1
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Yahav-Shafir D, Ilgiyaev E, Galante O, Gorfil D, Statlender L, Soroksky A, Carmi U, Sinai YB, Iprach N, Haviv-Yadid Y, Makhoul M, Fatnic E, Ginosar Y, Einav S, Helviz Y, Fink D, Sternik L, Kogan A. Extracorporeal membrane oxygenation in obstetric patients: An Israeli nationwide study. Artif Organs 2024; 48:392-401. [PMID: 38112077 DOI: 10.1111/aor.14691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 11/19/2023] [Accepted: 11/26/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND The leading causes of maternal mortality include respiratory failure, cardiovascular events, infections, and hemorrhages. The use of extracorporeal membrane oxygenation (ECMO) as rescue therapy in the peripartum period for cardiopulmonary failure is expanding in critical care medicine. METHODS This retrospective observational study was conducted on a nationwide cohort in Israel. During the 3-year period, between September 1, 2019, and August 31, 2022, all women in the peripartum period who had been supported by ECMO for respiratory or circulatory failure at 10 large Israeli hospitals were identified. Indications for ECMO, maternal and neonatal outcomes, details of ECMO support, and complications were collected. RESULTS During the 3-year study period, in Israel, there were 540 234 live births, and 28 obstetric patients were supported by ECMO, with an incidence of 5.2 cases per 100 000 or 1 case per 19 000 births (when excluding patients with COVID-19, the incidence will be 2.5 cases per 100 000 births). Of these, 25 were during the postpartum period, of which 16 (64%) were connected in the PPD1, and 3 were during pregnancy. Eighteen patients (64.3%) were supported by V-V ECMO, 9 (32.1%) by V-A ECMO, and one (3.6%) by a VV-A configuration. Hypoxic respiratory failure (ARDS) was the most common indication for ECMO, observed in 21 patients (75%). COVID-19 was the cause of ARDS in 15 (53.7%) patients. The indications for the V-A configuration were cardiomyopathy (3 patients), amniotic fluid embolism (2 patients), sepsis, and pulmonary hypertension. The maternal and fetal survival rates were 89.3% (n = 25) and 100% (n = 28). The average ECMO duration was 17.6 ± 18.6 days and the ICU stay was 29.8 ± 23.8 days. Major bleeding complications requiring surgical intervention were observed in one patient. CONCLUSIONS The incidence of using ECMO in the peripartum period is low. The maternal and neonatal survival rates in patients treated with ECMO are high. These results show that ECMO remains an important treatment option for obstetric patients with respiratory and/or cardiopulmonary failure.
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Affiliation(s)
- Dana Yahav-Shafir
- Department of Anaesthesiology, Sheba Medical Centre, Tel Hashomer, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eduard Ilgiyaev
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of General Intensive Care, Shamir Medical Center, Zerifin, Israel
| | - Ori Galante
- Intensive Care Unit, Soroka University Medical Centre, Beer-Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Dan Gorfil
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiothoracic Surgery, Cardiothoracic Intensive Care Unit, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
| | - Liran Statlender
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- General Intensive Care Unit, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
| | - Arie Soroksky
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Intensive Care Unit, Wolfson Medical Centre, Holon, Israel
| | - Uri Carmi
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Anesthesia, Pain and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yitzhak Brzezinski Sinai
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Anesthesia, Pain and Intensive Care, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Nisim Iprach
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Anesthesia and Intensive Care, Meir Medical Center, Kfar-Saba, Israel
| | - Yael Haviv-Yadid
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Intensive Care Unit, Sheba Medical Center, Tel Hashomer, Israel
| | - Maged Makhoul
- Department of Cardiac Surgery, Rambam Medical Center, Haifa, Israel
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Elena Fatnic
- Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Hebrew University, Ein Karem Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yehuda Ginosar
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Anesthesiology, Mother & Child Anesthesia Unit, Hadassah Hebrew University, Ein Karem Medical Center, Jerusalem, Israel
| | - Sharon Einav
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Yigal Helviz
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Daniel Fink
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Cardiothoracic Surgery, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Leonid Sternik
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiac Surgery, Sheba Medical Centre, Tel Hashomer, Israel
| | - Alexander Kogan
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Cardiac Surgery, Sheba Medical Centre, Tel Hashomer, Israel
- Cardiac Surgery Intensive Care Unit, Sheba Medical Centre, Tel Hashomer, Israel
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2
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Kakar V, Ahmed I, Ahmed W, Raposo N, Kumar G P. Peripartum veno-venous extracorporeal membrane oxygenation in patients with severe CoViD-19-related-ARDS. Perfusion 2024; 39:426-432. [PMID: 36484202 PMCID: PMC9742351 DOI: 10.1177/02676591221144729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
We describe a case series of five pregnant or postpartum women with severe CoViD-19-related ARDS requiring VV ECMO at our centre between Jan 1 and Sep 30, 2021. All patients were cannulated at the referring hospitals by our team before transferring to our centre. None of the women were vaccinated against CoViD-19. All had severe ARDS with Murray's Lung Injury Score of 3-4 and met the severity threshold for ECMO initiation that was used in the EOLIA study. All patients were discharged alive to home, acute rehabilitation, or lung transplant centre. One patient suffered intrauterine death before ECMO initiation and another while on ECMO. VV ECMO for refractory CoViD-19 related ARDS in the peripartum period is safe, and in this small series, it was associated with good maternal survival rates.
