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

  1. VV and VA ECMO are feasible in pregnancy and peripartum with generally favorable maternal and fetal outcomes.
  2. Multidisciplinary team (MDT) input is essential for candidacy, management, and delivery planning.
  3. Physiological changes in pregnancy demand special cannulation, ventilation, and anticoagulation strategies.
  4. Survival outcomes in obstetric patients are better than general populations, including in ECPR.
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