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Venovenous Extracorporeal Membrane Oxygenation to Prolong Pregnancy: A Case Report

Alyamani, Omar MD*,†; Mazzeffi, Michael A. MD*; Bharadwaj, Shobana MBBS*; Galey, Jessica H. MD*; Yao, Ruofan MD; Shah, Nirav G. MD§; Malinow, Andrew M. MD*,‡

Author Information
doi: 10.1213/XAA.0000000000000671
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Abstract

Extracorporeal membrane oxygenation (ECMO) has been used to support gravidae suffering both cardiac and severe respiratory failure.1–3 However, ECMO in pregnancy is still a rare event and any additional reports will help guide clinicians in their future management of gravidae requiring ECMO.4 We describe a gravida, placed on venovenous (VV) ECMO in her early third trimester, who was managed on ECMO both before and after delivery. ECMO initiated before delivery raises multiple maternal and fetal concerns. We discuss these concerns, the complications encountered, and present our plan of management. Written consent to publish this article has been obtained from the patient.

CASE DESCRIPTION

A 38-year-old gravida 9 para 8 (previous classical cesarean delivery [CD]) presented at 275/7 weeks estimated gestational age (EGA) with worsening cough and dyspnea. Her medical history included severe pulmonary sarcoidosis, asthma, hypertension, supermorbid obesity (~155 kg), and obstructive sleep apnea. Despite exacerbations of sarcoidosis, the patient remained resolute to continue her pregnancy during repeated counseling.

Diagnosed with acute respiratory distress syndrome (ARDS) due to rhinovirus pneumonia, her trachea was intubated and she was transferred to a medical intensive care unit (ICU) for mechanical ventilation. During the next 19 days, she was administered sedation, intermittent paralytics, and inhaled epoprostenol for severe ARDS and refractory hypoxemia. However, her pulmonary status continued to deteriorate.

The patient demonstrated inadequate tidal volumes with paradoxical respiration. Her peripheral capillary oxygen saturation (Spo2) measured 89% while breathing 100% oxygen. After complete paralysis, her respiratory status improved slightly. Analysis of arterial blood revealed a pH = 7.34; Pco2= 60 mm Hg; Po2= 100 mm Hg while ventilated on positive end-expiratory pressure = 20 cm H2O with an inspired oxygen concentration of 60%. The intensivist’s notes in the medical record included the following descriptions of the patient’s condition: “end-stage” sarcoid with superimposed ARDS; difficulty in achieving satisfactory ventilation even with alteration in ventilator settings; and an “overall downward trajectory” in condition. He further stated that alternative therapies were “exhausted”; “demise was imminent”; and the patient would “not survive” a CD. For these reasons, he suggested ECMO. After consultation with her obstetricians, the institutional ECMO team and an ethicist, the patient’s family agreed to ECMO with a perimortem CD, if required to rescue the fetus.

At 303/7 weeks, VV ECMO (common femoral vein/right internal jugular vein) was initiated for refractory respiratory failure. The fetal heart rate (FHR) remained ~150 bpm. Occasional episodes of repeated FHR decelerations were noted with maternal hypotension (ameliorated with intravenous hydration) and episodes of maternal desaturation (Spo2 <92%). Average ECMO blood flow of ~6.0 L/min and sweep gas flow of at ~9 L/min maintained maternal Spo2 near 95% and arterial Pco2 in the range of 35–45 mm Hg. The patient’s condition improved. Without further FHR evidence of fetal deterioration, a decision was made to continue the pregnancy.

At 312/7 weeks EGA, imaging revealed diffuse pulmonary consolidation. Bronchoscopy confirmed alveolar hemorrhage. Profuse postprocedure bleeding was noted in the tracheal tube. Maternal desaturation occurred and recurrent FHR decelerations were noted. Given the FHR evidence of acute fetal deterioration and evaluating the possible risks of transportation to a distant operating room during a period of hemodynamic and respiratory instability, the patient was immediately prepared for CD. A prearranged team of perinatologists, anesthesiologists, neonatologists, nurses, and technicians responded to the ICU. Existing intravenous fentanyl and propofol infusions were rate-adjusted and a paralytic dose of rocuronium was intravenously injected to provide surgical anesthesia. A CD done “at the bedside” yielded a living male child: 1.92 kg with Apgar scores of 1, 5, and 8 at 1, 5, and 10 minutes, respectively. Analysis of umbilical arterial blood revealed a pH = 7.32; Pco2= 57 mm Hg; and Po2= 23 mm Hg. Blood loss was estimated at <750 mL. Suctioning of the tracheal tube revealed decreased bleeding.

The patient continued to improve after delivery. Eight days later, the ECMO cannulae were removed and the trachea was extubated shortly thereafter. Subsequently, the patient was diagnosed with cannula-associated deep venous thrombosis (DVT). On postoperative day 28, the patient was discharged to a rehabilitation facility and 3 days later, to home. Neonatal discharge occurred at age 38 days. Nine months later, the patient expressed gratitude for the efforts made to extend her pregnancy. Mother and baby continue to do well.

