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Araki H, Sekino M, Hasegawa Y, Kurobe M, Motokawa T, Tanigawa A, Egashira T, Iwasaki N, Suzumura M, Yano R, Matsumoto S, Ichinomiya T, Higashijima U, Kanayama N, Miura K, Hara T. Amniotic fluid embolism rescued using venoarterial extracorporeal membrane oxygenation without initial anticoagulation: A case report and literature review. Medicine (Baltimore) 2024; 103:e38176. [PMID: 38758915 PMCID: PMC11098262 DOI: 10.1097/md.0000000000038176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 04/18/2024] [Indexed: 05/19/2024] Open
Abstract
RATIONALE Amniotic fluid embolism (AFE) is a fatal obstetric condition that often rapidly leads to severe respiratory and circulatory failure. It is complicated by obstetric disseminated intravascular coagulation (DIC) with bleeding tendency; therefore, the introduction of venoarterial extracorporeal membrane oxygenation (VA-ECMO) is challenging. We report the case of a patient with AFE requiring massive blood transfusion, rescued using VA-ECMO without initial anticoagulation. PATIENTS CONCERNS A 39-year-old pregnant patient was admitted with a complaint of abdominal pain. An emergency cesarean section was performed because a sudden decrease in fetal heart rate was detected in addition to DIC with hyperfibrinolysis. Intra- and post-operatively, the patient had a bleeding tendency and required massive blood transfusions. After surgery, the patient developed lethal respiratory and circulatory failure, and VA-ECMO was introduced. DIAGNOSIS Based on the course of the illness and imaging findings, the patient was diagnosed with AFE. INTERVENTIONS By controlling the bleeding tendency with a massive transfusion and tranexamic acid administration, using an antithrombotic ECMO circuit, and delaying the initiation of anticoagulation and anti-DIC medication until the bleeding tendency settled, the patient was managed safely on ECMO without complications. OUTCOMES By day 5, both respiration and circulation were stable, and the patient was weaned off VA-ECMO. Mechanical ventilation was discontinued on day 6. Finally, she was discharged home without sequelae. LESSONS VA-ECMO may be effective to save the lives of patients who have AFE with lethal circulatory and respiratory failure. For safe management without bleeding complications, it is important to start VA-ECMO without initial anticoagulants and to administer anticoagulants and anti-DIC drugs after the bleeding tendency has resolved.
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Affiliation(s)
- Hiroshi Araki
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Motohiro Sekino
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yuri Hasegawa
- Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Masaya Kurobe
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tetsufumi Motokawa
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Akihiko Tanigawa
- Department of Cardiovascular Surgery, Nagasaki University Hospital, Nagasaki, Japan
| | - Takashi Egashira
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Naoya Iwasaki
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Miki Suzumura
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Rintaro Yano
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Sojiro Matsumoto
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Taiga Ichinomiya
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ushio Higashijima
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Naohiro Kanayama
- Department of Obstetrics and Gynecology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Kiyonori Miura
- Department of Obstetrics and Gynecology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Malfertheiner SF, Brodie D, Burrell A, Taccone FS, Broman LM, Shekar K, Agerstrand CL, Serra AL, Fraser J, Malfertheiner MV. Extracorporeal membrane oxygenation during pregnancy and peripartal. An international retrospective multicenter study. Perfusion 2022:2676591221090668. [PMID: 35549557 DOI: 10.1177/02676591221090668] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Extracorporeal Membrane Oxygenation (ECMO) may be used in the setting of pregnancy or the peripartal period, however its utility has not been well-characterized. This study aims to give an overview on the prevalence of peripartel ECMO cases and further assess the indications and outcomes of ECMO in this setting across multiple centers and countries. METHODS A retrospective, multicenter, international cohort study of pregnant and peripartum ECMO cases was performed. Data were collected from six ECMO centers across three continents over a 10-year period. RESULTS A total of 60 pregnany/peripartal ECMO cases have been identified. Most frequent indications are acute respiratory distress syndrome (n = 30) and pulmonary embolism (n = 5). Veno-venous ECMO mode was applied more often (77%). ECMO treatment during pregnancy was performed in 17 cases. Maternal and fetal survival was high with 87% (n = 52), respectively 73% (n = 44). CONCLUSIONS Various emergency scenarios during pregnancy and at time of delivery may require ECMO treatment. Peripartal mortality in a well-resourced setting is rare, however emergencies in the labor room occur and knowledge of available rescue therapy is essential to improve outcome. Obstetricians and obstetric anesthesiologists should be aware of the availability of ECMO resource at their hospital or region to ensure immediate contact when needed.
