ECMO) by performing a systematic review and meta-analysis. DATA SOURCES From database inception through August 2023, we explored MEDLINE, Web of Science, EMBASE, CINAHL, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials. Studies reporting maternal survival and live-birth rates in pregnant women with critical COVID-19 undergoing ECMO were included. METHODS OF STUDY SELECTION Two reviewers separately ascertained studies, obtained data, and evaluated study quality. Summary estimates of maternal survival and live-birth rates were measured, and 95% CIs were calculated. TABULATION, INTEGRATION, AND RESULTS Nine retrospective case series and 12 retrospective cohort studies were identified with 386 pregnant women with critical COVID-19 who underwent ECMO. Studies evaluated women that were treated from January 2020 to October 2022. Four studies were from the United States; three were from Turkey; two were from France; two were from Israel; and one each was from Columbia, Germany, Italy, Kuwait, Poland, Republic of Srpska, the United Arab Emirates, the United Kingdom, a consortium from Belgium, France, Switzerland, and an international registry. The pooled estimate of the maternal survival rate among pregnant patients who were initiated on ECMO was 75.6% (95% CI, 66.0-84.1%, I2 =72%). The pooled estimate of the live-birth rate among pregnant patients who were initiated on ECMO was 83.7% (95% CI, 76.8-89.6%, 153 neonates, I2 =11%). When the case series and cohort studies were examined separately, the results were similar. CONCLUSION Among pregnant women with acute respiratory distress syndrome attributable to critical COVID-19 who were managed with ECMO, maternal survival and live-birth rates were high. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42023442800.
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Affiliation(s)
- Amir A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, and the Department of Women's Health, University of Texas at Austin, Dell Medical School, Austin, Texas
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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.
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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
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Sundin CS, Gomez L, Chapman B. Extracorporeal Cardiopulmonary Resuscitation for Amniotic Fluid Embolism: Review and Case Report. MCN Am J Matern Child Nurs 2024; 49:29-37. [PMID: 38047601 DOI: 10.1097/nmc.0000000000000970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
ABSTRACT Amniotic fluid embolism (AFE) is a rare, sudden, and catastrophic complication of pregnancy that can result in cardiopulmonary arrest, potentially leading to death. The pathophysiology of an AFE includes an inflammatory and coagulopathic response due to fetal materials entering maternal circulation with the hallmark triad of symptoms: acute respiratory distress, cardiovascular collapse, and coagulopathy. Management of AFE should include high-quality cardiopulmonary resuscitation, immediate delivery of the fetus if applicable, early intubation to provide adequate oxygenation and ventilation, fluid volume resuscitation, and ongoing evaluation of coagulopathy. Priorities include thromoboelastography interpretation if available, control of hemorrhage and coagulopathy with blood component therapy, and cardiovascular support through inotropes and vasopressor administration. More recent approaches include implementing the A-OK (atropine, ondansetron, and ketorolac) protocol for suspected AFE protocol, extracorporeal cardiopulmonary resuscitation (ECPR), and extracorporeal membrane oxygenation (ECMO) therapies to increase survival and decrease complications. Venoarterial ECMO is the highest form of life support that provides support in patients with pulmonary and cardiac failure. ECPR is the application of Venoarterial ECMO during cardiopulmonary resuscitation in cases where the cause of arrest is believed to be reversible. Early implementation of ECPR during the acute phase of AFE can provide support for end-organ perfusion in place of the weakened and recovering heart while optimizing oxygenation, making venoarterial ECMO an ideal adjunctive therapy. Because of the rarity of AFE, many obstetrical teams may have limited prior experience in managing these catastrophic cases; however, with ongoing education and simulation, teams can be better prepared in the recognition and management of these life-threatening events.
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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.
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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
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Donahoe LL, Snelgrove JW, de Perrot M, Sermer M, Silversides C, Granton J, Keshavjee S. Pregnancy and pulmonary hypertension in the pre-lung transplant patient: Successfully saving two lives with extracorporeal lung support. JTCVS Tech 2023; 20:186-191. [PMID: 37555024 PMCID: PMC10405314 DOI: 10.1016/j.xjtc.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/01/2023] [Accepted: 05/17/2023] [Indexed: 08/10/2023] Open
Affiliation(s)
- Laura L. Donahoe
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - John W. Snelgrove
- Department of Obstetrics and Gynecology, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Marc de Perrot
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mathew Sermer
- Department of Obstetrics and Gynecology, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Candice Silversides
- Department of Obstetrics and Gynecology, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
| | - John Granton
- Division of Respirology and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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12
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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.
