Introduction
- Focus on physiological changes in pregnancy, ECMO implications, outcomes with VV and VA ECMO, and special considerations in cannulation and management.
- Case-based approach highlighting real clinical scenarios.
VV ECMO in Pregnancy
Case Study
- 37-year-old, 23 weeks pregnant, influenza-related ARDS requiring VV ECMO.
Applicability and Outcomes
- Systematic review (~400 patients, mostly COVID-19 ARDS).
- Complications:
- Venous thromboembolism: 17%
- Cardiac complications: 17%
- Neurological events (stroke/ICH): 7%
- Survival:
- Maternal: 75%
- Fetal: 83%
- Conclusion: VV ECMO is feasible and effective in pregnancy.
Physiological Changes and ECMO Implications
- Respiratory: ↓ colloid osmotic pressure, ↑ tidal volume, compensated respiratory alkalosis.
- Cardiovascular: ↓ SVR, ↑ CO by ~40%, IVC compression affects cannulation.
- Renal: ↑ clearance, ↓ creatinine/BUN.
- Hematology: Hypercoagulable state, gestational thrombocytopenia, ↑ risk of VTE.
Cannulation and Management
- Ultrasound essential; left tilt for IVC access.
- Prefer two-site cannulation for higher flows.
- Ventilation: lung-rest strategy; often need higher PEEP.
- Anticoagulation: unfractionated heparin preferred.
- Delivery:
- <32 weeks → avoid unless obstetric indication.
- 32 weeks → multidisciplinary decision.
- Mode (CS vs vaginal) individualized.
- Fetal Monitoring: after viability; adjust ECMO to optimize placental perfusion.
- Decannulation: higher DVT risk → Doppler surveillance and therapeutic anticoagulation.
VA ECMO in Peripartum Cardiomyopathy
Case Study
- 34-year-old with peripartum cardiomyopathy, EF 25%, progressed to cardiogenic shock and multiorgan failure.
- Managed with VA ECMO + Impella for LV unloading.
Indications
- Amniotic fluid embolism, peripartum cardiomyopathy, myocarditis, septic cardiogenic shock, PAH, RV failure, severe preeclampsia/eclampsia.
Outcomes
- Registry data:
- 72% successfully weaned.
- 64% discharged alive.
- Survival in PPCM: 60–73%, higher than non-obstetric populations.
- ECPR survival in obstetric cases: up to 60–87%, compared to ~30–40% general.
Key Take-Home Messages
- VV and VA ECMO are feasible in pregnancy and peripartum with generally favorable maternal and fetal outcomes.
- Multidisciplinary team (MDT) input is essential for candidacy, management, and delivery planning.
- Physiological changes in pregnancy demand special cannulation, ventilation, and anticoagulation strategies.
- Survival outcomes in obstetric patients are better than general populations, including in ECPR.