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Elective Extracorporeal membrane oxygenation in a laboring parturient with Eisenmenger’s Syndrome
Abstract Number: F-24
Abstract Type: Case Report/Case Series
A 29-year-old NYHA class 3 parturient with Eisenmenger’s syndrome (ES) presented at 18 wks gestation despite medical recommendation for termination. An echocardiogram showed bidirectional flow across a large PDA, moderately decreased RV function, preserved LV function and suprasystemic PA pressure.
Antepartum, the patient progressed to dyspnea at rest and treatment consisted of inhaled Iloprost, prophylactic thromboprophylaxis, bedrest, furosemide and supplemental O2.
At 34 wks, arterial, central venous and L4/5 epidural catheters, and 27 Fr bicaval dual lumen ECMO cannulas were placed in the OR. V-V ECMO was initiated at 2L/min after heparinization (aPTT 40-60) and post ductal SpO2 improved from 88% to 100%. The epidural catheter was tested and an infusion started. Induction of labor commenced with a cervical ripening balloon/oxytocin and cervical dilation progressed over 48 hrs.
Acutely, the patient developed tachycardia, hypertension and hypoxia while laboring (pre-ductal SpO2 of 75%), despite her denial of pain, which was treated with 100% oxygen, inhaled Iloprost and nitric oxide 20ppm. The patient’s preductal SpO2 improved to 88% but she underwent cesarean section (CS) secondary to maternal instability (FHR was reassuring). Epidural lidocaine (15cc of 2%) was titrated to a T6 level, while a femoral artery catheter was placed for V-A ECMO if necessary. Milrinone, phenylephrine and vasopressin were required for inotropic/vasopressor support after epidural loading, which was increased after delivery following a 1000cc blood loss and oxytocin administration.
In the post-operative period the patient developed an early peritoneal hematoma necessitating surgical evacuation, DIC, respiratory failure, acute renal failure necessitating CVVH, and cardiogenic shock requiring conversion to VA ECMO. The patient was discharged post-partum day 54 on 4L O2 and returned a month later ambulatory.
This is the first report of utilizing ECMO electively to mitigate the hemodynamic instability of labor in a PH/ES parturient and her fetus. Multidisciplinary discussions concluded that a vaginal delivery (VD) would be attempted because the literature, and our experience, support decreased blood loss, surgical stress, hemodynamic instability and mortality when CS is avoided in ES parturients. Labor was unlikely to be tolerated with profound right to left shunting across her PDA, suprasystemic PAP, and RV dysfunction. ECMO was initiated to provide better-oxygenated blood to the uteroplacental unit during labor, which likely resulted in increased fetal stability and decreased maternal decompensation during labor. CS for maternal indications still occurred however.
The use of ECMO to permit survival of this ES parturient, and delivery of a healthy child, when known mortality is unacceptably high, should be tempered against some expected complications of mechanical support, including renal failure and hemorrhage (both experienced by this patient).