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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
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13
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Dunlop M, Shainker SA, Hayes M. Physiology of the Critically Ill Pregnant Patient with COVID-19. ATS Sch 2023; 4:241-242. [PMID: 37538082 PMCID: PMC10394655 DOI: 10.34197/ats-scholar.2022-0098ot] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 01/19/2023] [Indexed: 08/05/2023] Open
Affiliation(s)
| | | | - Margaret Hayes
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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14
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Byrne JJ, Shamshirsaz AA, Cahill AG, Turrentine MA, Seasely AR, Eid J, Rouse CE, Richley M, Raghuraman N, Naqvi M, El-Sayed YY, Badell ML, Cheng C, Liu J, Adhikari EH, Patel SS, O’Neil ER, Ramsey PS. Outcomes Following Extracorporeal Membrane Oxygenation for Severe COVID-19 in Pregnancy or Post Partum. JAMA Netw Open 2023; 6:e2314678. [PMID: 37213099 PMCID: PMC10203887 DOI: 10.1001/jamanetworkopen.2023.14678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/05/2023] [Indexed: 05/23/2023] Open
Abstract
Importance Existing reports of pregnant patients with COVID-19 disease who require extracorporeal membrane oxygenation (ECMO) are limited, with variable outcomes noted for the maternal-fetal dyad. Objective To examine maternal and perinatal outcomes associated with ECMO used for COVID-19 with respiratory failure during pregnancy. Design, Setting, and Participants This retrospective multicenter cohort study examined pregnant and postpartum patients who required ECMO for COVID-19 respiratory failure at 25 hospitals across the US. Eligible patients included individuals who received care at one of the study sites, were diagnosed with SARS-CoV-2 infection during pregnancy or up to 6 weeks post partum by positive nucleic acid or antigen test, and for whom ECMO was initiated for respiratory failure from March 1, 2020, to October 1, 2022. Exposures ECMO in the setting of COVID-19 respiratory failure. Main outcome and measures The primary outcome was maternal mortality. Secondary outcomes included serious maternal morbidity, obstetrical outcomes, and neonatal outcomes. Outcomes were compared by timing of infection during pregnancy or post partum, timing of ECMO initiation during pregnancy or post partum, and periods of circulation of SARS-CoV-2 variants. Results From March 1, 2020, to October 1, 2022, 100 pregnant or postpartum individuals were started on ECMO (29 [29.0%] Hispanic, 25 [25.0%] non-Hispanic Black, 34 [34.0%] non-Hispanic White; mean [SD] age: 31.1 [5.5] years), including 47 (47.0%) during pregnancy, 21 (21.0%) within 24 hours post partum, and 32 (32.0%) between 24 hours and 6 weeks post partum; 79 (79.0%) had obesity, 61 (61.0%) had public or no insurance, and 67 (67.0%) did not have an immunocompromising condition. The median (IQR) ECMO run was 20 (9-49) days. There were 16 maternal deaths (16.0%; 95% CI, 8.2%-23.8%) in the study cohort, and 76 patients (76.0%; 95% CI, 58.9%-93.1%) had 1 or more serious maternal morbidity events. The largest serious maternal morbidity was venous thromboembolism and occurred in 39 patients (39.0%), which was similar across ECMO timing (40.4% pregnant [19 of 47] vs 38.1% [8 of 21] immediately postpartum vs 37.5% postpartum [12 of 32]; P > .99). Conclusions and Relevance In this multicenter US cohort study of pregnant and postpartum patients who required ECMO for COVID-19-associated respiratory failure, most survived but experienced a high frequency of serious maternal morbidity.
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Affiliation(s)
- John J. Byrne
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Health Science Center in San Antonio, San Antonio
| | - Amir A. Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Alison G. Cahill
- Department of Obstetrics and Gynecology, University of Texas at Austin, Dell Medical School, Austin
| | - Mark A. Turrentine
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Angela R. Seasely
- Center for Women’s Reproductive Health, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham
| | - Joe Eid
- Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus
| | - Caroline E. Rouse
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Indiana University School of Medicine, Indianapolis
| | - Michael Richley
- Department of Obstetrics and Gynecology, University of California, Los Angeles
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Mariam Naqvi
- Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, California
| | - Yasser Y. El-Sayed
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Obstetrics, Stanford University, Palo Alto, California
| | - Martina L. Badell
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - CeCe Cheng
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Health Science Center in San Antonio, San Antonio
- Department of Obstetrics and Gynecology, Methodist Hospital, San Antonio, Texas
| | - James Liu
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Emily H. Adhikari
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Soha S. Patel
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Erika R. O’Neil
- Department of Pediatrics, Brooke Army Medical Center, San Antonio, Texas
| | - Patrick S. Ramsey
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Health Science Center in San Antonio, San Antonio
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15
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Trela KC, Chaney MA. Are "Guidelines" for Acute Mechanical Circulatory Support Possible? J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00254-9. [PMID: 37321872 DOI: 10.1053/j.jvca.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 04/14/2023] [Indexed: 06/17/2023]
Affiliation(s)
| | - Mark A Chaney
- Department of Anesthesiology and Critical Care Medicine, University of Chicago, Chicago, Illinois
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16
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Richley M, Rao R. Extracorporeal membrane oxygenation in pregnancy during the SARS-CoV-2 pandemic. Semin Fetal Neonatal Med 2023; 28:101435. [PMID: 37062669 PMCID: PMC10073081 DOI: 10.1016/j.siny.2023.101435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Affiliation(s)
- Michael Richley
- University of California, Los Angeles, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, USA
| | - Rashmi Rao
- University of California, Los Angeles, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, USA.
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17
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Meng ML, Arendt KW, Banayan JM, Bradley EA, Vaught AJ, Hameed AB, Harris J, Bryner B, Mehta LS. Anesthetic Care of the Pregnant Patient With Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e657-e673. [PMID: 36780370 DOI: 10.1161/cir.0000000000001121] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
The pregnancy-related mortality rate in the United States is excessively high. The American Heart Association is dedicated to fighting heart disease and recognizes that cardiovascular disease, preexisting or acquired during pregnancy, is the leading cause of maternal mortality in the United States. Comprehensive scientific statements from cardiology and obstetrics experts guide the treatment of cardio-obstetric patients before, during, and after pregnancy. This scientific statement aims to highlight the role of specialized cardio-obstetric anesthesiology care, presenting a systematic approach to the care of these patients from the anesthesiology perspective. The anesthesiologist is a critical part of the pregnancy heart team as the perioperative physician who is trained to prevent or promptly recognize and treat patients with peripartum cardiovascular decompensation. Maternal morbidity is attenuated with expert anesthesiology peripartum care, which includes the management of neuraxial anesthesia, inotrope and vasopressor support, transthoracic echocardiography, optimization of delivery location, and consideration of advanced critical care and mechanical support when needed. Standardizing the anesthesiology approach to patients with high peripartum cardiovascular risk and ensuring that cardio-obstetrics patients have access to the appropriate care team, facilities, and advanced cardiovascular therapies will contribute to improving peripartum morbidity and mortality.