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Affiliation(s)
- Vivek Kakar
- Cardiac Critical Care and ECMO, Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Ihab Ahmed
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Walid Ahmed
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Nuno Raposo
- Vascular, and Thoracic Institute, Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Praveen Kumar G
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
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3
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O'Kelly AC, Sarma A, Naoum E, Easter SR, Economy K, Ludmir J. Cardiogenic Shock and Utilization of Mechanical Circulatory Support in Pregnancy. J Intensive Care Med 2024:8850666231225606. [PMID: 38204193 DOI: 10.1177/08850666231225606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
Maternal mortality rates are rising in the United States, a trend which is in contrast to that seen in other high-income nations. Cardiovascular disease and hypertensive disorders of pregnancy are consistently the leading causes of maternal mortality both in the United States and globally, accounting for about one-quarter to one-third of maternal and peripartum deaths. A large proportion of cardiovascular morbidity and mortality stems from acquired disease in the context of cardiovascular risk factors, which include obesity, pre-existing diabetes and hypertension, and inequities in care from maternal care deserts and structural racism. Patients may also become pregnant with preexisting structural heart disease, or acquire disease throughout pregnancy (ex: spontaneous coronary artery dissection, peripartum cardiomyopathy), and be at higher risk of pregnancy-related cardiovascular complications. While risk-stratification tools including the modified World Health Organization (mWHO) classification, Cardiac Disease in Pregnancy (CARPREG II) and Zwangerschap bij Aangeboren HARtAfwijking/Pregnancy in Women with Congenital Heart Disease (ZAHARA) have been designed to help physicians identify patients at increased risk for adverse pregnancy outcomes and who may therefore benefit from referral to a tertiary care center, the limitation of these scores is their predominant focus on patients with known preexisting heart disease. As such, identifying patients at risk for pregnancy complications presents a significant challenge, and it is often patients with high-risk cardiovascular substrates prior to or during pregnancy who are at a highest risk for adverse pregnancy outcomes including cardiogenic shock.
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Affiliation(s)
- Anna C O'Kelly
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Amy Sarma
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emily Naoum
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Rae Easter
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Katherine Economy
- Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Ludmir
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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4
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Buda KG, Urbach J, Saxena R, Stanberry L, Benson G, Hryniewicz K. Veno-Arterial Extracorporeal Membrane Oxygenation for Amniotic Fluid Embolism: A Report From the Extracorporeal Life Support Organization Registry. ASAIO J 2024; 70:e6-e8. [PMID: 37429016 DOI: 10.1097/mat.0000000000002011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023] Open
Affiliation(s)
- Kevin G Buda
- From the Minneapolis Heart Institute-Abbott Northwestern Hospital, Minneapolis, Minnesota
- Cardiology Division, Department of Internal Medicine, Hennepin Healthcare, Minneapolis, Minnesota
| | - Jonathan Urbach
- From the Minneapolis Heart Institute-Abbott Northwestern Hospital, Minneapolis, Minnesota
| | - Retu Saxena
- From the Minneapolis Heart Institute-Abbott Northwestern Hospital, Minneapolis, Minnesota
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | | | - Gretchen Benson
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | - Kasia Hryniewicz
- From the Minneapolis Heart Institute-Abbott Northwestern Hospital, Minneapolis, Minnesota
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5
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Palella S, Muscarà L, La Via L, Sanfilippo F. Veno-venous extracorporeal membrane oxygenation for rescue support in pregnant patients with COVID-19: a systematic review. Br J Anaesth 2023; 131:e130-e132. [PMID: 37544839 DOI: 10.1016/j.bja.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/13/2023] [Accepted: 07/07/2023] [Indexed: 08/08/2023] Open
Affiliation(s)
- Sofia Palella
- School of Anesthesia and Intensive Care, University "Magna Graecia", Catanzaro, Italy
| | - Liliana Muscarà
- School of Anesthesia and Intensive Care, University "Magna Graecia", Catanzaro, Italy
| | - Luigi La Via
- Department of Anesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, "Policlinico-San Marco" University Hospital, Catania, Italy; Department of Surgery and Medical-Surgical Specialties, University of Catania, Catania, Italy.
