Case report of massive hemoptysis in pregnancy requiring veno-venous extracorporeal membrane oxygenation

Massive hemoptysis in pregnancy treated by ECMO combined with electronic bronchoscopy: A case report

Background

Massive hemoptysis during pregnancy is very rare. Dieulafoy's disease is one of the causes of massive hemoptysis. There are few reports of ECMO use to treat massive hemoptysis during pregnancy.

Findings

We report for the first time a patient with Dieulafoy's disease diagnosed at 29 weeks of pregnancy. The patient's hemoptysis occurred rapidly with large volumes. The bleeding amount reached 500 ml within half an hour, with the development of asphyxia and respiratory and cardiac arrest due to a blood clot blocking the airway. After successful cardiopulmonary resuscitation, the ventilator could not maintain effective ventilation. Emergency establishment of VV-ECMO was performed to maintain oxygen, and hemostasis was successfully achieved by performing bronchial artery embolization twice. We successfully cleaned blood clots in the airway four times by freezing and using a foreign body retrieval basket with an electronic bronchoscope. At the same time, small and smooth nodular lesions were found under bronchoscopy, and blood vessels with a diameter of 1.5 mm were found under Doppler mode with an ultrasonic bronchoscope, which was consistent with a diagnosis of Dieulafoy's disease. VV-ECMO was successfully stopped on the 3rd day of the disease course, tracheal intubation was successfully removed on the 5th day of the disease course, and the patient was discharged with no complications on the 16th day of the disease course.

Management of life-threatening malignant central airway obstruction: A novel approach of using extracorporeal membrane oxygenation with tumor debulking and stenting

Extracorporeal membrane oxygenation (ECMO) is an artificial lung or heart used to oxygenate and circulate blood. Veno-venous ECMO is most commonly used as an emergency therapy in patients with acute respiratory distress syndrome (ARDS), but it has the potential to be useful in other respiratory-related diseases. We report a case where ECMO successfully allowed for interventional pulmonary procedures in a patient with life-threatening tracheal obstruction secondary to lung cancer, requiring tumor debulking and silicone Y stent placement. The patient was a 44-year-old male who was admitted to the intensive care unit (ICU) for an advanced stage subcarinal tumor invading into the trachea and bilateral main stem bronchi. The tumor was unresectable, and the first attempt to debulk the tumor was terminated due to the risk of complete airway occlusion. With the help of ECMO, the second attempt at tumor debulking was successful, and a Y stent was placed. The patient regained ventilation in both lungs and was transferred out of the ICU on day 2 post-op. The pathology confirmed squamous cell carcinoma, programmed death-ligand 1 (PD-L1) 99%. The patient received immunotherapy after hospital discharge. ECMO has the potential to be useful for patients with severe tracheal obstructions and compromised respiratory systems. For patients with certain types of lung cancer, who are good candidates for novel immunotherapies and targeted therapies, it offers a potential bridging therapy for procedures that would otherwise be too dangerous and should be considered when traditional treatments for these patients fail.

Extracorporeal membrane oxygenation in pregnant and postpartum patients: a systematic review

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.

Venovenous Extracorporeal Membrane Oxygenation Combined with Fiberoptic Bronchoscopy-Assisted CO2 Cryotherapy in the Treatment of Massive Hemoptysis in Pregnancy: A Case Report

Background

Massive hemoptysis in pregnancy is very rare but can be life-threatening for both the pregnant woman and fetus. Extracorporeal membrane oxygenation (ECMO) is extremely rare in the treatment of severe hemoptysis in pregnancy. Here we describe the case of massive hemoptysis in the second trimester of pregnancy successfully treated with a combination of venovenous (VV)-ECMO, and bronchial artery embolization combined with fiberoptic bronchoscopy–assisted CO₂ cryotherapy.

Case Presentation

A 34-year-old patient at 28 2/7 weeks gestation with a history of hemoptysis for 3 days was transferred to our care. Massive hemoptysis completely blocked the trachea and main bronchus, and a ventilator could not carry out ventilation. ECMO was performed immediately when oxygenation was not maintained. A right lower bronchial artery hemorrhage was found by bronchial arteriography under ECMO, and embolization with microcoils and gelatin sponge particles was then performed. An emergency bedside carbon dioxide cryo-thrombectomy was performed under fiberoptic bronchoscopy because of obstruction of the trachea and main bronchus. Endotracheal cryotherapy was repeated (for a total three times) until bronchoscopic evaluation confirmed no obstruction of the trachea and no active bleeding in the airway. On day 7, ECMO was successfully evacuated. On day 15, the patient was extubated. On day 17, the tracheotomy was closed and replaced by nasal oxygen inhalation. On day 20, the patient was discharged from hospital. The patient has had no recurrence of hemoptysis in 3-month follow-up.

Conclusion

VV-ECMO combined with carbon dioxide cryotherapy in the treatment of pregnancy complicated with massive hemoptysis is an effective treatment, when massive hemoptysis completely blocked the trachea.

Extracorporeal Membrane Oxygenation-Combined Surgery for Hemoptysis Caused by a Mediastinal Hemangioma

The diagnosis and treatment of massive hemoptysis remain challenging. We report a 28-year-old woman with refractory massive hemoptysis caused by a mediastinal hemangioma. Despite multiple bronchial artery embolizations and fiberoptic bronchoscopy treatments, effective control of the bleeding and clearing of the airway was not possible. Finally, with the support of venovenous extracorporeal membrane oxygenation, mediastinal hemangioma resection and right upper lobe sleeve resection were simultaneously performed. During the operation, many blood clots in the airway were removed. The airway bleeding was effectively controlled, and the patient recovered.