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Sebastian NA, Spence AR, Bouhadoun S, Abenhaim HA. Extracorporeal membrane oxygenation in pregnant and postpartum patients: a systematic review. J Matern Fetal Neonatal Med 2020; 35:4663-4673. [PMID: 33345652 DOI: 10.1080/14767058.2020.1860932] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Information on the use of extracorporeal membrane oxygenation (ECMO) in obstetric patients is scarce. The objective was to conduct a systematic review examining ECMO use in pregnant and postpartum patients in order to identify indications leading to ECMO use and to assess mortality rates. MATERIALS AND METHODS PubMed, EMBASE, Cochrane Library, and SCOPUS were searched using the terms "extracorporeal membrane oxygenation" and "pregnancy" up to 1 November 2020. Case reports and case series reporting the use of ECMO in pregnancy were eligible. Data about maternal age, gestational age, diagnosis, type of ECMO, time on ECMO, pregnancy outcomes, and maternal survival were extracted from studies. RESULTS The search yielded 1696 citations, of which 125 were included. There were 213 obstetric patients treated with ECMO over a 30-year period. The frequency of reports increased considerably over the last decade. The majority of patients were treated in their third trimester (28.2%) or postpartum (32.9%). Most common etiologies included influenza-induced ARDS (27.7%), pulmonary embolism (13.6%), peripartum cardiomyopathy (11.7%), and infection (11.7%). Pregnancy outcomes ended with live births, either on ECMO (15.5%, 95% CI 10.6-20.4) or not on ECMO (58.3%, 95% CI 51.7-64.9), in fetal demise (8.9%, 95% CI 5.1-12.7), or in spontaneous or induced abortion on ECMO (4.2%, 95% CI 1.5-6.9) or not on ECMO (4.2%, 95% CI 1.5-6.9). Maternal survival was 79.3%. CONCLUSION Although women placed on ECMO had a high mortality rate, this is likely an indication of the severity of illness. Overall, ECMO appears to be a valid therapy for the temporary support of vital organs in severely ill pregnant women.
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Affiliation(s)
- Natasha A Sebastian
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Andrea R Spence
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada
| | - Sarah Bouhadoun
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Haim A Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada
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Extracorporeal Membrane Oxygenation Utility in Postpartum Patients. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:191-195. [PMID: 32981956 DOI: 10.1182/ject-2000021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/14/2020] [Indexed: 01/26/2023]
Abstract
Although extracorporeal membrane oxygenation (ECMO) has been used in many different populations, its use in pregnant or postpartum patients has not been widely studied. This article reviews the ECMO experience in this population at a large urban hospital. Electronic medical records for all pregnant or postpartum patients who required ECMO between 2012 and 2019 were retrospectively reviewed. Data on clinical characteristics, outcomes, and complications were gathered. Comparisons between survivors and nonsurvivors were completed. Ten postpartum patients were identified. The patients presented as follows: four with cardiac arrest, one with a massive pulmonary embolism, three with acute respiratory distress syndrome (ARDS), one with combined ARDS and cardiogenic shock, and one with suspected amniotic embolism. Survival to decannulation was 70%, and survival to discharge was 60%. When comparing survivors vs. nonsurvivors, ECMO survivors tended to have shorter support times vs. nonsurvivors. Otherwise, no differences were noted in age, mechanical ventilation time, or length of stay. Disseminated intravascular coagulation was a common phenomenon in this patient cohort. After initiation of ECMO, elevated serum lactate levels, lower systolic blood pressure, and acute renal failure were predictors of mortality. In a single institution at a large metroplex, we present data regarding the use of ECMO in postpartum patients. ECMO can be successfully used in selected postpartum patients with severe cardiac or respiratory dysfunction. Multidisciplinary collaboration on a regular basis will streamline the ECMO referral in a timely manner. Furthermore, larger studies are indicated to understand the utility of ECMO in larger cohorts.
