So Dr. Plante has made my talk a lot easier. All right, so, oh, wait, where am I going? What am I doing? Okay, I have no disclosures, but I would like to say that I give a special thanks to my husband of 30 years who has made my amazing career possible as well as my friends in this room. Okay, I'm going backwards again. What's going on? So we're going to talk a little bit about where ECMO stands in pregnant patients. We are going to discuss some maternal and fetal outcomes, kind of a follow-up to Dr. Plante, and then some pending questions, which I think Dr. Plante has actually answered for me. I'm still going backwards. It's my life. All right, so let me just set the stage. So it's extracorporeal membrane oxygenation or really extracorporeal life support, and you can go from just removal of CO2 with smaller cannulas and lower flow, and that's called ECOR. You can do mostly oxygenation with VVECMO, or you can do hemodynamic support and oxygenation with VAECMO. But we need to remember one thing. All right, ECMO is a support tool. It is not a therapy, okay. So you have to have, before you put the patient on, you have to have an exit strategy because taking patient's palliative off ECMO is a thing that no one wants to go through. So they're mechanical devices that support the heart or lung and end organs. They're temporary. They have partial support or total support, and they're a bridge to something, whether it's recovery, decision like an LVAD, or bridge to transplant. So what exactly are we talking about? So we're really talking about oxygen delivery that everyone knows in this room. So you have oxygen delivery is the pump plus the oxygen content and that is hemoglobin and saturation. You're talking about cardiac output, which remember is heart rate and stroke volume, preload contractility and afterload. And then ECMO, VV-ECMO supports the lungs as well as VA-ECMO supports the heart. So types of cannulation real quick, okay. I'm not going to debate what's better, femoral or the Avalon catheter or the Protec catheter, but just the basics. So on A is actually VV. You have a drainage catheter. We do mostly femoral catheters. Comes out, it's a counter current oxygenator and you have a blender with air and O2, which actually the sweep actually takes care of your CO2. CO2 is much more dissolvable and removable than oxygen and I've lost my, okay, there it is. And then it returns to the superior vena cava, okay. VA-ECMO, for this you need a adequate native cardiac output. Here's VA-ECMO, same drainage catheter coming this way in this particular case, coming counter current and then coming back to the distal aorta or the proximal femoral with a little reperfusion catheter here, okay. So that's how VA-ECMO supports the heart and some supports the lungs. We're not going to talk about the hybrid extracannulas. So what configuration? Well, if you're hypoxic and have no shock, it's a straight shot to VV-ECMO. If you're hypoxic but you have shock, if it's right side of ventricular failure, you're more than likely to be able to get away with VV-ECMO What you're doing is you're allowing your pulmonary vascular bed to have more oxygen. There you have vasodilation. It's decreased afterload for the poor right ventricle. Right ventricular works better and the left ventricle then works better. Now, if you have biventricular failure or left-sided failure, then you really kind of need to think about VA-ECMO. Hypercapnia, again, same thing. If you have ECOR, great. If you don't, it's with hypoxia, you have VV-ECMO. So, all right. So how did this come about? In the last 30 years, again, I've lost myself, ECMO in and of itself has grown exponentially. Why is that? Better pumps, right? Back when I was a fellow, we had roller pumps, a lot of hemolysis, things like that. Better machines, better cannulas, okay? This, so the maternal use actually correlates with that. The blue arrow is H1N1, and also it correlated with the time when all these changes started. But look, these are series reviews and case reports. There are no prospective randomized trials here, okay? Like Dr. Plant said. We have maybe 230 patients in this report by Nome et al. It's a great paper. And that shows maternal survival of 70 to 80%, okay? And now this is all commerce. This isn't just COVID, okay? Field survival, 65 to 72%. But the question comes, is looking at Dr. Plant's conversations about COVID and looking at these numbers, I suggest to you that it's not as much the better survival due to the youth and the less comorbidities as much as we put these patients on ECMO sooner than we do other non-pregnant patients. I don't have data for that because, anyway. So this ARDS was 65% of this. ECMO runs average at 11 days. And preterm delivery was almost 50% with a third of the babies needing NICU. This is another review of cases by ELSO, similar and similar findings. 33% were delivered on ECMO, mostly C-sections, and mostly the average age of 26 weeks. So this is, we all know this study from the EOLA trial, okay, this is what you look at. And now I wanna show you. I don't think any of us are gonna let a pregnant patient get to this point because only reason is, is we don't have the data, number one. But number two, we're always afraid that they're gonna get sick, they're gonna get sick quick because they don't have the reserve, right? They don't have the reserve. But there's no hard and fast rule here, okay? Majority of the papers suggest using this as our guideline, you know, as we would a non-pregnant patient is what I'm saying. Okay, now, this is from maternal-fetal. Let's just go back for a second and look at the absolute contraindications because I will argue with you that the relative contraindications may not actually be relative contraindications, especially anticoagulation or coagulopathy. We can deal with that on the circuit, okay? Absolute contraindications really are, you know, is this patient gonna survive, okay? If they're not gonna survive, I'm not gonna get into supporting the mother to get to fetal viability. That's a whole other story. All right, so as Dr. Plant talked