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Affiliation(s)
- S Fill Malfertheiner
- Department of Obstetrics and Gynecology, Hospital St. Hedwig of the Order of St. John, Regensburg University, Regensburg, Germany
| | - D Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, 12294Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - A Burrell
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - F S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, ULB, Brussels, Belgium
| | - L M Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - K Shekar
- Critical Care Research Group, 67567The Prince Charles Hospital, Brisbane, Australia
| | - C L Agerstrand
- Division of Pulmonary, Allergy, and Critical Care Medicine, 12294Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - A L Serra
- Division of Pulmonary, Allergy, and Critical Care Medicine, 12294Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - J Fraser
- Critical Care Research Group, 67567The Prince Charles Hospital, Brisbane, Australia
| | - M V Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, University Hospital Regensburg, Regensburg, Germany
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Ge C, Liu J, Fu Y, Jia L, Bai Y, Yang Z, Du Q. A case report of early application of veno-arterial extracorporeal membrane oxygenation in amniotic fluid embolism. Medicine (Baltimore) 2021; 100:e27896. [PMID: 34797339 PMCID: PMC8601314 DOI: 10.1097/md.0000000000027896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/03/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Amniotic fluid embolism (AFE) is a rare obstetrical complication and is a leading cause of maternal death in developed countries. Despite the development of supportive therapeutic measures, the mortality rate remains high. PATIENT CONCERNS A 38-year-old nulliparous pregnant woman, who underwent in vitro fertilization-embryo transfer, was admitted for labor at 37 weeks' gestation. Approximately 30 minutes after delivery of the placenta, the puerpera developed postpartum hemorrhage with uterine atony. Soon after, the patient experienced hypotension, repeated cardiac arrest, refectory hypoxia, and disseminated intravascular coagulopathy. DIAGNOSIS AFE is diagnosed clinically. The pregnant woman in this case fulfilled the diagnostic criteria for AFE: acute hypotension, cardiac arrest, acute hypoxia, and coagulation disorders within approximately 30 minutes after delivery of the placenta. INTERVENTIONS The patient was intubated, connected to a ventilator, and was administered a high dose of vasoactive drugs to maintain blood pressure and underwent an emergency hysterectomy. Considering the risk for recurrent cardiac arrest and severe refractory hypoxia, venoarterial extracorporeal membrane oxygenation was initiated and discontinued as soon as cardiac function was restored based on serial bedside ultrasound assessment. OUTCOMES The patient stabilized on day 7 in the intensive care unit and was transferred to the obstetrics ward and, 1 week later, was discharged with no complications. Two months later, follow-up revealed that the patient was in good condition. LESSON Serial bedside ultrasound was crucial for assessing cardiac function and optimal weaning. Timely application of venoarterial extracorporeal membrane oxygenation and weaning was significant to avoid the occurrence of complications and improve long-term outcomes.
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Affiliation(s)
- Chen Ge
- Department of Intensive Medicine, Hebei General Hospital, Shijiazhuang City, Hebei Province, P.R. China
| | - Junhang Liu
- Department of Orthopaedics Surgery, Children's Hospital of Hebei, Shijiazhuang City, Hebei Province, P.R. China
| | - You Fu
- Department of Intensive Medicine, Hebei General Hospital, Shijiazhuang City, Hebei Province, P.R. China
| | - Lijing Jia
- Department of Intensive Medicine, Hebei General Hospital, Shijiazhuang City, Hebei Province, P.R. China
| | - Yinxiang Bai
- Department of Intensive Medicine, Hebei General Hospital, Shijiazhuang City, Hebei Province, P.R. China
| | - Zhiwei Yang
- Department of Intensive Medicine, Hebei General Hospital, Shijiazhuang City, Hebei Province, P.R. China
| | - Quansheng Du
- Department of Intensive Medicine, Hebei General Hospital, Shijiazhuang City, Hebei Province, P.R. China
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Adachi M, Adachi T, Fujita T, Hyuga S, Onishi Y, Okutomi T. Venoarterial extracorporeal membrane oxygenation as an early treatment for amniotic fluid embolism with cardiac arrest: A case report. J Obstet Gynaecol Res 2021; 47:3374-3378. [PMID: 34132000 DOI: 10.1111/jog.14880] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 04/02/2021] [Accepted: 05/29/2021] [Indexed: 11/28/2022]
Abstract
Amniotic fluid embolism (AFE) is a rare but fatal obstetric complication, characterized by sudden cardiovascular collapse, respiratory failure, and disseminated intravascular coagulation. Maternal mortality associated with AFE is high, making early recognition and prompt treatment important. In AFE with cardiac arrest, survival following acute cardiopulmonary dysfunction is crucial. In recent years, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has attracted attention as an aggressive treatment for AFE with cardiac arrest. A 40-year-old woman experienced sudden cardiac arrest due to AFE during cesarean section. Cardiopulmonary resuscitation and VA-ECMO (also called percutaneous cardiopulmonary support) were initiated early. Finally, she recovered without any complications. VA-ECMO can provide temporary respiratory and hemodynamic support until cardiopulmonary function improves after a few days in intensive care. VA-ECMO should be considered as an early treatment for AFE with cardiac arrest.