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18
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Cueto-Robledo G, Cervantes-Naranjo FD, Gonzalez-Hermosillo LM, Roldan-Valadez E, Graniel-Palafox LE, Castro-Escalante KY, Orozco-Zuñiga B. Pulmonary embolism during pregnancy: an updated review with case series description. Curr Probl Cardiol 2023; 48:101683. [PMID: 36898596 DOI: 10.1016/j.cpcardiol.2023.101683] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/02/2023] [Indexed: 03/12/2023]
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition that can occur during pregnancy and pose a significant risk to the mother and the developing fetus. It is a major contributor to pregnancy-related morbidity and mortality in any trimester. It is estimated that the incidence of PE during pregnancy is approximately 1 in 1000 pregnancies. The mortality rate for pregnant women with PE is about 3%, significantly higher than that for non-pregnant women with PE. Overall, the topic of PE and pregnancy is essential for healthcare professionals to be aware of the risks, signs, and treatment options to improve outcomes and ensure the best possible care for both the mother and the developing fetus. To prevent the fatal condition, the physician is encouraged when there is a suspicion of the pathology. This report presents an updated comprehensive review of PE during pregnancy, discussing critical aspects of the clinical and imaging diagnosis, use of heparin, thrombolysis, and prevention. We believe this article will be helpful for cardiologists, obstetricians, and other health-related professionals.
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Affiliation(s)
- Guillermo Cueto-Robledo
- Cardiorespiratory Emergencies, Hospital General de México "Dr Eduardo Liceaga", 06720, Mexico City, Mexico; Pulmonary Circulation Clinic, Hospital General de México "Dr. Eduardo Liceaga", 06720, Mexico City, Mexico; Faculty of Medicine, National Autonomous University of Mexico, 04510, Mexico City, Mexico.
| | | | | | - Ernesto Roldan-Valadez
- Directorate of Research, Hospital General de Mexico "Dr. Eduardo Liceaga," 06720, Mexico City, Mexico; I.M. Sechenov First Moscow State Medical University (Sechenov University), Department of Radiology, 119992, Moscow, Russia.
| | | | | | - Benjamin Orozco-Zuñiga
- Ginecology Department, Hospital General de México ¨Dr. Eduardo Liceaga¨, Mexico City, Mexico.
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19
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van Bockxmeer JJ, Haining CM, Atkinson A. Advance care planning for pregnant patients. Med J Aust 2023; 218:161-164. [PMID: 36549666 DOI: 10.5694/mja2.51820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 09/18/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Affiliation(s)
| | - Casey M Haining
- Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD.,Centre for Health Equity, University of Melbourne, Melbourne, VIC
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20
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Extracorporeal Membrane Oxygenation During Pregnancy. Clin Obstet Gynecol 2023; 66:151-162. [PMID: 36044634 DOI: 10.1097/grf.0000000000000735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In the last 2 decades, the use of venovenous (VV) and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) during pregnancy and the postpartum period has increased, mirroring the increased utilization in nonpregnant individuals worldwide. VV ECMO provides respiratory support for patients with acute respiratory distress syndrome (ARDS) who fail conventional mechanical ventilation. With the COVID-19 pandemic, the use of VV ECMO has increased dramatically and data during pregnancy and the postpartum period are overall reassuring. In contrast, VA ECMO provides both respiratory and cardiovascular support. Data on the use of VA ECMO during pregnancy are extremely limited.
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21
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Quintero A, Vinck EE, Pérez LE, Escobar JJ, Rendón JC, Uribe JD. Extra-corporeal membrane oxygenation and emergency C-section for a pregnant COVID-19 positive patient. Perfusion 2023; 38:405-409. [PMID: 34617859 DOI: 10.1177/02676591211049769] [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: 11/17/2022]
Abstract
INTRODUCTION Data on extra-corporeal membrane oxygenation (ECMO) therapy for pregnant patients with Coronavirus 2019 (COVID-19) infection are limited. Here we report a case of an emergency cesarean section performed while the COVID-19 positive mother was on ECMO support. CASE REPORT A 36-year-old COVID-19 positive patient at 26 weeks gestational age presented with respiratory failure requiring extra-corporeal membrane oxygenation therapy. Nine days later fetal distress demanded an emergency C-section. After 5 weeks on ECMO, the patient was weaned off. Both mother and child were discharged. DISCUSSION The decision to perform an urgent C-section is one that requires meticulous thought from the attending team. Pulmonary maturation is key as pregnancy may need to be terminated at any time during ECMO. CONCLUSION Data on ECMO support for pregnant patients with COVID-19 infection are scarce. Best results can be achieved ensuring adequate anticoagulation, meticulous choice of cannulas, continued fetal monitoring, early lung maturation, and precision timing of delivery.
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Affiliation(s)
- Alejandro Quintero
- Department of Cardiovascular Surgery & Mobile ECMO, Pontifical Bolivarian University, Cardio VID Clinic, Medellín, Antioquia, Colombia
| | - Eric E Vinck
- Department of Cardiovascular Surgery & Mobile ECMO, Pontifical Bolivarian University, Cardio VID Clinic, Medellín, Antioquia, Colombia
| | - Luz E Pérez
- Department of Clinical Research, Cardio VID Clinic, Medellín, Antioquia, Colombia
| | - José J Escobar
- Department of Cardiovascular Surgery & Mobile ECMO, Pontifical Bolivarian University, Cardio VID Clinic, Medellín, Antioquia, Colombia
| | - Juan C Rendón
- Department of Cardiovascular Surgery & Mobile ECMO, Pontifical Bolivarian University, Cardio VID Clinic, Medellín, Antioquia, Colombia
| | - Juan D Uribe
- Department of Cardiovascular Critical Care & Mobile ECMO, Cardio VID Clinic, Medellín, Antioquia, Colombia
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22
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Gur M, Pollak M, Bar-Yoseph R, Bentur L. Pregnancy in Cystic Fibrosis-Past, Present, and Future. J Clin Med 2023; 12:jcm12041468. [PMID: 36836003 PMCID: PMC9963833 DOI: 10.3390/jcm12041468] [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: 12/20/2022] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
The introduction of mutation-specific therapy led to a revolution in cystic fibrosis (CF) care. These advances in CF therapies have changed the disease profile from a severe incurable disease with limited survival to a treatable disease with improved quality of life and survival into adulthood. CF patients are now able to plan their future, including marriage and parenthood. Side by side with the optimism, new issues and concerns are arising, including fertility and preparation for pregnancy, maternal and fetal care during pregnancy, and post-partum care. While cystic fibrosis transmembrane regulator (CFTR) modulators show promising results for improving CF lung disease, data on their safety in pregnancy are still limited. We performed a literature review on pregnancy in CF from the past, with the first described pregnancy in 1960, through the current fascinating changes in the era of CFTR modulators, to ongoing studies and future directions. Current advances in knowledge give hope for improved outcomes of pregnancy, towards the best possible prognosis for the mother and for the baby.