about, this is the MFM kind of COVID algorithm. If the PAO2 is less than 70, consider that's refractory hypoxemia. And then the other thing is here, and I think Dr. Plant went over this very nicely, so we won't spend much time, but if it's greater than 32 weeks, you go to a controlled delivery. Again, you're taking a very sick patient for a not small operation in that. So this is one of our patients. This is actually an H1N1 patient. She was 36. She was G4P3 at 30 weeks, ARDS from influenza, unvaccinated, active tobacco abuse. I'm not saying that with any judgment whatsoever. She was transferred from an outside hospital with rapidly progressive hypoxic and hypercapnic respiratory failure. She was tried on BiPAP and quickly went into tracheal intubation. She arrived at the door. We had MFM, obstetrics, and our ECMO team and our critical care team and nurses ready to go. Her PF ratio on arrival was 58. We quickly tried to do any type of PV tool. We paralyzed, sedated her, and we cannulated her. So what were our goals here? Like Dr. Plant said, our cardiac output in our pregnant patients are higher. So we have to start with higher flows. Now, here's the kicker, okay? These cannulas, the femoral cannulas, give you higher flows. Use the biggest cannula you can because you're gonna need higher flows. You're gonna need higher RPMs to match this cardiac output. However, you get into a situation that you may have what's called recirculation, right? So the oxygenated blood that's coming back is actually getting sucked out before it goes to the heart. So you have a couple situations. You could put another drainage catheter in for more oxygenation, or you can slow down that mother's heart with a beta blockade. However, you have to worry about perfusion to the uterine artery. The PaO2 we talked about is 70, the magic number, 60, as Dr. Plant said, may be acceptable, saturation of 90. Usually on ECMO, we'll accept a saturation of 80%, as long as the lactate is normal because we are delivering oxygen at a greater than a two to one oxygen delivery, okay? So the fetal heart tones are considered the fifth vital sign. So if you have viability and you're watching the fetal heart tones, not only does that help you, the baby, but it also helps you with how the mom's doing. All right, so pH, fetal acidosis, babies don't, fetuses don't tolerate acidosis as well as Dr. Plant said. The PCO2, we want that gradient 28 to 32, and then the bicarb as you see it there. If they're acidotic, some experts consider adding a little bit of bicarb, and we can talk about that at the panel. So considerations for ECMO, as Dr. Plant said, avoid severe respiratory alkalosis because it can cause UA vasoconstriction. Acidosis is poorly tolerated. Always maintain some PEEP even when you're on ECMO so you don't de-recruit. Plateau pressures, again, we do the same things we would do for a non-pregnant patient, okay? And then on ECMO, we don't have to waste the resource of oxygen. Cannulation can be done femorally, largest bore cannula that you have. You can consider the dual lumen, IJ. It's a little bit difficult sometimes to place, and sometimes it's too small. Uterine displacement, so as we all know in this room, after 20 weeks, we really should have the patient on the left lateral decubitus with a little bump, but during cannulation, it's oftentimes easier just to manually displace the uterus to the left side, which we did in our patient that we cannulated in the room. The ECMO circuits, you know, heparin is well-known in pregnancy. It doesn't cross the placenta. There are other drugs out there that have not been studied much in pregnant patients. The same parameters for coagulation that we would use for non-pregnant patients, but the ultimate thing is on VV ECMO, we really don't need anticoagulation. You need to realize that patients who are pregnant are thrombogenic, so we may need to change out oxygenators, but we don't necessarily need to anticoagulate them. When you decannulate them, you should look for DVT, because oftentimes they're there. Again, hemoglobin seven or above, and then many common drugs such as fentanyl get adsorbed, and it's better to use something like Dilaudid. You can use propofol, but just know that that volume of distribution from pregnancy plus the circuit is higher, so use your pharmacist in these situations. One other thing before I go is just don't forget about the epidural if she gets put on ECMO while she's laboring, because that has led to some problems on anticoagulation. Overall goals is like any other patient we have. You want to give them nutrition, and you want to move them and keep up their, these patients can walk with femoral cannulas. Amy's done it several times. She's one of our nurse experts. So I won't go into timing of delivery, because Dr. Plant did. The real question is, it's an individual thing, and there's no evidence that early delivery is any benefit to the mother. ECMO complications, mostly bleeding, thromboembolism. Don't forget that stroke actually is about 6% in both VA and VV, and we think it's because it is the rapid change of CO2 on the circuit, because we don't pay attention to it. It happens very quickly, especially in someone like a status asthmaticus. Okay, so our lady, she got decannulated at seven days. She got extubated five days later, and then she delivered at 35 weeks a four-pound, eight-ounce son, but in the post-op clinic, she had severe post-traumatic stress disorder, which all of our ECMO patients go to, and the COVID patients are even worse. So in summary, ECMO is an increasingly used and successful supportive platform in the peripartum patient. The peripartum patient survival rates are actually higher than projected from the non-pregnant. That may be because we put them on earlier. ECMO requires a highly communicative, talk-to-one-another, multidisciplinary team. Everybody needs to know what everybody else is doing. And then some suggested sources, and thank you very much.

Extracorporeal membrane oxygenation

pregnant patients

ECMO configuration

advancements in technology

survival rates