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Naoum EE, Chalupka A, Haft J, MacEachern M, Vandeven CJM, Easter SR, Maile M, Bateman BT, Bauer ME. Extracorporeal Life Support in Pregnancy: A Systematic Review. J Am Heart Assoc 2020; 9:e016072. [PMID: 32578471 PMCID: PMC7670512 DOI: 10.1161/jaha.119.016072] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background The use of extracorporeal life support (ECLS) has expanded to include unique populations such as peripartum women. This systematic review aims to (1) quantify the number of cases and indications for ECLS in women during the peripartum period reported in the literature and (2) report maternal and fetal complications and outcomes associated with peripartum ECLS. Methods and Results This review was registered in PROSPERO (CRD42018108142). MEDLINE, Embase, and CINAHL were searched for case reports, case series, and studies reporting cases of ECLS during the peripartum period that reported one or more of the following outcomes: maternal survival, maternal complications, fetal survival, and/or fetal complications. Qualitative assessment of 221 publications evaluated the number of cases, clinical details, and maternal and fetal outcomes of ECLS during the peripartum period. There were 358 women included and 68 reported fetal outcomes in cases where the mother was pregnant at the time of cannulation. The aggregate maternal survival at 30 days was 270 (75.4%) and at 1 year was 266 (74.3%); fetal survival was 44 (64.7%). The most common indications for ECLS overall in pregnancy included acute respiratory distress syndrome 177 (49.4%), cardiac failure 67 (18.7%), and cardiac arrest 57 (15.9%). The most common maternal complications included mild to moderate bleeding 66 (18.4%), severe bleeding requiring surgical intervention 48 (13.4%), and intracranial neurologic morbidity 19 (5.3%). The most commonly reported fetal complications included preterm delivery 33 (48.5%) and neonatal intensive care unit admission 19 (27.9%). Conclusions Reported rates of survival in ECLS in pregnant and postpartum women are high and major complications relatively low.
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Affiliation(s)
- Emily E. Naoum
- Department of AnesthesiologyUniversity of MichiganAnn ArborMI
| | - Andrew Chalupka
- Department of Anesthesia, Critical Care and Pain MedicineMassachusetts General HospitalBostonMA
| | - Jonathan Haft
- Department of Cardiac SurgeryUniversity of MichiganAnn ArborMI
| | - Mark MacEachern
- Taubman Health Sciences LibraryUniversity of MichiganAnn ArborMI
| | - Cosmas J. M. Vandeven
- Department of Obstetrics and GynecologyMaternal‐Fetal MedicineUniversity of MichiganAnn ArborMI
| | - Sarah Rae Easter
- Division of Maternal‐Fetal MedicineDepartment of Obstetrics and GynecologyBrigham and Women’s HospitalBostonMA
| | - Michael Maile
- Department of AnesthesiologyUniversity of MichiganAnn ArborMI
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and PharmacoeconomicsDepartment of MedicineDepartment of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s HospitalBostonMA
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Cotter EK, Banayan J, Tung A, Gupta A, Mueller A, Shahul S. Trends and Outcomes of Mechanical Circulatory Support in Peripartum Women, 2002-2014: A Nationwide Inpatient Sample Analysis. J Cardiothorac Vasc Anesth 2020; 34:1198-1203. [DOI: 10.1053/j.jvca.2019.11.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/26/2019] [Accepted: 11/29/2019] [Indexed: 11/11/2022]
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Successful Use of Extracorporeal Membrane Oxygenation for Status Asthmaticus in a Woman With a Periviable Pregnancy. Obstet Gynecol 2019; 132:1007-1010. [PMID: 30130348 DOI: 10.1097/aog.0000000000002799] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Status asthmaticus is a severe asthma exacerbation with persistent airway obstruction despite standard therapy. Use of extracorporeal membrane oxygenation (ECMO) as rescue therapy in pregnancy is exceedingly rare. We describe a case of ECMO for treatment of status asthmaticus in woman with a periviable pregnancy culminating in a term delivery. CASE The patient was a 33-year-old woman, gravida 3 para 1, admitted at 23 2/7 weeks of gestation with respiratory failure secondary to status asthmaticus. Venovenous ECMO was initiated and continued for 6 days. After hospital discharge, she had no further respiratory issues. She ultimately developed fetal growth restriction and gestational hypertension and underwent a repeat cesarean delivery at 38 weeks of gestation. CONCLUSION Venovenous ECMO can be used successfully for status asthmaticus during a periviable pregnancy and enable delivery at term.
