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An Early Success Story: Extracorporeal Membrane Oxygenation (ECMO) for Acute Respiratory Distress Syndrome (ARDS) during Pregnancy
Abstract Number: F-75
Abstract Type: Case Report/Case Series
A 25-year-old AA female, G2P0010 at 19 weeks GA was admitted with severe sepsis and ARDS following a cardiac arrest secondary to iatrogenic hypoglycemia. History was significant for T1DM, gastroparesis, CRI, hydronephrosis, HTN, and medical non-compliance. Following resuscitation at an OSH, she became difficult to oxygenate. CXR was consistent with aspiration pneumonitis, which likely occurred during ACLS. Despite escalating treatment, she continued to decompensate. Maximum ventilator settings did not improve oxygenation. She was transferred to our tertiary care facility for further management. Given that her fetus was pre-viable, preservation of her life was the primary goal. On arrival, she was immediately cannulated for venovenous ECMO and received a tracheostomy. The fetus was intermittently monitored during ECMO and showed reassuring growth for GA. After 7 days, the patient was decannulated from ECMO. She discharged home 2 weeks later. The following week, she was readmitted with DKA, HTN, and concern for preeclampsia. Despite negative HELLP labs, a non-reassuring fetal assessment prompted urgent cesarean delivery of the infant at 26+3/7 weeks GA. The delivery was uncomplicated, but due to pulmonary edema and social issues, she was not discharged until POD12. The male infant suffered from apnea and feeding difficulties. After 2.5 months in NICU, he was discharged stable on room air, feeding well, with no obvious sequelae of his mother’s illness or ECMO requirement.
Mortality from ARDS in parturients is 40-50%. ARDS can develop from many obstetric etiologies (AFE, preeclampsia, septic abortion), but aspiration pneumonitis continues to be an important cause of ARDS and maternal mortality.(2,3)
Less than 70 cases of peripartum ECMO have been reported, most of which were for ARDS from H1N1 influenza. Maternal survival rate is 80%, fetal survival is 70%.(3,4) Aside from technical concerns of low femoral catheter flow due to gravid uterus, the major complication in parturients is catastrophic postpartum hemorrhage due to systemic anticoagulation.(3,4) Our patient required many blood products while on ECMO, but there were no thrombotic complications or hemorrhage from pump trauma or anticoagulation. She was not anticoagulated at time of delivery.
Given the paucity of evidence or guidelines for peripartum ECMO, this is a remarkable success for both our patient and her son. As technology advances, ethical issues will arise regarding use of fetal well-being, in addition to recalcitrant maternal hypoxia, as a factor in the decision to initiate ECMO.(1) Longitudinal studies of maternal and fetal outcomes are required. This case represents a paradigm shift in maternal resuscitation. When non-invasive measures fail, ECMO is a viable life-saving measure for a parturient with ARDS.
1. J Card Surg. 2015 Oct;30(10):781-6
2. Clin Obstet Gynecol. 2014 Dec;57(4):862-70
3. Intensive Care Med. 2011 Apr;37(4):648-54
4. ASAIO J. 2015 Jan-Feb;61(1):110-4