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Affiliation(s)
- Michal Gur
- Pediatric Pulmonary Institute and CF Center, Rappaport Children’s Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
- Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa 3525422, Israel
- Correspondence: ; Tel.: +972-4-7774360; Fax: +972-4-7774395
| | - Mordechai Pollak
- Pediatric Pulmonary Institute and CF Center, Rappaport Children’s Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
- Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa 3525422, Israel
| | - Ronen Bar-Yoseph
- Pediatric Pulmonary Institute and CF Center, Rappaport Children’s Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
- Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa 3525422, Israel
| | - Lea Bentur
- Pediatric Pulmonary Institute and CF Center, Rappaport Children’s Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
- Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa 3525422, Israel
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23
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Tapaskar N, Tremblay-Gravel M, Khush KK. Contemporary Management of Cardiogenic Shock During Pregnancy. J Card Fail 2023; 29:193-209. [PMID: 36243342 DOI: 10.1016/j.cardfail.2022.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 09/13/2022] [Accepted: 09/20/2022] [Indexed: 11/07/2022]
Abstract
Cardiogenic shock is the most extreme cardiovascular disease state during pregnancy. Peripartum cardiomyopathy is the most common cause of cardiogenic shock toward the end of pregnancy and in the early postpartum period. Therapy for cardiogenic shock relies on appropriate phenotyping of shock etiology, severity and ventricular predominance, which are critical in the appropriate selection of medical and mechanical therapy. Mechanical circulatory support may be used as a bridge to recovery or as definitive therapy. Intra-aortic balloon pumps, percutaneous left ventricular assist devices and venoarterial extracorporeal circulatory devices have been successfully used in pregnancy and the postpartum period. The most commonly used mechanical therapy in the pregnant patient is extracorporeal membranous oxygenation circulatory support. The use of mechanical circulatory devices in peripartum cardiomyopathy has contributed to improved survival rates in recent years. Further efforts to identify the optimal mechanical circulatory support strategy for peripartum cardiomyopathy and cardiogenic shock in the peripartum period are needed.
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Affiliation(s)
- Natalie Tapaskar
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA.
| | | | - Kiran K Khush
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
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24
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Challenges and pitfalls of extracorporeal membrane oxygenation in critically-ill pregnant and peripartum women with COVID-19: a retrospective case series. Int J Obstet Anesth 2023; 53:103625. [PMID: 36682135 PMCID: PMC9811850 DOI: 10.1016/j.ijoa.2023.103625] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 12/23/2022] [Accepted: 12/30/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Available data identify pregnancy as a strong determinant of a severe course of COVID-19 with increased mortality. Extracorporeal membrane oxygenation (ECMO) remains the last resort treatment in the critical course of COVID-19 yet may increase the risk of excessive bleeding, especially in the immediate post-cesarean section period. One in five patients receiving ECMO during the COVID-19 pandemic were women who were pregnant or postpartum. While the risk of critical respiratory failure in the peripartum period is high, in an early survey only 52% of pregnant patients intended to receive the COVID-19 vaccine. METHODS Our study aimed to evaluate clinical characteristics and treatment modalities in a series of five pregnant and peripartum women supported with ECMO and anticoagulated with anti-Xa-guided nadroparin therapy in our center. We reviewed the full treatment courses; inflammatory, hemodynamic, and coagulation variables; and maternal and neonatal outcomes. We identified adverse events during the therapy. RESULTS All five patients developed acute respiratory distress syndrome due to COVID-19 in the third trimester of pregnancy. Termination of pregnancy occurred between 28 and 36 gestational weeks. While four of five newborns survived to hospital discharge, only two of the five mothers survived to leave hospital. CONCLUSIONS ECMO is feasible in the third trimester but not devoid of complications. The severity of respiratory failure during COVID-19 and extracorporeal support may not adversely impact neonatal outcomes.
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25
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Asano F, Tanigaki S, Sato Y, Kobayashi C, Kobayashi Y. Successful Outcome of Mother and Baby in a Woman With Severe COVID-19 Pneumonia in the Third Trimester of Pregnancy Who Required Extracorporeal Membrane Oxygenation Therapy. Cureus 2023; 15:e34627. [PMID: 36891020 PMCID: PMC9987341 DOI: 10.7759/cureus.34627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2023] [Indexed: 02/09/2023] Open
Abstract
Some studies have reported increased severe coronavirus disease (COVID-19) infection in the third trimester of pregnancy. Therefore, prenatal care in the third trimester requires careful judgment. It has been reported that extracorporeal membrane oxygenation (ECMO) therapy is useful for severe coronavirus disease 2019 (COVID-19) pneumonia; however, the optimal timing for the initiation of ECMO is controversial because the risks and benefits to the mother and fetus require careful consideration. We report a good outcome for mother and baby in a pregnant woman with severe COVID-19 pneumonia at 29 weeks gestation, who underwent urgent delivery and required ECMO therapy. A 34-year-old woman tested positive for COVID-19 at 27 weeks gestation. Despite treatment with remdesivir and prednisolone, her respiratory condition worsened. Consequently, she underwent emergent endotracheal intubation at 28 weeks and 2 days. Although the PaO2/FiO2 (P/F ratio) improved temporarily after endotracheal intubation, her respiratory condition progressively worsened. At 29 weeks gestation, an emergency cesarean section was performed and ECMO was initiated the next day. Although hematoma was observed after ECMO initiation, her respiratory condition improved. She was discharged home 54 days after the cesarean delivery without any complications. The neonate was intubated and transferred to the neonatal intensive care unit and was ultimately discharged home without any complications. Considering the risks and benefits of ECMO for the mother and fetus in the third trimester, ECMO should be initiated after delivery for better outcomes. The P/F ratio may be useful for an appropriate decision regarding delivery and the initiation of ECMO.