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Radsel P, Gorjup V, Jazbec A, Knafelj R, Lucovnik M, Kavsek G, Kornhauser Cerar L, Noc M. Pregnancy complicated by influenza A ARDS requiring consecutive VV-ECMO treatment with successful vaginal delivery. J Artif Organs 2018; 21:471-474. [PMID: 29774445 DOI: 10.1007/s10047-018-1050-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/14/2018] [Indexed: 10/16/2022]
Abstract
A 29-year-old woman presented with influenza A ARDS at 23+0 weeks of gestation. Mechanical ventilation failed and VV-ECMO was started in a non-ECMO hospital. Transportation was performed on ECMO. Within 5 days ECMO weaning was successful. Fetal condition was stable, and decision to continue pregnancy was taken. However, second VV-ECMO was needed due to ventilator-associated pneumonia. At 25+6 weeks, the patient spontaneously delivered a neonate vaginally. Patient's condition improved, and ECMO could be removed 10 days postpartum. 2-year follow-up showed no severe consequences in the mother and the child.
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Affiliation(s)
- Peter Radsel
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia.
| | - Vojka Gorjup
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Anja Jazbec
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Rihard Knafelj
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Miha Lucovnik
- Division of Gynecology and Obstetrics, Department of Perinatology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Gorazd Kavsek
- Division of Gynecology and Obstetrics, Department of Perinatology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Lilijana Kornhauser Cerar
- Division of Gynecology and Obstetrics, Department of Perinatology, University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Marko Noc
- Department of Intensive Internal Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia
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A Case Report of Recurrent Severe Peripartum Cardiomyopathy Complicated by Factor V Leiden and Multiple Endocrine Neoplasia Type 1: A Management Conundrum. A A Pract 2018; 10:195-197. [PMID: 29652683 DOI: 10.1213/xaa.0000000000000659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cardiovascular disease is the leading cause of peripartum death in the United States during pregnancy. The presence of concomitant diagnoses may complicate or conflict with the management of the primary cardiovascular diagnosis and further complicate pregnancy and delivery. We describe the management of a 29-year-old, gravida 5, para 1 woman with severe peripartum cardiomyopathy during this and a previous pregnancy complicated by multiple endocrine neoplasia type and factor V Leiden thrombophilia, limiting therapeutic options and contributing to considerable perioperative management challenges.
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Steinack C, Lenherr R, Hendra H, Franzen D. The use of life-saving extracorporeal membrane oxygenation (ECMO) for pregnant woman with status asthmaticus. J Asthma 2016; 54:84-88. [PMID: 27340744 DOI: 10.1080/02770903.2016.1193871] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Status asthmaticus can develop into a life-threatening disorder that requires mechanical ventilation. Severe respiratory failure during pregnancy can worsen maternal and fetal outcomes. Previous case studies have demonstrated extracorporeal membrane oxygenation (ECMO) as a life-saving measure for pregnant women with acute respiratory distress syndrome (ARDS) as well as non-pregnant patients with status asthmaticus. CASE STUDY A 25-year-old woman, who was 5 weeks pregnant, was admitted with status asthmaticus and severe hypercapnic respiratory failure. Despite rescue therapies such as pressure control ventilation with high inspiratory pressures, inhaled beta2 agonists and antimuscarinic drugs, intravenous salbutamol, methylprednisolone and magnesium sulfate, her condition gradually deteriorated. Veno-venous ECMO was initiated for respiratory support and the patient's clinical condition as well as the gas exchange improved within the next few days. ECMO was removed and the patient was extubated after 2 days. Sonography, however, revealed a retrochorial hematoma; the patient was diagnosed with abortus imminens and successfully treated with magnesium substitution and bed rest. Finally, she gave birth to a healthy boy at 38 weeks of gestation. CONCLUSIONS This is the first case report on the successful use of ECMO in a pregnant woman with severe respiratory insufficiency due to status asthmaticus, who failed to respond to invasive mechanical ventilation and maximum pharmacological treatment. Despite this life-threatening condition, the use of ECMO in our patient has greatly improved the chance of survival for the mother and the baby, who was born without any complications.
