Extra-Corporeal Membrane Oxygenation (ECMO) in Pregnancy: Challenges, Considerations and Clinical Management

Joanne Guerrero^*
*Correspondence: Joanne Guerrero, Department of Anesthesia and Intensive Care Medicine, Hanyang University College of Medicine, Seongdong-gu, Republic of Korea, Email:

Keywords

Therapeutic • Healthcare • Contraindications • Respiratory

Introduction

Pregnancy imposes significant physiological changes on the cardiovascular and respiratory systems, which may exacerbate pre-existing conditions or precipitate acute illnesses. In cases of severe respiratory or cardiac failure refractory to conventional therapy, Extra-Corporeal Membrane Oxygenation (ECMO) serves as a life-saving intervention. However, the application of ECMO in pregnancy necessitates a nuanced approach due to the unique physiological and ethical considerations involved. This article aims to elucidate the challenges, considerations and clinical management strategies associated with ECMO use in pregnant patients [1]. Pregnancy induces alterations in cardiovascular, respiratory and hematological systems to meet the metabolic demands of the fetus.

Literature Review

These changes, including increased cardiac output, decreased functional residual capacity and hypercoagulability, impact the management of ECMO in pregnant women. Clinicians must adapt ECMO settings and anticoagulation protocols to accommodate these physiological shifts while ensuring maternal and fetal well-being. The decision to initiate ECMO in pregnancy hinges on the underlying pathology, gestational age, maternal condition and fetal viability. Common indications include severe Acute Respiratory Distress Syndrome (ARDS), cardiogenic shock, pulmonary embolism and post-cardiotomy syndrome [2]. However, certain conditions such as advanced maternal age, fetal anomalies incompatible with life and severe pre-eclampsia may preclude ECMO initiation due to futility or ethical concerns. Despite its lifesaving potential, ECMO is associated with various complications, including hemorrhage, thrombosis, infection and hemolysis. Pregnant patients are particularly susceptible to these complications due to physiological changes and the need for anticoagulation. Close monitoring, multidisciplinary care and vigilant management of ECMO-related complications are essential to optimize maternal and fetal outcomes. The use of ECMO in pregnancy raises complex ethical dilemmas regarding maternal autonomy, fetal well-being and resource allocation. Healthcare providers must navigate these issues while upholding principles of beneficence, non-maleficence, justice and respect for patient autonomy. Shared decision-making involving the patient, family members and the healthcare team is crucial in determining the appropriateness of ECMO therapy in pregnancy. Optimal management of ECMO in pregnancy entails a multidisciplinary approach involving obstetricians, intensivists, neonatologists and ethicists. Close fetal monitoring, timely delivery planning and meticulous attention to ECMO circuitry and anticoagulation are paramount. Moreover, psychological support for the patient and family members is vital throughout the ECMO course and beyond [3].

Discussion

Extra-Corporeal Membrane Oxygenation (ECMO) has become a cornerstone therapeutic option for pregnant women encountering severe respiratory or cardiac compromise. The physiological alterations during gestation pose unique challenges and considerations for the application of ECMO in pregnancy. This article aims to comprehensively explore the utilization of ECMO in pregnant patients, encompassing indications, contraindications, complications, ethical considerations, and clinical management strategies. By synthesizing current evidence and guidelines, this article endeavors to equip healthcare professionals with a nuanced understanding of ECMO's role in pregnancy, thus facilitating optimal maternal and fetal outcomes. Pregnancy induces profound physiological changes, including increased cardiac output, decreased systemic vascular resistance, and altered respiratory mechanics. These alterations pose challenges in managing severe respiratory or cardiac failure, necessitating advanced life support measures like ECMO. However, the unique hemodynamic and respiratory dynamics in pregnancy mandate tailored approaches to ECMO initiation, monitoring, and weaning [4].

The decision to initiate ECMO in pregnancy hinges upon careful consideration of maternal and fetal well-being. Indications may include severe Acute Respiratory Distress Syndrome (ARDS), refractory cardiac failure, pulmonary embolism, and acute respiratory failure secondary to conditions like pneumonia or sepsis. Multidisciplinary collaboration between obstetricians, intensivists, and ECMO specialists is paramount in evaluating the appropriateness of ECMO in each case. Despite its potential benefits, ECMO in pregnancy is not without risks. Contraindications such as irreversible maternal brain injury, uncontrollable hemorrhage, and advanced maternal age with poor prognosis necessitate judicious patient selection. Complications associated with ECMO, including hemorrhage, thrombosis, infection, and fetal complications such as prematurity and placental dysfunction, demand vigilant monitoring and prompt intervention. The utilization of ECMO in pregnancy raises ethical dilemmas regarding maternal autonomy, fetal well-being, and resource allocation. Shared decision-making involving the patient, family members, and healthcare providers is essential in navigating these complex ethical considerations [5]. Principles of beneficence, non-maleficence, justice, and respect for patient autonomy guide the ethical framework surrounding ECMO use in pregnancy. Optimal management of pregnant patients on ECMO necessitates a multidisciplinary approach, including close obstetric monitoring, fetal assessment, and ECMO circuit management. Strategies for anticoagulation, ventilation, sedation, and nutritional support must be tailored to mitigate maternal and fetal risks while maximizing therapeutic efficacy [6].

Conclusion

ECMO represents a life-saving intervention for pregnant women facing severe respiratory or cardiac compromise. However, its application in pregnancy necessitates a nuanced understanding of the physiological changes, indications, contraindications, complications and ethical considerations. By adhering to evidence-based guidelines and adopting a multidisciplinary approach, healthcare professionals can optimize maternal and fetal outcomes while navigating the complex landscape of ECMO therapy in pregnancy. Continuous evaluation of maternal and fetal parameters guides ECMO management, with a focus on timely weaning and maternal-fetal dyad optimization.

Acknowledgement

None.

Conflict of Interest

None.

References

1. Makdisi, George and I-wen Wang. “Extra Corporeal Membrane Oxygenation (ECMO) review of a lifesaving technology.”J Thorac Dis7 (2015): E166.

   Google Scholar, Crossref, Indexed at

2. Guérin, Claude, Jean Reignier, Jean-Christophe Richard and Pascal Beuret, et al. “Prone positioning in severe acute respiratory distress syndrome.”N Engl J Med368 (2013): 2159-2168.

   Google Scholar, Crossref, Indexed at

3. Moore, Sarah A., Charles A. Dietl and Denise M. Coleman. “Extracorporeal life support during pregnancy.”J Thorac Cardiovasc Surg151 (2016): 1154-1160.

   Google Scholar, Crossref, Indexed at

4. Frenckner, B1. “Extracorporeal membrane oxygenation: A breakthrough for respiratory failure.” J Intern Med278 (2015): 586-598.

   Google Scholar, Crossref, Indexed at

5. Pacheco, Luis D. and Amir A. Shamshirsaz. “Extracorporeal membrane oxygenation during pregnancy.”Clin Obstet Gynecol66 (2023): 151-162.

   Google Scholar, Crossref, Indexed at

6. Sharma, Nirmal S., Keith M. Wille, Scott C. Bellot and Enrique Diaz-Guzman. “Modern use of extracorporeal life support in pregnancy and postpartum.”Asaio J61 (2015): 110-114.

   Google Scholar, Crossref, Indexed at