Hello, my name is Dr. Ali Tabatabai. I am the Medical Director for the Adult ECMO Program and Lung Rescue Unit, which is the ECMO-dedicated unit at the University of Maryland. I have no disclosures to make, and all images in this presentation are public domain, cited, or used with express permission. We will discuss the use of ECMO in pregnant patients with COVID-related cardiopulmonary failure, including selection criteria management and outcomes. All case reports and case series regarding the use of ECMO in COVID ARDS pregnant patients use standard inclusion criteria. Here we see the most recent Extracorporeal Life Support Organization Algorithm for Assessment for Inclusion Criteria for VB ECMO after treating the underlying causes and using standard lung protective ventilation strategies. If the PF ratio remains less than 150, they recommend prone positioning and neuromuscular blockade in the high PEEP strategy, and to consider recruitment maneuvers or inhaled pulmonary basal dilators. And if despite all of that, the PF ratio is less than 80 for an extended period of time or less than 50, acutely, or if there's significant respiratory acidosis, to then consider for ECMO if there's no contraindication. So for COVID, I also recommend using the usual indications as in the previous slide, but make some specific adjustments to contraindications. We also note the age cutoff at 65 years, where in general, they did not give an age pre-COVID, the new inclusion of BMI, and some more granular detail regarding what other comorbid conditions should be considered. So this algorithm brings together the inclusion and exclusion criteria and the ELSO crisis standard recommendations. And if the ECMO indications are met, we look at our patient selection strategy. And if there are no contraindications, we assess our capacity. And if we're in our conventional capacity, then we consider ECMO support for that patient. If we are in contingency capacity tier one, then we look at a more restrictive set of exclusion criteria to select patients with the highest likelihood of survival. If we're in tier two, we really become even more selective and only use ECMO in cases with the best chance of survival. And if there are no potential additional contraindications, then we still consider the use of ECMO support. As we will see in future slides, the data would indicate that the pregnant patient in need of ECMO support should qualify based on these criteria. In terms of management considerations for the COVID-19 pregnant patient cannulation configuration as with non-COVID pregnant ARDS patients is important to consider. Bifemoral cannulation strategies have increased risk of difficulty achieving and maintaining adequate ECMO flow, and there is a risk of recirculation. Using a right internal jugular and femoral cannulation strategy has similar challenges as the draw cannula is in the IVC, but should have less risk of recirculation. The dual lumen cannulas have less difficulty with maintaining flows, but usually with lower max flow overall, and positioning needs to be monitored closely to avoid hemolysis. The newer RAPA cannulas are harder to place, requiring TEE or cath lab for angiography. There is also an upper limit on flow, but provide the additional benefit of supporting the RV as well. In later stages of pregnancy, as the fetus grows in size, it may compress the vena cava, a situation that is obviously well known to anesthesiologists and obstetricians. Here we see a diagram of vena cava compression that is impairing advancement of a femoral cannula. And this is something that needs to be considered and addressed in planning for cannulation of the COVID-19 pregnant patient. As this diagram indicates, use of a left lateral tilt by wedge-shaped cushion or pillow or inflatable device or table tilt can assist with lateral displacement of the fetus and uterus off the IVC to aid with femoral cannula insertion. Another consideration that we will discuss in future slides and in some of the case series is that perhaps in the pregnant patient, an alternative cannulation strategy should be considered, such as a right IJ dual lumen cannula. All of the COVID pregnancy ECMO case reports and case series describe using essentially standard management when compared to non-pregnant ECMO support. And in fact, in our case series of COVID pregnant patients, we describe one patient on ECMO and ventilator support who we successfully proned. In terms of pulmonary management for the COVID-19 pregnant patient on ECMO, as with other patients on ECMO, the recommendations are for low-volume, low-pressure ventilator management, no restriction regarding percutaneous tracheostomy, and prone positioning when possible. Now proning may be more difficult in the pregnant patient. And if that's the case, lateral positioning may be better tolerated and provide some degree of benefit, including postural drainage or secretions. In these situations, we recommend and use 90-degree lateral decubitus positioning. In terms of hematologic and hemodynamic recommendations, anticoagulation practices should follow the standard recommendation for other ECMO patients. And there's no indication for cytokine removal. In terms of blood transfusions for the COVID-19 pregnant patient, the usual hemoglobin goal of 7 grams per deciliter should be adequate for fetal benefit as well. If the patient is persistently hypoxic, then a higher threshold may be used. In terms of general management for the COVID-19 patient and the COVID-19 pregnant patient on ECMO, protective strategies for PPE should still be followed. And there's no reason to manage the membrane lung or rehabilitation and mobilization any differently than for any other ECMO patient. So we'll start looking at outcomes data by examining the pre-COVID data. This meta-analysis examined pregnant and postpartum patients and examined all studies published between 1972 and 2017. Ultimately, nine studies were included in the meta-analysis ranging from 2010 to 2017. The total number of patients included in this meta-analysis was 78. Here we see the pooled prevalence of maternal survival across these studies, which was at 77%. Hemorrhagic complications were the most common complication reported in these studies and reported in six of the nine studies. And here we see the pooled prevalence of hemorrhagic complications, and this is at 37%. Most patients had uterine or intra-abdominal hemorrhage