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Affiliation(s)
- Carolin Steinack
- a Division of Pulmonology , University Hospital Zurich , Zurich , Switzerland
| | - Renato Lenherr
- b Surgical Intensive Care Unit , University Hospital Zurich , Zurich , Switzerland
| | - Heidy Hendra
- c Acute Care Common Stem, Broomfield Hospital , Chelmsford , UK
| | - Daniel Franzen
- a Division of Pulmonology , University Hospital Zurich , Zurich , Switzerland
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Moore SA, Dietl CA, Coleman DM. Extracorporeal life support during pregnancy. J Thorac Cardiovasc Surg 2016; 151:1154-60. [DOI: 10.1016/j.jtcvs.2015.12.027] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 11/27/2015] [Accepted: 12/12/2015] [Indexed: 11/17/2022]
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Abstract
One-third of pregnant asthmatics experience a worsening of their asthma that may progress to a critical asthma syndrome (CAS) that includes status asthmaticus (SA) and near-fatal asthma (NFA). Patients with severe asthma before pregnancy may experience more exacerbations, especially during late pregnancy. Prevention of the CAS includes excellent asthma control involving targeted early and regular medical care of the pregnant asthmatic, together with medication compliance. Spontaneous abortion risk is higher in pregnant women with uncontrolled asthma than in non-asthmatics. Should CAS occur during pregnancy, aggressive bronchodilator therapy, montelukast, and systemic corticosteroids can be used in the context of respiratory monitoring, preferably in an Intensive Care Unit (ICU). Systemic epinephrine should be avoided due to potential teratogenic side-effects and placental/uterine vasoconstriction. Non-invasive ventilation has been used in some cases. Intratracheal intubation can be hazardous and rapid-sequence intubation by an experienced physician is recommended. Mechanical ventilation parameters are adjusted based on changes to respiratory mechanics in the pregnant patient. An inhaled helium-oxygen gas admixture may promote laminar airflow and improve gas exchange. Permissive hypercapnea is controversial, but may be unavoidable. Sedation with propofol which itself has bronchodilating properties is preferred to benzodiazepines. Case reports delineating good outcomes for both mother and fetus despite intubation for SA suggest that multidisciplinary ICU care of the pregnant asthmatic with critical asthma are feasible especially if hypoxemia is avoided.
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11
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Anselmi A, Ruggieri VG, Letheulle J, Robert AL, Tomasi J, Le Tulzo Y, Verhoye JP, Flécher E. Extracorporeal Membrane Oxygenation in Pregnancy. J Card Surg 2015; 30:781-6. [DOI: 10.1111/jocs.12605] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Amedeo Anselmi
- Division of Thoracic, Cardiac and Vascular Surgery; Pontchaillou University Hospital; Rennes France
- INSERM (French National Institution for Healthcare and Medical Research) Unit 1099; University of Rennes 1; Rennes France
| | - Vito G. Ruggieri
- Division of Thoracic, Cardiac and Vascular Surgery; Pontchaillou University Hospital; Rennes France
- INSERM (French National Institution for Healthcare and Medical Research) Unit 1099; University of Rennes 1; Rennes France
| | - Julien Letheulle
- Division of Medical Intensive Care Unit; Pontchaillou University Hospital; Rennes France
| | - Anne L. Robert
- Division of Obstetrics and Gynecology; Pontchaillou University Hospital; Rennes France
| | - Jacques Tomasi
- Division of Thoracic, Cardiac and Vascular Surgery; Pontchaillou University Hospital; Rennes France
| | - Yves Le Tulzo
- Division of Medical Intensive Care Unit; Pontchaillou University Hospital; Rennes France
| | - Jean-Philippe Verhoye
- Division of Thoracic, Cardiac and Vascular Surgery; Pontchaillou University Hospital; Rennes France
- INSERM (French National Institution for Healthcare and Medical Research) Unit 1099; University of Rennes 1; Rennes France
| | - Erwan Flécher
- Division of Thoracic, Cardiac and Vascular Surgery; Pontchaillou University Hospital; Rennes France
- INSERM (French National Institution for Healthcare and Medical Research) Unit 1099; University of Rennes 1; Rennes France
