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ECMO Consultation and Anesthetic Management of Cesarean Section in a Parturient with Severe Pulmonary Arterial Hypertension
Abstract Number: S3C-1
Abstract Type: Case Report/Case Series
A 34 year old G4P2 woman with a PMH of SLE presented at 36 weeks GA with exertional dyspnea and peripheral edema. Her ECG showed right heart strain and TTE found RVSP 88 mmHg, global RV hypokinesis, dilation, and hypertrophy with an LV EF 77%. Given her severe pulmonary hypertension (PH), a multidisciplinary team including Maternal Fetal Medicine, Obstetric and Cardiac Anesthesiology, Critical Care Medicine, Pulmonology, and Cardiac Surgery coordinated medical optimization, surgical planning, and postoperative management. She was admitted to the ICU, had arterial and central lines placed, and IV epoprostenol was initiated.
A repeat cesarean section was planned in the cardiac surgery suite equipped for rapid initiation of ECMO. A MAC introducer and PA catheter were placed prior to a lumbar epidural catheter that was slowly bloused with medication to obtain an anesthetic sensory level to T4. Infusions of milrinone, norepinephrine, and vasopressin and inhaled NO were started and femoral arterial and venous sheaths were placed for potential conversion to ECMO. Immediately following delivery, she developed suprasystemic PA pressures and increased inotrope requirements but did not require escalating support. Postpartum, she was weaned off of vasopressors and oxygen with gentle diuresis. The sheaths and lines were removed on post-operative day 2 and she was discharged on post-operative day 12.
Early involvement of a cardiac surgeon for an ECMO Consultation has been increasingly utilized for pregnant patients with PH at our institution given the potential for rapid deterioration and the possible need for advanced cardiopulmonary support. ECMO has been successfully used in pregnant patients with maternal survival ranging from 70-80%1,2, although the current literature focuses on VV ECMO for ARDS. In experienced centers, VA ECMO has been increasingly utilized for decompensated PH to support the RV, bypass the pulmonary vasculature, and provide cardiopulmonary support for a reversible process3. Consultation with cardiac surgery for patients at high risk of requiring extracorporeal support allows for pre-delivery placement of femoral sheaths to facilitate rapid conversion to ECMO in the case of abrupt deterioration4. This case is one in a series to support the use of ECMO Consultation in pregnant patients with PH to potentially improve outcomes.
1. Moore SA, Dietl CA, Coleman DM. Extracorporeal life support during pregnancy. J Thorac Cardiovasc Surg 2016; 151(4):1154-60.
2. Agerstrand C, Abrams D, Biscott M, et al. Extracorporeal Membrane Oxygenation for Cardiopulmonary Failure During Pregnancy and Postpartum. Ann Thorac Surg 2016;102(3):774-9.
3. Abrams D, Brodie D. Novel uses of extracorporeal membrane oxygenation in adults. Clin Chest Med 2015;36:373-84
4. Hara R, Hara S, Ong CS, et al. Cesarean section in the setting of severe pulmonary hypertension requiring extracorporeal life support. Gen Thorac Cardiovasc Surg 2017;65(9):532-4.