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6
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Donahoe LL, Snelgrove JW, de Perrot M, Sermer M, Silversides C, Granton J, Keshavjee S. Pregnancy and pulmonary hypertension in the pre-lung transplant patient: Successfully saving two lives with extracorporeal lung support. JTCVS Tech 2023; 20:186-191. [PMID: 37555024 PMCID: PMC10405314 DOI: 10.1016/j.xjtc.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/01/2023] [Accepted: 05/17/2023] [Indexed: 08/10/2023] Open
Affiliation(s)
- Laura L. Donahoe
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - John W. Snelgrove
- Department of Obstetrics and Gynecology, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Marc de Perrot
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mathew Sermer
- Department of Obstetrics and Gynecology, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
| | - Candice Silversides
- Department of Obstetrics and Gynecology, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, University of Toronto, Toronto, Ontario, Canada
| | - John Granton
- Division of Respirology and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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7
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Tsuchiya N, Obata S, Kasai M, Miyagi E, Aoki S. A case of cardiac arrest due to postpartum hemorrhage treated with hysterectomy and extracorporeal membrane oxygenation. Clin Case Rep 2023; 11:e7554. [PMID: 37323277 PMCID: PMC10264733 DOI: 10.1002/ccr3.7554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/14/2023] [Accepted: 05/30/2023] [Indexed: 06/17/2023] Open
Abstract
Although extracorporeal membrane oxygenation is relatively contraindicated in patients with severe disseminated intravascular coagulation (DIC), it can be safely introduced by providing adequate anti-DIC therapy.
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Affiliation(s)
- Naoki Tsuchiya
- Perinatal Center for Maternity and NeonatesYokohama City University Medical CenterYokohamaJapan
| | - Soichiro Obata
- Perinatal Center for Maternity and NeonatesYokohama City University Medical CenterYokohamaJapan
| | - Michi Kasai
- Perinatal Center for Maternity and NeonatesYokohama City University Medical CenterYokohamaJapan
| | - Etsuko Miyagi
- Department of Obstetrics and GynecologyYokohama City University HospitalYokohamaJapan
| | - Shigeru Aoki
- Perinatal Center for Maternity and NeonatesYokohama City University Medical CenterYokohamaJapan
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8
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Extracorporeal Membrane Oxygenation During Pregnancy. Clin Obstet Gynecol 2023; 66:151-162. [PMID: 36044634 DOI: 10.1097/grf.0000000000000735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
In the last 2 decades, the use of venovenous (VV) and venoarterial (VA) extracorporeal membrane oxygenation (ECMO) during pregnancy and the postpartum period has increased, mirroring the increased utilization in nonpregnant individuals worldwide. VV ECMO provides respiratory support for patients with acute respiratory distress syndrome (ARDS) who fail conventional mechanical ventilation. With the COVID-19 pandemic, the use of VV ECMO has increased dramatically and data during pregnancy and the postpartum period are overall reassuring. In contrast, VA ECMO provides both respiratory and cardiovascular support. Data on the use of VA ECMO during pregnancy are extremely limited.
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9
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Coffey P, Sakharuk I, Yoshida S, Drevets P, Patel V. Successful Cesarean Section in a COVID-19 Patient on Extracorporeal Membrane Oxygenation (ECMO). Am Surg 2023:31348231157858. [PMID: 36803096 PMCID: PMC9940999 DOI: 10.1177/00031348231157858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
The pandemic of COVID-19-related respiratory failure has increased utilization of ECMO in diverse patient populations. There are limited published reports of ECMO use in pregnancy, and reports of successful delivery of the fetus with survival of the mother on ECMO are exceptionally rare. We present a case of Cesarean section while on ECMO for COVID-19-related respiratory failure with survival of both mother and infant.A 37-year-old pregnant female presented with dyspnea following a positive COVID-19 test. D-Dimer and CRP were elevated and chest radiography was consistent with COVID-19 pneumonia. Her respiratory status rapidly decompensated-requiring endotracheal intubation within 6 hours of presentation, and ultimately veno-venous ECMO cannulation. Three days later, fetal heart rate decelerations prompted emergent caesarean delivery. The infant was transferred to the NICU and progressed well. The patient improved and she was decannulated on hospital day 22 (ECMO day 15) before discharge to rehab on hospital day 49.In this case, ECMO allowed survival of both mother and infant in an otherwise non-survivable respiratory failure. Consistent with existing reports, we believe ECMO is a viable strategy for refractory respiratory failure in the pregnant patient.