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Viktorsdottir O. Pulmonary Hypertension in Pregnancy and Anesthetic Implications. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-014-0097-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Pulmonary hypertension is a medical condition characterized by elevated pulmonary arterial pressure and secondary right heart failure. Pulmonary arterial hypertension is a subset of pulmonary hypertension, which is characterized by an underlying disorder of the pulmonary arterial vasculature. Pulmonary hypertension can also occur secondarily to structural cardiac disease, autoimmune disorders, and toxic exposures. Although pregnancies affected by pulmonary hypertension and pulmonary arterial hypertension are rare, the pathophysiology exacerbated by pregnancy confers both high maternal and fetal mortality and morbidity. In light of new treatment modalities and the use of a multidisciplinary approach to care, maternal outcomes may be improving.
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Affiliation(s)
- Sarah G Običan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 622 W 168th St, PH 16-66, New York, NY 10032.
| | - Kirsten L Cleary
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, 622 W 168th St, PH 16-66, New York, NY 10032
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Madsen K, Strange DG, Hedegaard M, Mathiesen ER, Damm P. Maternal and fetal recovery after severe respiratory failure due to influenza: a case report. BMC Res Notes 2013; 6:62. [PMID: 23414816 PMCID: PMC3583672 DOI: 10.1186/1756-0500-6-62] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Accepted: 02/06/2013] [Indexed: 11/18/2022] Open
Abstract
Background During pregnancy women are at increased risk of severe complications to influenza infection, including death of mother or fetus, especially if chronic comorbid medical conditions such as diabetes mellitus are present. Case presentation A 36 years old Caucasian pregnant woman with type 1 diabetes underwent mechanical ventilation in gestation week 27 for severe respiratory failure due to influenza and pneumonia. For three weeks during and following her most severe illness, fetal growth could not be detected and the umbilical flows and amniotic fluid volumes were affected too. The possibility of preterm delivery and extracorporeal membrane oxygenation (ECMO) treatment were considered, however the patient and her fetus recovered gradually on conservative treatment. Under close surveillance the pregnancy continued until term, with delivery of an infant with appropriate weight for gestational age. Conclusion Preterm delivery and decreased birth weight were reported for women with antepartum pneumonia. Mechanical ventilation and ECMO treatment for severe respiratory failure in pregnancy are life threatening conditions and have been associated with preterm delivery. It remains uncertain if delivery improves the respiratory status of a critically ill woman, and the fetal condition is likely to improve, if the maternal condition is stabilized. Severe respiratory insufficiency requiring mechanical ventilation in a diabetic pregnant woman with influenza was successfully treated conservatively. Despite clear signs of impaired fetal condition in the acute phase, watchful waiting resulted in delivery of a normal weight infant at term.
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Affiliation(s)
- Kristine Madsen
- Department of Obstetrics, Center for Pregnant Women with Diabetes, The Juliane Marie Centre, Rigshospitalet, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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Grimme I, Winter R, Kluge S, Petzoldt M. Hypoxic cardiac arrest in pregnancy due to pulmonary haemorrhage. BMJ Case Rep 2012; 2012:bcr-2012-006741. [PMID: 22922930 DOI: 10.1136/bcr-2012-006741] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
A 23-year-old woman developed massive pulmonary haemorrhage in the 19th week of pregnancy. Essential invasive ventilation was seriously impaired by the mechanical properties of the blood-filled lungs. Consecutive severe respiratory failure (pO(2) 10 mm Hg, pCO(2) 320 mm Hg, pH 6.73) induced a cardiac arrest. Bronchoscopy could not identify the source of bleeding. During 45 min of cardiopulmonary resuscitation, veno-venous extracorporeal membrane oxygenation (ECMO) was installed. Subsequently, neither a high-resolution CT (HRCT) scan nor pulmonary angiography could identify the origin of the haemorrhage. Finally, the excessive pulmonary bleeding was controlled by placing an endobronchial blocker in the middle lobe bronchus. However, pulmonary haemorrhage reoccurred and this time HRCT revealed an isolated bronchiectasis in the middle lobe. Based on this finding, surgical lobectomy was performed. The patient recovered fully without any neurological sequelae. A solitary bronchiectasis has not previously been described as a cause of massive pulmonary haemorrhage in pregnancy.
