ECMO in pregnancy and the peripartum period

Extracorporeal membrane oxygenation (ECMO) is increasingly being used in adult patients with either cardiac or respiratory failure or both in many settings.1,2 This includes pregnant patients and those who are postpartum experiencing cardiac or respiratory failure, a particularly vulnerable population where both the mother and the fetus are at risk. There is scant literature addressing the use of ECMO for either cardiac or respiratory failure in patients who are pregnant or postpartum. However, there are many potential indications, such as the acute respiratory distress syndrome (due to pneumonia, especially influenza pneumonia; aspiration; transfusion-related lung injury; or non-pulmonary sepsis), pulmonary embolism, amniotic fluid embolism, management of pre-existing or newly diagnosed pulmonary hypertension, cardiomyopathy (including postpartum cardiomyopathy), extracorporeal cardiopulmonary resuscitation (most frequently in the setting of pulmonary embolism or amniotic fluid embolism), and other conditions that are less commonly seen in the pregnant and peripartum patient population, which nevertheless may be encountered by clinicians. Case reports and case series are beginning to illuminate the management of such patients and suggest that ECMO in this setting may be beneficial to save the lives of both the mother and child. A case series of four patients reported survival in all four mothers and in three of the four fetuses.3 The largest case series in the literature reported on 18 peripartum patients, four of whom were pregnant at the time of cannulation.4 Mortality in that series was 11.1% with only two patients not surviving to hospital discharge. Fetal survival was 100% in those patients cannulated after fetal viability – overall fetal survival was 77.8%. One-third of the patients in this cohort had bleeding as a complication of their ECMO with no fetal complications attributable to ECMO. Other complications in the mothers included: DIC, as well as occlusive and non-occlusive deep vein thromboses. The risk of complications must be weighed against any potential benefits of using ECMO in these patients. A subset of patients were able to participate in active physical therapy while receiving ECMO (38.9%), with four patients being able to ambulate around the intensive care unit while receiving ECMO. The duration of ECMO was relatively brief overall (median 6.6 days), which was similar in both of these series.3,4 While ECMO appears from case reports and case series to be both feasible and reasonably safe in patients who are pregnant or postpartum with cardiac or respiratory failure, more data are clearly needed to better appreciate the potential indications, contraindications, and specific techniques involved. However, given the potential for recovery in a population that skews younger and healthier than the general population, deploying ECMO, even in severely critically ill patients in this setting, may be appropriate in centers experienced with the use of ECMO for cardiac and respiratory failure. For centers that do not have this experience, early referral is encouraged in those cases where deterioration may be anticipated.