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Affiliation(s)
- Philip Coffey
- Department of Surgery, Medical College of Georgia at Augusta University, Augusta, GA, USA,Philip Coffey, MD, Department of Surgery, Medical College of Georgia at Augusta University, 1120 15th Street, Room BI 4076, Augusta, GA 30912, USA.
| | - Ilya Sakharuk
- Department of Surgery, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | | | - Peter Drevets
- Department of Surgery, Medical College of Georgia at Augusta University, Augusta, GA, USA,Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vijay Patel
- Department of Surgery, Medical College of Georgia at Augusta University, Augusta, GA, USA
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10
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Li Y, Xu C, Li F, Yan Z, Ye S, Ma J, Wen J. Five critically ill pregnant women/parturients treated with extracorporeal membrane oxygenation. J Cardiothorac Surg 2022; 17:321. [PMID: 36528774 PMCID: PMC9759865 DOI: 10.1186/s13019-022-02093-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Maternal mortality has always been a major medical concern. Recently, the successful application of extracorporeal membrane oxygenation (ECMO) technology in the rescue of near-death patients has been reported. CASE PRESENTATION This study retrospectively analyzed 5 cases of critically ill pregnant women/parturients treated with ECMO for respiratory and circulatory failure in the Wuxi People's Hospital from 2018 to 2020. The mean age of the 5 cases was 30.2 years. Among them, Cases 1 and 5 were treated with Venoarterial (VA) ECMO. Case 1 was diagnosed with congenital heart disease, atrial septal defect, and severe pulmonary hypertension. VA ECMO was applied before cesarean section and was successfully removed after double lung transplantation, but the patient died 10 months after delivery from lung infection. While Case 5 was diagnosed with systemic lupus erythematosus, lupus nephritis, thrombotic vascular disease, HELLP syndrome, and cerebral hemorrhage. VA ECMO was applied 39 days after cesarean section, and the patient died 40 days after delivery due to multiple organ failure. Cases 3 and 4 were treated with Venovenous (VV) ECMO. Case 3 was diagnosed with refractory postpartum hemorrhage, and Case 4 was diagnosed with postpartum hypoglycemic coma, aspiration pneumonia, and shock. They were treated with VV ECMO after delivery, and all survived after successful evacuation. Another Case (Case 2) was diagnosed with postpartum pelvic infection, sepsis and septic shock, and was treated with VA ECMO at 15 days after delivery. The patient changed to VV ECMO at 30 days after delivery due to significant improvement in heart function and poor lung function, but eventually died of multiple organ failure. For the 5 cases, the mean duration of ECMO was 8.7 days, the mean duration of intensive care was 22.0 days, and the mean length of hospital stay was 57.6 days. As a result, 3 patients gradually returned to normal with significant improvement in ventilation and oxygenation after ECMO treatment. CONCLUSIONS ECMO technology can be used to treat some of the critical obstetric patients with respiratory and circulatory failure that is ineffective to conventional treatment, but it has no therapeutic effect on the primary disease.
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Affiliation(s)
- Ying Li
- grid.89957.3a0000 0000 9255 8984Department of Obstetrics and Gynecology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Chi Xu
- grid.89957.3a0000 0000 9255 8984Emergency Department, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Furong Li
- grid.89957.3a0000 0000 9255 8984Department of Obstetrics and Gynecology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Zheng Yan
- grid.89957.3a0000 0000 9255 8984Department of Critical Care Medicine, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Shugao Ye
- grid.89957.3a0000 0000 9255 8984Department of Thoracic Surgery, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Jinqi Ma
- grid.89957.3a0000 0000 9255 8984Department of Obstetrics and Gynecology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Juan Wen
- grid.459791.70000 0004 1757 7869Nanjing Maternity and Child Health Care Institute, Women’s Hospital of Nanjing Medical University, Nanjing Maternity and Child Health Care Hospital, Nanjing, China
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11
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Abstract
Although the pregnant population was affected by early waves of the COVID-19 pandemic, increasing transmission and severity due to new viral variants has resulted in an increased incidence of severe illness during pregnancy in many regions. Critical illness and respiratory failure are relatively uncommon occurrences during pregnancy, and there are limited high-quality data to direct management. This paper reviews the current literature on COVID-19 management as it relates to pregnancy, and provides an overview of critical care support in these patients. COVID-19 drug therapy is similar to that used in the non-pregnant patient, including anti-inflammatory therapy with steroids and IL-6 inhibitors, although safety data are limited for antiviral drugs such as remdesivir and monoclonal antibodies. As both pregnancy and COVID-19 are thrombogenic, thromboprophylaxis is essential. Endotracheal intubation is a higher risk during pregnancy, but mechanical ventilation should follow usual principles. ICU management should be directed at optimizing maternal well-being, which in turn will benefit the fetus.