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Affiliation(s)
- Mariko Adachi
- Division of Obstetric Anesthesia, Center for Perinatal Care, Child Health and Development, Kitasato University Hospital, Sagamihara, Japan
| | - Takeshi Adachi
- Department of Anesthesiology, Kitasato University, School of Medicine, Sagamihara, Japan
| | - Tomoe Fujita
- Division of Obstetric Anesthesia, Center for Perinatal Care, Child Health and Development, Kitasato University Hospital, Sagamihara, Japan
| | - Shunsuke Hyuga
- Division of Obstetric Anesthesia, Center for Perinatal Care, Child Health and Development, Kitasato University Hospital, Sagamihara, Japan
| | - Yoko Onishi
- Department of Obstetrics and Gynecology, Center for Perinatal Care, Child Health and Development, Kitasato University Hospital, Sagamihara, Japan
| | - Toshiyuki Okutomi
- Division of Obstetric Anesthesia, Center for Perinatal Care, Child Health and Development, Kitasato University Hospital, Sagamihara, Japan
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Sebastian NA, Spence AR, Bouhadoun S, Abenhaim HA. Extracorporeal membrane oxygenation in pregnant and postpartum patients: a systematic review. J Matern Fetal Neonatal Med 2020; 35:4663-4673. [PMID: 33345652 DOI: 10.1080/14767058.2020.1860932] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Information on the use of extracorporeal membrane oxygenation (ECMO) in obstetric patients is scarce. The objective was to conduct a systematic review examining ECMO use in pregnant and postpartum patients in order to identify indications leading to ECMO use and to assess mortality rates. MATERIALS AND METHODS PubMed, EMBASE, Cochrane Library, and SCOPUS were searched using the terms "extracorporeal membrane oxygenation" and "pregnancy" up to 1 November 2020. Case reports and case series reporting the use of ECMO in pregnancy were eligible. Data about maternal age, gestational age, diagnosis, type of ECMO, time on ECMO, pregnancy outcomes, and maternal survival were extracted from studies. RESULTS The search yielded 1696 citations, of which 125 were included. There were 213 obstetric patients treated with ECMO over a 30-year period. The frequency of reports increased considerably over the last decade. The majority of patients were treated in their third trimester (28.2%) or postpartum (32.9%). Most common etiologies included influenza-induced ARDS (27.7%), pulmonary embolism (13.6%), peripartum cardiomyopathy (11.7%), and infection (11.7%). Pregnancy outcomes ended with live births, either on ECMO (15.5%, 95% CI 10.6-20.4) or not on ECMO (58.3%, 95% CI 51.7-64.9), in fetal demise (8.9%, 95% CI 5.1-12.7), or in spontaneous or induced abortion on ECMO (4.2%, 95% CI 1.5-6.9) or not on ECMO (4.2%, 95% CI 1.5-6.9). Maternal survival was 79.3%. CONCLUSION Although women placed on ECMO had a high mortality rate, this is likely an indication of the severity of illness. Overall, ECMO appears to be a valid therapy for the temporary support of vital organs in severely ill pregnant women.
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Affiliation(s)
- Natasha A Sebastian
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Andrea R Spence
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada
| | - Sarah Bouhadoun
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Haim A Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada
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Extracorporeal Membrane Oxygenation for Amniotic Fluid Embolism-Induced Cardiac Arrest in the First Trimester of Pregnancy: A Case Report. Crit Care Explor 2020; 2:e0162. [PMID: 32766559 PMCID: PMC7368879 DOI: 10.1097/cce.0000000000000162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text. Amniotic fluid embolism is a rare obstetric emergency that can be accompanied by profound hypoxemia, coagulopathy, hemorrhage, and cardiogenic shock. Extracorporeal membrane oxygenation may provide a rescue strategy in amniotic fluid embolism with cardiopulmonary collapse. Approaches to anticoagulation must be balanced against the risk of hemorrhage with concomitant coagulopathy. Although extracorporeal membrane oxygenation has been described for cardiopulmonary collapse in the setting of amniotic fluid embolism, its initiation as a bridge to hemostasis and cardiopulmonary recovery in amniotic fluid embolism–induced hemorrhagic and cardiogenic shock remains a novel resuscitation strategy.
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