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Affiliation(s)
- Ina Grimme
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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16
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Nair P, Davies AR, Beca J, Bellomo R, Ellwood D, Forrest P, Jackson A, Pye R, Seppelt I, Sullivan E, Webb S. Extracorporeal membrane oxygenation for severe ARDS in pregnant and postpartum women during the 2009 H1N1 pandemic. Intensive Care Med 2011; 37:648-54. [PMID: 21318437 PMCID: PMC7095332 DOI: 10.1007/s00134-011-2138-z] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 01/17/2011] [Indexed: 12/13/2022]
Abstract
PURPOSE To describe the technical challenges, efficacy, complications and maternal and infant outcomes associated with extracorporeal membrane oxygenation (ECMO) for severe adult respiratory distress syndrome (ARDS) in pregnant or postpartum patients during the 2009 H1N1 pandemic. METHODS Twelve critically ill pregnant and postpartum women were included in this retrospective observational study on the application of ECMO for the treatment of severe ARDS refractory to standard treatment. The study was conducted at seven tertiary hospitals in Australia and New Zealand. RESULTS Of the 12 patients treated with ECMO, 7 (58%) were pregnant and 5 (42%) were postpartum. Their median (interquartile range [IQR]) age was 29 (26-33) years, 6 (50%) were obese. Two patients were initially treated with veno-arterial (VA) ECMO. All others received veno-venous (VV) ECMO with one or two drainage cannulae. ECMO circuit-related complications were rare, circuit change was needed in only two cases and there was no sudden circuit failure. On the other hand, bleeding was common, leading to relatively large volumes of packed red blood cell transfusion (median [IQR] volume transfused was 3,499 [1,451-4,874] ml) and was the main cause of death (three cases). Eight (66%) patients survived to discharge and seven were ambulant, with normal oxygen saturations. The survival rate of infants whose mothers received ECMO was 71% and surviving infants were discharged home with no sequelae. CONCLUSIONS The use of ECMO for severe ARDS in pregnant and postpartum women was associated with a 66% survival rate. The most common cause of death was bleeding. Infants delivered of mothers who had received ECMO had a 71% survival rate and, like their mothers, had no permanent sequelae at hospital discharge.
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Affiliation(s)
- Priya Nair
- Department of Intensive Care, Intensive Care Unit, St Vincents Hospital, Sydney, NSW, 2010, Australia.
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17
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Abstract
I reflected on the training I had on an extraordinary treatment for profound respiratory failure. The result of training enabled us to successfully treat a young female with the influenza A virus with extracorporeal membrane oxygenation (ECMO). I report the positive outcome that occurred, while continuing to run a busy general intensive care unit (ICU). She was the first of six patients who were all successfully treated with ECMO. Ten trained and experienced critical care nurses and two doctors attended the ECMO training course provided by the national centre in the UK. Five patients had already received ECMO therapy in the Scottish specialist unit (over the period of 8 years). As our Scottish specialist unit purchased exactly the same equipment as the national centre, it was easier for the multidisciplinary team to utilize their new-found knowledge and treat future patients with ECMO. With the predicted swine flu (H1N1) pandemic and the subsequent demand for critical care beds, funding was obtained to facilitate ECMO training. The potential need for increased provision of ECMO therapies was highlighted by recent events in Australia and New Zealand. Their most recent winter produced 68 patients requiring ECMO, whereas the previous year had manifested only three. Using our new equipment and adapted protocols from the national centre, we used these new skills to treat our first patient in October 2009. Johns' reflective practice tool was used to evaluate the care provided. Our patient was on ECMO for 9 days. She went on to make a remarkable recovery and was discharged from the ICU 1 week after ECMO was discontinued. She was discharged to the cardiothoracic high-dependency unit, where she was successfully rehabilitated. We were able to successfully treat a young lady, while providing the care for all other patients. This was a complex treatment, one that uses many resources including time and finance. Now that we have all the equipment, the necessary training and the knowledge, we can continue to deliver this service to the public in our locality.