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Affiliation(s)
- Fumio Asano
- Department of Obstetrics and Gynecology, Kyorin University School of Medicine, Tokyo, JPN
| | - Shinji Tanigaki
- Department of Obstetrics and Gynecology, Kyorin University School of Medicine, Tokyo, JPN
| | - Yasunori Sato
- Department of Obstetrics and Gynecology, Kyorin University School of Medicine, Tokyo, JPN
| | - Chie Kobayashi
- Department of Obstetrics and Gynecology, Kyorin University School of Medicine, Tokyo, JPN
| | - Yoichi Kobayashi
- Department of Obstetrics and Gynecology, Kyorin University School of Medicine, Tokyo, JPN
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26
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Furzan A, Krajewski ML, Dalia AA, Ortoleva J. What is New in ECMO for COVID-19? J Cardiothorac Vasc Anesth 2023; 37:331-334. [PMID: 36404228 PMCID: PMC9632238 DOI: 10.1053/j.jvca.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/21/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Alberto Furzan
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
| | - Megan L Krajewski
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jamel Ortoleva
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, MA
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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.
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Trela KC. Invited Commentary on the Postpartum Preeclampsia ECMO Case Conference. J Cardiothorac Vasc Anesth 2023; 37:1036-1038. [PMID: 36707378 DOI: 10.1053/j.jvca.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023]
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Kariyawasam S, Brown J. Pulmonary arterial hypertension in pregnancy. BJA Educ 2023; 23:24-31. [PMID: 36601027 PMCID: PMC9805939 DOI: 10.1016/j.bjae.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
| | - J. Brown
- Westmead Hospital, Sydney, NSW, Australia
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Full-Term Delivery and Complete Lung Recovery following VV ECMO Support Midpregnancy in a Patient with COVID-19 ARDS. Case Rep Crit Care 2023; 2023:3472718. [PMID: 36923498 PMCID: PMC10010870 DOI: 10.1155/2023/3472718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 09/16/2022] [Accepted: 01/09/2023] [Indexed: 03/08/2023] Open
Abstract
Pregnant women are especially vulnerable to coronavirus disease 2019 (COVID-19). We present a twin pregnancy case with acute respiratory distress syndrome following COVID-19 infection at 19 weeks. The patient's ARDS was successfully managed with veno-venous extracorporeal membrane oxygenation (VV ECMO). She recovered completely and delivered healthy twins.
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Li Y, Xu C, Li F, Yan Z, Ye S, Ma J, Wen J. Five critically ill pregnant women/parturients treated with extracorporeal membrane oxygenation. J Cardiothorac Surg 2022; 17:321. [PMID: 36528774 PMCID: PMC9759865 DOI: 10.1186/s13019-022-02093-1] [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: 07/21/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Maternal mortality has always been a major medical concern. Recently, the successful application of extracorporeal membrane oxygenation (ECMO) technology in the rescue of near-death patients has been reported. CASE PRESENTATION This study retrospectively analyzed 5 cases of critically ill pregnant women/parturients treated with ECMO for respiratory and circulatory failure in the Wuxi People's Hospital from 2018 to 2020. The mean age of the 5 cases was 30.2 years. Among them, Cases 1 and 5 were treated with Venoarterial (VA) ECMO. Case 1 was diagnosed with congenital heart disease, atrial septal defect, and severe pulmonary hypertension. VA ECMO was applied before cesarean section and was successfully removed after double lung transplantation, but the patient died 10 months after delivery from lung infection. While Case 5 was diagnosed with systemic lupus erythematosus, lupus nephritis, thrombotic vascular disease, HELLP syndrome, and cerebral hemorrhage. VA ECMO was applied 39 days after cesarean section, and the patient died 40 days after delivery due to multiple organ failure. Cases 3 and 4 were treated with Venovenous (VV) ECMO. Case 3 was diagnosed with refractory postpartum hemorrhage, and Case 4 was diagnosed with postpartum hypoglycemic coma, aspiration pneumonia, and shock. They were treated with VV ECMO after delivery, and all survived after successful evacuation. Another Case (Case 2) was diagnosed with postpartum pelvic infection, sepsis and septic shock, and was treated with VA ECMO at 15 days after delivery. The patient changed to VV ECMO at 30 days after delivery due to significant improvement in heart function and poor lung function, but eventually died of multiple organ failure. For the 5 cases, the mean duration of ECMO was 8.7 days, the mean duration of intensive care was 22.0 days, and the mean length of hospital stay was 57.6 days. As a result, 3 patients gradually returned to normal with significant improvement in ventilation and oxygenation after ECMO treatment. CONCLUSIONS ECMO technology can be used to treat some of the critical obstetric patients with respiratory and circulatory failure that is ineffective to conventional treatment, but it has no therapeutic effect on the primary disease.
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Affiliation(s)
- Ying Li
- grid.89957.3a0000 0000 9255 8984Department of Obstetrics and Gynecology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Chi Xu
- grid.89957.3a0000 0000 9255 8984Emergency Department, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Furong Li
- grid.89957.3a0000 0000 9255 8984Department of Obstetrics and Gynecology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Zheng Yan
- grid.89957.3a0000 0000 9255 8984Department of Critical Care Medicine, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Shugao Ye
- grid.89957.3a0000 0000 9255 8984Department of Thoracic Surgery, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Jinqi Ma
- grid.89957.3a0000 0000 9255 8984Department of Obstetrics and Gynecology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Juan Wen
- grid.459791.70000 0004 1757 7869Nanjing Maternity and Child Health Care Institute, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
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Knapp C, Bhatia K. Maternal collapse in pregnancy. Br J Hosp Med (Lond) 2022; 83:1-12. [PMID: 36594762 DOI: 10.12968/hmed.2022.0259] [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: 12/13/2022]
Abstract
Maternal collapse is a rare life-threatening event that can occur at any stage of pregnancy or up to 6 weeks postpartum. Prompt identification and timely intervention by a multidisciplinary team that includes an obstetrician, midwifery staff and an obstetric anaesthetist are essential to improve maternal and fetal outcomes. Standard adult resuscitation guidelines need to be followed with some modifications, taking into account the maternal-fetal physiology, which clinicians should be familiar with. During cardiac arrest, the emphasis is on advanced airway management, manual uterine displacement to relieve aortocaval compression and performing a resuscitative hysterotomy (peri-mortem caesarean delivery) swiftly in patients who are more than 20 weeks gestation to improve maternal survival. Annual multidisciplinary simulation training is recommended for all professionals involved in maternity care; this can improve teamwork, communication and emergency preparedness during maternal collapse.
