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Cesarean delivery in a patient on extracorporeal membrane oxygenation for acute respiratory distress syndrome
Abstract Number: F-10
Abstract Type: Case Report/Case Series
Introduction: We present a case of cesarean delivery in a patient on extracorporeal membrane oxygenation (ECMO). This is the second cesarean delivery performed during ECMO therapy at our institution.
Case: A previously healthy 33 year-old G2P1 at 26 weeks was transferred with acute respiratory distress syndrome (ARDS) for ECMO. Five days prior to presentation, she was admitted to an outside hospital for management of community-acquired pneumonia and started on antibiotics. Her symptoms worsened, necessitating intubation. She continued to decompensate, requiring increasing respiratory support and vasopressor therapy. Our ECMO team was consulted, and venovenous ECMO was initiated at the outside hospital, immediately prior to transfer. At our institution, a nasal swab was positive for influenza H1N1 virus. During her ECMO course, the patient developed renal failure requiring continuous venovenous hemofiltration, as well as intermittent episodes of severe hypertension (SBP 200s), despite sedation with propofol (50 mcg/kg/min), midazolam (70 mg/hr), and hydromorphone (70 mg/hr). After consultation with several obstetric experts, and debate among the local care team, the patient was given a diagnosis of preeclampsia, and a decision was made for cesarean delivery at 28 weeks. Heparin infusion (required for ECMO) was discontinued one hour prior to surgery, and 10U of cross-matched blood, 10U of fresh frozen plasma, and platelets were immediately available. Anesthesia was maintained with propofol 150 mcg/kg/min and 3% desflurane, in addition to the midazolam and hydromorphone infusions. Brain function monitoring and transesophageal echocardiography were performed intraoperatively. The neonate was delivered 9 minutes after skin incision with Apgar scores of 7 and 8 at 1 and 5 minutes. EBL was approximately 1.4 L. The patient received 3 units of packed red blood cells. She remained stable throughout and was transferred back to the intensive care unit.
Discussion: H1N1 can cause ARDS in otherwise healthy patients. For reasons that are not completely understood, pregnant women are at higher risk of morbidity and mortality from H1N1 infection (1). The physiologic changes of pregnancy may interfere with the ability to clear the virus. When conventional therapy fails to reverse ARDS, ECMO may save patients who would have otherwise succumbed to the disease (2). Although the evidence for preeclampsia was not overwhelming in this case, there was a general consensus that delivery of the neonate might increase the patient’s chance for recovery. The fact that she appeared to require such high dose sedation, commonly seen in patients on ECMO, made it difficult to determine what would constitute an effective anesthetic. Since the neonate cried at delivery, we were convinced that the maternal and fetal blood levels of midazolam and hydromorphone were not excessively high.
1. Mak TK. Lancet. 2008.
2. Bonacchi M. Interv Med Appl Sci. 201