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Affiliation(s)
- Sean Berryman
- Intensive Care Unit, Aberdeen Royal Infirmary, Aberdeen, UK.
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18
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Robertson LC, Allen SH, Konamme SP, Chestnut J, Wilson P. The successful use of extra-corporeal membrane oxygenation in the management of a pregnant woman with severe H1N1 2009 influenza complicated by pneumonitis and adult respiratory distress syndrome. Int J Obstet Anesth 2010; 19:443-7. [PMID: 20705450 PMCID: PMC7127547 DOI: 10.1016/j.ijoa.2010.04.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Revised: 03/18/2010] [Accepted: 04/16/2010] [Indexed: 11/30/2022]
Abstract
We report a case of H1N1 2009 influenza A, in a previously fit woman at 24 weeks of gestation, who presented atypically with abdominal pain. The infection was complicated by severe respiratory failure and acute respiratory distress syndrome, requiring ventilatory support, including extra-corporeal membrane oxygenation (ECMO). This was one of the first cases of severe H1N1 disease presenting in the UK. Use of extra-corporeal membrane oxygenation for the complications of H1N1 resulted in full maternal recovery and subsequent delivery of a healthy infant.
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Affiliation(s)
- L C Robertson
- Department of Anaesthesia, Crosshouse Hospital, Kilmarnock, UK.
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Oluyomi-Obi T, Avery L, Schneider C, Kumar A, Lapinsky S, Menticoglou S, Zarychanski R. Perinatal and maternal outcomes in critically ill obstetrics patients with pandemic H1N1 Influenza A. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2010; 32:443-447. [PMID: 20500952 DOI: 10.1016/s1701-2163(16)34497-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND During the influenza pandemic of spring 2009, Manitoba had a disproportionate number of pregnant women who became critically ill. Information about these cases will be useful to help us understand the potential impact of future outbreaks and review critical illness in pregnancy. METHODS We describe the clinical details of six critically ill pregnant women with pandemic H1N1 2009 influenza virus admitted to two ICUs in Manitoba between March 1 and August 31, 2009. RESULTS Thirty adult pregnant women tested positive for pandemic H1N1 2009 virus in Manitoba. Six women were admitted to the ICU. The time from onset of symptoms to life-threatening deterioration was on average five days. Most patients presented with worsening fever and cough and had H1N1-positive contacts. Five of six patients (83%) were Aboriginal. Four of six cases occurred in the third trimester. These patients frequently required non-conventional ventilatory support such as high frequency ventilation or extracorporeal membrane oxygenation (ECMO). All patients received oseltamivir. Two patients died while in the ICU. Three of six patients had adverse perinatal outcomes, and there was one spontaneous abortion and one early preterm delivery. CONCLUSION Pandemic H1N1 2009 influenza virus has the potential to cause severe illness in pregnant patients. Those patients requiring ICU admission for respiratory support have a high risk for poor fetal and neonatal outcome. The experience of this cohort underscores the appropriateness of public health measures directed at prevention and early treatment of H1N1 infection in pregnancy.
