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Operative vaginal delivery during extracorporeal membrane oxygenation support for severe acute respiratory distress syndrome
Abstract Number: SUN-11
Abstract Type: Case Report/Case Series
The incidence of acute respiratory distress syndrome (ARDS) during pregnancy is estimated at 1.5-70/100,000 with a mortality of 23-50%. Management of severe ARDS with extracorporeal membrane oxygenation (ECMO) is described in a limited number of case reports/series. In the following report we describe a case of instrumented vaginal delivery of a viable fetus during ECMO.
A G8P2052 at 29w4d was admitted to the ICU for management of ARDS and septic shock due to multifocal H1N1 pneumonia. She was intubated within 24 hrs of admission for progressive hypoxemia and cannulated for ECMO on hospital day (HD) 7. Continuous fetal monitoring was started on admission, but was decreased to twice daily NSTs at the time of ECMO, as delivery would only be attempted for maternal decompensation. Approximately 24 hrs after ECMO initiation the patient had significant vaginal bleeding. The heparin infusion was discontinued and exam revealed complete dilation with bulging membranes. Resources and personnel were mobilized for expectant delivery of the now 30w3d fetus. Amniotomy was performed and the fetus progressed to 3+ station. This was associated with a sustained deceleration of the fetal heart rate and the decision was made to attempt an operative vaginal delivery. Forceps were applied and the fetus was delivered over 1 pull and passed to the NICU team after immediate cord clamping. The placenta was delivered with active management of the third stage of labor with rectal misoprostol and a 3u intravenous bolus of oxytocin followed by infusion of 40u of oxytocin mixed in 1000mL of lactated ringer's. Adequate uterine tone was rapidly achieved with no evidence of ongoing bleeding. Heparin correlation and aPTT were checked hourly, and heparin infusion was restarted 4 hrs after delivery. The neonate was initially intubated, but was extubated to nasal CPAP in <24 hrs, and discharged home on day 44 of life. Unfortunately, the mother’s respiratory function failed to recover. She was terminally decannulated on ECMO day 13/HD 20 and died after continued palliative care on HD 26.
Fetal monitoring in parturients on ECMO may be beneficial as a marker of maternal well-being. Unrecognized placental abruption or imminent delivery pose unique risks to a parturient who is therapeutically anticoagulated. Recognition of need for delivery may allow for discontinuation of anticoagulation and preparation for a potential post-partum hemorrhage. In this case fetal compromise was the primary indication for operative vaginal delivery, however, our patient also benefited from a shortened second stage of labor, allowing early treatment with uterotonic agents and a shortened interval without anticoagulation. Our case highlights how multidisciplinary care optimizes maternal and fetal survival in the critically ill parturient.
Duarte AG. Clin obstet and gynecol. 2014;57:862-870.
Mehta N et al. Best prac res clin obstet gynaecol. 2015;29:598-611.