followed by cannulation site bleeding. Several patients did have multiple sites of bleeding that were not specified. The next most common complication in these studies was disseminated intravascular coagulation and other thrombotic complications, which were reported in three of the nine studies. Here we see the pooled prevalence of fetal survival across these studies, which was at 69%. In this meta-analysis, there was no difference between survival for pulmonary versus cardiac indications for ECMO support in these pregnant and postpartum women and no statistical difference between VV and VA ECMO survival. When you compare these numbers to the ELSO survivals at that time of 59% for pulmonary and 42% for cardiac, this would suggest that there are similar and possibly even better outcomes for pregnant and postpartum patients versus the general ARDS ECMO patient population. It is important to note, however, that this is selecting for those larger centers that publish robust data sets that were able to qualify for inclusion into the meta-analysis. So next, let's examine the data for COVID pregnant ECMO support. This retrospective cohort study included all adult women over 18 years of age who were supported on VV ECMO for COVID ARDS between January 2020 and April 2021, as reported to the ELSO registry. The primary outcome was survival to hospital discharge, and secondary outcomes were ECMO-related complications. There were 1,180 adult female patients supported with VV ECMO for COVID, of which 100 were pregnant or peripartum. Here we can see survival and ECMO-related complications of the propensity score match cohorts comparing the pregnant peripartum to the non-pregnant cohort. The pregnant peripartum patients had higher survival with an odds ratio of 1.18 and suffered fewer ECMO-related renal complications with an odds ratio of 0.9 and no other difference in any other ECMO-related complications. Also the pregnant peripartum patients were more likely to survive to hospital discharge with 84 versus 51.5% survival, and this compares favorably to the 77% survival in the pre-COVID pregnant postpartum meta-analysis we just reviewed, and the current ELSO COVID survival to discharge of 52%. Unfortunately, the pregnancy peripartum indicator in the ELSO registry does not distinguish if actively pregnant nor how many weeks postpartum. In order to address some of the issues that are not discernible from large registry datasets, we can look at first this COVID-19 Pregnant ECMO Case Series from February of 2021, which examined patients from February through September of 2020 who were pregnant and supported on ECMO for COVID-19 ARDS. There were a total of nine patients, seven were postpartum, two were pregnant. Cannulation strategies were evenly divided between bifemoral, femoral IJ, and right IJ dual lumen cannulation strategies, but interestingly, both of the pregnant patients had a right IJ dual lumen cannulation strategy utilized. All of the patients survived to decannulation, and seven were discharged with two still admitted as inpatients at the time of publication. The two pregnant patients both had infant survival to discharge, and of the seven postpartum patients, there was one known fetal death, four infants that survived to discharge, and two cases where the fetal survival was unknown at time of publication. Interestingly, the authors noted that there was no vertical COVID transmission in these patients. A second case series with more pregnant patients was published in November of 2021. Looking at outcomes from a single system, they published a total of 10 patients, five who were postpartum and five who were pregnant when supported on ECMO. Six were supported with a bifemoral cannulation strategy, and the rest were supported with either femoral subclavian or a single right IJ dual lumen cannulation strategy. At the time of publication, two patients remained as inpatients, one who was still on ECMO support and one who was decannulated. So 78% of the patients who completed ECMO therapy survived, and they had a 67% survival to discharge as one decannulated patient had remained as an inpatient. The authors noted that bleeding was the most common complication. For infant survival in this series, 100% of the postpartum patients had infant survival, and all of these infants were delivered by preterm cesarean. Unfortunately, there was only 20% survival in the pregnant cohort as two patients had intrauterine fetal demise and two had urgent cesarean with infant demise. When we talk about cannulation strategy, it's important to note that one of these deaths occurred in an infant that had to be delivered because the patient had uterine compression of the ECMO cannula that could not be managed, and they had to undergo resuscitative hysterotomy to prioritize maternal survival. So I'd like to share with you, with her express permission, the case from our pronin case series above. Here we have a young pregnant woman with COVID ARDS who was admitted and cannulated for VV ECMO while pregnant. She was kept on ECMO until her fetus was viable and then delivered via cesarean. Unfortunately, she almost died due to hemorrhagic complications requiring surgical intervention and even had a cardiac arrest for approximately 45 minutes until I finally defibrillated her out of ventricular tachycardia into sinus rhythm. As an aside, her husband was admitted at the same time to our medical service with a much milder case of COVID, and he would walk over to visit her regularly. Her baby stayed in the NICU and, when safe, would be brought over for skin-to-skin contact and visitation until eventually the infant was able to recover and go home. All three, mom, dad, and infant, are home and healthy now, and here you can see her visiting in clinic. So for the COVID pregnant patient in need of ECMO support, we should be using standard selection criteria and processes, standard management, including proning as much as possible while focusing on maternal health and paying special attention to the cannulation strategy, and remembering that outcomes are at least comparable to other cohorts and likely for pregnant patients better than for comparable non-pregnant ARDS patients. I thank the Society of Critical Care Medicine and the Critical Care Congress for the privilege of the podium. Thank you.

ECMO

pregnant patients

COVID-related cardiopulmonary failure

selection criteria

management considerations