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Affiliation(s)
- Stephen E Lapinsky
- Faculty of Medicine, University of Toronto, Canada,Intensive Care Unit, Mount Sinai Hospital, Canada,Interdepartmental Division of Critical Care Medicine, University of Toronto,
Canada,Stephen Lapinsky, Faculty of Medicine, University
of Toronto, 600 University Ave, #18-214, Toronto, ON M5G1X5, Canada
| | - Maha Al Mandhari
- Interdepartmental Division of Critical Care Medicine, University of Toronto,
Canada
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12
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Franquet N, Pierart J, Defresne A, Joachim S, Fraipont V. Veno-venous Extracorporeal Membrane Oxygenation for pregnant women with Acute Respiratory Distress Syndrome: a narrative review. ACTA ANAESTHESIOLOGICA BELGICA 2022. [DOI: 10.56126/73.3.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Acute respiratory distress syndrome remains an uncommon condition during pregnancy. In patients with severe acute respiratory distress syndrome, when oxygenation or ventilation cannot be supported sufficiently using best practice conventional mechanical ventilation and additional therapies, veno-venous extracorporeal membrane oxygenation may be considered. In the past two decades, there has been increasing adoption of this technique to support adult patients with refractory acute respiratory distress syndrome. However, its use for the management of pregnant women is rare and remains a challenge. This narrative review addresses acute respiratory distress syndrome and its management during pregnancy, and then focuses on indications, contraindications, challenges, potential complications, and outcomes of the use of veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome in the pregnant patient.
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13
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Malfertheiner SF, Brodie D, Burrell A, Taccone FS, Broman LM, Shekar K, Agerstrand CL, Serra AL, Fraser J, Malfertheiner MV. Extracorporeal membrane oxygenation during pregnancy and peripartal. An international retrospective multicenter study. Perfusion 2022:2676591221090668. [PMID: 35549557 DOI: 10.1177/02676591221090668] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Extracorporeal Membrane Oxygenation (ECMO) may be used in the setting of pregnancy or the peripartal period, however its utility has not been well-characterized. This study aims to give an overview on the prevalence of peripartel ECMO cases and further assess the indications and outcomes of ECMO in this setting across multiple centers and countries. METHODS A retrospective, multicenter, international cohort study of pregnant and peripartum ECMO cases was performed. Data were collected from six ECMO centers across three continents over a 10-year period. RESULTS A total of 60 pregnany/peripartal ECMO cases have been identified. Most frequent indications are acute respiratory distress syndrome (n = 30) and pulmonary embolism (n = 5). Veno-venous ECMO mode was applied more often (77%). ECMO treatment during pregnancy was performed in 17 cases. Maternal and fetal survival was high with 87% (n = 52), respectively 73% (n = 44). CONCLUSIONS Various emergency scenarios during pregnancy and at time of delivery may require ECMO treatment. Peripartal mortality in a well-resourced setting is rare, however emergencies in the labor room occur and knowledge of available rescue therapy is essential to improve outcome. Obstetricians and obstetric anesthesiologists should be aware of the availability of ECMO resource at their hospital or region to ensure immediate contact when needed.
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Affiliation(s)
- S Fill Malfertheiner
- Department of Obstetrics and Gynecology, Hospital St. Hedwig of the Order of St. John, Regensburg University, Regensburg, Germany
| | - D Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, 12294Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - A Burrell
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - F S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, ULB, Brussels, Belgium
| | - L M Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - K Shekar
- Critical Care Research Group, 67567The Prince Charles Hospital, Brisbane, Australia
| | - C L Agerstrand
- Division of Pulmonary, Allergy, and Critical Care Medicine, 12294Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - A L Serra
- Division of Pulmonary, Allergy, and Critical Care Medicine, 12294Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York.,Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - J Fraser
- Critical Care Research Group, 67567The Prince Charles Hospital, Brisbane, Australia
| | - M V Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, University Hospital Regensburg, Regensburg, Germany
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14
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Ghafoor H, Abdus samad A, Bel Khair AOM, Ahmed O, Khan MNA. Critical Care Management of Severe COVID-19 in Pregnant Patients. Cureus 2022; 14:e24885. [PMID: 35572463 PMCID: PMC9097928 DOI: 10.7759/cureus.24885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 12/15/2022] Open
Abstract
Since December 2019, the coronavirus disease (COVID-19) pandemic has had a disastrous impact worldwide. COVID-19 is caused by the SARS-CoV-2 virus and was declared a pandemic by the WHO on March 11, 2020. The virus has been linked to a wide range of respiratory illnesses, ranging from mild symptoms to acute pneumonia and severe respiratory distress syndrome. Pregnant women are more vulnerable to COVID-19 complications owing to the physiological and immunological changes caused by pregnancy. According to the CDC, pregnant patients with COVID-19 are commonly hospitalized and often require admission to ICUs and ventilator support. Therefore, it is especially important for pregnant women to adhere to disease prevention measures to lower the risk of contracting the disease. In addition, the guidelines of several clinical societies and local health authorities should be followed when caring for pregnant women with suspected or confirmed COVID-19. In this review article, we discuss the epidemiology of COVID-19 during delivery, its effect on the physiological and immunological changes during pregnancy, the classification of COVID-19 severity, maternal and fetal risks, antenatal care, respiratory management, treatment/medication safety, timing and mode of delivery, anesthetic considerations, and the outcome of critically ill pregnant patients with COVID-19, as well as their post-delivery care and weaning from mechanical ventilation.