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Affiliation(s)
- C Knapp
- North West School of Anaesthesia, Health Education England North West, Manchester, UK
| | - K Bhatia
- Department of Anaesthesia, St Mary's Hospital, Manchester University NHS Foundation Trust, University of Manchester, Manchester, UK
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Veronese G, Nonini S, Cannata A, Aresta F, Olivieri G, Montrasio E, De Caria D, Perna E, Calini A, Bottiroli M, Cislaghi F, Pedrazzini G, Baltaro F, Quattrocchi G, Pedrotti P, Russo CF, Garascia A, Mondino M, Ammirati E. Fulminant Lymphocytic Myocarditis During Pregnancy Treated With Temporary Mechanical Circulatory Supports and Aggressive Immunosuppression. Circ Heart Fail 2022; 15:e009810. [PMID: 36305298 DOI: 10.1161/circheartfailure.122.009810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Giacomo Veronese
- Department of Health Sciences, University of Milano-Bicocca, Milan, Italy (G.V.)
| | - Sandra Nonini
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Aldo Cannata
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Francesca Aresta
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Guido Olivieri
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Elisa Montrasio
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Daniele De Caria
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Enrico Perna
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Angelo Calini
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Maurizio Bottiroli
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Francesca Cislaghi
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Giovanna Pedrazzini
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Federica Baltaro
- Department of Obstetrics and Gynecology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (F.B.)
| | - Giuseppina Quattrocchi
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Patrizia Pedrotti
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Claudio F Russo
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Andrea Garascia
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Michele Mondino
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
| | - Enrico Ammirati
- "De Gasperis" Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (S.N., A. Cannata, F.A., G.O., E.M., D.D.C., E.P., A. Calini, M.B., F.C., G.P., G.Q., P.P., C.F.R., A.G., M.M., E.A.)
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van den Bosch OFC, Chaudhry R, Wicker J, Mubashir T, Limb D, Jogendran R, Munshi L, Balki M. Predictors and Hospital Outcomes in Pregnant Patients Undergoing Extracorporeal Membrane Oxygenation: A Nationwide Study. Anesth Analg 2022; 135:1172-1179. [PMID: 36384013 DOI: 10.1213/ane.0000000000006210] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is increasingly used in patients with severe cardiorespiratory collapse. Although prior large database reviews of ECMO use in the peripartum population exist, they do not stratify by ECMO indication nor do they include obstetric conditions such as preeclampsia. Our objective was to characterize the incidence, indication-associated mortality, and factors associated with mortality in pregnant patients who underwent ECMO. METHODS We examined the United States National Inpatient Sample database to identify hospitalizations for pregnancy from January 1, 2010 to December 31, 2016. We identified pregnant patients who underwent ECMO using International Classification of Diseases ninth and tenth revisions codes. The primary outcome was in-hospital all-cause mortality across pregnant patients who underwent ECMO for any indication. We evaluated the indication for ECMO, incidence, prevalence of risk factors, comorbidities and conditions, and their association with in-hospital mortality. RESULTS Fifty-nine of 5'346,517 pregnant patients underwent ECMO during our study period (incidence, 1.1; 95% confidence interval [CI], 0.84-1.4 per 100,000 hospitalizations). Indications for ECMO support included respiratory failure (79.7%), cardiogenic shock (64.4%), or circulatory arrest (25.4%). Most patients (57.6%) had more than 1 indication. The overall in-hospital mortality rate was 30.5%. Mortality was 29.8% in patients with respiratory failure, 39.5% with cardiogenic shock, 46.7% with cardiac arrest, and 42.4% in those with combined diagnoses. Cardiogenic shock was associated with a significantly higher mortality rate and adjusted odds ratio 5.0 (95% CI, 1.25-27.0). Most patients (62.7%) had one or more comorbidities. CONCLUSIONS The frequency of ECMO use across the pregnant population was low over this time period, with a mortality rate of 1 in 3 patients. Mortality was greatest in patients with cardiogenic shock. Further work is needed to understand how best to improve ECMO outcomes in pregnant patients.
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Affiliation(s)
- Oscar F C van den Bosch
- From the Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rabail Chaudhry
- From the Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - James Wicker
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, United Kingdom
| | - Talha Mubashir
- Department of Anesthesia and Critical Care, McGovern Medical School, University of Texas, Houston, Texas
| | - Daniel Limb
- Department of Anesthesia and Critical Care, McGovern Medical School, University of Texas, Houston, Texas
| | | | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Mrinalini Balki
- From the Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Obstetrics & Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Physiology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
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35
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Kaplow R, Miller C. Use of Extracorporeal Membrane Oxygenation Therapy During Pregnancy and COVID-19: A Case Study. AACN Adv Crit Care 2022; 33:247-252. [PMID: 36067262 DOI: 10.4037/aacnacc2022111] [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: 11/01/2022]
Abstract
Extracorporeal membrane oxygenation is emerging as a vital resource for survival of patients with acute respiratory distress syndrome related to COVID-19. Although recent research provides much insight into the advantages of extracorporeal membrane oxygenation in this patient population, little has been published on its use in pregnancy. This case study describes the use of venovenous extracorporeal membrane oxygenation in a young pregnant woman with acute respiratory distress syndrome due to COVID-19. It illustrates the benefits of a multidisciplinary approach to this treatment modality, allowing time for a fetus to become viable while preserving the life of the mother. In this case, the mother was able to return home after receiving this therapy and resume normal activities of daily living independently.
