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Two Cases of Fulminant Respiratory Failure Requiring Combined Cesarean Delivery and VV ECMO Placement
Abstract Number: S-63
Abstract Type: Case Report/Case Series
H1N1 influenza is notable for its propensity to cause severe illness in young, healthy patients. Pregnant women are at increased risk and represent a disproportionate number of deaths. In January 2014, we treated two pregnant patients with H1N1 influenza who required Cesarean delivery (CD) immediately followed by VV ECMO with excellent short-term results.
Case 1: 27 year old at 26 weeks with severe, refractory hypoxia was transferred from an outside hospital intubated and sedated. SpO2 was 83% on 100% FiO2. Fetal heart tones were absent variability with decelerations. She was taken to the OR emergently, intravenous anesthesia was provided, and a left internal jugular central venous catheter, radial arterial line, and TEE probe were placed. A guidewire for a bicaval, dual lumen ECMO cannula was placed via the right internal jugular vein so that cannulation could be quickly completed if decompensation occurred. CD was performed. Oxytocin infusion and methylergonovine IM were administered. Heparin 3,000 units was given, cannula placed, and VV ECMO initiated. Heparin infusion began six hours post delivery, and no bleeding complications occurred.
Case 2: 24 year old at 37 weeks with severe, refractory hypoxia was transferred intubated and sedated. SpO2 was 83% on 100% FiO2. Fetal heart tones were reassuring. Intraoperative management paralleled the first case. Oxytocin infusion and misoprostol PR were administered after CD. Heparin 5,000 units was given, cannula placed, and VV ECMO initiated. Heparin infusion began six hours post delivery. The patient passed two large clots vaginally on postop day 1, but no other bleeding complications occurred.
Bleeding complications are common and increase with duration of ECMO therapy. Hemodynamic instability requiring vasoactive agents is common. Therefore, we felt that the best chance for good maternal and fetal outcome was prompt CD followed by initiation of ECMO. With meticulous surgical hemostasis, aggressive resuscitation and prompt administration of uterotonics, CD followed by initiation of VV ECMO was safely performed. Collaboration between cardiothoracic surgery, obstetrics, intensive care, and anesthesiology teams was essential for success.
1. Crit Care Clin 2011;627-646
2. Obstet Gynecol 2010;115:717-26