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15
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Cardiac disease in pregnancy. Best Pract Res Clin Anaesthesiol 2022; 36:191-208. [PMID: 35659955 DOI: 10.1016/j.bpa.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/16/2022] [Indexed: 11/22/2022]
Abstract
In the developed world, cardiovascular disease has become the most frequent cause of death during pregnancy and postpartum, outnumbering by far obstetric causes of death such as bleeding or thromboembolism. Many factors contribute to this phenomenon, including an increasing age of pregnant women, co-morbidities, and an unhealthy lifestyle. The cardiovascular system is not only significantly challenged by physiological alterations in pregnancy but also by obstetric medication. Depending upon the severity of the underlying condition, pregnant women with cardiovascular disease should be managed by a multidisciplinary heart team in which anaesthesiologists play an important role. Profound knowledge of the cardiac pathophysiology is a prerequisite for the successful anaesthesiologic management of pregnant patients with cardiovascular disease. As there is no difference in general and regional anaesthesia regarding maternal outcomes, neuraxial anaesthesia using incremental techniques should be preferred for labour and (caesarean) delivery if not contraindicated by non-cardiac issues.
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16
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(Tatsuya Harada) 原巽, (Satoyuki Ogino) 荻聡, (Shunkichi Sasazawa) 笹俊, (Fumio Asano) 浅史, (Shinji Tanigaki) 谷伸, (Yasuhiko Kaita) 海賢, (Yoshihiro Yamaguchi) 山芳. 妊娠中期に重症化した新型コロナウイルス感染症に対して集学的加療を行い母子ともに救命した1例(A case of a pregnant woman with severe COVID–19 who was treated by multidisciplinary therapy). NIHON KYUKYU IGAKUKAI ZASSHI: JOURNAL OF JAPANESE ASSOCIATION FOR ACUTE MEDICINE 2022. [PMCID: PMC9088687 DOI: 10.1002/jja2.12699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We report a case of a patient with coronavirus disease (COVID–19) in the second trimester of pregnancy who was started on venovenous extracorporeal membrane oxygenation (VV–ECMO) immediately after a cesarean section with ventilation and prone positioning, resulting in a good outcome for both the mother and the child. The patient, a woman in her 30s was transferred to our hospital due to worsening respiratory status at 28 weeks and 0 days of gestation, 8 days after the onset of COVID–19. On the second day, she was started on mechanical ventilation. Although the period of pregnancy was prolonged by prone ventilation, because the PaO2/FiO2 ratio (P/F) decreased to 76, we performed a cesarean section on the eighth day. She was started on VV–ECMO on the ninth day. Thereafter, her respiratory condition gradually improved, and she was weaned from VV–ECMO on the twenty–second day. Later, she was extubated on the twenty–fourth day and transferred from the intensive care unit to the general ward on the thirtieth day. In cases of COVID–19 that become severe in the second trimester of pregnancy, multidisciplinary treatment is necessary, taking into consideration the number of weeks of pregnancy.