DISCUSSION

ARDS is associated with maternal acidemia/hypoxemia, fetal acidemia, and low Apgar score at delivery.5 A recent analysis of ARDS during pregnancy reveals that prolonged mechanical ventilation is associated with an almost doubled mortality rate.6 Many rescue strategies for severe ARDS, including prone positioning that has been shown to decrease mortality in adults,7 are not validated in gravida. ECMO has been described as a viable option. Early reports of ECMO in pregnancy originated during the 2009 H1N1 pandemic,3 but use of ECMO during pregnancy is still not considered “routine.”4 Questions about optimal management remain.4 Maternal mortality associated with VV ECMO is 22% with fetal mortality reported at 35%.1–4

In this patient diagnosed with severe refractory respiratory failure, there was grave concern that she would not survive delivery. However, there were no signs of fetal deterioration. A multidisciplinary discussion generated a plan, accepted by her family, which initiated ECMO support in an attempt to salvage the mother, with perimortem CD, if indicated. After cannulation and support on ECMO, the patient improved. In the face of an improving maternal condition, a decision was then made to maintain ECMO, allowing continued in utero development, with an ultimate goal of reaching 32–34 weeks EGA, a fetal age associated with a 10-fold decrease in infant mortality.8

ECMO blood flow rates are routinely maintained to keep oxygen saturation at 80%–85%.9 In our patient, the management of the blood flow rate was influenced by the appearance of recurrent fetal decelerations associated with a maternal Spo2 below 90%–92%. The blood flow rate was increased to keep saturation above this level. The sweep gas flow rate maintained maternal Paco2 at a slightly lower level than routinely suggested (40 mm Hg).9 This level was elected in an attempt to maintain a favorable fetal-maternal gradient, enabling transplacental diffusion of CO2.

Complications of ECMO include severe hemorrhage.10 Bronchoscopy-assisted suctioning in mechanically ventilated patients is an accepted treatment for arterial desaturation related to (lower) airway obstruction. Bronchoscopy carries an increased risk in anticoagulated patients on ECMO, perhaps more so in a gravida with airway hyperemia. In this patient, bronchoscopy exacerbated her pulmonary hemorrhage leading to maternal desaturation with recurrent decelerations in the FHR. Our patient had an emergent CD. Interestingly, although massive hemorrhage may occur in any anticoagulated patient presenting for delivery, the patients’ blood loss, estimated at <750 mL, was not considered excessive.

During adult ECMO, a more prolonged activated partial thromboplastin time (aPTT) is associated with hemorrhage and mortality. Perhaps, using an alternative anticoagulation regimen would have avoided pulmonary hemorrhage. Some suggest low-dose heparin anticoagulation if ECMO blood flow remains normal and there is low risk for thrombosis.11 Our institutional adult VV ECMO guidelines suggest a goal aPTT of 45–55 seconds, but guidelines for anticoagulation for maternal VV ECMO have not been established. Due to an increase in factor VIII, fibrinogen, and nonspecific binding of heparin during pregnancy, aPTT may underestimate the anticoagulant effects of unfractionated heparin,12 leading to increased doses as compared to nonpregnant patients. Many ECMO centers now monitor antifactor Xa activity and ATIII levels, and use viscoelastic methods to manage anticoagulation.13 We have discussed changing our institutional guidelines for managing anticoagulation in all patients supported on ECMO, especially in those who are pregnant.

Despite protocol-driven anticoagulation and routine postdecannulation DVT surveillance, the patient suffered cannula-associated (Ca-) DVT. Our institutional rate of CaDVT is 85%.14 The rate of CaDVT is not correlated with the mean aPTT while on ECMO.14 CaDVT tends to occur in those patients who are older, more obese, and on ECMO for a longer duration.14 Anticoagulation therapy was extended for 3 months after the diagnosis of CaDVT.

In this patient, an emergent CD was indicated in response to sudden maternal or fetal deterioration. Therefore, an experienced perinatal team was designated and asked to respond immediately if called to the medical intensive care unit, a location distant from both the operating room suite and the labor and delivery unit. A cache of surgical instruments, neonatal resuscitation equipment, obstetric-related (eg, oxytocin) and anesthetic-related medications, and equipment was also preassembled and maintained in the medical intensive care unit. If the pregnancy had reached 32–34 weeks EGA, with noted improvement in maternal condition, then any scheduled CD would have occurred in a Labor and Delivery operating room.

In summary, our case demonstrates that VV ECMO is feasible to prolong a pregnancy in a gravida suffering severe ARDS. Critical care support should be well planned, addressing both maternal and fetal considerations of ECMO (eg, flow rate–associated cardiovascular and respiratory goals, fetal monitoring, and anticoagulation). A plan for emergent delivery should be well established, including maintaining open lines of communication between the intensive care and perinatal clinicians; the immediate availability of a team to perform CD; and the prepositioning of required equipment and medications in an ICU often distant from the Labor and Delivery suite.

DISCLOSURES

Name: Omar Alyamani, MD.

Contribution: This author helped write and approve the final manuscript.

Name: Michael A. Mazzeffi, MD.

Contribution: This author helped conceive, write, edit, and approve the final manuscript.

Name: Shobana Bharadwaj, MBBS.

Contribution: This author helped conceive, write, edit, and approve the final manuscript.

Name: Jessica H. Galey, MD.

Contribution: This author helped write and approve the final manuscript.

Name: Ruofan Yao, MD.

Contribution: This author helped write, edit, and approve the final manuscript.

Name: Nirav G. Shah, MD.

Contribution: This author helped write, edit, and approve the final manuscript.

Name: Andrew M. Malinow, MD.

Contribution: This author helped conceive, write, edit, and approve the final manuscript.

This manuscript was handled by: Hans-Joachim Priebe, MD, FRCA, FCAI.

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