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Affiliation(s)
- Roberta Kaplow
- Roberta Kaplow is Clinical Nurse Specialist in the Acute Respiratory ICU, Emory University Hospital, 1364 Clifton Rd NE, Atlanta, GA 30319
| | - Casey Miller
- Casey Miller is ECMO Coordinator, Emory University Hospital, Atlanta, Georgia
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36
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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.
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Coggins AS, Gomez E, Sheffield JS. Pulmonary Embolism and Amniotic Fluid Embolism. Obstet Gynecol Clin North Am 2022; 49:439-460. [PMID: 36122978 DOI: 10.1016/j.ogc.2022.02.015] [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: 10/14/2022]
Abstract
Venous thromboembolism (VTE) as well as other embolic events including amniotic fluid embolism (AFE) remain a leading cause of maternal death in the United States and worldwide. The pregnant patient is at a higher risk of developing VTE including pulmonary embolism. In contrast, AFE is a rare, but catastrophic event that remains incompletely understood. Here the authors review the cause of VTE in pregnancy and look at contemporary and evidence-based practices for the evaluation, diagnosis, and management in pregnancy. Then the cause and diagnostic difficulty of AFE as well as what is known regarding the pathogenesis are reviewed.
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Affiliation(s)
- Ashley S Coggins
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 228, Baltimore, MD 21287-4922, USA.
| | - Erin Gomez
- Diagnostic Imaging Division, Diagnostic Radiology Residency, JHU SOM Diagnostic Radiology Elective, Department of Radiology, Johns Hopkins Hospital, Baltimore, 600 N. Wolfe St. Nelson MRI Building #143 Baltimore, MD 21287, USA
| | - Jeanne S Sheffield
- Division of Maternal-Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 228, Baltimore, MD 21287-4922, USA
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O’Kelly AC, Ludmir J, Wood MJ. Acute Coronary Syndrome in Pregnancy and the Post-Partum Period. J Cardiovasc Dev Dis 2022; 9:jcdd9070198. [PMID: 35877560 PMCID: PMC9319853 DOI: 10.3390/jcdd9070198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/14/2022] [Accepted: 06/16/2022] [Indexed: 11/16/2022] Open
Abstract
Cardiovascular disease is the leading cause of maternal mortality in the United States. Acute coronary syndrome (ACS) is more common in pregnant women than in non-pregnant controls and contributes to the burden of maternal mortality. This review highlights numerous etiologies of chest discomfort during pregnancy, as well as risk factors and causes of ACS during pregnancy. It focuses on the evaluation and management of ACS during pregnancy and the post-partum period, including considerations when deciding between invasive and non-invasive ischemic evaluations. It also focuses specifically on the management of post-myocardial infarction complications, including shock, and outlines the role of mechanical circulatory support, including veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Finally, it offers additional recommendations for navigating delivery in women who experienced pregnancy-associated myocardial infarction and considerations for the post-partum patient who develops ACS.
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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.
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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
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DeFilippis EM, Beale A, Martin T, Agarwal A, Elkayam U, Lam CSP, Hsich E. Heart Failure Subtypes and Cardiomyopathies in Women. Circ Res 2022; 130:436-454. [PMID: 35175847 PMCID: PMC10361647 DOI: 10.1161/circresaha.121.319900] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure affects over 2.6 million women and 3.4 million men in the United States with known sex differences in epidemiology, management, response to treatment, and outcomes across a wide spectrum of cardiomyopathies that include peripartum cardiomyopathy, hypertrophic cardiomyopathy, stress cardiomyopathy, cardiac amyloidosis, and sarcoidosis. Some of these sex-specific considerations are driven by the cellular effects of sex hormones on the renin-angiotensin-aldosterone system, endothelial response to injury, vascular aging, and left ventricular remodeling. Other sex differences are perpetuated by implicit bias leading to undertreatment and underrepresentation in clinical trials. The goal of this narrative review is to comprehensively examine the existing literature over the last decade regarding sex differences in various heart failure syndromes from pathophysiological insights to clinical practice.
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Affiliation(s)
| | - Anna Beale
- Department of Cardiology, Alfred Hospital, Melbourne, Australia (A.B.)
| | - Trejeeve Martin
- Department of Cardiology, Cleveland Clinic, Ohio (T.M., E.H.)
| | - Anubha Agarwal
- Northwestern University Feinberg School of Medicine (A.A.)
| | - Uri Elkayam
- Division of Cardiovascular Medicine, Keck School of Medicine, University of Southern California (U.E.)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
| | - Eileen Hsich
- Department of Cardiology, Cleveland Clinic, Ohio (T.M., E.H.)
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41
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Wong MJ, Bharadwaj S, Galey JL, Lankford AS, Galvagno S, Kodali BS. Extracorporeal Membrane Oxygenation for Pregnant and Postpartum Patients. Anesth Analg 2022; 135:277-289. [PMID: 35122684 DOI: 10.1213/ane.0000000000005861] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has seen increasing use for critically ill pregnant and postpartum patients over the past decade. Growing experience continues to demonstrate the feasibility of ECMO in obstetric patients and attest to its favorable outcomes. However, the interaction of pregnancy physiology with ECMO life support requires careful planning and adaptation for success. Additionally, the maintenance of fetal oxygenation and perfusion is essential for safely continuing pregnancy during ECMO support. This review summarizes the considerations for use of ECMO in obstetric patients and how to address these concerns.