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Affiliation(s)
- 原田 巽矢 (Tatsuya Harada)
- 杏林大学医学部付属病院高度救命救急センター(Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine)
| | - 荻野 聡之 (Satoyuki Ogino)
- 杏林大学医学部救急医学(Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine)
| | | | - 浅野 史男 (Fumio Asano)
- 杏林大学医学部産科婦人科学(Department of Obstetrics and Gynecology, Kyorin University School of Medicine)
| | - 谷垣 伸治 (Shinji Tanigaki)
- 杏林大学医学部産科婦人科学(Department of Obstetrics and Gynecology, Kyorin University School of Medicine)
| | - 海田 賢彦 (Yasuhiko Kaita)
- 杏林大学医学部救急医学(Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine)
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17
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Wong MJ, Bharadwaj S, Galey JL, Lankford AS, Galvagno S, Kodali BS. Extracorporeal Membrane Oxygenation for Pregnant and Postpartum Patients. Anesth Analg 2022; 135:277-289. [PMID: 35122684 DOI: 10.1213/ane.0000000000005861] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has seen increasing use for critically ill pregnant and postpartum patients over the past decade. Growing experience continues to demonstrate the feasibility of ECMO in obstetric patients and attest to its favorable outcomes. However, the interaction of pregnancy physiology with ECMO life support requires careful planning and adaptation for success. Additionally, the maintenance of fetal oxygenation and perfusion is essential for safely continuing pregnancy during ECMO support. This review summarizes the considerations for use of ECMO in obstetric patients and how to address these concerns.
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Affiliation(s)
- Michael J Wong
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Shobana Bharadwaj
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jessica L Galey
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Allison S Lankford
- Department of Obstetrics and Gynecology, University of Maryland School of Medicine and Program in Trauma and Anesthesia Critical Care, Shock Trauma Center, Baltimore, Maryland
| | - Samuel Galvagno
- Department of Anesthesiology, Multi Trauma Critical Care Unit, Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bhavani Shankar Kodali
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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18
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Gu Q, Peng W, Zhu Y, Xi S, Diao M, Hu W, Zeng X. Clinical Characteristics of 10 Pregnant and Postpartum Women With Extracorporeal Membrane Oxygenation: A Retrospective Study. Front Med (Lausanne) 2022; 8:778889. [PMID: 35047527 PMCID: PMC8761626 DOI: 10.3389/fmed.2021.778889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 10/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The aim of study was to summarize the clinical characteristics and experience of extracorporeal membrane oxygenation (ECMO) in pregnant and postpartum patients. Methods and Results: We retrospectively reviewed 131 consecutive ECMO patients at our center from May 2015 to May 2021. A total of 10 Chinese patients were pregnant or postpartum at the time of ECMO initiation. Patients ranged in age from 25 to 36 years (median age 30.5 years). The ECMO duration ranged from 3 to 31 days (median duration 8 days). There was a stabilizing trend of acid-base balance and decreasing lactic acid over the 3 days following ECMO initiation. Seven (70%) patients survived at least 48 h after weaning from ECMO. Four (40%) patients survived until discharge, and four (40%) fetuses survived until discharge. Conclusion: ECMO provides a suitable temporary cardiopulmonary support for pregnant and postpartum patients. ECMO shows a favorable effect on short-term stability in critical obstetric patients.
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Affiliation(s)
- Qiao Gu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weihua Peng
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ying Zhu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaosong Xi
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Mengyuan Diao
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Hu
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaokang Zeng
- Department of Critical Care Medicine, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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19
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Wong MJ, Bharadwaj S, Lankford AS, Galey JL, Kodali BS. Mechanical ventilation and prone positioning in pregnant patients with severe COVID-19 pneumonia: experience at a quaternary referral center. Int J Obstet Anesth 2021; 49:103236. [PMID: 34840019 PMCID: PMC8574076 DOI: 10.1016/j.ijoa.2021.103236] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/08/2021] [Accepted: 10/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND We present the care of 17 consecutive pregnant patients who required mechanical ventilation for Coronavirus disease 2019 (COVID-19) pneumonia at a quaternary referral center in the United States. We retrospectively describe the management of these patients, maternal and fetal outcomes, as well as the feasibility of prone positioning and delivery. METHODS Between March 2020 and June 2021, all pregnant and postpartum patients who were mechanically ventilated for COVID-19 pneumonia were identified. Details of their management including prone positioning, maternal and neonatal outcomes, and complications were noted. RESULTS Seventeen pregnant patients required mechanical ventilation for COVID-19. Thirteen patients received prone positioning, with a total of 49 prone sessions. One patient required extracorporeal membrane oxygenation. All patients in this series survived until at least discharge. Nine patients delivered while mechanically ventilated, and all neonates survived, subsequently testing negative for SARS-CoV-2. There was one spontaneous abortion. Four emergent cesarean deliveries were prompted by refractory maternal hypoxemia or non-reassuring fetal heart rate after maternal intubation. CONCLUSIONS Overall, maternal and neonatal survival were favorable even in the setting of severe COVID-19 pneumonia requiring mechanical ventilation. Prone positioning was well tolerated although the impact of prone positioning or fetal delivery on maternal oxygenation and ventilation are unclear.