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Affiliation(s)
- Titilayo Oluyomi-Obi
- Department of Obstetrics, Gynaecology and Reproductive Sciences, University of Manitoba, Winnipeg MB
| | - Lisa Avery
- Department of Obstetrics, Gynaecology and Reproductive Sciences, University of Manitoba, Winnipeg MB; Centre for Global Pubic Health, Department of Community Health Sciences, University of Manitoba, Winnipeg MB; Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg MB
| | - Carol Schneider
- Department of Obstetrics, Gynaecology and Reproductive Sciences, University of Manitoba, Winnipeg MB
| | - Anand Kumar
- Department of Internal Medicine, University of Manitoba, Winnipeg MB
| | - Stephen Lapinsky
- Department of Internal Medicine, University of Toronto, Toronto ON
| | - Savas Menticoglou
- Department of Obstetrics, Gynaecology and Reproductive Sciences, University of Manitoba, Winnipeg MB
| | - Ryan Zarychanski
- Department of Internal Medicine, University of Manitoba, Winnipeg MB; Department of Haematology and Medical Oncology, Cancer Care Manitoba, Winnipeg MB
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Welch SA, Snowden LN, Buscher H. Pandemic (H1N1) 2009 influenza, pregnancy and extracorporeal membrane oxygenation. Med J Aust 2010; 192:668. [DOI: 10.5694/j.1326-5377.2010.tb03675.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Accepted: 04/11/2010] [Indexed: 11/17/2022]
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Abstract
BACKGROUND Safety and efficacy of extracorporeal membrane oxygenation (ECMO) in pregnancy is unknown. CASE A 33-year-old pregnant woman at 23 weeks of gestation presented with acute respiratory distress syndrome unresponsive to conventional mechanical ventilation. Early initiation of ECMO therapy along with protective mechanical ventilation strategy resulted in an excellent maternal and fetal outcome. CONCLUSION Extracorporeal membrane oxygenation can be life saving when initiated early in pregnant patients with severe acute respiratory insufficiency unresponsive to conventional mechanical ventilation.
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Affiliation(s)
- Jennifer A Cunningham
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
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Dasan J, Littleford J, McRae K, Farine D, Winton T. Mediastinal tumour in a pregnant patient presenting as acute cardiorespiratory compromise. Int J Obstet Anesth 2006; 11:52-6. [PMID: 15321577 DOI: 10.1054/ijoa.2001.0915] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A parturient at 35 weeks' gestation presented with severe shortness of breath, orthopnea and signs of fetal compromise. She was diagnosed with a large mediastinal tumour occupying 65% of transthoracic diameter, and a pericardial effusion. The trachea, both mainstem bronchi, pulmonary artery and superior vena cava were compressed. Her dyspnea continued despite relief of the cardiac tamponade by percutaneous drainage. Tissue obtained via anterior mediastinotomy, performed under local anesthesia infiltration, revealed a definitive diagnosis of non-Hodgkin's lymphoma. The patient improved symptomatically following initiation of steroids and chemotherapy. She was delivered by elective cesarean section under epidural anesthesia on the fifth day after starting chemotherapy. The postoperative course was complicated by the development of a large pleural effusion that required drainage. Mother and baby were well at three and six-month follow up oncology visits.
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Affiliation(s)
- J Dasan
- Department of Anesthesia, Mount Sinai Hospital, Toronto, Canada
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Abstract
Asthma is a common cause of morbidity and mortality in the United States, with over two million Emergency Department (ED) visits each year. Airway inflammation is recognized as a major component in the pathophysiology of asthma. The classic presentation of asthma is that of wheezing, cough, and dyspnea, however, the severity of airflow limitation correlates poorly with clinical signs. Forced exhaled volume in 1 s (FEV(1)) and the peak expiratory flow rate (PEFR) are direct reflections of the severity of airflow obstruction and are the standard measures used in the ED to assess the severity of airflow obstruction and the response to therapy. Beta2-adrenergic bronchodilators, ipratropium bromide, and corticosteroids form the cornerstone of therapy. Inhaled corticosteroids, leukotriene modifying drugs, and noninvasive positive pressure ventilation should be considered in patients with severe disease and in those who have responded poorly to standard therapy. Mechanical ventilation is usually well tolerated and may be lifesaving in patients with refractory asthma. Precautions are required to prevent dynamic hyperinflation during assisted ventilation.
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Affiliation(s)
- Paul E Marik
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15261, USA
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