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Affiliation(s)
- Michael J Wong
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Shobana Bharadwaj
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jessica L Galey
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Allison S Lankford
- Department of Obstetrics and Gynecology, University of Maryland School of Medicine and Program in Trauma and Anesthesia Critical Care, Shock Trauma Center, Baltimore, Maryland
| | - Samuel Galvagno
- Department of Anesthesiology, Multi Trauma Critical Care Unit, Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bhavani Shankar Kodali
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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42
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Zalle I, Barthelemy Y, Piperata A, Galvaing G, Camilleri L, d'Ostrevy N. Low fetal age is not a contraindication for extracorporeal membranous oxygenation in COVID‐19‐related ARDS. J Card Surg 2022; 37:1059-1062. [DOI: 10.1111/jocs.16251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Issaka Zalle
- Cardiac surgery, CHU Gabriel Montpied Clermont‐Ferrand France
| | - Yann Barthelemy
- Cardiac surgery, CHU Gabriel Montpied Clermont‐Ferrand France
| | | | | | | | - Nicolas d'Ostrevy
- Cardiac surgery, CHU Gabriel Montpied Clermont‐Ferrand France
- Cardiac surgery, CHU Haut‐Lévêque Bordeaux France
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43
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44
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Radvansky BM, Shah R, Feinman J, Augoustides JG, Kiers A, Younger J, Sanders J, Knott VH, Fernando RJ. Pulmonary Hypertension in Pregnancy: A Positive Outcome with a Multidisciplinary Team and Individualized Treatment Plan. J Cardiothorac Vasc Anesth 2022; 36:3403-3413. [DOI: 10.1053/j.jvca.2021.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 11/11/2022]
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45
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Stout A, Crichton R, Tahmasebi F. Maternal death secondary to COVID-19 infection: A case report and review of the literature. Obstet Med 2021; 14:248-252. [PMID: 34880939 DOI: 10.1177/1753495x20970816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/01/2020] [Accepted: 10/09/2020] [Indexed: 11/15/2022] Open
Abstract
Maternal death secondary to coronavirus disease 19 (COVID-19) infection in a previously well woman is described. The woman presented with an eight-day history of productive cough and shortness of breath. Rapid deterioration of respiratory function was seen following admission, with associated tachycardia, tachypnoea and hypoxia. Emergency caesarean section was performed followed by transfer to the intensive care unit. COVID-19 PCR throat swab from day 0 was positive. Later, she developed hypoxaemia refractory to mechanical ventilation, proning and paralysis. The woman was transferred for veno-venous Extra Corporeal Membrane Oxygenation therapy but unfortunately died despite rigorous management. We review the conflicting information regarding physiological and immunological changes occurring during pregnancy and how these may affect susceptibility to respiratory viral disease. An overview of the current literature concerning ventilation and intensive care support in pregnant women suffering from COVID-19 is given. Further documentation of such cases is called for to progress understanding and management strategies.
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Affiliation(s)
- Annabel Stout
- West Midlands School of Obstetrics and Gynaecology, UK
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46
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Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation. Anesth Analg 2021; 133:1459-1477. [PMID: 34559089 DOI: 10.1213/ane.0000000000005738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.
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Affiliation(s)
- Michael A Mazzeffi
- From the Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Mazzeffi MA, Rao VK, Dodd-O J, Rio JMD, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: an Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2021; 35:3496-3512. [PMID: 34774252 DOI: 10.1053/j.jvca.2021.07.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.
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Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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48
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Soar J, Becker LB, Berg KM, Einav S, Ma Q, Olasveengen TM, Paal P, Parr MJA. Cardiopulmonary resuscitation in special circumstances. Lancet 2021; 398:1257-1268. [PMID: 34454688 DOI: 10.1016/s0140-6736(21)01257-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/13/2021] [Accepted: 05/24/2021] [Indexed: 12/21/2022]
Abstract
Cardiopulmonary resuscitation prioritises treatment for cardiac arrests from a primary cardiac cause, which make up the majority of treated cardiac arrests. Early chest compressions and, when indicated, a defibrillation shock from a bystander give the best chance of survival with a good neurological status. Cardiac arrest can also be caused by special circumstances, such as asphyxia, trauma, pulmonary embolism, accidental hypothermia, anaphylaxis, or COVID-19, and during pregnancy or perioperatively. Cardiac arrests in these circumstances represent an increasing proportion of all treated cardiac arrests, often have a preventable cause, and require additional interventions to correct a reversible cause during resuscitation. The evidence for treating these conditions is mostly of low or very low certainty and further studies are needed. Irrespective of the cause, treatments for cardiac arrest are time sensitive and most effective when given early-every minute counts.
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Affiliation(s)
- Jasmeet Soar
- Anaesthesia and Intensive Care Medicine, Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
| | - Lance B Becker
- Emergency Medicine, Zucker School of Medicine at Hofstra-Northwell, Northwell Health, New Hyde Park, NY, USA
| | | | - Sharon Einav
- Surgical Intensive Care, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Qingbian Ma
- Emergency Medicine, Peking University Third Hospital, Beijing, China
| | | | - Peter Paal
- Anaesthesiology and Intensive Care, St John of God Hospital, Paracelsus, Salzburg, Austria
| | - Michael J A Parr
- Intensive Care, Liverpool University Hospital, University of New South Wales, Sydney, NSW, Australia; Macquarie University Hospital, Macquarie University, Sydney, NSW, Australia
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49
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Breda JR, Aljure O, Sfakianaki AK, Loebe M. Cesarean section in patient with metastatic Ewing sarcoma requiring VA-ECMO support. J Card Surg 2021; 36:4756-4758. [PMID: 34523160 DOI: 10.1111/jocs.15984] [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: 07/12/2021] [Revised: 08/24/2021] [Accepted: 08/29/2021] [Indexed: 11/30/2022]
Abstract
A 26-year-old pregnant woman, with multiple metastatic Ewing sarcoma, presented with a sternal mass that began enlarging during pregnancy. Due to high-risk pregnancy, the patient was discussed in a multidisciplinary meeting and intubation was considered too risky without cardiopulmonary support. Computed tomography showed extrinsic tumor compression of the right ventricle outflow tract. Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) was initiated before general anesthesia, followed by Cesarean section (C-section). VA ECMO was initiated with the patient in the awake position, ECMO support was discontinued when the patient had stable ventilation and hemodynamics. This case represents a unique indication of VA ECMO, during C-section, with maternal and fetal survival.
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Affiliation(s)
- Joao R Breda
- Division of Thoracic Transplantation and Mechanical Support, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Oscar Aljure
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Anna K Sfakianaki
- Department of Maternal and Fetal Medicine, Obstetrics and Gynecology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Matthias Loebe
- Division of Thoracic Transplantation and Mechanical Support, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
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50
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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.
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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
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