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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Pre-emptive Extra Corporeal Membrane Oxygenation Cannulation in a Patient with Peripartum Cardiomyopathy

Abstract Number: S3C-8
Abstract Type: Case Report/Case Series

Lorena Nunez MD1 ; Selina Patel MD2; Moaveni Daria MD3; Juanita Henao MD4

Peripartum cardiomyopathy (PPCM) in the United States affects 1:1000 to 1:4000 live births.1 It is a diagnosis of exclusion and it is characterized by heart failure occurring during pregnancy and postpartum period. 1 We present a case where extracorporeal membrane oxygenation (ECMO) cannulas were pre-emptively inserted for cesarean delivery (CD) in a parturient with PPCM.

A 34 years old G2P1 with past medical history of class 3 obesity (BMI of 53 kg/m2), hypertension and type 2 diabetes was transferred to our institution at 25.1 weeks gestation with newly diagnosed PPCM and superimposed preeclampsia. Initial echocardiogram showed an EF 45% worsening to EF 20-25% on repeat exam one day later. Urgent multidisciplinary meeting was arranged for optimal management and delivery planning. The patient was admitted to intensive care unit (ICU) for optimization prior to delivery where invasive monitoring was established. She was commenced on continuous veno-veno hemodialysis to treat metabolic acidosis, fluid overload and hyperkalemia.

General anesthesia was chosen to secure a potentially difficult airway early as well as allow provision of intraoperative transesophageal echo (TEE). Given concern for cardiopulmonary collapse during induction of anesthesia and /or CD, arterial and venous ECMO cannulas were placed under local anesthesia prior to induction. Induction of anesthesia was conducted using a modified rapid sequence technique and a TEE probe was placed for evaluation and monitoring. Estimated blood loss was 1000ml and no transfusion was needed. Norepinephrine and epinephrine infusions were started guided by TEE and pulmonary artery catheter to maintain hemodynamics, however ECMO was not initiated. Post operatively, she was taken to the ICU intubated and with ECMO cannulas still in situ. She was extubated post-operative day 1 and inotropes were gradually discontinued. She was managed in the ICU for 4 days and was discharged from the hospital on post-operative day 8.

Obstetric patients with heart failure presenting for cesarean delivery pose substantial challenges to all specialties involved. This case report highlights how preemptive ECMO cannulation as a potentially life-saving measure can be utilized in the peripartum period. It also illustrates the extensive resources required and the importance of a multidisciplinary approach when caring for these high-risk parturients. The paucity of published data and the absence of evidence-based protocols indicate a need for further research regarding the role of ECMO in parturients.

References:

1. Arany, Z., Elkayam, U. (2016). Peripartum Cardiomyopathy. Circulation. 133(14) pp1397-1409

SOAP 2018