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Affiliation(s)
- M J Wong
- Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, United States.
| | - S Bharadwaj
- Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - A S Lankford
- Department of Obstetrics and Gynecology, University of Maryland School of Medicine and Program in Trauma and Anesthesia Critical Care, Shock Trauma Center, Baltimore, MD, United States
| | - J L Galey
- Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - B S Kodali
- Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, United States.
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20
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Tafesse H, Shanmugam G, Long B, BuAbbud A, Aziz S, Parr KG. ECMO for TACO Secondary to Massive Post-Cesarean Section Hemorrhage. J Cardiothorac Vasc Anesth 2021; 36:2578-2582. [PMID: 34629239 DOI: 10.1053/j.jvca.2021.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/31/2021] [Accepted: 09/03/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Hanan Tafesse
- Department of Anesthesia and Critical Care Medicine, George Washington University, Washington DC
| | - Geetha Shanmugam
- Department of Anesthesia and Critical Care Medicine, George Washington University, Washington DC
| | - Beverly Long
- Division of Gynecologic Oncology, Sarasota Memorial Healthcare System, Sarasota, FL
| | - Anna BuAbbud
- Department of Obstetrics and Gynecology, George Washington University, Washington DC
| | - Salim Aziz
- Division of Cardiac Surgery, George Washington University, Washington DC
| | - K Gage Parr
- Department of Anesthesia and Critical Care Medicine, George Washington University, Washington DC.
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21
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Abstract
Heart failure (HF) remains the most common major cardiovascular complication arising in pregnancy and the postpartum period. Mothers who develop HF have been shown to experience an increased risk of death as well as a variety of adverse cardiac and obstetric outcomes. Recent studies have demonstrated that the risk to neonates is significant, with increased risks in perinatal morbidity and mortality, low Apgar scores, and prolonged neonatal intensive care unit stays. Information on the causal factors of HF can be used to predict risk and understand timing of onset, mortality, and morbidity. A variety of modifiable, nonmodifiable, and obstetric risk factors as well as comorbidities are known to increase a patient's likelihood of developing HF, and there are additional elements that are known to portend a poorer prognosis beyond the HF diagnosis. Multidisciplinary cardio‐obstetric teams are becoming more prominent, and their existence will both benefit patients through direct care and increased awareness and educate clinicians and trainees on this patient population. Detection, access to care, insurance barriers to extended postpartum follow‐up, and timely patient counseling are all areas where care for these women can be improved. Further data on maternal and fetal outcomes are necessary, with the formation of State Maternal Perinatal Quality Collaboratives paving the way for such advances.
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Affiliation(s)
- Rachel A Bright
- Division of Cardiovascular Medicine Department of Medicine State University of New YorkStony Brook University Medical CenterRenaissance School of Medicine Stony Brook NY
| | - Fabio V Lima
- Division of Cardiology Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute Providence RI
| | - Cecilia Avila
- Department of Obstetrics, Gynecology and Reproductive Medicine Stony Brook University Medical Center Stony Brook NY
| | - Javed Butler
- Department of Medicine University of Mississippi Jackson MS
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22
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Blondon M, Martinez de Tejada B, Glauser F, Righini M, Robert-Ebadi H. Management of high-risk pulmonary embolism in pregnancy. Thromb Res 2021; 204:57-65. [PMID: 34146979 DOI: 10.1016/j.thromres.2021.05.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/24/2021] [Accepted: 05/29/2021] [Indexed: 12/30/2022]
Abstract
Pregnancy-associated high-risk pulmonary embolism (PE) is among the most frequent causes of maternal mortality in the Western world, by causing hemodynamic instability and circulatory failure through a large thrombotic pulmonary obstruction. The very challenging management of these dramatic situations comprises the need to quickly select a therapy of pulmonary reperfusion or hemodynamic replacement, while taking into account both maternal and fetal risks. In this review, we discuss the role of risk stratification in pregnancy-associated PE and the available evidence to support the use of thrombolysis, catheter-directed thrombectomy/thrombolysis, surgical embolectomy and extracorporeal membrane oxygenation. Despite the lack of comparative studies and solid evidence, most reported cases of high-risk pregnancy-associated PE have been treated with thrombolysis, with high maternal and fetal survivals, and thrombolysis is suggested by guidelines in life-threatening PE. For women in the peripartum and early post-partum period, non-fibrinolytic treatments may be preferred as a first-line treatment, if available, because of the particularly high bleeding risk. In all cases, pregnancy-associated high-risk PE requires a multidisciplinary approach involving PE response teams and obstetricians.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | | | - Frederic Glauser
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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